Every finding on record at Loma Linda Post Acute

Based on interview and record review, the facility failed to ensure a resident was protected from financial exploitation (the illegal or improper use of a person's money, property, or assets) for one of three residents (Resident 1) reviewed for allegations of financial abuse when Certified Nursing Assistant 1 (CNA 1) attempted to add Resident 1's debit card to the CNA's Apple Pay account. This failure had the potential to placed Resident 1 at risk for financial loss and misappropriation of personal property.Findings: During a review of Resident 1's admission Record (clinical record containing demographic and admission information), the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dislocation of the left knee (a knee joint that was forced out of its normal position), fractures of the upper and lower right fibula (breaks in the smaller bone of the lower leg), anxiety (a condition causing excessive worry or fear), and depression (a mood disorder causing persistent feelings of sadness). A review of Resident 1's Interdisciplinary Team Note dated April 14, 2026, indicated Social Services Director (SSD) assisted Resident 1 in contacting the bank regarding suspicious activity involving Resident 1's debit card. On April 10, 2026, attempts were made to contact the bank; however, staff were unsuccessful in speaking with a representative. On April 13, 2026, Resident 1 requested follow-up regarding suspicious activity that occurred on April 8, 2026, involving Resident 1's debit card. The SSD and Resident 1 contacted the bank's fraud department and was able to confirm the phone number associated with the suspicious Apple Pay activity. The phone number was identified as (telephone number). Resident 1's suspected the phone number belonged to a CNA employed by the facility. Human Resources Department matched the cell phone number to CNA 1. A review of Resident 1's Social Service note dated April 13, 2026, indicated, Resident 1 and SSD spoke directly with a customer service representative from the bank Fraud Mobile Wallet Department. The representative confirmed fraudulent activity had occurred when an individual attempted to add Resident 1's debit card to an Apple Pay account. The bank identified the phone number ending in 7560 did not belong to Resident 1 and froze the transaction request before it could be completed. The representative also confirmed the complete phone number associated with the attempted transaction was (telephone number). A review of the facility's Five-Day Summary Report dated April 17.2026, the report indicated, Resident 1 reported receiving a call from (name of the bank) informing her debit card had been used with a different phone number ending in 7560. The bank immediately blocked Resident 1's debit card to prevent unauthorized use and confirmed no money had been removed from Resident 1's account. The SSD continued the investigation and contacted the bank, which confirmed the phone number associated with the attempted transaction was (telephone number). An attempt had been made to add Resident 1's debit card to an Apple Pay account; however, the transaction was declined by the bank due to suspicious activity. The staff member associated with the phone number was immediately suspended pending further investigation and that local law enforcement was notified of the incident. During an interview on April 29, 2026, at 2:25 PM, with Resident 1, Resident 1 stated CNA 1 had stolen the resident's debit card information. Resident 1 further stated they did not know how CNA 1 obtained the debit card information but reported the bank confirmed CNA 1's phone number was used in an attempt to add Resident 1's debit card to an Apple Pay account. During an interview on April 29, 2026, at 3:10 PM, with the SSD, the SSD stated on April 13, 2026, both Resident 1 and SSD spoke with a representative from bank's Fraud Department. The SSD stated the bank representative verified the phone number used in the attempted Apple Pay transaction was (telephone number). The SSD further stated the phone number was verified through the facility's Human Resources Department as belonging to CNA 1. During an interview on April 29, 2026, at 4:26 PM, with the Administrator (ADMIN), the ADMIN stated Resident 1's debit card information had been used in an attempted Apple Pay transaction by CNA 1. The Administrator confirmed (name of the bank) Fraud Department verified the phone number associated with the attempted transaction and the number belonged to CNA 1. A review of the facility's policy and procedure (P&P) titled, Abuse, neglect, exploitation and miss appropriation prevention program, revised in April 2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the residents' symptoms. 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. Facility staff.

Based on observation, interview, and record review, the facility failed to ensure dishwashing equipment and food serving utensils were kept in a sanitary condition when:1. The dish drying racks were found to be unsanitary.2. Three scoops stored in a clean storage drawer were found to have dry food particles sticking on the inside part of the scoops.3. Four (4) bags of wheat tortilla were found in the refrigerator past expiration date of June 25, 2025.These failures had the potential to cause cross-contamination of food prepared in the kitchen which can cause severe illness and even be fatal for the 77 vulnerable residents who resided at the facility.Findings:1. During the dishwasher area inspection on July 1, 2025, at 9:42 AM, the dish drying racks (sanitized dishes are placed on these dish racks to air dry) were observed to have significant amount of black-colored substance build-up, scratches, cracks and corrosions in the interior and exterior walls and on the supporting pillars of the drying racks.During an interview with the Director of Kitchen 1 (DOK 1) on July 1, 2025, at 9:50 AM, the DOK 1 confirms the problem and recognizes the risk of food becoming cross contaminated due to the unsanitary drying racks. DOK 1 explained that she had been trying to order new drying racks for some time, but the supplier has been taking longer than expected to ship them. 2. During the inspection of kitchen drawers on July 1, 2025, at 10:03 AM, three scoops with dry food residue sticking on the inside of the scoops were found stored in a clean drawer among other clean scoops.During an interview with DOK 1 on July 1, 2025 at 10:03 AM, the DOK 1 confirmed three scoops with dry food residue sticking on the inside of the scoops were found stored in a clean drawer among other clean scoops. DOK 1 can't explain why these unsanitary scoops are stored in a clean drawer with other clean scoops.3. During an inspection of the walk-in refrigerator on June 30, 2025, at 7:56 AM, four (4) bags of wheat tortilla with an expiration date of June 25, 2025, were found on the shelf.During an interview with DOK 1 on June 30, 2025 at 7:56 AM, DOK 1 confirmed the expired tortilla bags found in the refrigerator. DOK 1 further stated they should have been discarded on June 25, 2025, rather than being kept on the shelf. During a concurrent interview and record review on July 2, 2025, at 10:52 AM with DOK 1, the facility's undated Policy and Procedure (P&P) titled, Sanitation was reviewed.The P&P indicated, 1. The Food and Nutrition Services Director (FNSD) is responsible for training employees in sanitation fundamentals and ensuring the use of proper techniques . 3. The FNSD is tasked with selecting and ordering all necessary equipment for the Food and Nutrition Service Department after consulting with the Administrator and Facility Registered Dietitian as needed . 11. All utensils, counters, shelves, and equipment must be clean, well-maintained, and free from breaks, corrosion, open seams, cracks, and chipped areas.DOK 1 stated the P&P were not followed.During a concurrent interview and record review on July 2, 2025, at 10:52 AM with DOK 1, the facility's undated P&P titled, Storage of Food and Supplies, was reviewed.The P&P indicated, No food will be kept longer than the expiration date on the product.The DOK 1 stated the P&P were not followed.During a record review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. in addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.

Based on interview, and record review, the facility failed to update Resident 30's Pre-admission Screening and Resident Review (PASARR - a federally mandated program that requires all individuals seeking admission to a Medicaid-certified nursing facility to be screened to ensure individuals who are identified to have a significant mental illness [SMI], intellectual or developmental disability [I/DD] are not inappropriately placed in skilled nursing facilities for long term care) when Resident 30 did not have his diagnoses of major depressive disorder, and anxiety disorder included in the PASARR assessment used to admit Resident 30 into the skilled nursing facility.This failure had the potential to result in Resident 30 being not accurately assessed regarding the need for supplemental treatment and services to better suite the needs of Resident 30.Findings:During a review of Resident 30's admission Record (contains medical and demographic information), the admission Record, indicated Resident 30 was admitted to the facility on [DATE], with diagnosis which included major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a diminished ability to function in daily life), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event).During a review of Resident 30's Social History Assessment, signed February 12, 2025, the assessment indicated Resident 30 had been taking the medication buspirone (medication commonly used to treat anxiety) oral tablet 15 milligrams (mg - unit of measure) by mouth two times a day to treat anxiety since January 9, 2025. Further review indicated Resident 30 had been taking the medication Fluoxetine (medication commonly used to treat depression) oral tablet 20 mg one time a day to treat depression.During an interview on July 3, 2025, at 8:43 AM, with the Administrator (ADMIN), the ADMIN stated Minimum Data Set Nurse 1 (MDS 1) was responsible for reviewing completion and accuracy of PASARR assessments when residents were admitted into the facility.During a review of Resident 30's PASARR assessment dated [DATE] (PASARR assessment used to admit the resident into the facility), the PASARR indicated NO to the question 9, Diagnosed Serious Mental Illness [SMI]. Does the individual have a serious diagnosed mental disorder such as depressive disorder, anxiety disorder .During a concurrent interview and record review on July 3, 2025, at 9:00 AM, with MDS 1, MDS 1 stated it was her responsibility to review PASARR assessments for all newly admitted residents. Resident 30's PASARR assessment, dated January 9, 2025, was reviewed. The MDS 1 acknowledged the PASARR assessment did not accurately indicate Resident 30 had major depressive disorder, and anxiety disorder. MDS 1 stated it should have been identified that the PASARR did not include Resident 30's diagnoses for depression and anxiety and a revision to the PASARR should have been done, but was not. During a review of the facility's policy and procedure (P&P) titled, admission Criteria, revised March 2019, the policy indicated, .9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. A. The facility conducts a Level 1 PASARR screen for all potential admissions .to determine if the individual meets the criteria for a MD, ID or RD. B. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process 1. The skilled nursing facility admitted the patient and never identified the PASARR discrepancy or revised/updated the PASARR assessment.

Based on observation, interview, and record review, the facility failed to notify the State Mental Health authority or the State Intellectual Disability authority of a resident's new mental illness diagnosis, when on December 3, 2024, Resident 31 was newly diagnosed with Paranoid Schizophrenia ( a mental disorder that affects a person's ability to think, feel, and behave clearly).This failure had the potential to prevent Resident 31 to receive specialized care and services.Findings:A review of the face sheet (contains demographic information) reveals that Resident 31 was admitted to the facility on [DATE], with diagnoses which include bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels), unspecified dementia (a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment ) with other behavioral disturbance, and post-traumatic stress disorder (a mental health condition that develops after experiencing or witnessing a traumatic event).During a review of Resident 31's clinical record, the clinical record indicated on December 3, 2024, Resident 31 was diagnose with Paranoid Schizophrenia and Schizophreniform Disorder (a mental health condition where individuals experience psychotic symptoms like hallucinations, delusions, and disorganized speech). During a further review of Resident 31's clinical record, there is no documented evidence a PASSAR was completed upon receiving the newly diagnosis and the California Department of Health Services and the State Mental Health Department were not notified. During an interview with the Director of Nurses (DON) on July 2, 2025, at 10:56 AM, the DON stated that the MDS Coordinator is responsible for making the referral to the appropriate state-designated authority when a resident is identified as having an evident or possible Mental Disorder or related condition. During an interview with the MDS Coordinator on July 3, 2025, at 1:33 PM, the MDS Coordinator acknowledged that when there is a new diagnosis of Schizophrenia or a significant change in status was identified in a resident with a mental disorder or intellectual disability, the appropriate state mental health or intellectual disability authority must be promptly notified. The MDS Coordinator stated she can't explain the reason as of why the California Department of Health Services and the State Mental Health Department were not notified regarding Resident 31's new mental diagnosis and a new PASARR was not completed. During a concurrent interview, and record review with the DON on July 3, 2025, at 1:49 PM, the Policy and Procedure (P&P) titled, Psychotropic/Anti-Psychotropic Medication Use/PASSRR last revised on December 2016, was reviewed. The P&P indicated, Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic or psychotropic medications will be evaluated for the appropriateness and indications of use. The interdisciplinary team will (a) Complete PASRR screening (preadmission screening for mentally ill individuals), and facility will see the State program requirements for specific procedures on the completion of PASRR. The DON acknowledged that the facility's P&P was not followed. The DON stated, The facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MD or ID experiences a significant change in mental or physical status.

Based on observation, interview, and record review, the facility failed to ensure physical therapy services were provided to one of two residents (Resident 35) sampled for rehabilitative and restorative services when Resident 35 did not receive physical therapy four times a week as ordered by the physician.This failure had the potential to contribute to a delay in Resident 35's ability to reach his highest level of physical functioning.Findings:During a concurrent observation and interview on June 30, 2025, at 1:08 PM, Resident 35 was lying in bed. When asked how his physical therapy was going, Resident 35 stated he did not think he was receiving physical therapy as often as he was supposed to.During a review of Resident 35's Physical Therapy Medicare PT [physical therapy] Evaluation & Plan of Treatment (outlines resident current level of functioning, diagnoses, goals and physical therapy treatment plan), dated May 19, 2025, the plan indicated Resident 35's start of care date was May 19, 2025, and Resident 35 had diagnoses which included end stage renal disease (the final, irreversible stage of chronic kidney disease (CKD). It occurs when the kidneys are no longer able to filter waste and excess fluid from the blood at a level sufficient to sustain life. At this point, individuals require dialysis or a kidney transplant), encephalopathy (A broad term for any brain disease that alters brain function or structure). Further review of the plan indicated Resident 35 was to have physical therapy four times a week for four weeks.During a review of Resident 35's care plan (an individualized plan of care for the medical treatment of a resident) titled, ADL [activities of daily living]/mobility, dated March 11, 2025, the care plan indicated, Resident has actual ADL/mobility decline and requires assistance related to encephalopathy .respiratory failure, wounds, ESRD [end stage renal disease] .legally blind . goals for this care plan included, .will have no significant declines in ADLs or mobility .physical therapy referral and treatment as indicated .During a review of Resident 35's physician's orders, an order dated May 19, 2025, indicated, PT [physical therapy 4x/week [four times a week] for 4 weeks.During a review of Resident 35's Service Log Matrix (document which outlines treatment services provided in a calendar layout), the log indicated Resident 35 only received three physical therapy visit sessions on the week of May 26, 2025 (instead of four as ordered by the physician).During a review of Resident 35's Physical Therapy Treatment Encounter Note(s) (notes documented from each physical therapy session), dated May 19, 2025 (start of care), through May 31, 2025, the notes indicated Resident 35 only received three physical therapy visit sessions on the week of May 26, 2025. The resident had a PT visit session on May 26, 28, and 29, of 2025. During a concurrent interview and record review on June 2, 2025, at 12:50 PM, with the Regional Rehab Resource (RRR), Resident 35's clinical record was reviewed. The RRR stated residents were supposed to receive physical therapy services in the frequency as ordered by the physician. The RRR further stated Resident 35 only had three physical therapy sessions during the week of May 26, 2025, and there was a missed visit on May 27, 2025. The RRR stated she was unable to find documentation regarding why the resident only had three physical therapy sessions that week or why the appointment on May 27, 2025 was missed. The RRR stated facility staff were expected to input documentation in the residents clinical record regarding missed visits, but they did not.During a review of the facility's policy and procedure (P&P) titled, Specialized Rehabilitative Services, revised December 2009, the P&P indicated, .2. Specialized rehabilitative services include the following: a. Physical Therapy .3. Therapeutic Services are provided only upon the written order of the resident's Attending Physician .During a review of the facility document titled, Best Practices: Daily Notes, (undated), the document indicated, Required daily for all patients when treatment was rendered or attempted .contains the reason why plan of care was discontinued or modified .include missed or refused treatments .

Based on observation, interview, and record review, the facility failed to ensure staff provided nutritional services to one of one sampled residents (Resident 49) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when Resident 49 was not provided a sack lunch on multiple days in May 2025, and June 2025.This failure had the potential for Resident 49 to experience undesirable weight loss.Findings:During a review of Resident 49's admission Record (contains medical and demographic information), the admission Record, indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should), dependence on renal dialysis (the state where an individual's kidneys have permanently failed and they require regular dialysis treatments to sustain life), anemia in chronic kidney disease (condition in which the body does not have enough healthy red blood cells to carry oxygen to the organs), and sepsis (a serious condition in which the body responds improperly to an infection).During a concurrent observation and interview on June 30, 2025, at 9:17 AM, Resident 49 was lying in bed and stated he underwent dialysis three times each week.During an interview on June 30, 2025, at 2:56 PM, Resident 49 stated last Saturday June 28, 2025, he had dialysis but he didn't receive a sack lunch to take with him. Resident 49 further stated sometimes staff is behind and don't prepare his lunch in time before he leaves for dialysis and he gets really hungry because he also sometimes doesn't have breakfast. Resident 49 was unable to remember specifically what dates he didn't receive a sack lunch but stated it occurred on multiple occasions. During a review of Resident 49's physician's orders, an order dated May 21, 2025, indicated Resident 49 was to have dialysis procedures three times a week on Tuesday, Thursday and Saturday at an outside facility.During a review of Resident 49's Hemodialysis Communication Observation/Assessment (a document used to record the assessment of a dialysis patient before dialysis, at the dialysis center, and after dialysis upon return to the facility), dated May 1, 2025, through June 25, 2025, the assessments dated May 8, 2025, May 24, 2025, May 29, 2025, May 31, 2025, June 19, 2025, and June 24, 2025, all indicated No to the question whether a sack meal was provided to the resident for his dialysis appointment.During a review of Resident 49's clinical record, the facility's Electronic Health Record (EHR) indicated Resident 49 dry post dialysis weight (resident's weight without excess fluid accumulated between dialysis treatments) on April 3, 2025, was 174 pounds and Resident 49's dry post dialysis weight on July 1, 2025, was 165 pounds (5.17% weight loss).During a review of Resident 49's physician's orders, an order dated May 28, 2025, indicated Resident 49 was on a Renal diet [eating plan designed specifically for people with kidney disease or those on dialysis], mechanical soft texture [foods that have been altered to be easily chewed and swallowed], thin liquids consistency. In addition, a physician's order dated May 28, 2025, indicated, [name of nutritional supplement drink] 8 oz [ounces] 1 [one] time a day for supplement.During an interview on July 3, 2025, at 9:34 AM, with the Director of Nursing (DON), the DON stated Resident 49 was supposed to receive a sack lunch to take with him every day he has dialysis. The DON further stated he was supposed to receive sack lunches for his dialysis since the time he was first admitted since he was on dialysis when he came to the facility. The DON stated it was the responsibility of the nurse who admitted him at the facility to ensure a physician's order for a sack lunch was obtained from the doctor. The DON stated that was never done for the resident, but should have been.During a review of the facility's policy and procedure (P&P) titled, Dialysis, Coordination of Care and Assessment, revised March 2024, the P&P indicated, .While at the skilled facility: this facility has direct responsibility for the care of the resident, including the customary standard care provided by the facility and the following: .6. Notification of dietary for need of sack lunch on dialysis days will be done .11. Providing and monitoring any special diets.

Based on observation, interview, and record review, the facility failed to ensure nursing staff provide a complete pain assessment when a Licensed Vocational Nurse 3 (LVN 3) and a Registered Nurse Supervisor 1 (RNS 1) were observed not performing a complete pain assessment during an emergency for Resident 278 who was experiencing chest pain.This failure had the potential to cause Resident 278 to experience a decline in health status and function.Findings:A record review of Resident 278's Face Sheet (a document which contains basic information about the resident) indicated Resident 278 was admitted to the facility on [DATE], with diagnoses which included presence of prosthetic heart valve (an artificial valve implanted to replace a damaged or diseased heart valve), paroxysmal atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and rapidly), and hypertension (high blood pressure).During an observation On July 2, 2025, at 5:28 AM, A certified nursing assistant informed licensed vocational Nurse 3 ( LVN 3) Resident 278 was experiencing pain. Upon arriving at Resident 278's room, Resident 278 was found in bed, supine, on room air, and covered with a blanket up to the neck. LVN 3 asked Resident 278 about the pain's location and intensity on a 0-10 scale. Resident 278 stated, the pain is 10/10 in the middle. LVN 3 said, The doctor prescribed Norco for pain; I will give you Norco. There were no further pain assessment done concerning the chest pain. LVN 3 proceeded to check Resident 278's vital signs. Resident 278 vital signs were as follows: blood pressure 121/66, heart rate 82, and oxygenation was 90% on room air. Resident 278 was able to sit up, scoot to the bed's edge, and place both feet on the floor. During an observation on July 2, 2025, At 5:38 AM, Registered Nurse Supervisor 1 (RNS 1) arrived at the scene, RNS 1 asked Resident 278 about the pain's location and intensity, and Resident 278 reiterated it was 10/10 in his mid-chest. RNS 1 informed Resident 278 that she needed to call 911 and left the room. There was no further pain assessment by RNS 1.During an Interview with LVN 3 on July 2, 2025, at 6:45 AM, LNV 3 was asked to describe the facility's protocol, pain assessment, and interventions for chest pain. LVN 3 stated, I called the Registered nurse supervisor, and then she called 911 because the patient was having chest pain. There was no further explanation given concerning pain assessment procedures.A review of LVN 3's Performance Evaluation, dated June 24, 2024, in the Self-Evaluation section, completed by LVN 3 indicated, In what areas associated with your job would you like more training? LVN3 responded: Patient assessment.During a review of the LVN job description on July 2, 2025, at 10:41 AM, with the director of staff development (DSD), the LVN job description was reviewed. It indicated a LVN Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Must possess the ability to make independent decisions when circumstances warrant such actions . must be knowledgeable of nursing and medical practices and procedures, as well as laws regulations and guidelines that pertain to nursing care facilities . Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. LVN 3 actions did not follow the expectations detailed in the job description.During an interview with RNS 1 on July 2, 2025, at 7:04 AM, RNS 1 was asked to describe the facility's protocol, pain assessment, and interventions for chest pain. RNS 1 stated, we go in, look at the residents and make an assessment. When asked how she completes a chest pain assessment, the RNS 1 said that when a resident complains of chest pain, it is the facility's protocol to call 911. When questioned about the thoroughness of her pain assessment in relation to the residents' symptoms, RNS 1 did not provide a further explanation. RNS 1 was unable to explain how she completed a chest pain assessment and repeatedly said we call 911. There was no further explanation given concerning pain assessment procedures. During a review of RNS 1's Performance Evaluation, dated May 21, 2025, the Self-Evaluation section, completed by RNS 1, indicated, In what areas associated with your job would you like more training? RNS 1 responded: NADuring a review of the RN job description on July 2, 2025, at 10:41 AM with DSD, the RNS job description was reviewed. It indicated, .Perform skilled care assessments. Respond to and monitor care issues and changes in condition. Coordinate and respond to medical emergencies. Report significant findings or changes in condition and potential concerns to the director of nursing. Oversee direct care activities to ensure care delivery is consistent and follows policies and procedures. RNS 1 actions did not follow the expectations detailed in the job description.During an interview and record review with the Director of Nursing (DON) on July 3, 2025, at 8:12 AM, the facility's Policies and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing revised August 2022, was reviewed. The P&P states, .3) Staff must demonstrate the skills and techniques necessary to care for resident needs including but not limited to the following areas: residents rights, behavioral health, psychosocial care, dementia care, person centered care, communication, basic nursing skills, basic restorative services, skin and wound care, medication management, pain management, infection control, identification of change in condition, and cultural competency.The DON acknowledged that facility's P&P was not followed.During an interview and record review with the DON on July 3, 2025, at 8:12 AM, the facility's P&P titled, Pain Assessment and Management, dated 2001, was reviewed.The P&P indicated, assessing Pain.B. Characteristics of a pain, including: 1. location 2, intensity 3. Description 4. Pattern 5. Frequency, timing, and duration. f. symptoms that accompany pain (example nausea, anxiety)The DON acknowledged the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure staff provided assessment and monitoring for one of one sampled residents (Resident 49) reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys no longer function) when there was no documented evidence staff assessed Resident 49's dialysis access site (the location where a dialysis machine is connected to a patient) after Resident 49 dialysis procedure on June 14, 2025, and June 17, 2025. This failure had the potential for a delay in the staff identification and subsequent treatment of possible dialysis associated complications such as symptoms of infection, bleeding or dislodgement of the dialysis access site for Resident 49. Findings:During a review of Resident 49's admission Record (contains medical and demographic information), the admission Record, indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease (a condition where the kidneys are damaged and can't filter blood as well as they should), dependence on renal dialysis (the state where an individual's kidneys have permanently failed and they require regular dialysis treatments to sustain life), anemia in chronic kidney disease (condition in which the body does not have enough healthy red blood cells to carry oxygen to the organs), and sepsis (a serious condition in which the body responds improperly to an infection).During a concurrent observation and interview on June 30, 2025, at 9:17 AM, Resident 49 was lying in bed and stated he underwent dialysis three times each week.During a review of Resident 49's physician's orders, an order dated May 21, 2025, indicated Resident 49 was to have dialysis procedures three times a week on Tuesday, Thursday and Saturday at an outside facility.During a review of Resident 49's care plan (a medical plan of care) titled, Dialysis, dated January 7, 2024. The care plan indicated, The resident needs hemodialysis r/t [related to] renal failure .Goal .The resident will have immediate intervention should any s/sx [sign and symptoms] of complications from dialysis occur . Interventions listed for this care plan indicated, .Monitor/document/report PRN [as needed] any s/sx of infection to access site: redness, swelling, warmth or drainage .Monitor/document/report PRN [as needed] s/sx of the following: bleeding, hemorrhage .During a review of Resident 49's Hemodialysis Communication Observation/Assessment (a document used to record the assessment of a dialysis patient before dialysis, at the dialysis center, and after dialysis upon return to the facility), dated June 14, 2025, the tool indicated for the section that was supposed to be completed by facility staff upon return to the facility post dialysis treatment to be completed by Licensed Nurse Post dialysis treatment, it was blank next to Access site: swelling, redness, drainage, pain, or no complications. In addition, the section for Resident General condition upon return to facility . was left blank, and the section for pain level and location was left blank.During a review of Resident 49's Hemodialysis Communication Observation/Assessment, dated June 17, 2025, the tool indicated for the section that was supposed to be completed by facility staff upon return to the facility post dialysis treatment to be completed by Licensed Nurse Post dialysis treatment, it was blank next to Access site: swelling, redness, drainage, pain, or no complications.During a concurrent interview and record review on July 3, 2025, at 9:34 AM, with the Director of Nursing (DON), Resident 49's Hemodialysis Communication Observation/Assessments, dated June 14, 2025, and June 15, 2025, were reviewed. The DON stated staff were supposed to assess the access site and status of dialysis residents upon their return to the facility post dialysis to ensure there was no complications or bleeding from the access site. The DON further stated it was important that residents were assessed immediately upon return to the facility because a lot can change quickly if there were complications. The DON stated staff should have done the assessment of the resident and documented it (their assessment) of the resident on the Hemodialysis Communication Observation/Assessment, notes dated June 14, 2025, and June 17, 2025, but they did not.During a review of the facility's policy and procedure (P&P) titled, Dialysis, Coordination of Care and Assessment, revised March 2024, the P&P indicated, .While at the skilled facility: this facility has direct responsibility for the care of the resident, including the customary standard care provided by the facility and the following: Assessment of the resident, including: .the condition of the resident's dialysis access site or device .a description of the resident's general condition .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals stored in the facility were not expired when on July 2, 2025, three over-the-counter bottles of medications were found to be stored in the medication storage room past their expiration date. This failure had the potential for the expired medications to be accessed and administered to a vulnerable population of 77 residents, potentially resulting in altered effectiveness of the medication and worsening of the residents' symptoms, requiring medical intervention.Findings:On July 2, 2025, at 7:21 AM during the inspection of the medication storage room, three over the counter bottles of expired medications were found stored in a medication cabinet: Simethicone ( a medication used for gas) expired January 2025, Vitamin A - expired June 2024, and Vitamin B complex - expired September 2024.During an interview with the Registered Nurse Supervisor (RNS) on July 2, 2025, at 7:25 AM, the RNS acknowledged that the Simethicone, Vitamin A, and Vitamin B complex medications were expired and stated, these should have been discarded since they're expired.During a concurrent interview and record review of the Policy and Procedure (P&P) titled, Medication Storage in the Facility dated June 2016, the P&P was reviewed with the Director of Nurses (DON) on July 2, 2025, at 9:03AM. The P&P indicated, All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. The DON stated the medication should have been discarded and replaced.During a concurrent interview and record review, the P&P titled, Storage of Medications, revised April 2007, the P&P was review with the DON on July 2, 2025 at 9:03 AM. The P&P indicated, 4. The facility shall not use discontinued, expired, or deteriorated drugs and biologicals. The DON stated that the Simethicone - expiration date January 2025, Vitamin A - expiration date July 2024, and Vitamin B complex - expiration date September 2024 should have been discarded and replaced. The DON acknowledged that the facility's P&P were not followed.

Based on observation, interview, and record review, the facility failed to post the results of the facility's most recent recertification survey when it was discovered the survey results were not posted anywhere in the facility.This failure resulted in residents and visitors inability to read the survey results and assess facility's compliance with regulations which directly impacts their well-being and quality of life within the skilled nursing facility.Findings:During an observation on July 3, 2025, at 10:40 AM, a binder titled, Survey Results Binder 2022, 2023, 2024 was observed to be posted on the wall in one of the main hallways of the facility. Upon review of the contents of the binder, there was no survey information in the binder for the facility's recertification survey in 2024.During a concurrent observation and interview on July 3, 2025, at 10:43 AM, with the Administrator (ADMIN), the ADMIN stated the facility's previous recertification survey results were supposed to be in the survey binder. The ADMIN reviewed the survey binder and stated he did not know why the most recent survey results from 2024 were not in the binder. The ADMIN further reviewed the binder and stated he did not realize only complaints were in the binder. The ADMIN stated the facility did not post the survey results anywhere else in the facility and the only place it was supposed to be posted was in the survey binder. During a review of the facility's policy and procedure (P&P) titled, Examination of Survey Results, revised April 2017, the P&P indicated, Survey reports and plans of correction are readily accessible to the resident, family members, resident representatives and to the public .2. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' day room .

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of bed. This failure contributed to Resident 1 being sent out to acute hospital for evaluation. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: pulmonary edema (excess fluid in lungs), abnormalities of gait and mobility, hypertension (high blood pressure), acute and chronic respiratory failure (lungs cannot exchange oxygen properly), colon cancer (cancer in rectum). During a concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON) reviewed and verified the following: 1. Fall risk assessment on admission March 28, 3025, High Risk=18. 2. Careplan: Falls: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking, unsteady gait, UNWITNESSED-FALL Date Initiated: 04/16/2025, Created on: 03/28/2025. 3. Change of Condition Fall April 16, 2025: Sleeping when round was made alert with forgetfulness and confusion, needs assistance with Activities of Daily Living (ADL). At 1:30AM, Certified Nursing Assistant (CAN) assigned reposition resident and resident go back to sleep. 3:30AM resident changed she had a Bowel movement (BM) and around 4AM resident calling for help noted on the floor in her back in between her room door. Body assessment done, vital signs and neuro check initiated, no visual injury noted. During an interview on May 08, 2025, with Director of Nursing (DON) DON states, I explained to resident son about the rails, we have the grab bars upper bars. It's considered a restraint, I was notified after the fall about family requesting bedrails. After fall, I told the Resident son we will place her at nurse station. Bed was at lowest position, we were constantly and reminding her to use call light. She was not ambulatory. When she did have a fall, we did a (COC) and sent her out for eval. I offered interventions of room change near nurse station, we had already care planed it. I would do a medication review as well. The nurse station is in middle, this resident was not by nurse station but it was in a busy hallway. During a review of the facility's policy and procedure titled, Fall and Fall Risk Managing revised [March 2018], the policy and procedure indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. During a review of the facility's policy and procedure titled, Falls- Clinical Protocol revised [March 2018], the policy and procedure indicated, The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause. The physician will help identify individuals with a history of falls and risk factors for falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). c. While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause.

Based on interview, record review, document review, and facility policy review, the facility failed to complete and transmit a discharge Minimum Data Set (MDS) for 1 (Resident #22) 1 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, Resident Assessments, revised in 03/2022, indicated, A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments - conducted for all residents in the facility: (1) Admission Assessment; (2) Quarterly Assessment; (3) Annual Assessment; (4) Significant Change in Status Assessment; (5) Significant Correction to Prior Comprehensive Assessment; (6) Significant Correction to Prior Quarterly Assessment; and (7) (7) Discharge Assessment. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, dated 10/2023, indicated, Discharge assessment refers to an assessment required on resident discharge from the facility. An Admission Record indicated the facility readmitted Resident #22 on 09/10/2022. According to the Admission Record, Resident #22 discharged from the facility on 03/13/2024. Resident #38's medical record revealed no evidence to indicate a discharge MDS was completed. During an interview on 06/20/2024 at 8:34 AM, the MDS Coordinator stated Resident #22 was discharged on [DATE]. The MDS Coordinator stated a discharge MDS was not completed for Resident #22, and she was just made aware that it was not completed. Per the MDS Coordinator, she had 14 days to complete and submit a discharge MDS after a resident discharged from the facility. During an interview on 06/20/2024 at 9:22 AM, the Director of Nursing (DON) stated the discharge MDS for Resident #22 was not completed or submitted. The DON stated, the discharge MDS for Resident #22 was missed. According to the DON, a discharge MDS should have been completed and submitted for Resident #22. The DON stated she expected MDS assessments to be completed accurately and submitted timely. During an interview on 06/20/2024 at 9:45 AM, the Administrator stated he expected MDS assessments to be accurately completed and submitted timely.

Based on interview and record review, the facility failed to report a possible overdose of narcotics for one of three sampled residents (Resident 1) per the facility policy of within 24 hours to the state agency. This failure had the potential for the possible overdose of narcotics to go uninvestigated and unreported thereby increasing the chances of potential harm to (Resident 1). Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: chronic respiratory failure (lungs cannot get enough oxygen), end stage renal disease (loss of kidney function), type 2 diabetes (condition affecting how body processes sugar), renal dialysis (treatment to filter blood), post-traumatic stress disorder (disorder in which a person has difficulty recovering for experiencing or witnessing a terrifying event). During a review concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON), reviewed are as follows: 1. Nurse Note dated [DATE], at 8:25AM LATE ENTRY: Patient was sent to acute hospital for unresponsiveness with shallow breathing, Vital Signs: Blood Pressure ,d+[DATE], Pulse 93, Respirations 18, Temperature 96.9, 0xygen 67%, unprescribed and unlabeled opened bottle of pills was found on bedside table. Called paramedics at 08:00, paramedics arrived at 08:03, left at 08:15 to emergency department on gurney. Doctor and POA were notified. Power of Attorney (POA) asked if her brother had visited and stated that her brother has a history of providing patient with narcotics. When l called brother, he stated Where did he get the pills from. Bottle of pills were not noted in patient's room in undersigned's previous shift nor during change of shift when getting bedside report from NOC shift nurse on [DATE], at 07:15, then at 07:45 checked on patient again and did not notice any distress. Notice of transfer sent to Ombudsman. 2. Situation Background Assessment Recommendation (SBAR) Communication Form /Change of Condition dated [DATE]. 2024 at 10:45: Unresponsiveness; Called 911, resident had unprescribed and unlabeled pills at bedside. 3. Acute hospital emergency department admitted [DATE], Diagnosis: cardiac arrest, opioid overdose intentional self-harm, initial encounter, hyperkalemia (high potassium levels), and End Stage Renal Disease. Suspected Norco overdose with cardiac arrest. 4. Fax notification of incident dated [DATE], 10:01AM, to California Department of Public Health (CDPH) and Ombudsman. Investigation from DON dated [DATE] . Following the conclusion of this investigation, we submitted the report to CDPH as an unusual occurrence due to a verbal report from the [acute hospital] Social Worker that resident had expired at emergency room due to overdose medications despite the facility having no valid hospital clinical record. (Incident took place [DATE].) During an interview on [DATE], with the Director of Nursing DON (DON), the DON stated, The incident happened on [DATE], we sent out Resident 1. We were waiting for the call from the hospital and family regarding update. Then the social worker from the hospital came in on [DATE], that's the day we called the district office to report, I left a message on direct line, and I left a message on answering machine on the supervisor assigned to our facility. I faxed the reporting documents to the district office [DATE]. Yes, I can agree based on the policy reviewed, the reporting was late, it should have been reported that day. During a review of the facility's policy and procedure titled, Unusual Occurrence Reporting revised [DATE], the policy and procedure indicated: As required by federal or state regulations, our facility reports unusual occurrences or other repo1table events which affect the health, safety, or welfare of our residents, employees or visitors . 2.Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3.A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

Based on interview, and record review, the facility failed to follow the physician ' s order for blood glucose level (the amount of sugar in the blood) monitoring for one of three sampled diabetic (residents with diagnosis of diabetes mellitus [DM- a health condition that affects how your body turns food into energy]) residents (Resident 1). This failure had the potential to cause conditions related to DM such as hypoglycemia (low blood sugar level) and hyperglycemia (high blood sugar level) to remain undetected and cause medical complications. Findings: A review of Resident 1 ' s Admission Record (AR), dated December 12, 2023, indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis of diabetes mellitus among others. During an interview on December 12, 2023, at 10:06 AM with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 has an order for Insulin Glargine (a long-acting insulin [a medication used to lower blood sugar]) and blood sugar monitoring prior to insulin administration. A review of Resident 1 ' s Order Summary, dated November 26, 2023, indicated, . (Insulin Glargine) Inject 10 unit subcutaneously (injected under the skin) at bedtime for dm type 1 Accucheck (a term used to check blood sugar level) with fingerstick (pricking of a finger to obtain a small sample of blood) prior to insulin as ordered given . During a concurrent interview and record review on December 12, 2023, at 10:55 AM, with the Infection Preventionist (IP- a licensed nurse), Resident 1 ' s Medication Administration Record (MAR). for the dates November 26, 2023, to December 11, 2023, were reviewed. The IP stated there were no blood sugar level check done before the insulin was administered at bedtime during the reviewed dates. During a concurrent interview and record review on December 20, 2023, at 5:39 PM, with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled, Insulin Administration, revised September 2014 was reviewed. The P&P indicated, .To provide guidelines for the safe administration of insulin to residents with diabetes .Steps in the procedure .2. Check blood glucose per physician order or facility protocol . The DON stated Resident 1 ' s blood sugar level should have been checked as ordered by the physician.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from injury when the Certified Nurse Assistant 1 (CNA 1) was assisting Resident 1 from a standing position and held Resident 1 with one hand, while reaching for the wheelchair with the other hand during transfer from bed to wheelchair. Resident 1's knees lost postural stability while standing. This failure resulted in Resident 1 falling and sustaining a fractured pelvis (hip bone). Findings: During an interview of on December 7, 2023, at 1:35 PM with Resident 1, Resident 1 stated she had a fall incident, but was unable to give details about it. During a review of Resident 1's Admission Record (AR) , dated December 7, 2023, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included senile (poor mental ability because of old age) degeneration of brain and hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain) affecting left non-dominant side. During a review of Resident 1's History and Physical (H&P-a brief documentation of a resident's medical condition), dated November 27, 2023, the H&P indicated, Resident 1 has fluctuating capacity to understand and make decisions. During a review of Resident 1's Section GG- Functional Abilities and Goals, dated November 9, 2023, the Section GG indicated Resident 1 uses wheelchair for mobility and requires partial/moderate assistance during transfers from bed to wheelchair. During a concurrent interview and record review on December 7, 2023, at 4:06 PM with the Director of Nursing (DON), Resident 1's Progress Notes (PN), dated November 17, 2023, was reviewed. The PN indicated, Patient (Resident 1) fell on floor on left side of body during a transfer from bed to wheelchair. CNA turned around to reach for the wheelchair when patient fell . The DON stated the CNA referred on the PN is CNA 1. The DON stated CNA 1 was assisting Resident 1 with both hands while standing up from bed when CNA 1 turned and grabbed the wheelchair with her right hand. Resident 1's legs lost stability while standing and fell to the floor while being held by CNA 1. The DON further stated Resident 1 was eventually sent to the hospital on the same day. During a record review on December 7, 2023, at 4:25 PM with the Director of Nursing (DON), Resident 1's Adult Trauma H&P/Consult from (Name of Hospital), dated November 18, 2023, was reviewed. The H&P indicated Resident 1 had a fall incident and underwent a CT (Computerized Tomography- a diagnostic imaging used to assess a medical condition) of the Abdomen and Pelvis on November 17, 2023. The CT result indicated, .Impression: Minimally displaced oblique (slanting direction) fracture (a break or crack) of the left inferior (lower position) pubic ramus (bones that make up part of the pelvis) and left superior (higher position) pubic ramus adjacent (next or near) to the symphysis (a place where two bones are closely joined) . During an interview on December 7, 2023, at 5:20 PM with Physical Therapist 1 (PT 1), PT 1 stated residents should be held with both hands during transfer from bed to wheelchair using standing pivot (a technique used to transfer a person). PT 1 further stated letting go of one hand would not provide support and stability should the resident fall. During an interview on December 11, 2023, at 10:21 AM with CNA 1, CNA 1 stated she was transferring Resident 1 from bed to wheelchair. CNA 1 stated she assisted Resident 1 to stand up from bed to transfer to the wheelchair. CNA 1 stated she noticed that the wheelchair was not as close to them as it should be. CNA 1 stated reached for the wheelchair with her right hand to bring it closer for the transfer but Resident 1's knees lost stability. CNA 1 stated Resident 1 fell on the floor while she was attempting to reach the wheelchair. During a concurrent interview and record review on December 12, 2023, at 1:00 PM, with the Director of Staff Development (DSD), the facility's policy and procedure (P&P) titled Resident Safety and Transfer Technique, revised July 2017 was reviewed. The P&P indicated, Policy Statement. Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and transfer assistance to prevent accidents are facility-wide priorities .Helping patient to stand. When helping a patient to stand up from a chair or bed, it is important to guard the patient from falling .2. Put on a transfer belt around the patient 's waist if you have one. 3. Lock your hands behind the patient 's waist or grip the transfer belt .7. Stand and lift the patient, while pivoting towards the chair .From bed to wheelchair .5. Help the patient to standing position. 6. Support the patient with your arms and knee as needed . DSD stated CNA should have held Resident 1 with both hands at all times during the transfer to guard against fall.

Based on interview and record review the facility failed to follow Policy on reporting when one of three sampled Resident's (Resident 1) eloped from facility. This failure had the potential to cause serious health and psychosocial harm to a clinically compromised Resident (Resident 1). Findings: During review of resident 1s Admission Record (General demographics) on ., indicates admitted to facility on June 23, 2023, with diagnosis (DX) of Primary Osteoarthritis (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints), Diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), Rheumatoid Arthritis (the body's immune system attacks its own tissue, including joints. In severe cases, it attacks internal organs) Gout (occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain) and Edema (occurs when tiny blood vessels in the body, also known as capillaries, leak fluid). During concurrent interview on June 30, 2023, at 1:00 PM with Director if Nursing (DON) and Administrator, they both stated the resident was only gone for 2 hours, resident walked home to get his hat . Resident resides 3 miles from the facility. They both states they did not report it because the resident was only gone for 2 hours, and he came back on an Uber. During an interview on July 10, 2023, at 11:15 AM with Licensed Vocational Nurse (LVN 1), he stated the resident left facility without notifying anyone. States they went to VA Hospital, and surrounding areas to locate resident and he was nowhere to be found. The sheriff's department was called, and they arrived and looked for resident also. Later that evening the resident arrived at facility with a hat on stating he went home to get hat. During record review, Progress Notes on June 25.2023 1745 by LVN 2, indicated 1745 attention was brought by Charge Nurse (CN) on duty that resident is not in his room, and he checked all room and around the building. Asked Certified Nursing Assistant (CAN 1) on duty at the time saying the resident at 1630 PM he saw resident on the hallway and asked him where you are going? Resident 1 said I'm walking around. This writer (LVN 2) called Acute ER. San [NAME] police notified at (number of police station ins San [NAME]) spoke with dispatcher all information's about the resident given. at 1809 I called Acute ER to check, triage told me resident not there. Doctor notified at 1818. Resident's daughter phone number unable to leave a message as it states busy. DON and administrator made aware. At 1847 Deputy Sheriff 1 from San [NAME] in the facility and reported given at 1921, I called San [NAME] police office and spoke with dispatcher resident home address provided to her to go check to his home. At 2010 this writer calls back VA ER to check again if resident is there. 2015 resident walk himself in the facility saying he went home to get his hat. Writer called and spoke with [NAME] dispatcher from San [NAME] police office notified resident is back and DON/Administrator made aware. Doctor 1 notified resident is back. @ 2042 Deputy 1 from San [NAME] back to the facility to see and talk to resident, writer walk him thru the resident room. 6/25/23 at 2015 by LVN 1: Resident arrived saying that he rode the bus to his home to pick up some stuff (hat). He then found out that the bus service stopped when he wanted to go back here. He then called his friend who paid for his Uber to be taken back here. Resident says that he is sorry for not informing anyone about his intent. During a review of the facility's policy and procedure titled Elopements Revised December 2007, the Policy indicated: 4. If an employee discovers that a resident is missing from the facility, he/she shall: If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and as necessary, (based on the regulatory guideline), required or volunteer agencies (i.e., Regulatory, Emergency Management, Rescue Squads, etc.) During a record review of the facility's policy and procedure titled Unusual Occurrence Reporting Revised December 2009, the Policy indicated, Policy Statement: Our facility reports, as required by federal or state regulations, unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: h. Other occurrences shall be reported via telephone to the state survey agency (and other appropriate agencies as required by law) within twenty-four (24) hours of such incident or as required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be emailed, faxed, or sent by special carrier to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

Based on interview and record review the facility failed to follow their Policy when the licensed nurse failed to transcribe and follow physician treatment order for 1 of 3 sampled Residents (Resident 1) This failure had the potential to place a clinically compromised Resident 1 health and safety at risk, when a Licensed nurse failed to transcribe and follow physician treatment order. Findings: During review of resident 1's Admission Record (general demographics) on April 4,2023 , indicates admitted to facility on February 03, 2023 with diagnosis (DX) of Type 2 Diabetes Mellitus (body doesn't produce insulin), venous insufficiency ( failure of the veins to adequately circulate the blood especially from the lower extremities), congestive heart failure ( A chronic condition in which the heart doesn't pump blood as well as it should be), cellulitis of left lower limb ( A common and potentially serious bacterial skin infection), cirrhosis of Liver ( Chronic liver damage , leading to scarring and liver failure), chronic kidney disease ( Longstanding disease of the kidneys leading to renal failure), benign prostatic hyperplasia ( age-associated gland enlargement that can cause urination difficulty), Muscle weakness, Chronic Pulmonary Disease (block airflow, difficult to breathe), Obesity (over weight), Hyperlipidemia (high fats in blood). During review of Resident 1 History and Physical records from the admitting hospital on April 4, 2023, at 4:30PM, indicates, a handwritten verbal order from Physician (MD) stated, wrap leg with Ace wrap QD . During review of Resident 1 Admission orders on April 4, 2023, at 4:40PM. There was no order of wrap leg with Ace wrap QD during review of MD1 admission order. During concurrent interview and record review of admission orders and MD 1's History and Physical ( H&P) with Director of Nursing (DON) on April 4, 2023, at 4:30PM, when asked, regarding the record review of the admission order for Resident 1; What is the expectation of your Admitting Nurse (LVN1) regarding transcribing orders? DON stated, to follow physicians' orders and transcribe it as order by the MD to the admission orders. During concurrent interview and record review with LVN1 on April 4,2023 at 5:05PM, when asked, if LVN 1 receives and transcribe a verbal order from MD for Resident 1 that states wrap leg with Ace wrap QD ? LVN 1 stated he received the order but forgot to transcribe the order to the admission orders. During review of the facility's policy and procedure (P&P) titled, Physician/Prescriber Authorization and Communication of Orders to Pharmacy revised 10/31/2016, the P&P indicated . Facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of Physician/Prescriber, and the signature of the person recording the order. All verbal orders should be recorded by a licensed nurse .

Based on observations, interviews, and record reviews the facility failed to follow the menu when: 1.The incorrect portion of the alternate starch was served to seven residents on a renal (special diet for those with kidney failure) diet and three residents who preferred mashed potatoes instead of rice. They were served with a #12 scoop (2.8 ounces) but should have been served with a #8 scoop (4 ounces), for lunch on January 3, 2023. 2.The cook used a slotted spoon (large plastic or metal spoon with holes in it) instead of a standardized portion server or scoop (Level scoops, ladles, and portion servers provide more accurate portion control than serving spoons that are not volume-standardized measure) to portion the ground meatballs and vegetables (zucchini) according to the Daily Spreadsheet (document that indicates what foods are being served and how much to serve). The 23 residents on a mechanical soft diet (foods are chopped for residents who have difficulty chewing or swallowing) did not receive the correct portion of the meatball as indicated on the Daily spreadsheet. 67 residents who received the vegetables did not receive the correct portion as indicated on the Daily Spreadsheet. This failure had the potential for 67 residents to receive the wrong caloric intake when not following the menu, which could result in overnutrition or undernutrition, and further compromise their medical status. Findings: 1. During an observation of the cook serving food on the plates for residents on January 3, 2023 at 12:24 PM, the cook served the alternate starch (mashed potatoes and plain rice) with a #12 scoop (2.8 ounces) scoop. During an interview with the Dietetics Service Supervisor (DSS) on January 4, 2023, at 9:18 AM, the DSS stated the cook should have served the alternate starch with the same scoop size, #8 as the main starch (parslied rice), as indicated on the Daily Spreadsheet. During a review of the Daily Spreadsheet, dated January 3, 2023, indicated, parslied rice, regular portion, #8 scoop. During an interview with the Registered Dietitian RD) on January 5, 2023, at 9:40 AM, the RD stated that the cook should have served the alternate starch with the same scoop size as the main starch (parslied rice) as indicated on the Daily Spreadsheet. During a review of facility Policy and Procedure (P &P) Cycles Menu, dated September 14, 2018, indicated .3. Menus must be followed as written . 46709 2. During an observation of the cook serving food on the plates for residents on January 3, 2023, at 12:24 PM, the cook used a slotted spoon to serve the ground meatballs and vegetables (zucchini). The DSS took a portion of the ground meatballs from a resident's plate and weighed it on a food scale. The food scale read 2.2 ounces. During an interview with the DSS on January 4, 2023, at 9:18 AM, the DSS stated the cook should be using a standardized scoop for the ground meatballs and vegetables as indicated on the Daily Spreadsheet. She stated, for the ground meatballs, the recipe indicated three meatballs is equivalent to 3 ounces, so the cook should use a scoop that provides 3 ounces of ground meatballs for residents. During a review of the Daily Spreadsheet, dated January 3, 2023, the Daily spreadsheet indicated the portion size for the meat for the mechanical soft diet was three meatballs each. The spreadsheet also indicated the portion for the seasoned zucchini for the regular portion #8 scoop. During a review of the recipe for Sweet and Sour Meatballs, undated, the recipe indicated 3 meatballs is equivalent to 3 ounces serving size. During a review of facility Policy and Procedure (P &P) Cycles Menu, dated September 14, 2018, indicated .3. Menus must be followed as written .

Based on observations, interviews, and record reviews, the facility failed to maintain professional standards for food service safety when: 1.The walk-in freezer floor had food crumbs and trash under the shelves and under the crates that were storing food. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 2.The microwave had yellow food crumbs and build-up on the inside, this had the potential to contaminate food heated in the microwave. 3.The stainless-steel wall behind the food preparation area, where the microwave was, had yellow food stains on the wall. This had the potential to attract pests and for microorganism growth that could be inadvertently transferred to food. 4.The floor under the convection oven had black grime, food crumbs and trash. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 5.There was food crumbs, black grime and trash build-up under the stove range. This had the potential for microorganisms growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 6.The stove had grease build-up on the sides, in crevices and on the knobs. This had the potential for microorganism growth that could be inadvertently transferred to food. 7.In the dry storage room, under the shelves in the back corners, there was food crumbs and trash. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 8.Under the shelves that stored raw potatoes and [Brand Name] nutrition supplement drinks, there was food crumbs. This had the potential to attract pests. 9.The walls and baseboard near the kitchen entrance had yellow stains and build-up of food crumbs. This had the potential for microorganism growth that could be inadvertently transferred to food and may also provide an environment for attraction of pests. 10.The handle of the food warmer was sticky with yellow build-up, which had the potential to contaminate the hands of food workers. 11.The wall behind the dishwasher had incomplete repair. The surface was not easily cleanable, and this had the potential for microorganism growth. The facility's failure to maintain professional standards for food service safety had the potential to expose 73 highly susceptible residents who received food from the kitchen to foodborne illness (illness caused by ingestion of contaminated food or beverages) due to cross- contamination (the transfer of harmful substances or disease- causing microorganisms to food). Findings: 1. During a concurrent observation and interview with Dietetics Service Supervisor (DSS) on January 3, 2023, at 8:20 AM, the walk-in freezer floor had food crumbs and trash under the shelves and under the crates that were stacked with food boxes. The DSS stated that the walk- in freezer floor should be kept clean and free of trash and food crumbs. During an interview with the facility Registered Dietitian (RD) on January 5, 2023 at 9:36 AM, the RD stated that the freezer floor should be kept clean and swept up regularly. During a concurrent interview and record review on January 5, 2023, at 9:40 AM, with the RD, the facility Cleaning Schedule Record log, dated December 11, 2022 to January 03, 2023 was reviewed. The RD acknowledged that the floors under the shelves in the freezer was not on the cleaning log. During a record review of facility's Policy and Procedure ( P&P) titled Cleaning Schedules, revised August 2018, indicated The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 46709 2. During a concurrent observation and interview with the DSS on January 3, 2023, at 8:30 AM, the microwave had yellow food crumbs and yellow build-up on the inside. The DSS stated that the microwave should be kept clean and free of food residue. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the microwave should be kept clean. During a concurrent interview and record review on January 5, 2023, at 9:40 AM, with the RD, the facility Cleaning Schedule Record log, dated December 11, 2022 to January 03, 2023 was reviewed. The RD acknowledged that the microwave was not included on the list of equipment to be cleaned. During a record review of facility's P&P titled Cleaning Schedules, revised 08/31/2018 ,indicated The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-601.11, indicates The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 3 .During a concurrent observation and interview with the DSS on January 3, 2023, at 8:35 AM, the stainless-steel wall behind the food preparation area, where the microwave was, had yellow stains on the wall. The DSS stated that the area should be kept clean and free of stains. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the stainless steel wall behind the food preparation area, where the microwave was, should be kept clean and free of stains. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. During a record review of facility's P&P titled Cleaning Schedules ,revised August 31, 2018, indicated The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. 4. During a concurrent observation and interview with the DSS on January 3, 2023, at 8:38 AM, the floor under the convection oven had black grime, food crumbs and trash. The DSS stated that the area should be kept clean and free of trash, food crumbs and black grime. The DSS stated it is hard to clean under the equipment but she stated she will communicate with the maintenance department to clean the area. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the floor under the convection oven should be kept clean. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 5. During a concurrent observation and interview with the DSS on January 03, 2023, at 8:42 AM, there was food crumbs, black grime and trash buildup under the stove range. The DSS stated that the area should be kept clean and free of trash and food crumbs. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the stove range and its surrounding areas should be maintained clean. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 6. During a concurrent observation and interview with the DSS on January 3, 2023, at 8:45 AM, the stove had grease build-up on the sides, in crevices and on the knobs. The DSS stated that the stove should be kept clean and free of grease build-up. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the stove should be kept clean and free of grease build-up. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 7. During a concurrent observation and interview with the DSS on January 3, 2023, at 8:49 AM, in the dry storage room, under the shelves in the back corners, there was food crumbs and trash. The DSS stated the area should be kept clean and free of trash and food crumbs. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the dry storage room should be kept clean. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 8. During a concurrent observation and interview with the DSS on January 3, 2023, at 8:53 AM, under the shelves that stored raw potatoes and [Brand Name] nutritional supplement drinks, there was food crumbs and debris. During an interview with the facility RD on January 05, 2023 at 9:36 AM, the RD stated that the shelves that stored raw potatoes and [Brand name] nutritional supplement drinks should be kept clean and free of food crumbs and debris. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 9. During a concurrent observation and interview with the DSS on January 3, 2023, at 8:58 AM, the handle of the food warmer was sticky with yellow build-up. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the handle of the food warmer should be kept clean. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 10. During a concurrent observation and interview with DSS on January 3, 2023, at 9:03 AM, the walls and baseboard near the kitchen entrance had yellow stains and build-up of food crumbs. During an interview with the facility RD on January 5, 2023, at 9:36 AM, the RD stated that the walls and baseboard near the kitchen entrance should be kept clean. In a review of the FDA Federal Food Code 2017, 4-601.11 titled Equipment, Food- Contact Surfaces, Nonfood- Contact Surfaces and Utensils, indicated, .(C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. In addition, 4-602.13, indicates 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. 11. During a concurrent observation and interview with the DSS on January 3, 2023, at 9:08 AM, the wall behind the dishwasher had incomplete repair. The surface was not easily cleanable. The DSS stated the maintenance department had not completed the repair. During an interview with the facility RD on January 05, 2023, at 9:36 AM, the RD stated she expects the repair to be finished as soon as possible. In a review of the FDA Federal Food Code 2017 4-101.19 Nonfood-Contact Surfaces indicated, non- food contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material.

Based on interview and record review the facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS - computerized resident assessment completed by a licensed nurse) Assessments for 12 sampled residents when: 1. The facility did not complete MDS Discharge Assessments for 11 residents (Residents 79, 88, 84, 89, 58, 85, 6, 42, 87, 86, and 77) who were reviewed for MDS data completion. 2. The facility did not accurately code Section N: Medications of the MDS for antibiotics (medication given to treat bacterial infections) for Resident 83. This failure to notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents has the potential for monies to continue to be paid to the facility after a resident has been discharged , and for services not rendered to the resident. Findings: 1. During a review of the facility's MDS assessments on January 5, 2023, at 2:15 PM, 11 residents (Residents 79, 88, 84, 89, 58, 85, 6, 42, 87, 86, and 77) did not have discharge MDS assessments completed. Upon review, the delay of the discharge MDS assessments ranged between 82 and 144 days late. Resident and discharge information for the 11 residents are as follows: a. Resident 79 was discharged from the facility on September 6, 2022. Discharge MDS assessment 107 days overdue. b. Resident 88 was discharged from the facility on October 1, 2022. Discharge MDS assessment 82 days overdue. c. Resident 84 was discharged from the facility on August 10, 2022. Discharge MDS assessment 134 days overdue. d. Resident 89 was discharged from the facility on September 6, 2022. Discharge MDS assessment 107 days overdue. e.Resident 58 was discharged from the facility on August 11, 2022. Discharge MDS assessment 133 days overdue. f. Resident 85 was discharged from the facility on August 10, 2022. Discharge MDS assessment 134 days overdue. g Resident 6 was discharged from the facility on August 28, 2022. Discharge MDS assessment 116 days overdue. h. Resident 42 was discharged from the facility on August 11, 2022. Discharge MDS assessment 133 days overdue. i. Resident 87 was discharged from the facility on August 29, 2022. Discharge MDS assessment 115 days overdue. j. Resident 86 was discharged from the facility on August 31, 2022. Discharge MDS assessment 113 days overdue. k. Resident 77 was discharge from the facility on August 2, 2022. Discharge MDS assessment 142 days overdue. During an interview with the MDS Consultant (MDS 1) on January 5, 2023, at 2:59 PM, MDS 1 stated she did not know why the discharge assessments were not done. MDS 1 further stated the discharge assessments should have been completed. During a review of CMS's Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual Version 1.17.1, Chapter 5: Submission and Correction of MDS Assessments, revised October 2019, the RAI Manual indicated, .long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions .Discharge and Reentry records must be completed within 7 days of the Event Date . 40171 2. A clinical record review of Resident 83's Admission Record, indicated Resident 83 was admitted on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body), dysphagia (difficulties with swallowing), and muscle weakness. During a review of Resident 83's MDS, dated [DATE], the MDS Section N0410 for medications received indicated resident 83 had received antibiotics for six of the last seven days of the lookback period (the period of 7 days prior to the date of the assessment on October 20, 2022). During a review of Resident 83's physicians orders, there was no active order for an antibiotic to be administered to the resident during the month of October 2022. During a review of Resident 83's Medication Administration Record (MAR - a document used to record the administration of medications) dated October 2022, the MAR did not indicate an antibiotic was administered to the resident at any time throughout the month of October. During an interview on January 9, 2023, at 9:55 AM, with the Director of Nursing (DON), the DON reviewed Resident 83's MAR dated October 2022, and physicians' orders for October 2022. The DON stated she could not find any evidence that an antibiotic was administered to Resident 83 in October 2022, and she was not sure why antibiotics were indicated on the residents MDS dated [DATE], and that she thought it was an error. During an interview on January 9, 2023, at 10:30 AM, with the Minimum Data Set Consultant (MDS 1), MDS 1 reviewed Resident 83's MAR dated October 2022. The MDS 1 stated there was no documentation which indicated Resident 83 was administered an antibiotic in October 2022. The MDS 1 further stated the MDS section N for medications should have been a 0 (zero) instead of 6 and it was a coding error. The MDS 1 further stated the facility used the current version of the RAI manual [Resident Assessment Instrument manual - the guidance document on instructions regarding completion of MDS assessments] as a guide for completion of the MDS assessments. During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual, dated October 2019, version 1.17.1, the manual indicated on page N-6, Steps for Assessment 1. Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period .

Based on observation, interview, and record review, the facility failed to ensure resident food was stored, prepared, distributed and served under sanitary conditions when: 1. Roast beef and the beef juices were not safely cooled and found to have temperatures in the Danger Zone (the Danger Zone refers to temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms in foods that are capable of causing foodborne disease). 2. Wood shelves in the dry storage room, used to store resident food were significantly worn on the edges which made them rough and not easily cleanable per the Food Code requirements. 3. Social Worker was observed transporting uncovered cups of hot fluids through the facility. 4. A fan was blowing on dishwashing area with gray fuzzy accumulation on the metal grate cover. These failures had the potential to result in food borne illness in a highly susceptible population (persons who are more likely to experience food borne illness because they are immunocompromised { person with poor ability to fight infection } of 69 residents. An Immediate Jeopardy situation was declared on June 1, 2016 at 1:04 PM, in the presence of the Administrator and the Director of Nursing (DON), due to the facility's failure to ensure potentially hazardous foods (PHF, a food that requires time/temperature control to safely limit microorganism growth) were safely cooled according to the cooling procedure. PHF held in the Danger Zone if cooked and cooled, may cause a foodborne illness outbreak if consumed. Findings: 1. During an initial tour of the kitchen on May 31, 2016 at 8:15 AM, beef with juices was observed cooking in the oven. During a follow up tour on May 31, 2016 at 2:30 PM, beef juices were observed in a large, deep stock pot on the counter sitting in two to three inches of ice. The meat juices were removed from the oven by Cook 1. The survey team checked the temperature of the beef juices and identified the temperature at 105 degrees F. During a concurrent interview and record review with Cook 1 on May 31, 2016 at 2:36 PM, she stated the beef and juices were cooked for tomorrow's lunch. She stated she had not checked the temperature of the juices and we don't keep records on juices. She also stated she removed the roast beef and juices from the oven on May 31, 2016 at 10:30 AM. She was unable to produce any cool down records for the juices. A review of facility's policy titled Cooling Monitor For Hazardous Foods dated 7/2014, indicated .food should be cooled from 140 degrees F to 70 degrees F within 2 hours and cooled from 70 degrees to 41 degrees in additional 4 hours . According to the 2013 Food and Drug Administration Food Code, Cooked time/temperature for safety food shall be cooled: within two hours from 135 degrees F to 70 degrees F and within a total of six hours from 135 degrees F to 41 degrees F or less. An Immediate Jeopardy situation was declared on June 1, 2016 at 1:04 PM, in the presence of the Administrator and the DON due to the facility's failure to ensure PHF were safely cooled according to the cooling procedure. PHF kept in the Danger Zone by not being cooled properly may cause a foodborne illness outbreak if consumed. On June 2, 2016 at 11:30 AM, the Immediate Jeopardy was removed in the presence of the Administrator and the DON when the facility's Corrective Action Plan was approved and the survey team confirmed implementation of the Corrective Action Plan, which included the following components: a. Registered Dietician and Dietary Supervisor will re-educate all dietary staff on the proper protocol/policies and procedures related to the cooling and monitoring of hazardous foods. b. The dietary staff will monitor and maintain updated log to ensure appropriate temperature ranges are met in a timely manner. c. The dietary supervisor and Registered Dietician will provide ongoing training on cooling and monitoring of hazardous foods. d. The Dietary Supervisor or designee will conduct daily audits of the cooling monitoring process as it relates to hazardous foods including drippings used for sauces or gravies for 30 days to make sure that the deficient practice will not reoccur. The focus will be on all foods that are cooked and cooled. 2. During initial tour with the Dietary Services Supervisor on May 31, 2016 at 8:15 AM, the wood shelves in the dry storage area were worn with rough edges that were not smooth, peeling paint and not easily cleanable. A review of the facility's policy titled Dry Storage, dated 2015, indicated 1 . Shelving should be sturdy and provided with a surface which is smooth and easily cleaned . According to 2013 FDA food code, Non-FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 3. During an observation on May 31, 2016 at 12:29 PM, Social Services Director was observed transporting two uncovered cups of hot fluids from the dining room to resident rooms. During an interview on May 31, 2016 at 12:30 PM with Social Services Director, she was asked if beverages being transported through the facility were supposed to have lids, she stated she did not know, she also stated that it may be in the facility's policy, but she was unaware. During interview on 6/3/2016 at 1:30 PM with the Dietary Services Supervisor (DSS), she stated food and beverages must be covered when transported to the resident's room. According to the 2013 Food and Drug Administration Food Code, food shall be protected from cross contamination by storing food in packages, covered containers or wrapping. 4. During an observation on June 2, 2016 at 11:27 AM, a fan was blowing on dishwashing area with an accumulation of gray fuzzy particles on the metal grate. A concurrent interview with cook 1 stated the fan was dirty but it was hardly used. She stated the fan is used when mopping the floors. When asked about a cleaning schedule she did not know the last time it was cleaned. According to the 2013 Food and Drug Administration Food Code, cleaned equipment and utensils shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination.

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous food (PHF, food that requires time and temperature control for safety to limit the growth of bacteria or the formation of toxins produced by bacteria within the food) served to residents during an extended power outage was stored, held, and served at safe temperatures (below 41 degrees Fahrenheit (°F) or above 135 °F). This failure had the increased potential to result in food-borne illness in a highly susceptible population of 74 of 78 residents. Findings: Upon arrival to the facility on [DATE], at 4:25 PM, electric company work trucks were observed in the facility parking lot and on the street in front of a power pole. During an interview with the administrator and the receptionist upon entering the facility on September 15, 2015, at 4:30 PM, the Administrator stated the electric company trucks observed in their parking lot, were there working on the power outage, which occurred between 8:30 to 9:00 AM, that morning from a blown transformer and downed power line outside the facility. The administrator stated he did not report the outage to the Department and the facility was using its emergency generators for power. During an interview with the facility Environmental Director (ED), on September 15, 2015, at 5:17 PM, when the ED was asked about the location of the Dietary Services Supervisor (DSS), the ED stated the DSS was off for the day. Upon entering the kitchen at 5:21 PM, on September 15, 2015, a Dietary Staff (Cook 1) identified herself as the person in charge of dietary services for the day. During an observation of the walk in refrigerator and freezer in the kitchen on September 15, 2015, from 5:21 to 5:27 PM, no light was on in either the refrigerator or freezer. Using a flashlight provided by the facility and escorted by Cook 1, the following concerns were identified: 1. In the walk-in refrigerator, the temperature was 54.4 ° F as indicated by the refrigerator's thermometer and the following foods with the potential to cause food-borne illness were found: a. All the cartons of milk and nutritional supplements on three shelves had moisture on the outside of the cartons and plastic wrap, b. The nutritional supplements cartons were in puddles of water on trays. c. Meats (chicken, lunchmeat, ground beef, and another red meat) were sitting in liquid meat juices inside plastic bags or wrapped in plastic. d. Moisture was on all cheese packages both inside and outside the plastic. According to the 2013 Food and Drug Administration (FDA) Food Code, except during preparation, cooking, or cooling potentially hazardous food (PHF, food that requires time and temperature control for safety to limit the growth of bacteria or the formation of toxins produced by bacteria within the food) shall be maintained at 135 ºF or above, or at 41 ºF or less. 2. The temperature inside the walk-in freezer measured 16.4 °F using the thermometer inside the freezer and breads and ice cream were observed to be soft, not frozen solid. During an interview with Cook 1, on September 15, 2015, at 5:27 PM, Cook 1 stated they served Chicken Alfredo with noodles, broccoli, salad, bread, and choice of beverage for lunch and that for dinner they were using the disaster menu. A review of the facility policy and procedure titled, Disaster Menu, dated September 2011, indicated, 3. In the event of an emergency . c. Inventory freezer and refrigerator for items that can be used. Inspect for wholesomeness. Use these items first. Do not use frozen foods that appeared to have thawed or refrigerated items greater than 41 °F. A record review of the facility's document titled, Week at a Glance Menu, dated August 23 to September 26, 2015, indicated lunch at 11:30 AM, was Chicken Alfredo with Noodles, Broccoli Florets (small, cut pieces of broccoli), Caesar Salad, Breadstick and Margarine, Chocolate and Vanilla Cream Pie and choice of beverage. The alternate lunch menu was Chicken Tenders over Romaine with Dressing. The menu also indicated dinner at 5:15 PM, was Vegetable Beef Soup, Trio Salad Plate, Banana Bread and Margarine, ABC Fruit Cup, Milk, and Coffee, Tea or Decaf. The alternate dinner was a Garden Tuna Salad Sandwich. A record review of the facility document titled, Disaster Menu, dated September 2011, indicated the evening meal was peanut butter, jelly, saltine crackers or bread, canned fruit, cookies, and milk made from powered milk and water. The optional alternate evening meal on the disaster menu was canned meat (tuna, ham, or chicken), canned potato or bread, canned vegetables, canned fruit, cookies, and milk made from powdered milk and water. An observation of the dinner tray-line (resident meal tray assembly) on September 15, 2015, at 5:30 PM, revealed residents were served either a tuna or egg salad sandwich. The sandwiches were noted on metal tray pans which were placed on ice and water in gray plastic pans. Also noted were individual milk cartons stored in gray plastic tubs with ice, and nutritional supplements on ice in gray plastic tubs. The ice in the gray plastic tubs was melted resulting in some water observed in the ice in each gray plastic pan. Temperatures taken with Cook 1 using the facility thermometers registered the following temperatures of PHF food on the tray-line: a. Tuna sandwiches were 54.1 °F, b. Egg salad sandwiches were 46.0 °F, c. Milk in individual cartons was 45.5 °F (milk on tray to one resident on meal cart was 51.4 °F), d. Juice was 55.8 °F. During an interview with Cook 1, on September 23, 2015, at 4:11 PM, Cook 1 stated that residents were served either a tuna or egg salad sandwich, chips and milk for the regular menu, or pureed tuna served by a number six serving scoop and tomato juice for the puree menu. A record review of a facility document titled, Food Temperature Chart, dated September 15, 2015, indicated guidelines for the following temperatures for the PHF on the tray line: milk 40-41°F, juice 41°F, cold entrees ranging from 10-40°F, and salads 35°F for food on the tray line served to the residents. During an observation of the dining room on September 15, 2015, at 5:35 PM, 39 residents were eating or had eaten the PHF food items that were not in the safe food temperature range. One food cart of 20 meals was served to residents and eaten by residents in their rooms. A total of 59 residents were served PHF food not in the safe food temperature range. During an interview with Cook 1, on September 23, 2015, at 4:12 PM, tray line started at 5:00 PM, and Cook 1 stated the Restorative Nursing Assistants (RNA) received their resident's food first, and then the dining room was served second. During a third observation in the kitchen with Cook 1 on September 15, 2015, at 6:20 PM, the four-door refrigerator unit was off and did not have power due to the power outage. The following temperatures of PHF items found in the refrigerator, which Cook 1 stated were prepared for breakfast on September 16, 2015, were measured using the facility thermometers at 6:26 PM: a. Milk with thickener (protein powder) in glasses measured at 58.9 °F, b. Thickened juice glass from a tray measured at 57.2 °F, c. Tomato juice in 46-ounce cartons measured at 56.3 °F, d. One carton of soymilk from three unopened cases measured at 57.8 °F. A fourth observation in the kitchen walk-in refrigerator with Cook 1, on September 15, 2015, at 6:45 PM, noted 58 °F on the refrigerator's thermometer. Using the facility thermometer, one sampled juice scheduled for breakfast the next day measured at 65.1 °F, a sampled pint of milk measured at 59.1 °F, a sampled nutritional shake supplement measured at 57.1 °F, and a sampled glass of milk from a one-gallon container poured into a glass measured at 56.6 °F. A review of the facility policy and procedure titled, Power Outages, dated August 2006 did not direct the facility to monitor and record food temperatures in refrigerators and freezers in the kitchen on an hourly basis during a power outage. During an interview with the DSS, upon her arrival to the facility at 7:10 PM, on September 15, 2015, the DSS stated she would be making dinner trays using the disaster menu for the residents identified by nursing staff who did not receive dinner. During an interview at 7:26 PM, on September 15, 2015, with Resident #1, the resident stated he was served a tuna salad sandwich and milk at 5:30 PM. The resident stated he knew the milk was hot and he did not drink it. The resident stated he had family bring in food to him. At 7:30 PM, on September 15, 2015, the DSS and Cook 1 met with surveyors in the kitchen to calibrate thermometers using ice and a small amount of water in a container. The purpose of the thermometer calibration was to ensure both the facility and surveyor thermometers were plus or minus 1.0° F when measuring PHF food temperatures. The following temperatures measured from the ice and water solution were recorded: Facility thermometer 33.0 °F, HFES thermometer 32.0 °F. During an interview with the DSS, on September 15, 2015, at 7:40 PM, the DSS stated their protocol for food during a disaster was to use perishable food first and then go to the canned disaster foods. The DSS stated dietary staff takes food temperatures on the tray line and assuming there was no power or ventilation, the dietary staff just placed food on ice. The DSS stated the dietary staff knew about the safe and unsafe temperature ranges of PHF. The DSS also stated what dietary staff was supposed to do during a disaster, which included contacting the DSS so that the DSS could give instructions to the staff. The DSS stated she was not aware of the whole situation and was told the power was off for only 20 minutes. The DSS stated that the dietary staff served tuna and egg salad sandwiches that were outside the safe temperature range to residents. The DSS reported her staff notified her at 10:00 AM, by phone about the power outage and when the staff had already begun preparation of the lunch meal. The DSS stated she instructed the dietary staff to serve the resident meals on paper goods since the dishwasher did not have power. During another observation in the kitchen with the DSS and Cook 1 at 8:10 PM, on September 15, 2015, a handwritten note on white paper in red ink was taped to the tray line and food preparation area. The note indicated the dinner menu was tuna salad with sliced tomato and lettuce, fruit, potato chips. The pureed diet was tuna and tomato juice. The renal diet was sliced pears. During an interview with Cook 1 on September 15, 2015, at 8:30 PM, about the preparation and cool down for both the tuna and egg salad, Cook 1 stated she used canned tuna and eggs that were cooked the previous day. Both the tuna salad and egg salad were made with mayonnaise and the egg salad contained celery, onion, and bell peppers. Cook 1 stated she stuck both the tuna and egg salad in a bowl on ice and placed both bowls in the walk-in refrigerator. Cook 1 stated, No, I don't, in response to having cool down temperature logs. The facility or DSS did not provide any cool down temperature logs. Cook 1 stated that she and the morning cook, Cook 2, just checked the refrigerator in the morning and before dinnertime using the big thermometer in the refrigerator. Cook 1 stated the kitchen had no ventilation or air conditioning during the day. A record review of one facility document titled, Record of Refrigeration Temperatures, dated September 15, 2015, AM, showed Cook 2's initials for the AM shift: a. 39 °F for the walk-in refrigerator b. -2 °F for the walk-in freezer A record review of one facility document titled, Record of Refrigeration Temperatures, dated September 15, 2015, PM, showed Cook 1's initials for the PM shift: a. 50 °F for the walk-in refrigerator b. 23 °F for the walk-in freezer During an interview with the administrator, on September 23, 2015, at 3:15 PM, the administrator stated that during the power outage on September 15, 2015, the walk-in refrigerator and freezer were not on the back-up power from the generators, but Unit #1 freezer was plugged into a generator power source. He stated he wished the facility had followed the disaster protocol to monitor the temperature of perishable food items the way they should have done during the power outage, but they did not. The administrator stated he asked the dietary staff if they were okay but did not realize the disaster procedures were not being followed. He was aware that the DSS was not working that day. During an interview with Cook 1, on September 23, 2015, at 3:35 PM, Cook 1 stated that the eggs used to make the egg salad during the power outage on September 15, 2015, were left over from breakfast on September 14, 2015. Cook 1 stated she did not check the egg temperatures when she removed the eggs from the walk-in refrigerator on September 15, 2015, before making the egg salad. She said it took her about 30 minutes to make the egg salad, which was made in a small metal bowl, and put on ice inside the walk-in refrigerator. Cook 1 stated she did not check the temperature of the egg salad until the tray line started, which was at 4:45 PM. She stated she did not check the temperature of the egg salad once she made the sandwiches. In the same interview, with Cook 1, she stated the mayonnaise used in the egg salad and tuna salad came from the walk-in refrigerator and she did not check the temperature of the mayonnaise. Cook 1 also stated that she did not receive any training regarding checking the temperature of the refrigerators or the PHF during a power outage that affected the refrigerators. During the continuing interview with Cook 1, on September 23, 2015, at 3:50 PM, she stated that she did not check the temperature of the walk-in refrigerator throughout the day. She stated that she didn't think about it. During an interview with the DSS, on September 23, 2015, at 3:35 PM, the DSS stated that on September 15, 2015, it did not cross her mind to instruct her staff to check the refrigerator temperatures or the temperature of the food served to the residents to ensure it was safe. The DSS stated the Dishwasher contacted her at 9:00 AM, and reported that the facility did not have power to run the dishwasher. The DSS stated she only instructed the Dishwasher to use paper plates for the regular lunch menu and that she did not think about the refrigerators. During a phone interview with the facility's Registered Dietician (RD), on September 24, 2015, at 10:18 AM, the RD stated that she was not made aware of the power outage problem until after the surveyors had identified unsafe food temperatures on tray line and in the refrigerators. The RD stated she was contacted by the DSS on September 15, 2015, between 5:30 to 6:30 PM, after the facility had served the dinner meal. During the same interview, the RD stated the guidance she provided to the DSS was to go in and evaluate the situation right away. The RD stated her expectations of the dietary staff during a disaster such as a power outage was that the staff should: a. Contacting the DSS b. Monitoring the refrigerator temperatures every hour depending on the situation c. Avoid opening the refrigerators as much as possible d. Use dry ice if needed e. Use the perishable food first and then the emergency supply food. The RD further stated that she had in-serviced the dietary staff on the Disaster Food Plan and Cook 1 was present at the in-service. A review of the facility in-service document titled Immediate Jeopardy Triggers #1, Handling of Environmental Hazards or Emergencies, dated March 26, 2015, noted a signature from Cook 1 indicating she had attended the in-service. The in-service materials did not provide guidance to the dietary staff on how to monitor the temperature of the refrigerators or the PHF in the event of a power outage that would affect the units. A review of the facility document titled, Disaster Menu, indicated, 3. In the event of an emergency . a. Notify the Dietician.

Based on interview and record review, the facility failed to ensure that: 1. All residents were protected from potential abuse while investigations regarding allegations of abuse were in progress for Resident C, 17, 18, 19, 20, 21, and 8. 2. All allegations of abuse were reported to the California Department of Public Health (CDPH) and the local Ombudsman (an organization that investigates reports of abuse or mistreatment). 3. The results of the investigations were reported to the California Department of Public Health (CDPH). The facility failed to ensure all (77) residents were protected from potential abuse while investigations regarding allegations of abuse were in progress for Resident C, 17, 18, 19, 20, 21, and 8. Because of the facility failure to take corrective actions to protect all residents while allegations of abuse were being investigated, and the failure to follow their policies and procedures (P/P) to ensure that all allegations of resident abuse or mistreatment were reported to the California Department of Public Health (CDPH), and Ombudsman, an Immediate Jeopardy was called on August 16, 2013, at 6:45 PM, with the Administrator and the Director of Nurses (DON). Findings: 1. A review of the facility "Abuse Report Log", on August 16, 2013, showed seven incidents of alleged abuse (Physical, Verbal, and Emotional) from February 2013 until July 2013. On August 19, 2013, during a review of the facility policy titled, "Abuse Allegations/ What to do when there is an abuse allegation" undated noted: "If accused is a staff member, they must be removed from patient care, questioned regarding the incident, and sent home." During a record review and interview on August 16, 2013, at 12:10 PM, with the Administrator/Abuse Coordinator, regarding the "Resident Abuse Investigation Report Form", the following was noted: Incident # 1 occurred in February 2013, and involved Certified Nursing Assistant (CNA 2) and Resident C, with an allegation of Staff to Resident Physical/ Verbal Abuse. The Administrator was asked, what happened to Resident C and CNA 2 during the investigation, the Administrator stated, "The involved staff was not assigned to care for that particular resident. The involved staff was reassigned to care for different residents on the other side of the building." Incident # 2 occurred in February 2013, and involved CNA 1 and Resident 17 with an allegation of Staff to Resident Physical Abuse. When asked what happened to Resident 17 and CNA 1 during the investigation, the Administrator stated, "The involved staff was reassigned to care for residents on the other side of the building and I assigned a different staff to care for the involved resident." Incident # 3 occurred in March 2013, and involved CNA 3 and Resident 18 with an allegation of Staff to Resident Physical Abuse. When asked what happened to Resident 18 and CNA 3 during the investigation, the Administrator stated, "I placed the staff involved on the other side of the building working with different residents. I assigned a different staff member to care for the involved resident." Incident # 4 occurred in March 2013, and involved CNA 4 and Resident 19 with an allegation of Staff to Resident Verbal Abuse. When asked what happened to Resident 19 and CNA 4 during the investigation, the Administrator stated, "I assigned the staff involved to another part of the building. The staff member and I had a conversation." Incident # 5 occurred in March 2013, and involved CNA 7 and Resident 20 with an allegation of Staff to Resident Verbal Abuse. When asked what happened to Resident 20 and CNA 7 during the investigation, the Administrator stated, "I removed the involved staff from the shower team and reassigned her to the floor." Incident # 6 occurred in May 2013, and involved CNA 1 and Resident 21 with an allegation of Staff to Resident Verbal Abuse. When asked what happened to Resident 21 and CNA 1 during the investigation, the Administrator stated, "The staff involved was reassigned to other residents and taken off that section (hallway)." Incident # 7 occurred in July 2013, and involved CNA 5 and CNA 6 and Resident 8 with an allegation of Staff to Resident Physical Abuse. During a record review of the Resident Abuse Investigation Report Form on August 16, 2013, the form noted: Resident 8 did not sustain any visable injuries. During an interview with the Administrator/Abuse Coordinator on August 16, 2013 at 6:35 PM, The Administrator stated: He did not remove accused staff from resident care areas and he did not suspend anyone. During an interview with the Administrator/Abuse Coordinator on August 16, 2013, at 6:00 PM, The Administrator was asked about protecting the residents during the investigations. The Administrator stated, "I identified that I didn't follow the policy of protecting the residents while the investigation was on going." 2. A review of the facility "Abuse Report Log", on August 16, 2013, showed seven incidents of alleged abuse (Physical, Verbal, and Emotional) from February 2013 until July 2013. The facility policies and procedures titled, "Reporting Abuse" revised September 2009, noted: "5. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will (not to exceed twenty-four hours of the alleged incident) notify the following person or agencies: a. The Department of Public Health b. The local Ombudsman .... " During a review of the facility's "Abuse Report Log", on August 16, 2013, it showed six of the six alleged allegations of abuse were not reported to CDPH and the Ombudsman Office. In a concurrent interview with the Administrator on August 16, 2013, at 11:30AM, the Administrator was asked, "If the six allegations of alleged abuse were reported to CDPH and the Ombudsman office?" The Administrator replied, "No, the incidents were not reported." During a record review on August 16, 2013, at 12:10 PM, with the Administrator/Abuse Coordinator regarding the "Resident Abuse Investigation Report Form" the following was noted, Incident # 2 occurred in February 2013, and involved Resident 17 and CNA 1 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 3 occurred in March 2013, and involved Resident 18 and CNA 3 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 4 occurred in March 2013, and involved Resident 19 and CNA 4 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 5 occurred in March 2013, and involved Resident 20 and CNA 7 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 6 occurred in May 2013, and involved Resident 21 and CNA 1 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 7 occurred in July 2013, and involved Resident 8 and CNA 5 and CNA 6 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." During an interview with the Administrator on August 16, 2013, at 4:00 PM, The Administrator was asked, "Why the facility did not report the alleged abuse incidents to the California Department of Public Health (CDPH)?" The Administrator replied, "I did not report the six allegations because I investigated them and felt they were not substantiated and I did not need to report them." The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" revised December 2006, noted: "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law." "1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following person(s) or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility. b. The local/ State Ombudsman." "3. The administrator, or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." 3. During a review of the facility policy on August 16, 2013, titled, "Abuse Investigations" revised December 2006, it noted: "15. Providing State Survey Agency with Copy of Results, the Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the ombudsman, the local police department and others as may be required by state or local laws, with in five (5) working days of the reported incident." Incident # 2 occurred in February 2013, and involved Resident 17 and CNA 1 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 3 occurred in March 2013, and involved Resident 18 and CNA 3 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 4 occurred in March 2013, and involved Resident 19 and CNA 4 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 5 occurred in March 2013, and involved Resident 20 and CNA 7 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 6 occurred in May 2013, and involved Resident 21 and CNA 1 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 7 occurred in July 2013 and involved Resident 8 and CNA 5 and CNA 6 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" revised December 2006, noted: "The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." Because of the facility's failure to ensure: 1. The residents were protected during the course of the abuse investigations, 2. The facility's abuse policies and procedures were followed, and 3. The allegations of resident abuse or mistreatment were reported to the proper authorities, an Immediate Jeopardy was called on August 16, 2013, at 6:45 PM, with the Administrator and the Director of Nurses. On August 16, 2013, at 11:25 PM the Administrator and the Director of Nurses presented a Corrective Action Plan (CAP) to the survey team. The CAP contained the following elements: a. Any staff accused of or participation in an allegation of abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been completed and resolved by the Administrator. b. The Administrator and DON will be in-serviced on the abuse policy specially regarding removing the accused from contact with all residents. The Registered Nurse Supervisors, and all department heads will be in-serviced on how to report allegations of abuse or suspected abuse. On August 16, 2013 at 11: 25 PM, the Immediate Jeopardy was abated (lifted) based on the implementation of the Corrective Action Plan (CAP) which included the above mentioned interventions.

Based on interview and record review the facility failed to ensure that they implemented their abuse policies and procedures related to the protection of residents and reporting allegations of abuse. The facility failed to ensure: 1. All residents were protected from potential abuse while investigations regarding allegations of abuse were in progress for Resident C, 17, 18, 19, 20, 21, and 8. 2. All allegations of abuse were reported to the California Department of Public Health (CDPH) and the local Ombudsman (an organization that investigates reports of abuse or mistreatment). 3. The results of the investigations were reported to the California Department of Public Health (CDPH). These failures had the potential to result in the appropriate State Agencies not being able to ensure that the facility was doing all that was within its control to protect residents and prevent the occurrence of abuse within the facility. Because of the facility's failure to follow their policies and procedures (P/P) to ensure that all allegations of resident abuse or mistreatment were reported to the California Department of Public Health (CDPH), and Ombudsman, and the failure to implement the policies to take corrective actions to protect all residents while allegations of abuse were being investigated an Immediate Jeopardy was called on August 16, 2013, at 6:45 PM, with the Administrator and the Director of Nurses (DON). Findings: 1. A review of the facility "Abuse Report Log", on August 16, 2013, showed seven incidents of alleged abuse (Physical, Verbal, and Emotional) from February 2013 until July 2013. On August 19, 2013, during a review of the facility policy titled, "Abuse Allegations/ What to do when there is an abuse allegation" undated noted: "If accused is a staff member, they must be removed from patient care, questioned regarding the incident, and sent home." During a record review and interview on August 16, 2013, at 12:10 PM, with the Administrator/Abuse Coordinator, regarding the "Resident Abuse Investigation Report Form", the following was noted: Incident # 1 occurred in February 2013, and involved Certified Nursing Assistant (CNA 2) and Resident C, with an allegation of Staff to Resident Physical/ Verbal Abuse. The Administrator was asked, what happened to Resident C and CNA 2 during the investigation, the Administrator stated, "The involved staff was not assigned to care for that particular resident. The involved staff was reassigned to care for different residents on the other side of the building." Incident # 2 occurred in February 2013, and involved CNA 1 and Resident 17 with an allegation of Staff to Resident Physical Abuse. When asked what happened to Resident 17 and CNA 1 during the investigation, the Administrator stated, "The involved staff was reassigned to care for residents on the other side of the building and I assigned a different staff to care for the involved resident." Incident # 3 occurred in March 2013, and involved CNA 3 and Resident 18 with an allegation of Staff to Resident Physical Abuse. When asked what happened to Resident 18 and CNA 3 during the investigation, the Administrator stated, "I placed the staff involved on the other side of the building working with different residents. I assigned a different staff member to care for the involved resident." Incident # 4 occurred in March 2013, and involved CNA 4 and Resident 19 with an allegation of Staff to Resident Verbal Abuse. When asked what happened to Resident 19 and CNA 4 during the investigation, the Administrator stated, "I assigned the staff involved to another part of the building. The staff member and I had a conversation." Incident # 5 occurred in March 2013, and involved CNA 7 and Resident 20 with an allegation of Staff to Resident Verbal Abuse. When asked what happened to Resident 20 and CNA 7 during the investigation, the Administrator stated, "I removed the involved staff from the shower team and reassigned her to the floor." Incident # 6 occurred in May 2013, and involved CNA 1 and Resident 21 with an allegation of Staff to Resident Verbal Abuse. When asked what happened to Resident 21 and CNA 1 during the investigation, the Administrator stated, "The staff involved was reassigned to other residents and taken off that section (hallway)." Incident # 7 occurred in July 2013, and involved CNA 5 and CNA 6 and Resident 8 with an allegation of Staff to Resident Physical Abuse. During a record review of thr Resident Abuse Investigation Report Form on August 16, 2013, the form noted: Resident 8 did not sustain any visable injuries. During an interview with the Administrator/Abuse Coordinator on August 16, 2013, at 6:35 PM, The Administrator stated: He did not remove any anyone from resident care areas and he did not suspend anyone. During an interview with the Administrator/Abuse Coordinator on August 16, 2013, at 6PM, the Administrator was asked about protecting the residents during the investigations. The Administrator stated: "I identified that I didn't follow the policy of protecting the residents while the investigation was on going." 2. A review of the facility "Abuse Report Log", on August 16, 2013, showed seven incidents of alleged abuse (Physical, Verbal, and Emotional) from February 2013 until July 2013. The facility policies and procedures titled, "Reporting Abuse" revised September 2009, noted: "5 . When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will (not to exceed twenty-four hours of the alleged incident) notify the following person or agencies: a. The Department of Public Health b. The local Ombudsman ...." The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" revised December 2006, noted: "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law." "1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following person(s) or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility. b. The local/ State Ombudsman" "3. The administrator, or his/her designee will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." During a record review on August 16, 2013, the "Abuse Report Log", Six of the seven alleged allegations of abuse were not reported to CDPH and the Ombudsman Office. In a concurrent interview with the Administrator on August 16, 2013, at 11:30 AM, the Administrator was asked, "If the six allegations of alleged abuse were reported to CDPH and the Ombudsman office?" The Administrator replied, "No, the incidents were not reported." During a record review on August 16, 2013, at 12:10 PM, with the Administrator/Abuse Coordinator regarding the "Resident Abuse Investigation Report Form" the following was noted, Incident # 2 occurred in February 2013, and involved Resident 17 and CNA 1 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 3 occurred in March 2013, and involved Resident 18 and CNA 3 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 4 occurred in March 2013, and involved Resident 19 and CNA 4 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 5 occurred in March 2013, and involved Resident 20 and CNA 7 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 6 occurred in May 2013, and involved Resident 21 and CNA 1 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 7 occurred in July 2013, and involved Resident 8 and CNA 5 and CNA 6 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the alleged allegations to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." During an interview with the Administrator on August 16, 2013, at 4:00 PM, The Administrator was asked: "Why the facility did not report the alleged abuse incidents to the California Department of Public Health (CDPH)?" The Administrator replied, "I did not report the six allegations because I investigated them and felt they were not substantiated and I did not need to report them." During an interview with the Administrator on August 16, 2013, at 6:00 PM, The Administrator verified he did not implement the facility's policy and procedure in regards to reporting allegations of abuse to CDPH and the Ombudsman. The Administrator verified he should have implemented the facility's policies and procedures. 3. During a review of the facility policy titled, "Abuse Investigations" revised December 2006, noted: "15. Providing State Survey Agency with Copy of Results, the Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the ombudsman, the local police department and others as may be required by state or local laws, with in five (5) working days of the reported incident." The facility policy and procedure titled "Reporting Abuse to State Agencies and Other Entities/Individuals" revised December 2006, noted: "The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident." Incident # 2 occurred in February 2013, and involved Resident 17 and CNA 1 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 3 occurred in March 2013, and involved Resident 18 and CNA 3 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or the Ombudsman?" The Administrator answered, "No." Incident # 4 occurred in March 2013, and involved Resident 19 and CNA 4 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 5 occurred in March 2013, and involved Resident 20 and CNA 7 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 6 occurred in May 2013, and involved Resident 21 and CNA 1 with an allegation of Staff to Resident Verbal Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Incident # 7 occurred in July 2013, and involved Resident 8 and CNA 5 and CNA 6 with an allegation of Staff to Resident Physical Abuse. The Administrator was asked, "Did the facility report the results of the abuse investigation to the California Department of Public Health or Ombudsman?" The Administrator answered, "No." Because of the facility's failure to ensure the residents were protected during the course of the abuse investigation, failure to follow the facility's abuse policies and procedures, and to ensure that allegations of resident abuse or mistreatment were reported to the proper authorities, an Immediate Jeopardy was called on August 16, 2013, at 6:45 PM, with the Administrator and the Director of Nurses. On August 16, 2013, at 11:25 PM the Administrator and the Director of Nurses presented a Corrective Action Plan (CAP) to the survey team. The CAP contained the following elements: a. Any staff accused of or participation in an allegation of abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been completed and resolved by the Administrator. b. The Administrator and DON will be in-serviced on the abuse policy specially regarding removing the accused from contact with all residents. The Registered Nurse Supervisors, and all department heads will be in-serviced on how to report allegations of abuse or suspected abuse. On August 16, 2013, at 11: 25 PM, the Immediate Jeopardy was abated (lifted) based on the implementation of the Corrective Action Plan which included the above mentioned interventions.

Based on interview and record review, the facility failed to ensure that all alleged violations are reported to the facility Administrator, failed to conduct an investigation of all alleged violations, and failed to report the results to the proper authorities including CDPH ( California Department of Public Health) and the local Ombudsman (an organization that investigates reports of abuse or mistreatment) for 2 of 15 sampled residents (Residents 10 and 8). 1. For Resident 10, the Social Services Designee (SSD), the Director of Nursing (DON) and the Director of Staff Development (DSD) failed to immediately report allegations of mistreatment and rough handling by CNA 3 to the facility Administrator after they became aware of the allegations and failed to protect the resident when the allegations were reported. The facility further failed to investigate the allegations of mistreatment and rough handling, and to report the allegations to CDPH and the local Ombudsman. 2. For Resident 8, the Administrator failed to thoroughly investigate an injury of unknown origin, a leg fracture (broken) when it was diagnosed on [DATE], and failed to report the injury to CDPH. These failures resulted in Resident 10 experiencing fearfulness over his care and prevented the State Agency (CDPH) from ensuring that the facility was taking the appropriate steps to protect the residents and investigate the allegation. These failures also had the potential to put Resident 8 at risk for abuse and further injury and had the potential for a universe of 73 residents of the facility to have alleged violations of abuse or mistreatment go unreported and not be thoroughly investigated. Because of the facility's failure to ensure that allegations of resident abuse or mistreatment were investigated and reported, and because Resident 10 was not protected when the allegation of rough handling and mistreatment was reported to facility staff, Immediate Jeopardy was called on 10/18/12 at 3:20 PM, with the Administrator and the DON. Findings: 1. On 10/17/12, at approximately 2:30 PM, during the resident group interview, Resident 10's family member stated that Resident 10 had told her he was afraid of a "shower lady" (CNA 3) and he told her that CNA 3 had been "rough" with him. Resident 10's family member went on to say that one day last week, she had spoken to CNA 3 when she observed CNA 3 being too rough with Resident 10 and after he told her he was afraid of CNA 3. Resident 10's family member stated that on this particular day last week, she witnessed Resident 10 asking CNA 3 for her name and she stated, "{Residents Name}You know my name. I have told you three times." Resident 10's family member also stated that she reported the incident to the SSD on the day of the incident and was told by the SSD that she would talk to CNA 3. During continued interview with Resident 10's family member, she said the next day she approached the SSD to ask about the follow up to her complaints about CNA 3's treatment of [REDACTED].{Residents Name.}" Resident 10's family member said that she did not inform the DON or the Administrator of the incident. She further stated that she and Resident 10 were afraid to report complaints for fear of making the staff upset and being transferred to another facility when Resident 10 does not want to leave the facility. On 10/17/12, at 3:40 PM, during a private interview with Resident 10's family member, she requested that the details of her interview regarding her concerns of mistreatment not be mentioned or shared with the staff of the facility for fear of retaliation by the facility. Resident 10's family member stated that she would have to think about allowing her concerns to be shared after discussing it with another family member. On 10/17/12, at 3:20 PM, during an interview with the SSD, she stated that anyone who has knowledge of abuse should start an investigation into the allegations. The SSD reported that examples of allegations of abuse that would require an investigation included reports of physical, sexual, verbal or fiduciary (money stolen) abuse. During further interview with the SSD, on 10/17/12, at 3:20 PM, she stated, "I would report allegations of abuse when I determined it was abuse." When the SSD was asked if reports of mistreatment or rough handling were investigated and reported, the SSD paused for a few seconds, and then asked, "Am I supposed to investigate all complaints and reports of mistreatment?" During further interview, the SSD was unable to state what the facility policy and procedure indicated regarding reporting allegations of abuse. The SSD stated, "I would report a valid complaint." The SSD was unable to state how she could determine if an allegation of mistreatment was valid if the allegation was not investigated. On 10/18/12, between 11:45 AM and 12:05 PM, during an interview with Resident 10's family member, in Resident 10's room, she stated that she had discussed her concerns with another family member and would permit her concerns to be shared and discussed with the facility staff. On further interview with Resident 10's family member, she stated that Resident 10 had told her that he was afraid of a "tall, shower lady." The family member stated that she knew who he meant because there were only a few staff who showered Resident 10. The resident's family member continued to share details of her observations of CNA 3's interaction with Resident 10, approximately one week ago, in which she reported to the SSD, as "rough, too hard for him and overall, mean." On 10/18/12, at 12:10 PM, during an interview with Resident 10, when asked if he remembered an incident regarding CNA 3, he took several seconds to respond and then stated, "Yes, I'm afraid of her." Resident 10 would not state why he was afraid of CNA 3, but continued to say repeatedly, "I'm afraid of her, I'm happy here, I'm happy here. I don't want to move." On 10/19/12, a review of the clinical record for Resident 10 indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record showed that Resident 10's Minimum Data Set (MDS- a comprehensive assessment of the resident), dated 7/6/12, indicated Resident 10 was able to understand others. On 10/18/12, at 12:15 PM, during an interview with the Administrator, the Abuse Coordinator for the facility, he said that the facility had not reported any allegations of abuse and to his knowledge he was unaware that there had been any allegations of abuse. The Administrator said that he was unaware of any allegations of mistreatment regarding Resident 10. The Administrator further stated that reports of rough handling and mistreatment of [REDACTED]. On 10/18/12, at 12:15 PM, during further interview with the Administrator, he said that either he or the DON would be responsible to investigate allegations of abuse or mistreatment. The Administrator further stated that if staff have information of allegations of abuse or mistreatment they should complete an incident or communication form regarding the concerns and give it to him for follow up. On further interview with the Administrator he stated, "There has been no abuse, I am sure of it. I cannot validate that because I have not investigated any allegations. Am I expected to investigate skin tears as well?" On 10/18/12, between 12:40 PM and 1:10 PM, during an interview with the SSD, in the DON's office, when asked if Resident 10's family member had reported to her any allegations of mistreatment by CNA 3 during Resident 10's care, the SSD stated, "I did not investigate the allegation. {Residents name} family member makes complaints all the time. I have set up a care conference with the family members for next week." The SSD went on to say that Resident 10's family member had made many complaints regarding staff treatment of [REDACTED].?" On 10/18/12, at 1:10 PM, during an interview with the DON in her office, in the presence of the SSD, she said that all allegations of abuse or mistreatment should be investigated. The DON stated that the SSD had made her aware of the incident regarding CNA 3 and Resident 10 approximately one week ago and said she did not investigate it or report it to the Administrator. On further interview with the DON, on 10/18/12, at 1:10 PM, she stated that Resident 10's family member makes allegations or complaints regarding staff treatment of [REDACTED]. The DON was unable to say how many allegations or complaints that she was aware of, however she did say that Resident 10's family members' complaints were ongoing. The DON said she had not completed an incident or communication form, nor had she informed the Administrator of any specific allegation of mistreatment made by Resident 10's family member. When the DON was asked if she had made a report regarding the incident with CNA 3 and Resident 10 approximately one week ago or any other allegations made regarding Resident 10's mistreatment to CDPH or to the Ombudsman, she did not answer. During an interview with the SSD on 10/18/12, between 1:10 PM and 1:15 PM, she stated that the Director of Staff Development (DSD) may have some evidence of investigations regarding the complaints or allegations made by Resident 10's family member. On 10/18/12, at 1:15 PM, during an interview with the DSD, she stated that she was aware of Resident 10's family members reports and allegations of CNA 3's rough handling or mistreatment of [REDACTED]. The DSD further stated that Resident 10's family member makes allegations or complaints all the time. On further interview with the DSD, on 10/18/12, at 1:15 PM, she stated that she had talked to CNA 3 regarding Resident 10's family members reports of mistreatment. The DSD presented a letter from CNA 3, dated 10/11/12, for review. The letter included details of the incident according to CNA 3's perspective regarding Resident 10's alleged mistreatment. On further interview with the DSD, when asked if there were any other documents to review regarding an investigation of the incident with CNA 3 and Resident 10 approximately one week ago, or if there were any interviews with Resident 10, the family member who made the allegation, or other staff or residents, the DSD stated, "The letter is not part of an investigation. We had the CNA write the letter to protect ourselves." The DSD further stated that she had not removed CNA 3 from the schedule after becoming aware of the allegations made by Resident 10's family member regarding complaints of mistreatment by CNA 3. The DSD further stated that she did not report the incident to the Administrator, nor did she report the allegation of mistreatment to CDPH or the Ombudsman. A twelve page document titled "Abuse Prevention Program" dated August 2009, was presented for review by the Administrator, on 10/15/12. On 10/18/12, a review of the facility policy and procedure titled "Reporting Abuse" revised August 2009, indicated "It is the responsibility of our employees, facility consultants, Attending Physicians, family member, visitors, et., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management." Section 2 ,"Retribution for Reporting Abuse" indicated "All personnel, resident, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff." Section 4 indicated, "The Administrator must be immediately notified of suspected abuse or incidents of abuse. "Section 5 indicated "When an alleged of suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will notify the following persons, or agencies of such incident: a. The Department of Public Health and b. The local Ombudsman..." On 10/18/12, a review of the facility policy and procedure titled "Abuse Investigations" revised July 2007, indicated, "Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator or his/her designee, will appoint a member of management to investigate the alleged incident. Section 3 indicated, "The individual conducting the investigation should, as a minimum: ...c. Interview the persons(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. Interview other residents to whom the accused employee provides care or services." Because of the facility's failure to follow the abuse policies and procedures and to ensure that allegations of resident abuse or mistreatment were investigated and reported, and that residents were protected during the course an investigation, Immediate Jeopardy was called on 10/18/12 at 3:20 PM with the Administrator and the Director of Nursing. On 10/18/12, at 6:50 PM, the Administrator presented a plan of corrective action to the survey team. The plan of correction consisted of the following elements: (1) The staff involved with the allegation (CNA 3) shall not be assigned to provide any care to any resident pending completion of the investigation. (2) All alert and oriented residents in the building will be interviewed to determine if there are any resident concerns or allegations of abuse that have not been reported or investigated. All residents will be notified on how to address and report concerns or allegations in the future without any fear of backlash. All staff will be in-serviced on abuse policies and reporting procedures, specifically identifying that all allegations or suspicions must be reported regardless of perceived severity or merit. In the future, all allegations of abuse, suspicions of abuse, neglect, or injuries of unknown origin will be reported to the (long term care) LTC Ombudsman, the California Department of Public Health (CDPH), law enforcement if necessary, and the responsible party regardless of the investigation findings. (3) All staff will receive training on abuse and abuse reporting immediately. The training will include examples of suspected abuse, neglect, and injuries of unknown origin. During the year Linda Valley Care Center (LVCC) will require all employees to participate in an additional supplementary in-service annually on abuse and abuse reporting. During the morning stand-up meeting, the DON or Administrator will inquire about any new allegations or suspicions of abuse in addition to the normal reporting process. The DON and Administrator's cell phone numbers will be posted at the nurses' station to allow staff to more easily report when they are not in the building. The notice will include directions that all allegations of abuse, neglect, or injuries of unknown origin must be reported to the DON/Administrator immediately. (4) All abuse incidents will be tracked in the daily stand-up meeting weekly for 2 months and monthly for 3 additional months. The Activities Director will be required to ask the resident council on a monthly basis if any residents have any concerns or allegations that have not been reported or addressed properly. The results from the resident council shall be reported to the abuse coordinator (Administrator). The Administrator will be the person responsible for monitoring the abuse program. A report will be given to the quarterly QA (quality assurance) committee meeting to discuss the number of allegations and incidents of abuse in the previous quarter. The report shall include the findings from the resident council and the committee will be refreshed on the abuse policy and abuse reporting procedures. On 10/19/12, at 4:15 PM, the survey team met with the Administrator regarding the facility's implementation of corrective measures to immediately remove the risk and prevention of repeated Immediate Jeopardy situations. Evidence of the facility's implemented corrective measures to have a system in place to ensure that allegations of resident abuse or mistreatment were investigated and reported, and residents are protected during the course of the investigation, was reviewed. The survey team informed the Administrator that the Immediate Jeopardy for investigating and reporting allegations of resident abuse and protecting residents during the course of the investigation was abated. 2. On 10/15/12, during the initial tour of the facility, accompanied by the MDS Nurse, Resident 8 was observed lying in bed with a cast on her lower right leg. On 10/16/12, a review of Resident 8's medical record revealed that she was admitted originally on 5/25/12, with [DIAGNOSES REDACTED]. Review of Resident 8's current MDS dated [DATE], showed that she had clear speech, was able to make herself understood and was able to understand others. Resident 8's history and physical dated 5/26/12, revealed that she was not her own responsible party. Review of Resident 8's nurse's notes showed an entry dated 8/30/12 at 11:05 PM, by Licensed Vocational Nurse 2, that she (LVN 2) went to assess Resident 8 after Certified Nursing Assistant 2 (CNA 2) reported Resident 8 had a "swollen right knee/leg." LVN 2's documentation revealed that Resident 8 replied, "No" after being asked if she had fallen, and that she was administered [MEDICATION NAME] (narcotic pain medication) for 8/10 pain to her right leg. During an interview with LVN 2 on 10/18/12 at 6:15 PM, she stated that at approximately 10:15 PM on 8/30/12 the CNA caring for Resident 8 that evening came and notified her that Resident 8's right knee/leg was swollen and that Resident 8 was complaining of pain. LVN 2 stated that upon interview with Resident 8 she denied falling and was unable to state how her knee/leg pain and swelling had occurred. Review of Resident 8's nurses' notes noted the following entries: 8/31/12 at 7:56 AM -- The Director of Nursing (DON) notified the physician of Resident 8's leg, and an X-ray was ordered for, "... the R (right) leg-stat (immediately) for pain and swelling." 8/31/12 at 8:00 AM--The DON documented, "...resd. (resident), alert, oriented x 2 with episodes of confusion, and episodes disoriented at times, verbalized needs known, resd. Denies any fall or incident noted, resd. stated 'I noticed my leg like that when my sister in law, my brother and my cousin visited me and before they had left they hug me and they wont let me go.' Spoke to staff on duty no reported fall or injury..." 8/31/12 at 11:21 AM--the Director of Staff Development (DSD) documented "Dr. notified of X-ray result...send resident to (name of hospital) emergency room for ortho eval (evaluation) and treatment-...fracture of right tibia and fibula (the two bones of the lower portion of the leg). On 10/17/12 Resident 8's X-ray report dated 8/31/12, revealed, "...There were comminuted fractures (breaks) of the proximal shafts of the right tibia and fibula..." During an interview with the facility Administrator on 10/16/12 at 11:35 AM, he confirmed that he was the facility's Abuse Coordinator. He further stated that Resident 8's fractured right leg was not reported to the Ombudsman (an organization that investigates reports of abuse or mistreatment) or the California Department of Public Health (CDPH). He stated that he had conducted an investigation regarding Resident 8's fractured leg, which included the physician's documentation, and concluded it was due to her "severe [MEDICAL CONDITION]." On 10/16/12 and 10/17/12, a document titled, "Resident Abuse Investigation Report Form" dated 8/31/12, and signed by the Administrator was reviewed. The form indicated that on 8/30/12, (no time documented) CNA 2 and LVN 2 reported the incident of pain and swelling to Resident 8's leg. Under the section, "Did the medical record review indicate any previous or unexplained injuries?," documentation hand written by the Administrator showed, "Yes Resident has history of frailty and [MEDICAL CONDITION] X-ray analysis shows the break was due to a pathological fracture and not trauma." Further review of the "Resident Abuse Investigation Report Form" dated 8/31/12, showed that the Administrator had interviewed Resident 8, two CNAs, one from the day shift and one from the evening shift, and the evening LVN (LVN 2) whom had provided care for Resident 8 on 8/30/12, the day Resident 8 was reported to have a "swollen right knee/leg." The final section of the document titled, "Result of findings and corrective action taken reported to:" revealed the portion titled, "Ombudsman" and "State Licensing Agency" (CDPH) were left blank and unchecked, which indicated there was no notification to the Ombudsman nor the State Licensing Agency (CDPH). Documentation by the Administrator further showed, " No abuse suspected. " During an interview with the Administrator on 10/17/12 at 3:00 PM, he stated that he had interviewed "Everyone" and that he was, "One hundred percent sure it was not abuse." On further interview with the Administrator, he stated that he had not interviewed Resident 8's roommate, Resident A, at the time Resident 8's right knee/leg was reported with pain and swelling. The Administrator confirmed that Resident A should have been interviewed and included in the investigation. During an interview on 10/15/12 at approximately 2:35 PM, with the MDS Nurse, she stated that Resident A was alert with periods of confusion and was usually interviewable. On 10/17/12, during a review of Resident A's current MDS (provided by the MDS Nurse), dated 7/25/12, it showed that Resident A had clear speech, was able to make herself understood and to understand others. The "cognitive pattern" section of the MDS dated [DATE], showed that Resident A scored 15 out of 15 (the highest possible score), which indicated perfect cognition. The MDS revealed that she was her own responsible party. During an interview with Resident A, Resident 8's roommate, on 10/17/12 at 4:48 PM, she stated that she did not know how Resident 8's leg was fractured, and denied ever witnessing any abuse. On 10/18/12 a review of the facility policy and procedure titled, "Abuse Investigations," revised July 2007, revealed that all reports of resident injuries of unknown source shall be thoroughly investigated. The person conducting the investigation should at a minimum,..."Interview the resident's roommate..." and ..."notify the ombudsman that an abuse investigation is being conducted..." The policy further indicated,..."The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the Department of Public Health..."

Based on interview and record review, the facility failed to follow their abuse policy and procedure for 2 of 15 sampled residents (Residents 8 and 10). For Resident 10, the facility failed to investigate allegations of rough handling and mistreatment by facility staff, to protect the resident after the allegation was made and failed to report the allegations of mistreatment to the California Department of Public Health (CDPH) and the local Ombudsman (an organization that investigates reports of abuse or mistreatment). For Resident 8, the facility failed to thoroughly investigate an injury of unknown origin, a leg fracture (broken leg) when it was diagnosed on [DATE], and failed to report the injury to CDPH. These failures resulted in Resident 10 experiencing fearfulness over his care and prevented the State Agency (CDPH) from ensuring that the facility was taking the appropriate steps to protect the resident and investigate the allegation. These failures also had the potential to put Resident 8 at risk for abuse and further injury and had the potential for a universe of 73 residents of the facility to have alleged violations of abuse or mistreatment go unreported and not be thoroughly investigated. Because of the facility's failure to follow their policies and procedures (P/P's) to ensure that allegations of resident abuse or mistreatment were investigated and reported, and the facility failed to protect Resident 10 when the allegation of rough handling and mistreatment was reported to facility staff, Immediate Jeopardy was called on 10/18/12 at 3:20 PM with the Administrator and the Director of Nursing (DON). Findings: 1. On 10/17/12, at approximately 2:30 PM, during the resident group interview, Resident 10's family member stated that Resident 10 had told her that he was afraid of a "shower lady" (CNA 3) and he told her that CNA 3 had been "rough" with him. Resident 10's family member went on to say that one day last week, she had spoken to CNA 3 when she observed CNA 3 being too rough with Resident 10 and after he told her he was afraid of CNA 3. Resident 10's family member stated that on this particular day last week, she witnessed Resident 10 asking CNA 3 for her name and she stated, "{Residents Name}You know my name I've told you three times." Resident 10's family member also stated that she reported the incident to the Social Services Designee (SSD) on the day of the incident and was told by the SSD that she would talk to CNA 3. During continued interview with Resident 10's family member, she said the next day she approached the SSD to ask about the follow up to her complaints about CNA 3's treatment of [REDACTED]." Resident 10's family member said that she did not inform the DON or the Administrator of the incident. She further stated that she and Resident 10 were afraid to report complaints for fear of making the staff upset and being transferred to another facility when Resident 10 does not want to leave the facility. On 10/17/12, at 3:40 PM, during a private interview with Resident 10's family member, she requested that the details of her interview regarding her concerns of mistreatment not be mentioned or shared with the staff of the facility for fear of retaliation by the facility. Resident 10's family member stated that she would have to think about allowing her concerns to be shared after discussing it with another family member. On 10/17/12, at 3:20 PM, during an interview with the SSD, she stated that anyone who has knowledge of abuse should start an investigation into the allegations. The SSD reported that examples of allegations of abuse that would require an investigation included reports of physical, sexual, verbal or fiduciary (money stolen) abuse. During further interview with the SSD, on 10/17/12, at 3:20 PM, she stated, "I would report allegations of abuse when I determined it was abuse." When the SSD was asked if reports of mistreatment or rough handling were investigated and reported, the SSD paused for a few seconds, and then asked, "Am I supposed to investigate all complaints and reports of mistreatment?" During further interview, the SSD was unable to state what the facility policy and procedure indicated regarding reporting allegations of abuse. The SSD stated, "I would report a valid complaint." The SSD was unable to state how she could determine if an allegation or complaint was valid if the allegation was not investigated. On 10/18/12, between 11:45 AM and 12:05 PM, during an interview with Resident 10's family member, in Resident 10's room, she stated that she had discussed her concerns with another family member and would permit her concerns to be shared and discussed with the facility staff. On further interview with Resident 10's family member, she stated Resident 10 had told her that he was afraid of a "tall, shower lady." The family member stated that she knew who he meant because there were only a few staff who showered Resident 10. The resident's family member continued to share details of her observations of CNA 3's interaction with Resident 10, approximately one week ago, in which she reported to the SSD, as "rough, too hard for him and overall mean." On 10/18/12, at 12:10 PM, during an interview with Resident 10, when asked if he remembered an incident regarding CNA 3, he took several seconds to respond and then stated, "Yes, I'm afraid of her." Resident 10 would not state why he was afraid of CNA 3, but continued to say repeatedly, "I'm afraid of her. I'm happy here. I'm happy here, I don't want to move." On 10/19/12, a review of the clinical record for Resident 10 indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record showed that Resident 10's Minimum Data Set (MDS-a comprehensive assessment of the resident), dated 7/6/12, indicated that Resident 10 was able to understand others. On 10/18/12, at 12:15 PM, during an interview with the Administrator, the Abuse Coordinator for the facility, he said that the facility had not reported any allegations of abuse and to his knowledge he was unaware that there had been any allegations of abuse. The Administrator said that he was unaware of any allegations of mistreatment regarding Resident 10. The Administrator further said reports of rough handling and mistreatment of [REDACTED]. On 10/18/12, at 12:15 PM, during further interview with the Administrator, he said that either he or the DON would be responsible to investigate allegations of abuse or mistreatment. The Administrator went on to say that if staff have information of allegations of abuse or mistreatment they should complete an incident or communication form regarding the concerns and give it to him for follow up. On further interview with the Administrator he stated, "There has been no abuse, I am sure of it. I cannot validate that because I have not investigated any allegations. Am I expected to investigate skin tears as well?" On 10/18/12, between 12:40 PM and 1:10 PM, during an interview with the SSD, in the DON's office, when asked about Resident 10's family member's concerns regarding his mistreatment by CNA 3, she stated, "I did not investigate the allegation. {Resident's name} family member makes complaints all the time. I have set up a care conference with the family members for next week." The SSD further stated that Resident 10's family member had made many complaints regarding staff treatment of [REDACTED].?" On 10/18/12, at 1:10 PM, during an interview with the DON in her office, in the presence of the SSD, she said that all allegations of abuse or mistreatment should be investigated. The DON stated that the SSD had made her aware of the incident regarding CNA 3 and Resident 10 approximately one week ago and said she did not investigate it, or report it to the Administrator. On further interview the DON, stated that Resident 10's family member makes allegations or complaints regarding staff treatment of [REDACTED]. The DON was unable to say how many allegations or complaints that she was aware of, however, she did say that Resident 10's family member's complaints were ongoing. The DON said that she did not complete an incident or communication form, nor had she informed the Administrator of any specific allegation of mistreatment made by Resident 10's family member. When the DON was asked if she made a report regarding the incident with CNA 3 and Resident 10 approximately one week ago, or any other allegations made regarding Resident 10's mistreatment to CDPH or to the Ombudsman, she did not answer. During an interview with the SSD between 1:10 PM and 1:15 PM, she stated that the Director of Staff Development (DSD) may have have some evidence regarding the complaints or allegations made by Resident 10's family member. On 10/18/12, at 1:15 PM, during an interview and with the DSD, she stated that she was aware of Resident 10's family members reports and allegations of CNA 3's rough handling or mistreatment of [REDACTED]. The DSD further stated that Resident 10's family member makes allegations or complaints all the time. On further interview with the DSD on 10/18/12, at 1:15 PM, she stated that she had talked to CNA 3 regarding Resident 10's family members reports of mistreatment. The DSD presented a letter from CNA 3 dated 10/11/12. The letter included details of the incident according to CNA 3's perspective regarding Resident 10's alleged mistreatment. On further interview with the DSD, when asked if there was any documentation regarding an investigation of the incident with CNA 3 and Resident 10 approximately one week ago, or if there were any interviews with Resident 10, the family member who made the allegation, other staff or residents, the DSD stated, "The letter is not part of an investigation. We had the CNA write the letter to protect ourselves." The DSD further stated that she had not removed CNA 3 after becoming aware of the allegations made by Resident 10's family member regarding complaints of mistreatment by CNA 3. The DSD further stated that she did not inform the Administrator, nor did she report the allegation to the CDPH or the Ombudsman. A twelve page document titled "Abuse Prevention Program" dated August 2009, was presented for review by the Administrator, on 10/15/12. On 10/18/12, a review of the facility policy and procedure titled "Reporting Abuse" revised August 2009, indicated "It is the responsibility of our employees, facility consultants, Attending Physicians, family member, visitors, et., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management." Section 2 ,"Retribution for Reporting Abuse" indicated "All personnel, resident, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff." Section 4 indicated, "The Administrator must be immediately notified of suspected abuse or incidents of abuse. "Section 5 indicated, "When an alleged of suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will notify the following persons, or agencies of such incident: a. The Department of Public Health and b. The local Ombudsman...." On 10/18/12, a review of the facility policy and procedure titled "Abuse Investigations" revised July 2007, indicated, "Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator or his/her designee, will appoint a member of management to investigate the alleged incident." Section 3 indicated, "The individual conducting the investigation should, as a minimum: ...c. Interview the persons(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. Interview other residents to whom the accused employee provides care or services." Because of the facility's failure to follow the abuse policies and procedures and to ensure that allegations of resident abuse or mistreatment were investigated and reported, and that residents were protected during the course an investigation, Immediate Jeopardy was called on 10/18/12 at 3:20 PM with the Administrator and the Director of Nursing. On 10/18/12 at 6:50 PM, the Administrator presented a plan of corrective action to the survey team. The plan of correction consisted of the following elements: (1) The staff involved with the allegation (CNA 3) shall not be assigned to provide any care to any resident pending completion of the investigation. (2) All alert and oriented residents in the building will be interviewed to determine if there are any resident concerns, or allegations of abuse that have not been reported or investigated. All residents will be notified on how to address and report concerns or allegations in the future without any fear of backlash. All staff will be in-serviced on abuse policies and reporting procedures, specifically identifying that all allegations or suspicions must be reported regardless of perceived severity or merit. In the future, all allegations of abuse, suspicions of abuse, neglect, or injuries of unknown origin will be reported to the (long term care) LTC Ombudsman, The California Department of Public Health (CDPH), law enforcement if necessary, and the responsible party regardless of the investigation findings. (3) All staff will receive training on abuse and abuse reporting immediately. The training will include examples of suspected abuse, neglect, and injuries of unknown origin. During the year Linda Valley Care Center (LVCC) will require all employees to participate in an additional supplementary in-service annually on abuse and abuse reporting. During the morning stand-up meeting, the DON or Administrator will inquire about any new allegations or suspicions of abuse in addition to the normal reporting process. The DON and Administrator's cell phone numbers will be posted at the nurses' station to allow staff to more easily report when they are not in the building. The notice will include directions that all allegations of abuse, neglect, or injuries of unknown origin must be reported to the DON/Administrator immediately. (4) All abuse incidents will be tracked in the daily stand-up meeting weekly for 2 months and monthly for 3 additional months. The Activities Director will be required to ask the resident council on a monthly basis if any residents have any concerns or allegations that have not been reported or addressed properly. The results from the resident council shall be reported to the abuse coordinator (Administrator). The Administrator will be the person responsible for monitoring the abuse program. A report will be given to the quarterly QA (quality assurance) committee meeting to discuss the number of allegations and incidents of abuse in the previous quarter. The report shall include the findings from the resident council and the committee will be refreshed on the abuse policy and abuse reporting procedures. On 10/19/12, at 4:15 PM, the survey team met with the Administrator regarding the facility's implementation of corrective measures to immediately remove the risk and ensure prevention of repeated Immediate Jeopardy situations. Evidence of the facility's implemented corrective measures to have a system in place to ensure that allegations of resident abuse or mistreatment were investigated and reported, and residents are protected during the course of the investigation, was reviewed. The survey team informed the Administrator that the Immediate Jeopardy for investigating and reporting allegations of resident abuse and protecting residents during the course of the investigation was abated. 2. On 10/15/12, during initial tour of the facility, accompanied by the MDS Nurse, Resident 8 was observed lying in bed with a cast on her lower right leg. On 10/16/12, a review of Resident 8's medical record revealed she was admitted originally on 5/25/12, with the [DIAGNOSES REDACTED]. Review of Resident 8's current MDS dated [DATE], showed that she had clear speech, was able to make herself understood and to understand others. Resident 8's history and physical dated 5/26/12, revealed she was not her own responsible party. Review of Resident 8's nurse's notes showed an entry dated 8/30/12 at 11:05 PM, by Licensed Vocational Nurse 2, that she (LVN 2) went to assess Resident 8 after Certified Nursing Assistant 2 (CNA 2) reported Resident 8 had a "swollen right knee/leg." LVN 2's documentation revealed that Resident 8 replied "No," after being asked if she had fallen, and that she was administered [MEDICATION NAME] (narcotic pain medication) for 8/10 pain to her right leg. During an interview with LVN 2 on 10/18/12 at 6:15 PM, she stated that at approximately 10:15 PM on 8/30/12 the CNA caring for Resident 8 that evening came and notified her that Resident 8's right knee/leg was swollen and that Resident 8 was complaining of pain. LVN 2 stated that upon interview with Resident 8 she denied falling and was unable to state how her knee/leg pain and swelling had occurred. Review of Resident 8's nurses' notes showed the following entries: 8/31/12 at 7:56 AM -- The Director of Nursing (DON) notified the physician of Resident 8's leg, and an X-ray was ordered for, "... the R (right) leg-stat (immediately) for pain and swelling." 8/31/12 at 8:00 AM--The DON documented, "...resd. (resident), alert, oriented x 2 with episodes of confusion, and episodes disoriented at times, verbalized needs known, resd. Denies any fall or incident noted, resd. stated 'I noticed my leg like that when my sister in law, my brother and my cousin visited me and before they had left they hug me and they wont let me go.' Spoke to staff on duty no reported fall or injury..." 8/31/12 at 11:21 AM--the Director of Staff Development (DSD) documented "Dr. notified of X-ray result...send resident to (name of hospital) emergency room for ortho eval (evaluation) and treatment-...fracture of right tibia and fibula (the two bones of the lower portion of the leg). On 10/17/12 Resident 8's X-ray report dated 8/31/12, revealed, "...There were comminuted fractures (breaks) of the proximal shafts of the right tibia and fibula..." During an interview with the facility Administrator on 10/16/12 at 11:35 AM, he confirmed that he was the facility's Abuse Coordinator. He further stated that Resident 8's fractured right leg was not reported to the Ombudsman (an organization that investigates reports of abuse or mistreatment) or the California Department of Public Health (CDPH). He stated that he had conducted an investigation regarding Resident 8's fractured leg, which included the physician's documentation, and concluded it was due to her "severe [MEDICAL CONDITION]." On 10/16/12 and 10/17/12, a document titled, "Resident Abuse Investigation Report Form" dated 8/31/12, and signed by the Administrator was reviewed. The form indicated that on 8/30/12, (no time documented) CNA 2 and LVN 2 reported the incident of pain and swelling to Resident 8's leg. Under the section, "Did the medical record review indicate any previous or unexplained injuries?," documentation hand written by the Administrator showed, "Yes Resident has history of frailty and [MEDICAL CONDITION] X-ray analysis shows the break was due to a pathological fracture and not trauma." Further review of the "Resident Abuse Investigation Report Form", dated 8/31/12, showed that the Administrator had interviewed Resident 8, two CNAs, one from the day shift and one from the evening shift, and the evening LVN (LVN 2) whom had provided care for Resident 8 on 8/30/12, the day Resident 8 was reported to have a "swollen right knee/leg." The final section of the document titled, "Result of findings and corrective action taken reported to:" revealed the portion titled, "Ombudsman" and "State Licensing Agency" (CDPH) were left blank and unchecked which indicated there was no notification to the Ombudsman nor the State Licensing Agency (CDPH). Documentation by the Administrator further showed, " No abuse suspected. " During an interview with the Administrator on 10/17/12 at 3:00 PM, he stated that he had interviewed "Everyone" and that he was, "One hundred percent sure it was not abuse." On further interview with the Administrator, he stated that he had not interviewed Resident 8's roommate, Resident A, at the time Resident 8's right knee/leg was reported with pain and swelling. The Administrator confirmed that Resident A should have been interviewed and included in the investigation. During an interview on 10/15/12 at approximately 2:35 PM, with the MDS Nurse, she stated that Resident A was alert with periods of confusion and is usually interviewable. On 10/17/12, during a review of Resident A's current MDS (provided by the MDS Nurse), dated 7/25/12, it showed that Resident A had clear speech, was able to make herself understood and to understand others. The "cognitive pattern" section of the MDS dated [DATE], showed that Resident A scored 15 out of 15 (the highest possible score), which indicated perfect cognition. The MDS revealed that she was her own responsible party. During an interview with Resident A, Resident 8's roommate, on 10/17/12 at 4:48 PM, she stated that she did not know how Resident 8's leg was fractured, and denied ever witnessing any abuse. On 10/18/12 a review of the facility policy and procedure titled, "Abuse Investigations," revised July 2007, revealed that all reports of resident injuries of unknown source shall be thoroughly investigated. The person conducting the investigation should at a minimum,..."Interview the resident's roommate..." and ..."notify the ombudsman that an abuse investigation is being conducted..." The policy further indicated,..."The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the Department of Public Health..."