Every finding on record at Medical Center Convalescent Hospital

Based on observation, interview, and record review, the facility failed to adhere with established food safety and sanitation standards when:1. A plastic wrapped container of beef roast was observed without a label indicating the preparation date, freeze by date, or discard date.2. Clean wet dishes were stacked on top of each other and not air dried.These had the potential to place susceptible residents who receive food from Dietary Services at risk for food-borne illnesses.Findings: 1. During an initial observation tour of the kitchen and interview, on 2/23/26, at 8:20 AM, with the Dietary Supervisor (DS), a plastic wrapped container of beef roast was observed in the walk-in freezer, without a label indicating the preparation date, freeze by date, or discard date.During an interview on 2/23/26 at 8:24 AM with the DS, the DS stated that the facility's policy was to ensure all food stored in the freezer was properly labeled and dated. The DS confirmed the facility's policy was not followed.A review of the facility's policy and procedure (P&P) titled, Food Storage, revised 12/14 indicated, . 5. Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with a plastic wrap, foil or a lid.2. During a concurrent follow up observation and interview of the kitchen on 2/25/26, at 11:10 AM, with the DS, wet dishes were found stacked on top of each other and not air dried. The DS stated that all dishes should be air dried before storing.A review of the facility's undated P&P titled, 3 Compartment Procedure for Manual Dishwashing was reviewed. The P&P indicated, . Step 6: All items are air-dried, which means no water droplets are present.A review of the 2022 FDA (Food and Drug Administration) Food Code, 4-901.11 indicated, Equipment and Utensils, Air-Drying Required .After cleaning and SANITIZING, EQUIPMENT and UTENSILS: ((A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 17) did not self-administer medication, when the facility assessment indicated Resident 17 was unable to do so. Resident 17 was given medications to self-administer while out on pass ([OOP] a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility). This failure had the potential for Resident 17 to have adverse effects.Findings:A review of Resident's admission Record, (a document showing a summary of the resident's information) dated 2/25/26 indicated Resident 17 was admitted to the facility on [DATE].A review of Resident 17's History and Physical (H&P), dated 11/18/25, indicated Resident 17 had a surrogate decision maker and was noted to have confusion in the Neurological Exam portion. The H&P also indicated Resident 17 had diagnoses including right sided weakness, seizures, and hypertension (high blood pressure). Further review of the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions.During an observation on 2/25/26 at 8:10 AM, Resident 17's bed was made and Resident 17 was not in the room.A review of Resident 17's Social Services Notes, dated 2/24/26 at 1:51 PM, indicated Resident 17 was out on pass for four days.A review of Resident 17's Order Summary Report, dated 2/25/26, showed a physician's order dated 2/23/26, May go OOP (out on pass) overnight from 2/24/26 to 2/28/26 one time only for 4 days. Further review of The Order Summary Report, dated 2/25/26 also indicated the following physician's orders:- Order dated 1/21/26, for Keppra (a medication used to treat seizures) oral tablet 500 mg ([milligrams] - unit of measurement), give 500 mg by mouth every 12 hours related to conversion disorder with seizures or convulsions.- Order dated 1/21/26, for Nifedipine (medication used to treat high blood pressure or chest pain) oral tablet extended release 24 hr (hours) 30 mg.A review of Resident 17's Self Administration of Medication Assessment, dated 10/31/25, indicated Resident 17 was not a candidate for safe self-administration of medications. Further review of Resident 17's Self Administration of Medication Assessment, indicated the facility assessed the resident as No for mental and physical capacity to self administer medications.During a concurrent interview and record review with Director of Nursing (DON), Resident 17's medical record was reviewed. The DON stated Resident 17 went out on pass on 2/24/26. The DON stated Resident 17 was sent with medications to self-administer, as evidenced by the medication being removed from the bubble pack (a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles, usually organized by day and time). The DON reviewed Resident 17's Self Administration of Medication Assessment, dated 10/31/25, and confirmed Resident 17 was unable to safely self-administer medication.A review of the facility's policy titled, Policy and Procedure on Self-Administration of Medications, indicated .as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications.If the staff determines that a resident cannot safely self-administer medications, the nursing staff will administer the residents medications.Cross Reference to F689 #1.

Based on observation, interview, and record review, the facility failed to ensure the call light was accessible for use for one of one sampled resident (Resident 2).This failure had the potential for Resident 2's care needs not being met. Findings:During an observation on 2/23/26 at 9:20 AM inside Resident 2's room, Resident 2 was observed sitting up in bed. Resident 2's call light was observed on the floor to the left side of Resident 2's bed. The Licensed Vocational Nurse (LVN 1) was observed exiting Resident 2's room.During a concurrent observation and interview on 2/23/26 at 9:50 AM with LVN 1 inside Resident 2's room, Resident 2's call light was observed on the floor to the left side of Resident 2's bed. LVN 1 verified the call light was not within Resident 2's reach and acknowledged it should have been accessible. LVN 1 stated Resident 2 was at risk for falls and having the call light within reach was important for Resident 2 to request assistance.A review of Resident 2's admission Record, (a document showing a summary of the resident's information) dated 2/25/26, indicated Resident 2 was readmitted to the facility on [DATE].A review of Resident 2's Minimum Data Set ([MDS], a standardized assessment tool) dated 12/23/25, indicated Resident 2 was dependent (helper did all the effort, resident did none of the effort to complete the activity) on staff with toileting, showering and lower body dressing.A review of Resident 2's Care Plan Report, indicated a Focus area titled Resident at risk for falling . dated 6/18/25, indicated an intervention to Keep call light in reach.During an interview on 2/26/26 at 7:40 AM, with the Director of Nursing (DON), the DON stated the importance of call lights was to ensure residents were able to alert and communicate with staff.A review of the facility's policy and procedure (P&P) titled Call Light/Bell, revised 12/14, indicated 6. Place the call device within resident's reach before leaving room.

Based on observation, interview, and record review, the facility failed to ensure the survey binder (a binder containing the results of the most recent survey which includes the Statement of Deficiencies (Form CMS-2567) which contains any deficiencies resulting from a complaint investigation or recertification survey) was readily accessible to the residents and visitors. This failure had the potential to limit residents' and visitors' ability to review the facility's compliance history and make informed decisions regarding care and services. Findings:During an interview on 2/24/26 at 1:30 PM at the Resident Council meeting, the residents were asked if they were able to review the results of the survey without having to ask a staff member. All 10 residents were present (Resident 4, Resident 6, Resident 16, Resident 27, Resident 34, Resident 37, Resident 38, Resident 62, Resident 65, and Resident 75) during the meeting and stated they did not know where the survey binder was located.During an observation on 2/24/26 at 2:30 PM, on the wall across from the nurses' station, a plastic shelf holding the survey binder was observed approximately 5.6 feet above the floor. During a concurrent interview and record review on 2/26/26 at 1:24 PM with the Director of Nursing (DON), the DON confirmed residents have the right to ask for and see the results of the survey binder. The DON acknowledged the survey binder was placed in an area that was not readily accessible to residents. A review of the facility's policy and procedures (P&P), titled Resident Rights, revised 11/14, indicated, . You may examine survey results and the plan of correction. These, or a notice of location, will be posted in a readily accessible place.

Based on interview and record review, the facility failed to provide written information concerning the right to formulate an Advance Directive (a written document specifying an individual's medical care wishes) for 4 of 14 sampled residents (Residents 1, 11, 49, 83).This failure had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.Findings:1. A review of Resident 1's admission Record, (a document showing a summary of the resident's information) dated 2/24/26, indicated Resident 1 was readmitted to the facility on [DATE]. A review of Resident 1's POLST, (Physician Orders for Life-Sustaining Treatment-a form that documents an individual's preferences for end-of-life care), dated 5/10/24 was signed by the legally Recognized Decisionmaker and indicated Resident 1 did not have an Advance Directive. During a concurrent interview and record review on 2/24/26 at 3:56 PM with the Social Services Designee (SSD), Resident 1's POLST was verified and the SSD confirmed Resident 1 did not have an Advance Directive and the legally Recognized Decisionmaker was not provided information on Advance Directives. The SSD reviewed the facility's policies and procedures (P&P) titled, Assisting with Health Care Directives, dated 12/14 and confirmed it was the SSD's responsibility to ensure information regarding Advance Directives were provided to the residents and the residents' families. A review of the facility's policies and procedures (P&P) titled, Assisting with Health Care Directives, dated 12/14 indicated, Social Services designee will assist residents in completing an advanced directive form if they wish to execute one. Social Services will assist residents by arranging for the Ombudsman to visit if they wish to prepare a Durable Power of Attorney for Health. 2. A review of Resident 11's admission Record, dated 2/25/26, indicated Resident 11 was admitted to the facility on [DATE]. A review of Resident 11's Initial History and Physical, dated 2/12/26, indicated Resident 11, Had the capacity to understand and make decisions. A review of Resident 11's POLST, dated 9/4/25, indicated Resident 11 did not have an Advance Directive. A review of Resident 11's signed Acknowledgement of Advance Directive, form dated 9/9/25, indicated Resident 11 Had not executed an Advance Directive. Resident 11's Acknowledgement of Advance Directive, form did not indicate documented evidence that Resident 11 was provided with additional written information concerning the right to formulate an Advance Directive. The box for I received information on my rights about formulating an Advance Directive was not checked. 3. A review of Resident 49's admission Record, dated 2/24/26, indicated Resident 49 was readmitted to the facility on [DATE]. A review of Resident 49's Initial History and Physical, dated 1/23/26 indicated, This resident has the capacity to understand and make decisions. A review of Resident 49's POLST, dated 1/23/26, indicated Resident 49 did not have an Advance Directive. A review of Resident 49's signed Acknowledgement of Advance Directive, form dated 12/6/24, indicated Resident 49, Had not executed an Advance Directive. Resident 49's Acknowledgement of Advance Directive, form did not indicate documented evidence that Resident 49 was provided with additional written information concerning the right to formulate an Advance Directive. The box for I received information on my rights about formulating an Advance Directive was not checked. 4. A review of Resident 83's admission Record, dated 2/24/26, indicated Resident 83 was admitted to the facility on [DATE]. A review of Resident 83's History and Physical, (H&P) dated 2/19/26, indicated, Patient is able to make own decisions. A review of Resident 83's POLST, dated 2/19/26, indicated Resident 4, Did not have an Advance Directive. A review of Resident 83's signed Acknowledgement of Advance Directive, form dated 2/24/26, indicated Resident 83, Had not executed an Advance Directive. Resident 83's Acknowledgement of Advance Directive, form did not indicate documented evidence that Resident 83 was provided with additional written information concerning the right to formulate an Advance Directive. The box for I received information on my rights about formulating an Advance Directive was not checked. During a concurrent interview and record review on 2/24/26 at 11:23 AM, with the SSD, the SSD was asked about the procedure for Advance Directives. The SSD stated that she was responsible for talking to the residents if they wanted help to formulate an Advance Directive, and it would be documented in the resident's chart. The SSD reviewed the medical records for the residents above and was unable to show written documentation help had been offered to formulate an Advance Directive. During a concurrent observation, interview and record review with the Director of Nursing (DON) on 2/25/26 at 2:30 PM at the nurses' station by the front lobby area, the DON stated facility P&Ps were reviewed annually and revised and updated as needed. The DON further stated facility P&Ps were also reviewed during Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings. A review of the facility's policies and procedures (P&P) titled, Advanced Directives, revised 7/12, indicated, .1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical surgical treatment, and the right to formulate advance directives.

Based on interview and record review, the facility failed to follow up with the Preadmission Screening and Resident Review ([PASARR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) to determine the resident's needs for specialized services and appropriate placement for one of one sampled resident (Resident 6).This failure had the potential to result in inappropriate placement and unidentified specialized services for Resident 6. Findings:A review of Resident 6's admission Record, (a document showing a summary of the resident's information), indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder depressive type (a mental health condition that combines symptoms of Schizophrenia [a mental disorder causing hallucinations, delusions, and disorganized thinking]) with major depressive episodes (a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 6's Progress Note, (a formal, often daily, record documenting a resident's clinical status, medical necessity, and response to treatment), dated 2/16/26, indicated Resident 6 had a diagnosis of Schizoaffective disorder.A review of Resident 6's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 10/17/25, indicated a level one screening was completed following a status change. Further review indicated under Section III -Serious Mental Illness, Resident 6's PASSR Level 1 screening was marked Yes to a diagnosed serious mental illness and the specified diagnoses included schizoaffective disorder, depressive type, major depressive disorder. A review of Resident 6's Notice of Attempted Evaluation, dated 10/21/25, indicated facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level one screening, therefore California Department of Health Care Services was unable to complete a level two evaluation for serious mental illness to determine if the individual could benefit from specialized services. During a concurrent interview and record review with Registered Nurse 2 (RN 2) on 2/24/26 at 10:59 AM, RN 2 reviewed Resident 6's Preadmission Screening and Resident Review PASSR - Level 1 Screening, dated 10/17/25, and Resident 6's Notice of Attempted Evaluation, dated 10/21/25. RN 1 stated they were responsible for completing and following up on the PASRR for the residents in the facility. RN 1 stated the process of the PASSR determined if residents required special services or if the residents were appropriate to stay in the facility. RN 1 was asked to provide documented evidence that the facility followed up on the attempted PASSR Level II Screening. RN 1 was unable to provide such evidence and stated it was missed, and it should have been completed.During a concurrent interview and record review with the Director of Nursing (DON) on 2/26/26 at 7:51 AM, the DON verified the PASSR was not completed. The DON stated completing the PASSR was important to ensure the services and placement at the facility was appropriate for Resident 6.A review of the facility's policy and procedure (P&P) titled PAS/PASSAR, revised 03/05, indicated, .PASARR should be completed for all residents . For the residents found to be mentally ill . this screening is used to determine whether the nursing facility care is appropriate and whether the resident needs specialized services.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) with an indwelling urinary catheter (a catheter inserted through the urethra into the bladder to drain urine) had accurate intake and output (I&O) monitored and documented as ordered.This failure had the potential to result in delayed identification of changes in urinary output, fluid imbalance, and other complications related to the use of an indwelling catheter.Findings:During an observation on 2/23/26 at 9:02 AM inside Resident 3's room, Resident 3 was observed lying in bed with an indwelling urinary catheter in place.A review of Resident 3's admission Record, (a document showing a summary of the resident's information), dated 2/25/26, indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's History and Physical (H&P), dated 12/26/25, indicated Resident 3 had diagnoses including benign prostatic hyperplasia ([BPH] - enlarged prostate gland causing obstruction and/or difficulty with urinating), urinary retention (the inability to fully empty the bladder), and obstructive uropathy (a condition in which the flow of urine is blocked).A review of Resident 3's Order Summary Report, dated 2/25/25, indicated Resident 3 had physician's orders dated on 12/25/25, for, Indwelling catheter for obstruction and to monitor intake and output every shift.A review of Resident 3's Care Plan Report, indicated a Focus area titled At risk for urinary tract infection related to indwelling foley catheter use, dated 12/29/25, indicated an intervention to monitor I&O.A review of Resident 3's Medication Administration Record, (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated January 2026 and February 2026, indicated intake and output monitoring were not consistently documented on certain shifts on the following dates: 1/25/26, 1/27/26 - 1/30/26, 2/16/26, and 2/20/26. During a concurrent interview and record review on 2/24/26 at 5:08 PM with the Licensed Vocational Nurse 3 (LVN 3), Resident 3's MAR for January and February 2026 were reviewed. LVN 3 verified the missing signatures on the MAR and stated licensed staff were responsible for monitoring and documenting the input and output of residents who had an order for an indwelling urinary catheter. LVN 3 stated that documenting the intake and output on the MAR would ensure the monitoring was completed. During a concurrent interview and record review on 2/26/26 at 7:43 AM with the Director of Nursing (DON), the DON acknowledged the missing MAR documentation for January and February 2026 and stated the licensed staff must ensure intake and output monitoring was documented in the MAR. The DON further stated the importance of monitoring the intake and output included assessing Resident 3's hydration status and the quality, color, odor, and consistency of Resident 3's urine.A review of the facility's policy and procedure (P&P) titled, Intake and Output, revised 07/2012, indicated It is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance for resident admitted with indwelling foley catheter . I&O assessments will be documented in the resident's medical record. Include average intake, average output, quality, color, odor, consistency of urine, resident's hydration status.

Based on observation, interview, and record review, the facility failed to ensure three out of three residents (Residents 17, 25, and 84) were kept free from accident hazards. 1. The facility failed to ensure Resident 17 was properly assessed to be safe prior to sending the resident out on pass ([OOP] - a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility.) 2. The facility failed to ensure Resident 25's had a physician order for floor mats and failed to implement care plan interventions. 3. The facility failed to identify and assess Resident 84 as a smoker upon admission and was observed smoking in the patio without a smoking assessment. These failures posed a risk for an unsafe environment for the residents. Findings:1. A review of Resident 17's admission Record, (a document showing a summary of the resident's information), dated 2/24/26, indicated the resident was admitted to the facility on [DATE]. A review of Resident 17's History and Physical, (H&P), dated 11/18/25, indicated Resident 17 had some confusion and Resident 17 had fluctuating capacity to understand and to make decisions. A review of the facility's Job Description and Performance Standards for the Position Title of Nursing Supervisor and Charge Nurse, (undated), indicated the Supervisor and the nurse were responsible for the safety of residents under his/her supervision During an observation on 2/25/26 at 8:10 AM inside Resident 17's bedroom, Resident 17 was not in the room and Resident 17's bed was observed to be freshly made. During an interview on 2/25/26 at 8:11 AM with the Medical Records Director, the Medical Records Director stated Resident 17 was OOP, left the faciity on 2/24/26, and would return to the facility on 2/28/26. During an interview on 2/25/26 at 8:22 AM with the Licensed Vocational Nurse 4 (LVN 4), LVN 4 acknowledged Resident 17 was currently OOP for several days. LVN 4 stated a residents who went OOP would require a physician's order indicating the date and the length of time the resident would be out of the facility. LVN 4 stated a licensed nurse should have performed a physical assessment and provided instructions to Resident 17 prior to leaving the facility. LVN 4 stated Resident 17's vital signs and skin condition should have been assessed prior to leaving the facility. During a concurrent interview and record review on 2/25/26 at 8:33 am with the Registered Nurse 2 (RN 2), Resident 17's Order Summary Report, dated 2/23/26, was reviewed and RN 2 verified the Order Summary Report indicated a physician's order dated 2/23/26, May go OOP overnight from 2/24/26 to 2/28/26 one time only for 4 days. RN 2 stated a licensed nurse should have performed a physical assessment and provided instructions to Resident 17 prior to Resident 17 leaving the facility. RN 2 further reviewed Resident 17's record and acknowledged there was no documented evidence indicating an assessment was conducted or instructions were provided to Resident 17 prior to leaving the facility. During a follow-up and concurrent interview and record review on 2/26/26 at 9:55 am with RN 2, Resident 17's Release for Temporary Absence was reviewed. The Release for Temporary Absence, indicated Resident 17 departed the facility on 2/24/26 at 10:08 AM with the destination of the resident listed as Family. Resident 17 signed the form and RN 2 acknowledged signing as a witness. RN 2 stated the purpose of the Release of Temporary Absence form was to ensure Resident 17 was assessed and provided instructions by a licensed nurse prior to leaving the facility. However, RN 2 acknowledged there was no documentation indicating an assessment or instructions were provided prior to Resident 17 leaving the facility. RN 2 further stated they could not recall the name or relationship of the individual who picked up Resident 17 from and did not assess the location of where Resident 17 was going. During a concurrent interview and record review on 2/26/26 at 1:30 pm with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator, Resident 17's Out on Pass Safety Checklist, (unfilled) was reviewed. The DON stated staff must ensure the Out on Pass Safety Checklist was completed prior to Resident 17 leaving the facility OOP and that the form was maintained in a binder with Resident 17's Release for Temporary Absence form located in the nurses' station. The safety checklist indicated Resident 17 should be assessed for the resident's name, destination address, length of time away from the facility, a contact phone number, and an emergency contact name and address. The DON and MDS Coordinator verified there was no completed Out on Pass Safety Checklist form in the binder to indicate Resident 17 was assessed for the required information prior to Resident 17 leaving the facility. 2. A review of Resident 25's admission Record, (a document showing a summary of the resident's information) dated 2/24/26, indicated Resident 25 was admitted to the facility on [DATE]. A review of Resident 25's History and Physical, (H&P) dated 2/9/26, showed Resident 25 was status post ([s/p] - after or following a significant event, procedure, or diagnosis) hip replacement. During an observation on 2/23/26 at 9:55 AM, Resident 25 was observed in bed with a floor mat on the left side. During an observation on 2/24/26 at 10:32 AM, Resident 25 was again observed in bed with a floor mat on the left side. During a concurrent observation, interview, and record review on 2/24/26 at 10:47 AM with RN 1, RN 1 was asked about Resident 25's care. RN 1 stated Resident 25 was a fall risk, because she was recovering from hip surgery. RN 1 verified Resident 25 had a floor mat on the left side of the bed. When asked about the process, RN 1 stated a physician's order was required for the use of floor mats. RN 1reviewed Resident 25's medical record and physicians orders dated 2/24/26, and was unable to find a physician's order for the use of floor mats. RN 1 reviewed Resident 25's plan of care and noted a care plan problem dated 2/8/26, for resident at risk for falling. Interventions included assure the floor is free from glare, liquids, and foreign objects. RN 1 stated the floor mat could be considered a foreign object in the absence of a physician's order. During an interview on 2/24/26 at 10:26 AM, with the DON, the DON was asked about the process for a resident using floor mats. The DON stated there should be a physician's order, care plan, and informed consent. The DON stated the floor mat could not be used without a physician's order in place. 3. During the Entrance Conference on 2/23/26 at 9:16 AM with the Administrator and DON, a list of residents who smoke in the facility was requested. A review of Smoking List, dated 2/21/25 indicated 20 residents smoked in the facility. Resident 84 was not listed on the Smoking List provided by the Administrator. A review of Resident 84's admission Record, dated 2/24/26, indicated Resident 84 was admitted to the facility on [DATE]. A review of Resident 84's History and Physical, dated 2/19/26, indicated Resident 84, Was able to make own decisions. During an observation on 2/23/26 at 3:56 PM, Resident 84 was smoking on the patio. During a concurrent interview and record review on 2/24/26 at 3:28 PM, the Admissions Director was asked about the process for residents who wish to smoke at the facility. The Admissions Director stated the facility had to complete a smoking assessment to determine if the resident smoked and was safe to smoke at the facility. The Admissions Director reviewed Resident 84's medical record and stated Resident 84 did not have a smoking assessment completed until 2/24/26 and should not have been smoking prior to that time. A review of the facility's policy and procedures (P&P) titled Smoking Policy, dated 7/12, showed that .Facility attempt to keep and maintain our residents, staff, and visitors free from any hazardous accidents. This includes but not limited to fire which could be due to unsafe smoking practice.

Based on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) with an indwelling urinary catheter (a catheter inserted through the urethra into the bladder to drain urine) received proper care and services by failing to ensure indwelling catheter care was consistently completed and documented as ordered. This failure had the potential to result in Resident 3 developing a urinary tract infection (UTI - an infection in the bladder/urinary tract) and other complications related to the use of an indwelling catheter. Findings: During an observation on 2/23/26 at 9:02 AM inside Resident 3's room, Resident 3 was observed lying in bed with an indwelling urinary catheter in place.A review of Resident 3's admission Record, (a document showing a summary of the resident's information), dated 2/25/26, indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's History and Physical (H&P), dated 12/26/25, indicated Resident 3 had diagnoses including benign prostatic hyperplasia ([BPH] - enlarged prostate gland causing obstruction and/or difficulty with urinating), urinary retention (the inability to fully empty the bladder), and obstructive uropathy (a condition in which the flow of urine is blocked).A review of Resident 3's Urinary Incontinence and Indwelling Catheter, dated 1/19/26 with an observation date of 12/25/25, indicated Resident 3 was admitted to the facility with a catheter from acute hospitalization for chronic urinary retention and BPH. A review of Resident 3's Minimum Data Set, ([MDS], a standardized assessment tool), dated 1/1/26, indicated Resident 3 was dependent (helper did all the effort, resident did none of the effort to complete the activity) on staff with toileting and personal hygiene. The MDS further indicated Resident 3 had an indwelling catheter.A review of Resident 3's Order Summary Report, dated 2/25/25, indicated Resident 3 had physician's orders dated on 12/25/25, for, Indwelling catheter for obstruction and Indwelling catheter care: wash with water and soap around urinary meatus (external opening where urine exits the body) every shift (Q shift) and as needed (PRN).A review of Resident 3's Care Plan Report, indicated a Focus area titled At risk for urinary tract infection related to indwelling foley catheter use, dated 12/29/25, indicated an intervention for foley catheter care every shift . cleanse with soap and water around the urinary meatus.A review of Resident 3's Treatment Administration Record, (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident), dated January 2026 and February 2026, indicated indwelling catheter care was not consistently documented as completed on certain shifts on the following dates: 1/5/26 - 1/11/26, 1/13/26 - 1/23/26, 1/27/26, 1/28/26, 2/9/26, and 2/10/26. During a concurrent interview and record review on 2/23/26 at 10:00 AM with the Licensed Vocational Nurse 2 (LVN 2), Resident 3's TAR for January and February 2026 were reviewed. LVN 2 verified the missing signatures on the TAR and stated licensed staff were responsible for signing the TAR after the urinary catheter care was completed. LVN 2 stated that documenting information on the TAR would ensure the urinary catheter care was completed and who the care was completed by. During a concurrent interview and record review on 2/26/26 at 11:19 AM with the Director of Nursing (DON), the DON acknowledged the missing TAR documentation for January and February 2026 and stated the licensed staff must ensure indwelling catheter care was documented to verify that the care was provided. The DON further stated failure to provide catheter care placed residents with an indwelling catheter at risk for infection.A review of the facility's policy and procedure (P&P) titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, revised June 2014, indicated The following catheter-associated urinary tract infections (CAUTI) prevention strategies have been adopted and are to be followed by clinical staff: . 7. Perform daily meatal (external opening where urine exits the body) hygiene with soap and water for residents with indwelling catheter.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. For one of four residents (Resident 84), a medication was not administered in accordance with prescriber's orders.This failure resulted in a medication error and the potential to result in unnecessary medications.2. In one of two medication rooms (Medication Room A), four normal saline (saltwater) IV (intravenous - into a resident's vein) solution bags were stored undated outside the plastic overwrap.This failure had the potential to compromise the stability of the IV solution bags.3. In one of two medication rooms refrigerators (Medication Room A), two opened and undated multiple-dose Aplisol (tuberculin purified protein derivative - aid to diagnose the tuberculosis infection) vial was observed stored in the medication refrigerator.This failure had the potential for the resident(s) to be exposed to ineffective Aplisol due to possible oxidation (chemical process) and degradation (reduced quality) which may affect potency (effectiveness) if the opened and undated vials were not discarded according to the drug manufacturer's instructions.Findings:1. During a concurrent observation and interview on 2/24/26, at 8:50 AM, with Registered Nurse (RN) 1, at the medication cart outside of Resident 84's room, two tablets of Senna S (combination medication of two laxative drugs to manage constipation - sennosides 8.6 milligrams (mg - a unit of dose for measurement) (total dose = sennosides 17.2 mg) and docusate 50 mg (total dose = 100 mg) were prepared at the medication cart. RN 1 acknowledged two tablets of the combination medication Senna S was poured into the medication cup for Resident 84.During a concurrent interview and record review on 2/24/26, at 11:45 AM, Resident 84's current physician orders were reviewed with RN 1. The medication orders indicated a medication order for sennosides 17.2 mg but not for the combination medication Senna S. RN 1 reviewed the current medication orders. RN 1 acknowledged the wrong medication was given during medication pass observation at 8:50 AM (on 2/24/26). During an interview on 2/26/26, at 9:54 AM, with the Director of Nursing (DON), the DON stated the expectation was to follow the 8 Rights of Medication Administration (safety practices to prevent medication errors) including administering the right medication to the resident.During a review of the facility's policy and procedure (P&P) titled, PREPARATION FOR MEDICATION ADMINISTRATION, reviewed 1/21/26, the P&P indicated, Procedure - Preparation.Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and the MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.Procedure - Administration.Medications are administered in accordance with written orders of the attending physician.2. During a concurrent observation and interview on 2/23/26, at 7:56 AM, an inspection of Medication Room A was conducted with the Minimum Data Set Coordinator ([MDS] - specialized nurse who ensures accurate resident data collection). Four undated normal saline IV solution 100 milliliters ([mLs] - a unit of measurement for volume) bags were observed stored outside the plastic overwrap in the compartment BED HOLD MEDICATIONS. The MDS acknowledged the four undated normal saline solution bags were stored outside of the plastic overwrap in Medication Room A. During an interview on 2/23/26, at 3:58 PM, with the MDS, the MDS stated the four undated normal saline bags observed in the Medication Room A at 7:56 AM 2/23/26) should have been dated with a 20 day beyond use date (BUD - the date or time the product should not be stored and when it should be discarded).During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the expectation is that the unlabeled and undated normal saline bags should have been discarded.During a review of the undated manufacturer's literature, titled APPENDIX D, the manufacturer's literature indicated Stability outside of overwrap. Intravenous solutions are packaged with an overwrap that prevents evaporation through the walls of the bag. Stability of the solution can be compromised if unwrapped for a length of time prior to use. Overwrap should ideally be removed just prior to use. However solutions that have been removed from the overwrap may be given the below beyond use dates as long as the manufacturer expiry date is not exceeded. [the name of the drug manufacturer] .Bag Size.100 mL and greater.Beyond use date once removed from overwrap.20 days.During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, reviewed 1/21/26, the P&P indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier.3. During a concurrent observation and interview on 2/23/26, at 7:56 AM, an inspection of Medication Room A was conducted with the MDS. Two opened and undated multiple-dose vials of tuberculin purified protein derivative (Aplisol) were observed stored in the medication refrigerator. The MDS acknowledged the opened and undated Aplisol vials were stored in the Medication Room A refrigerator.During an interview on 2/26/26, at 9:30AM, with the Infection Preventionist (IP), the IP stated Aplisol vial is to be dated because it is only good for a certain time.During an interview on 2/26/26, at 9:37 AM, with RN 2, RN 2 stated the Aplisol vial is labeled with the date when it is opened to determine when to discard it.During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the expectation is once the Aplisol vial is opened, it should be dated and kept no longer than 30 days.During a review of the Aplisol package insert (PI - document on how to safely use medications) dated May 2024, provided by the facility, the PI indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.During a review of the facility's P&P titled, Medication Labeling and Storage, revised 2/23, the P&P indicated, Multi-dose vials that been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on the observation, interview, and record review, the facility failed to ensure safe medication labeling practices and medications were stored at the proper temperature range in accordance with accepted standards of practice and/or manufacturer's instructions when:1. One of one opened inhaler mouthpiece for Resident 36 was not properly labeled with sufficient information to clearly identify the specific resident.This failure had to potential to cause medication errors and preventable infections from cross-contamination (transfer of germs) if accidently mixed up with other residents' similar or same drugs.2. Medications were observed stored at the incorrect temperature.a. An undated insulin (drug to manage high blood sugars) pen (portable device) for Resident 39 in one of three medication carts.b. Two medication cartons containing bisacodyl (laxative drug to manage constipation) in one of two medication rooms refrigerators.This failure had the potential for residents to be given deteriorated (reduced quality) medications if stored outside the temperature range specified by the drug manufacturer and for the suppositories to take longer to melt in the body which could result in suboptimal treatment.3. In one of one Central Supply (department which stocks and manages the inventory of medical supplies and drugs) storage areas, there was no room temperature monitoring logs to demonstrate medications were stored within the correct temperature range.This failure placed residents at risk for receiving ineffective medications and the potential for adverse clinical outcomes.Findings:1. During a concurrent observation and interview on 2/24/26, at 3:45 PM, an inspection of Medication Cart B was conducted with Licensed Vocational Nurse (LVN) 3. When the medication cart was opened, Resident 36's tiotropium (drug for chronic breathing problems) inhaler mouthpiece was not labeled with the resident-specific information. LVN 3 stated Normally, I would label it [the inhaler mouthpiece] with the resident's name.During an interview on 2/26/26, at 9:30 AM, with the Infection Preventionist (IP), the IP stated the inhaler mouthpiece should be labeled so it would not get mixed up with another resident.During an interview on 2/26/26, at 9:37 AM, with Registered Nurse 2 (RN 2), RN 2 stated the inhaler mouthpiece was labeled with resident's name when it was opened to prevent mix-ups with other residents.During an interview on 2/26/26, at 11:12 AM, with the Director of Nursing (DON), the DON acknowledged the inhaler mouthpiece should be labeled with resident specific information because the box could be ruined.During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised February 2023, the P&P indicated, Medication Labeling.Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.2a. During a concurrent observation and interview on 2/23/26, at 2:55 PM, an inspection of Medication Cart C was conducted with LVN 1. When the medication cart was opened, there was an undated and unused Humalog (rapid-acting) insulin pen for Resident 39 with a blue refrigerate sticker stored inside at room temperature. LVN 1 stated the unused insulin pen should be trashed.During an interview on 2/26/26, at 9:37 AM, with RN 2, RN 2 stated insulin was labeled with the date when it was stored in the medication cart at room temperature. RN 2 stated to also check with the manufacturer's instructions.During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the undated insulin pen should have been kept in the refrigerator. The DON expectation stated it should be dated when it is stored in the medication cart.During a review of the Humalog insulin package insert (PI - document on how to safely use medications) dated April 2025, provided by the facility, the PI indicated, Storing your Pen.Store unused Pens in the refrigerator.Unused Pens may be used until the expiration date printed on the Label, if the Pen has been kept in the refrigerator. During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, reviewed 1/21/26, the P&P indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier.2b. During a concurrent observation and interview on 2/23/26, at 7:56 AM, an inspection of Medication Room A was conducted with the Minimum Data Set Coordinator (MDS - specialized nurse who ensures accurate resident data collection). Two boxes containing bisacodyl 10 milligrams (mg - a unit of measurement for dose) suppositories (medications inserted into body cavities designed to melt) were observed stored inside the medication refrigerator at a temperature of 45 degrees Fahrenheit (F - a temperature scale). The product labeling on the two bisacodyl cartons indicated to store the medication at room temperature between 59 to 86 degrees F. The MDS acknowledged the two bisacodyl medication cartons were stored inside the refrigerator when the product labeling indicated to store at room temperature.During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the expectation was to store the suppositories at room temperature.During a review of the bisacodyl PI dated April 2025, provided by the facility, the PI indicated, Store at 15C [Celsius - a temperature scale] to 30C (59F to 85F).During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, reviewed 1/21/26, the P&P indicated, Procedure.Medications requiring storage at room temperature are kept at temperatures ranging from 15C (59C) to 30C (86F).3. During a concurrent observation and interview on 2/25/26, at 7:56 AM, an inspection of the Central Supply storage area was conducted with the Environmental Services Director (ESD) and Central Supply Staff (CSS). Multiple bottles of Dakins Quarter (to treat and prevent skin and tissue infections) solution with a National Drug Code (NDC) 0436-0672-16 and multiple cartons of triple antibiotic ointment (to treat and prevent minor skin infections) with a NDC 67777-217-14 were observed stored in the Central Supply storage area. The product labeling on the Dakins Quarter solution indicated to store at room temperature between a range of 20-25C (68-77F). The product labeling on the triple antibiotic ointment to store at room temperature between a range of 15-30C (59-86F). The ESD acknowledged the temperature range indicated on the product labeling on the bottles of Dakins Quarter solution and the cartons of triple antibiotic ointment. The ESD stated there were no temperature logs for the medications stored in the Central Supply storage area.During an interview on 2/26/26, at 9:54 AM, with the DON, the DON stated the facility threw away medications observed in the Central Supply storage area on February 25, 2026, because there were no temperature logs.During a review of the Dakins Quarter solution PI dated June 2025, provided by the facility, the PI indicated, Store at room temperature.During a review of the triple antibiotic ointment PI dated June 2025, provided by the facility, the PI indicated, Store at room temperature between 15C - 30C (59 - 86F).During a review of the facility's P&P titled, Medication Labeling and Storage, revised February 2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature.During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, reviewed 1/21/26, the P&P indicated, Procedure.Medications requiring storage at room temperature are kept at temperatures ranging from 15C (59C) to 30C (86F).

The facility failed to maintain an accurate Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of one sampled resident (Resident 17) when the facility indicated Resident 17 was hospitalized , while the resident was out on pass ([OOP] - a temporary, authorized absence from a medical facility for social, family, or therapeutic reasons, with the explicit requirement that they return for continued treatment from the facility).This failure had the potential for omission of necessary medications.Findings:A review of Resident 17's admission Record, (a document showing a summary of the resident's information) dated 2/24/26, indicated Resident 17 was admitted to the facility on [DATE].A review of Resident 17's Release for Temporary Absence form undated, indicated Resident 17 departed the facility on 2/24/26 at10:08 AM.During an observation on 2/25/26 at 8:10 AM Resident 17 was not in the room and the bed was made.During a concurrent interview and record review on 2/25/26 at 10:58 AM with the Director of Nursing (DON), Resident 17's Medication Administration Record, dated 2/1/26 - 2/28/26, was reviewed.Resident 17's MAR indicated:- On 2/25/26, the dose at 7:00 am for losartan potassium (a medication for high blood pressure) 100 milligrams (mg - unit of measurement) was marked with a number 6 with an initial of KB08,- On 2/25/26, the dose at 7:00 am for carvedilol (a medication for high blood pressure) 3.125 mg was marked with a number 6 with an initial of KB08.Further review of Resident 17's MAR, the record chart codes indicated the number 6 meant the resident was hospitalized .The DON verified the above findings. The DON acknowledged Resident 17 was provided with the resident's medications while out on pass. The DON further stated the resident would be out on pass until 2/28/26. The DON stated the medications above should have been marked with number 11 since the resident was out on pass. The number 6 documented in Resident 17's MAR was not an accurate code to reflect the status of the resident. The DON further stated the initial KB08 was the initial of the licensed nurse who documented the in the resident's MAR as described above.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. In the laundry room, two dryers were set below the facility policy requirement of 180 degrees Fahrenheit ( F- unit of measurement), to comply with infection control, on February 5, 2025. 2. Resident 192's Intravenous (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) tubing was not dated as per facility policy. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 71 highly vulnerable residents whose health conditions are already compromised. Findings: 1. During an observation on February 5, 2025, at 2:45 PM, with the Maintenance Director (MD), in the laundry room, the facility's two dryers were inspected. Both dryers were set to a medium setting (range of 140 F to 170 F). The temperature of each dyer was measured using an infrared thermometer (also known as a thermometer gun- handheld device that displays temperature readout after scanning portions of an object or area with a built-in laser), and it read 155 F for each dryer. On the bulletin board across from the dryers, there was an undated form titled Drying Guidelines pinned in both English and Spanish, which indicated . 3. Drying times are based on recommended drying capacity . During an interview on February 5, 2025, at 2:50 PM, with the Laundry Staff (LS), the LS stated she only set the dryer to two settings: medium for sheets/pillowcases and polyester. During a review of an undated facility form titled Drying Guidelines, it indicated the following: .Items: Sheets/pillowcases. Heat Setting: Medium. Drying Time: 12-15 minutes. Cool Time: 2-4 minutes. Dry Time Temperature Range: 160 F - 170 F. Items: Table napery (100% polyester, 50/50 blend). Heat Setting: Medium. Drying Time: 8-12 minutes or 12-16 minutes. Cool Time: 2-4 minutes. Dry Time Temperature Range: 140 F - 160 F . During a concurrent interview and record review on February 5, 2025, at 3:30 PM, with the Administrator and the Infection Control Preventionist (ICP) Nurse, the facility's Policy and Procedure (P&P) titled Policy and Procedure on Water Temperature, dated revised December 2014, was reviewed. The P&P indicated, The facility ensures that the health and safety of the residents are taken care of . When it comes to the dryer, it should not be below 180 degrees Fahrenheit. In this way, infection control can be complied with . The Administrator stated the facility should have an updated system to ensure the laundry system follows the facility policy. The ICP Nurse confirmed that the policy was not followed to minimize the growth of harmful microorganisms. 46917 2. During a review of Resident 192's Admission Record (contains medical and demographic information), it indicated Resident 192 was admitted to the facility on [DATE], with the diagnoses which included endocarditis (infection of the lining of the heart), weakness, and chronic obstructive pulmonary disease (COPD- chronic lung disease that makes it difficult to breathe). During an observation on February 3, 2025, at 9:29 AM, in Resident 192's room, Resident 192 was lying in bed while recieving an antibiotic (medications that inhibit germs) IV medication. The IV tubing was inspected. It did not have a label. During a follow-up observation and concurrent interview on February 3, 2025, at 9:37 AM, in Resident 192's room, with Registered Nurse (RN 1), RN 1 confirmed there was no date on Resident 192's IV antibiotic tubing. RN 1 further stated she missed it. During a concurrent interview and record review on February 6, 2025, at 11:15 AM, with the Director of Nursing (DON), the facility's undated P&P titled, Policy and Procedures for I.V. was reviewed. The P&P indicated, .III. Basic Procedures .12. Appy the appropriate label to the set, including a). Date b). Time c). Nurse's initials . The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure proper management and disposal of expired medications was being implemented when: 1. One expired bisacodyl (used to treat constipation- when a person cannot poop) suppository (solid form of medications that dissolve inside the body) was found in the medication storage room and was available for use. 2. One expired alginate dressing (absorbent wound care product) was found in the treatment cart and was available for use. These failures had the potential for the dressing and medication to not be effective or safe for resident use in 71 highly susceptible medically compromised residents. Findings: 1. During a concurrent observation and interview, with Licensed Vocational Nurse (LVN 5), on February 2, 2025, at 10:37 AM, the medication storage room was inspected. One bisacodyl suppository dated January 2025 was found inside the medication refrigerator. (One month expired) LVN 5 confirmed it was expired and stated it should not have been available for use. 2. During a concurrent observation and interview, with LVN 4, on February 2, 2025, at 11:51 AM, the treatment cart (contains supplies for wound care) was inspected. On the top drawer of the cart, one alginate dressing was found dated April 2023. (One year and 10 months expired.) LVN 4 confirmed it was expired and stated it should not have been in the cart available for use. During a concurrent interview and record review, with the Director of Nursing (DON), on February 6, 2025, at 11:16 AM, the facility's policy and procedure (P&P) titled, Disposal/Destruction of Expired or Discontinued Medications dated revised January 2015 was reviewed. The P&P indicated, . 4. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications . 10. Facility should dispose of . outdated medications . The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to follow their policy to store food in a way that conserves nutritive value, flavor, and appearance, when cups of pudding, which were designated to be used during medication pass (process of delivering and administering medications to residents at scheduled times) were not accurately dated to reflect when it was prepared. This failure had the potential for staff to serve outdated pudding to residents, which could lead to dissatisfaction. (Each day, two residents receive pudding as a snack, while 68 residents potentially receive pudding during the medication pass.) Findings: During a concurrent observation and interview, with the Dietary Supervisor (DS), on February 3, 2025, at 8:05 AM, in the kitchen, a tray containing 18 cups of 4-ounce (oz- unit of measurement) servings of pudding was inside the kitchen refrigerator. A piece of paper taped on the tray indicated, 2/2/25 [February 2, 2025]. The individual cups of pudding were not dated. The DS explained the date on the tray indicates when an item was prepared or opened. She stated the cups of pudding were designated for medication pass by the nurses and would be labeled with today's date [February 3, 2025], as nurses preferred not to use pudding cups labeled with a previous date [February 2, 2025]. The DS acknowledged that proper practice required putting a date on the cups of pudding with the actual preparation date. During an observation on February 3, 2025, at 9:18 AM, three cups of pudding, dated 2/3 (February 3), was on top of each medication cart (a wheeled, mobile storage unit used in healthcare settings to safely transport and store medications) during medication pass. During an interview on February 3, 2025, at 2:45 PM, with the Director of Nursing (DON), the DON stated that when the nurses request the pudding to be dated with today's date, they were not referring to the actual date, instead they wanted to ensure the pudding was prepared on the same day so that it remained fresh for the medication pass. The DON explained that since the pudding was prepared by mixing milk, it can get spoiled over time. During further interview with the DON, on February 3, 2025, at 2:55 PM, the DON stated the date serves as an indication that the pudding was still fresh, as this prevents the growth of bacteria that could cause illness. The DON further stated that is why nurses preferred to serve freshly prepared pudding to maintain good quality for the residents during the medication pass. During a follow-up observation and interview on February 3, 2025, at 4:05 PM, with Licensed Vocational Nurse (LVN 1), one cup of pudding was on top of Station A's medication cart. It was kept inside a clear iced container and was dated 2/3 (February 3). LVN 1 stated that her understanding was the date on the pudding reflected the day it was made. During a follow-up observation and interview on February 3, 2025, at 4:05 PM, with LVN 2, one cup of pudding was on top of Station B's medication cart. It was kept inside a clear iced container and was dated 2/3 (February 3). LVN 2 stated that her understanding was the date on the pudding reflected the day it was made. During a follow-up observation and interview on February 3, 2025, at 4:05 PM, with LVN 3, one pudding cup was on top of medication cart station C. It was kept inside a clear iced container and was dated 2/3 (February 3). LVN 3 stated that her understanding was the date on the pudding reflected the day it was made. During an interview on February 3, 2025, at 4:25 PM, with the DS, the DS stated she did not prepare any pudding today (February 3, 2025). She further stated she had prepared the pudding on February 2, 2025, but placed today's date (February 3, 2025) on the cups of pudding to satisfy the nurses' preference, without considering the reasoning behind the nurse's request and being aware that the pudding was prepared by mixing it with milk. The DS further stated that she should date the pudding the same day as it was prepared. During a phone interview, on February 3, 2025, at 5:05 PM, with the Registered Dietitian (RD), the RD admitted it was the DS's mistake for dating the pudding with today's date instead of the date it was made. The RD explained the facility's practice was to date both the tray and individual pudding cups on the day it was prepared to ensure food safety and maintain good quality. The RD further stated proper dating was crucial to ensure the pudding was fresh and safe to eat, reducing the risk of spoilage and foodborne illness. The RD added the correct date for the pudding should have been February 2, 2025, but this was not done. During concurrent interview and record review, on February 3, 2025, at 5:20 PM, with the DON, the DON reviewed the facility's undated policy and procedure (P&P) titled, Labeling and Dating of Food, which indicated, Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Procedure: . All prepared food need to be covered, labeled and dated. Items can be dated individually or in bulk . if going to be used for meal service . The DON stated all prepared food needed to be labeled and dated but the food items prepared for meals had the option to date it in bulk. The DON further stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to ensure their restorative nursing services (RNS; also known as RNA program; nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible; generally initiated when a resident is discharged from formalized rehabilitation therapy) policies and procedures were being implemented for one of three residents reviewed for position and mobility (Resident 61) when Resident 61 was not placed on the RNS program after his Physical Therapy (PT- medical treatment that uses physical techniques to help people regain movement and function after an injury or disease) treatment was completed. This failure had the potential for Resident 61 to be at risk for falls, further decline in ambulation, and a loss of independence. Findings: During a review of Resident 61's health record, the Admission Record (which contains demographic and medical information) indicated that Resident 61 was admitted to the facility on [DATE], with diagnoses which included a history of amputation (when a limb or part of a limb that surgically removed) of the right great toe and type 2 diabetes mellitus (body does not use insulin effectively or does not produce enough insulin) with foot ulcer (open sore or wound on the foot that does not heal properly). During an observation on February 3, 2025, at 10:36 AM, Resident 61 was in his room, sitting on the edge of his bed. Resident 61 was wearing a Controlled Ankle Motion boot (CAM boot- orthopedic device designed to support and immobilize the foot and ankle) on his right foot. During a follow up observation and concurrent interview, with Resident 61, on February 6, 2025, at 12:30 PM, Resident 61 was able to stand from his wheelchair using a grab bar, which was built into the wall along the hallway. Resident 61 stated he has not been able to walk since the PT treatment was completed, and no one comes to walk with him anymore. He further stated he used to be able to walk using the grab bars on both sides in the therapy room with the assistance of the therapist. Resident 61 further stated I'm scared of falling if I try to walk alone because I have a sore on my right foot and I don't want to hurt my left leg. During a review of Resident 61's PT discharge summary, dated January 4, 2025, it indicated . Objective progress/functional comparison with goal . Patient will safely ambulate . for correct hand/foot placement . for maintaining WB [weigh bearing is Supporting your body weight on a limb, like standing or walking] .for correct use of AD [Assisted device is a tool or piece of equipment that helps people to walk] and for safety while turning . to reduce risk for loss of balance . Discharge (1/2/25 [January 2, 2025]). Distance level surface [ambulate] 40 feet . Tests/measures and outcome . Gait. 1. Mobility with assisted device but erratic [something that is unpredictable or inconsistent]/unsafe . D/C [discharged ] location: Patient discharged to reside in this LTC [long term care] facility . Prognosis to maintain CLOF [Current Level of Function] = Good with consistent staff follow through . discharged Recommendation: Assisted device for safe functional mobility . During a concurrent interview and record review, with the Director of Nursing (DON), on February 6, 2025, at 12:55 PM, the DON reviewed Resident 61's health records and was not able to find documented evidence to indicate RNS was recommended for Resident 61 after his PT treatment was completed. The DON stated, I was not aware that the resident [Resident 61] PT was completed without the RNS program. During a concurrent interview and record review, with the Director of Rehab (DOR), on February 6, 2025, at 1:20 PM, the DOR reviewed the facility's policy and procedure (P&P) titled Restorative Nursing Services, dated revised July 2017, which indicated, Policy Statement. Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation 1. Restorative nursing care consists of nursing interventions . 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care . The DOR stated she should have placed Resident 61 on the RNS program to maintain his ability to ambulate and ensure his safety during ambulation, but she did not. The DOR further stated the facility policy was not followed.

Based on the observation, interview, and record review, the facility failed to meet the regulatory requirement to ensure the resident environment remains as free of accident hazards as possible when a resident (Resident 1) accidentally released a bear spray ( a spray which is twice as concentrated as pepper spray, a chemical can cause burning pain, watery eyes, and coughing upon contact with skin or eyes) which affected five other residents (Residents 2 , 3, 4 ,5 and 6) on July 23, 2024. This failure resulted in Residents 2 , 3, 4, 5 and 6 to experience red, watery eyes and coughing. Residents 2, 3, 5, and 6 required hospitalization s. Findings: 1. During a review of Resident 1's Admission Record (clinical record with demographic information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (mental health conditions that cause excessive fear or worry), restlessness and agitation (mean feeling uneasy or upset, making it hard to stay still or calm down). A review of Resident 1's physician order dated on July 9, 2024, indicated, Ativan (medication used for anxiety) .as needed for m/b [manifested behavior] verbalization of feeling anxious related to anxiety disorder . A review of Resident 1's physician progress note dated July 19, 2024, indicated, . other: Plan . Very aggressive foul language, though he followed me later to apologize. Will follow, will dismiss from care if not improved with psych following . A review of Resident 1's care plan indicated the following: a. Date-initiated January 30, 2024, indicated, Focus. Increased aggressive behavior and outburst. Goal. The resident will effectively cope with his/her feelings of unhappiness and anger . b. Date-initiated March 8, 2024, indicated, Focus. Resident make threatening remarks, that he will put a revolver to somebody's mouth if somebody disagree with him. Goal. Safety for the other resident and staff at all times . Target date: 10/09/2024 [October 9, 2024]. Intervention. 3/26/2024 [March 26, 2024] Discontinue hourly monitoring . 3/8/2024 [March 8,2024] Hourly monitoring for safety . c. Date-initiated July 15, 2024, indicated, Focus. Increased verbal aggression behavior and outburst. Goal. The resident will effectively cope with his/her feelings of unhappiness and anger . d. Date-initiated July 23, 2024, indicated, Focus. Resident is at risk for threat to self, other resident, and staff .Spray bear spray in the hallway .Goal. Resident will be monitored by a 1:1 staff monitoring for resident's safety, other residents and staff . During an interview on August 1, 2024, at 10:45 AM, with Resident 1, Resident 1 stated he usually kept his bear spray in his car at the facility's parking lot. Resident 1 stated that on July 23, 2024, he brought it with him to an appointment for safety reasons. He further added that normally, he would put it back in his car before entering the facility, however, he was upset that day because the transportation was two hours late. He stated he forgot to return the bear spray to his car, so he ended up keeping it in the basket of his walker. During further interview with Resident 1, Resident 1 stated when he was going into his room, he accidentally bumped into the door frame, removed the safety pin from the bear spray, and sprayed it toward the hallway. Furthermore, Resident 1 stated that the facility called the police, who later helped him return the bear spray to his car. 2. During a review of Resident 2's Admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which includes chronic obstructive pulmonary disease (a long-term lung condition that can cause breathlessness) and weakness. A review of Resident 2's clinical record nurses note dated July 23, 2024, indicated a body assessment done, noted eye redness accompanied by nonproductive cough secondary to exposure to bear spray . MD (Medical Doctor) in the facility gave order may transfer to [Name of Hospital] for eval due to exposure of bear spray . During an interview on August 1, 2024, at 11:15 AM, with Resident 2, Resident 2 stated that his eyes burned during the incident but felt better after returning from the hospital. 3. During a review of Resident 3's Admission Record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which includes parkinsonism (condition in which parts of the brain become progressively damaged over many years) and epilepsy (common chronic brain disease). A review of Resident 3's clinical record nurses note dated July 23, 2024, indicated, Resident exposed to bear spray . resident noted with redness to both eyes and nonproductive cough . MD aware and gave order to send to ER [emergency room ] for further evaluation r/t [related to] exposure to bear spray . During an interview on August 1, 2024, at 11:30 AM, with Resident 3, Resident 3 stated that his eyes burned during the incident but felt better after returning from the hospital. 4. During a review of Resident 4's Admission Record, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which includes cataracts (a clouding of the lens of the eye, which is typically clear) and bradycardia (a slow heart rate). A review of Resident 4's clinical record nurses note dated July 23, 2024, indicated Resident exposed to bear spray . resident noted with redness to both eyes and nonproductive cough . MD aware and gave order to send to ER [emergency room ] for further evaluation r/t [related to] exposure to bear spray . Resident declined to be transferred to the acute hospital. He claimed that he is alright, and when his eyes got washed out, he felt relief . During an interview on August 1, 2024, at 11:45 AM, with Resident 4, Resident 4 stated that his eyes burned during the incident but felt relief after the nursing staff washed his eyes. 5. During a review of Resident 5's Admission Record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which includes cerebrovascular disease (condition that affect blood flow to your brain) effecting right dominant side and dementia(a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 5's clinical record nurses note dated July 23, 2024, indicated, [Name of Private Ambulance Company] here to pick up the resident for medical evaluation, to [Name of Hospital] secondary to resident exposed to bear spray . resident noted with redness to both eyes and nonproductive cough . MD in facility gave order may transfer to [Name of Hospital] for further eval [read evaluation] due to inhalation/exposure of bear spray During an interview on August 1, 2024, at 12:05 PM, with Resident 5, Resident 5 stated that his eyes burned during the incident but felt better after returning from the hospital. 6. During a review of Resident 6's Admission Record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which includes pneumonia (an infection that affects one or both lungs) and heart failure (condition that occurs when your heart can't pump enough blood for your body's needs). A review of Resident 6's clinical record nurses note dated July 23, 2024, indicated, Resident exposed to bear spray . resident noted with redness to both eyes and nonproductive cough . Dr [name of the Medical Doctor] was notified and ordered to send to [Name of Hospital] or medical evaluation d/t [due to] toxic spray exposure. During an interview on August 1, 2024, at 12:20 PM, with Resident 6, Resident 6 stated that his eyes burned during the incident but felt better after returning from the hospital. Furthermore, Resident 6 stated more worried about his lung and breathing since he treated for pneumonia in the facility. During an interview on August 1, 2024, at 12:35 PM, with the Director of Nurses (DON), the DON stated to ensure the safety of Resident 1, other residents, and facility staff, the facility continues to keep Resident 1 under one-to-one observation for close monitoring. During a concurrent interview and record review with the DON, on August 1, 2024, at 12:45 PM, the DON reviewed the facility's policy and procedure (P&P) titled, Abuse and Neglect prevention management, revised December 2014, and stated that despite following all facility procedures and implementing interventions each time Resident 1 displayed behavior issues, the five residents affected by the bear spray should not have had to experience these situations. A review of the facility's P&P titled, Abuse and Neglect prevention management, revised December 2014, indicated, POLICY. It is the policy of the facility to ensure our residents safe . DEFINITIONS . Resident to resident altercations is an incident involving a resident who inflicts injury on another resident . Everyone's Responsibility. It takes a team to keep our residents safe. The multidisciplinary team identifies risk and develops interventions to manage resident safety, evaluates the effectiveness of interventions . INVESTIGATION C. Incidents and Accident reports and documentation will be reviewed by the multidisciplinary team, on the first business day after the occurrence, to identify events, patterns or trends . D. All unusual occurrences need to be reported to immediate supervisor for an investigation. Additional investigation components will be completed . PROTECTION. A. The protection of the residents is our main concern. B. Residents will be protected from harm during an investigation. C. Residents will be separated or moved to a place of safety, away from a harmful or abusive situation, to prevent a reoccurrence and for their protection INCIDENT MANAGEMENT. The facility system to follow up on altercations will place an emphasis on preventing future altercations. This system includes but is not limited to: Care Plan updates to incorporate individualized recommendations from the formal incident review process, in addition to the immediate updates that may have occu1 at the time, prior to the altercation .

Based on observation, interview, and record review, the facility failed to have a full-time qualified Dietary Services Supervisor, who was responsible for overseeing daily food production for breakfast, lunch, and dinner. This failure led to sanitation issues in the kitchen (cross-reference F-tag 812), staff who were not competent (cross-reference F-tag 802), deficiencies with food palatability when kitchen staff were using disposable dishware for resident meals (cross reference F-tag 804), and had the potential to affect 92 medically compromised residents at nutrition risk who received food from the kitchen. Findings: During an initial kitchen tour observation and interview, on May 2, 2023, at 8:50 AM, with Cook 1, Cook 1 stated the facility did not have a Dietary Services Supervisor. During an interview, with the Director of Nursing (DON), on May 2, 2023, at 11:35 AM, the DON stated the former Dietary Services Supervisor quit on April 24, 2023, via text message. During a review of an undated facility provided copy of a printed text message, it indicated, Good morning, (Administrator), I'm (Dietary Services Supervisor (DSS)), I want to let you know (I) give my resignation for position Dietary Supervisor since 4/24/2023 (April 24, 2023). During an interview, with the Registered Dietitian (RD), on May 4, 2023, at 12:25 PM, the RD stated the facility knew they needed to have a full-time Dietary Services Supervisor. During a review of an undated facility document titled Job Description and Performance standards, it indicated, the purpose of this position is to implement and maintain, effective system to operate the dietary department and provide food services to residents in a cost-effective, efficient manner to safely meet residents needs in compliance with federal, state, and local requirements. In addition: Delegation of authority is delegated to the individual in this position to: - Implement dietary and food service policies and procedures to meet resident's needs and in compliance with federal, state, and local requirements. - Determine the personnel requirements for the dietary department to make recommendations for sufficient staff to implement dietary and food service policies and procedures. - Implement and monitoring system for the dietary and food service department and make recommendations for implementation to assure compliance with federal, state, and local requirements. - Supervise preparation of menus to meet residents' dietary needs. - Assess residents' dietary needs and develop appropriate dietary plans in compliance with physician's orders - Supervise the entire operation of the dietary department.

Based on observation, interview, and record review the facility failed to store and serve food that conserved flavor and appearance and was an appetizing temperature when: 1. A 20-pound box of carrots was stored in the freezer, open and unsealed, and was available for use. 2. In the cooking area, there was a container with onions sprouting and growing mold, and potatoes that were sprouting, and was available for use. 3. Residents were served lunch on May 2, 2023, on Styrofoam take-out containers and with plastic utensils These failures had the potential to cause 92 medically compromised residents who received food from the kitchen not to enjoy their food which could affect their nutrition status. Findings: 1. During an initial kitchen tour observation, on May 2, 2023, at 8:33 AM, there was a 20-pound open box of frozen carrots in the freezer. It was open, unsealed, and was available for use. During an interview with the Registered Dietitian (RD), on May 4, 2023, at 12:25 PM, the RD stated all food should be sealed before being placed in the freezer. During a review of the facility's policy and procedure titled Procedure for Freezer Storage, dated 2018, it indicated, . Procedure . 5. Store frozen foods in an airtight moisture-resistant wrapper such a plastic bag or freezer paper to prevent freezer burn. 2. During an initial kitchen tour observation, on May 2, 2023, at 9:32 AM, in the cooking area, there was a container with onions sprouting and growing mold. Three onions were sprouting, and one had mold on the side. There were red potatoes, stored in a plastic container, growing roots. The onions and potatoes were available for use. During an interview, with the RD, on May 4, 2023, at 12:28 PM, the RD stated if the vegetables were sprouting, growing roots or have mold, they should be immediately thrown out. During a review of the facility's policy and procedure titled Produce Storage guidelines, dated 2018, it indicated, . may use longer if no signs of spoilage are visible. During a review of the facility's policy and procedure titled General Receiving of Delivery of food and supplies, dated 2018, it indicated . Produce is to be fresh of any wilting or spoilage. During a review of the facility's policy and procedure titled Storing Produce, dated 2018, it indicated: . 1. Check boxes of .and vegetables for rotten, spoiled items. One .or potato in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items. 3. During a concurrent observation and interview, in the kitchen on May 2, 2023, at 12:19 PM, dietary staff were plating food for the residents for lunch. Dietary Aide 1 (DA 1) was adding utensils to the trays for each resident. DA 1 started using plastic forks. DA 1 stated they ran out of the metal forks. During an observation and concurrent interview, in the dining room, on May 2, 2023, at 1:04 PM, residents were eating lunch. Their meals were served on Styrofoam take-out containers. Some had plastic utensils or a mix of plastic and metal utensils. Certified Nursing Assistant (CNA 1) stated there were no specific reason the kitchen served their meals on the Styrofoam take-out containers. CNA 1 further stated they sometimes serve the meals in them but she was not sure why. During an interview, with Resident 26, on May 2, 2023, at 1:05 PM, Resident 26 was unable to verbalize if the temperature of her meal, which was served in a Styrofoam take-out container, was satisfactory. During an interview, with Resident 35, on May 2, 2023, at 1:07 PM, Resident 35 could not verbalize if her meal, which was served in a Styrofoam take-out container, was a good temperature. She was unable to respond. During an observation and concurrent interview, with Resident 23, on May 2, 2023, at 1:18 PM, Resident 23's meal tray contained plastic utensils. She stated she would had preferred metal utensils because staff have to feed her and it was more difficult with the plastic utensils. During an interview, with the RD, on May 4, 2023, at 12:25 PM, the RD stated they should not be serving meals on Styrofoam take-out containers or using plastic utensils. During a review of the facility's policy and procedure titled Meal Service, dated 2018, it indicated .7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot.

Based on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen in accordance with professional standards for food safety when: 1. Three-compartment sink was not sanitizing dishes. It required 200 ppm (part per million- unit of measurement) of quaternary ammonia (chemical used to kill bacteria, viruses, and mold). The test was conducted and resulted to 100 ppm of quaternary ammonia. 2. The stainless steel shelf, used to store clean metal pans, had a sticky residue and food crumbs. 3. The floor, under the stainless steel shelves, had dirt, food crumbs, and black grime. 4. Three cupcake pans, stored on a shelf, had black burn residue and were available for use. These failures had the potential for microorganism growth that could be inadvertently transferred to the food of 92 medically compromised residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview, in the kitchen, on May 2, 2023, at 8:55 AM, the three-compartment sink was inspected. A Dietary Aide 1 (DA 1) tested its' sanitation with a quaternary ammonia. It indicated a result of 100 ppm. DA 1 stated it should be 200 ppm. During an interview with the Registered Dietitian (RD), on May 4, 2023, at 12:20 PM, the RD stated if the sink did not have the correct level of quaternary ammonia then the dietary staff should stop using the three-compartment sink immediately, and switch to using the dish machine for cleaning and sanitizing pots and pans. During a review of the facility's policy and procedure titled 3 Compartment Procedures for Manual Dish Washing, dated December 2014, it indicated . Step 5 the third compartment is for sanitizing. Fill the third compartment with clean, clear to the fill line (20 gallons.) . Test the concentration with appropriate test strip, which is a dipped in the sanitizer solution 10 seconds before reading . Must read 200 ppm . During a review of the Food and Drug Administration (FDA) Federal Food Code, dated 2022, under 4-603.16, it indicated Efficacious sanitization depends on ware washing being conducted within certain parameters. Other parameters, such as rinse pressure, temperature, and chemical concentration are used in combination with time to achieve sanitization. 2. During an observation in the kitchen, on May 2, 2023, at 8:50 AM, the stainless steel shelf, used to storing clean metal pans, had a sticky residue when touched, and had food crumbs. During an interview with the RD, on May 4, 2024, at 12:25 PM, the RD stated shelves should be kept clean and free of any crumbs or residue. During a review of the facility's policy and procedure titled Sanitation, dated 2018, it indicated . 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion . During a review of the FDA Federal Food Code, dated 2022, under 4-601.11, it indicated (C) Nonfood- contact surfaces of equipment shall be kept free of accumulation of dust, dirt, food residue and other debris. Under 4-602.13, it indicated The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During an observation in the kitchen, on May 2, 2023, at 8:52 AM, the floor, under the stainless steel shelves, had dirt, food crumbs and black grime. During an interview with the RD, on May 4, 2023, at 12:27 PM, the RD stated the floors should be kept clean and free of any crumbs or residue. During a review of the facility policy and procedure titled Sanitation, dated 2018, it indicated . 14. The kitchen staff is responsible for al the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. During a review of the FDA Federal Food Code, dated 2022, under 4-601.11, it 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, indicated The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 4. During an observation in the kitchen on May 2, 2023, at 8:45 AM, three cupcake pans, which were stored on a shelf, had black burn residue and was available for use. During an interview with the RD, on May 4, 2023, at 12:10 PM, she stated the dietary staff should clean the black burn residue off of the cupcake pans. She further stated if it cannot be cleaned off, it needed to be replaced. During a review of the facility policy and procedure titled Sanitation, dated 2018, it indicated . 9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion . During a review of the FDA Federal Food Code, dated 2022, under 4-602-12, it indicated Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use.

Based on observation, interview, and record review, the facility failed to ensure their policy and procedures for the use of physical restraints was followed for five of five Justice -Involved Residents (JIR, residents under the care of law enforcement, community supervision, in custody, held involuntarily through operation of law enforcement authorities) (Residents 1,2, 3, 4, and 5) were denied the right to be treated with respect and dignity including the right to be free from any physical restraint imposed for the purpose of discipline and not required to treat the resident ' s medical condition. The facility instead imposed the policies and procedures of the California Department of Corrections and Rehabilitation (CDCR), which maintained the custody of public offenders (inmates) to be always shackled at the ankle to the bedrail. In addition, the facility failed to ensure for five of five sampled residents (Residents 1,2,3,4 and 5) there were ongoing assessments, monitoring and documentation of shackles/restraints. These failures had the potential to place clinically compromised Residents (Resident 1,2,3,4 and 5) at risk of serious injury and psychosocial harm, resulting from the lack of nursing assessments, monitoring, and documentation of their skin integrity due to shackles/restraints. Findings: During observation of Resident 1 on August 11, 2022, at 4:14 PM, in Red Zone (a separation of Residents who have tested positive for COVID 19 a contagious respiratory virus), Resident 1 was lying in bed unshackled with one end of the [NAME] attached to bedrail. During an observation on August 15, 2022, at 2:15 PM, Resident 1 was observed sitting on side of the bed, no [NAME] was noted on either ankle. One end of the [NAME] was attached to the bedrail and both of Resident 1's legs appeared to have mild swelling. During review of Residents 1's Admission Record (general demographics) on August 11, 2022, the document indicated Resident 1 was initially admitted to the facility on [DATE] with readmission July 07, 2022, with diagnosis (DX) which included: heart failure (heart does not pump as well), chronic embolism and [CONDITION(S)] (blood clot develops in blood vessel), [CONDITION(S)] pectoris (severe pain in chest), [CONDITION(S)] (low blood pressure), [CONDITION(S)] of liver (liver damage/failure usually related to alcoholism), ascites (accumulation of fluid in abdominal cavity), weakness, abnormalities of gait and mobility, moderate intellectual disabilities (delay in developmental milestones with intelligent quotient of 35-49), [CONDITION(S)] (low activity of [CONDITION(S)]), [CONDITION(S)] (a thought disorder characterized hallucinations and delusions) anxiety disorder due to known physiological condition (feelings of worry), pain, gastro-[CONDITION(S)] reflux disease without esophagitis (gastric fluid backflow into the esophagus), dependence on supplemental oxygen, long term (Current) use of anticoagulants (blood thinners). During review on August 11, 2022, at 11:14 AM, of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. During review of Resident 1's Care plan related to restraint/[NAME] indicated, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH-State Hospital contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. Date Initiated: July 07, 2022. GOAL: Resident will Not develop, if possible, skin discoloration, impaired circulation, and skin breakdown QD (every day) X (times) 90 days. Date initiated July 07, 2022, Revision on July 26, 2022, Target Date October 07, 2022. INTERVENTION: Assessment of skin integrity to extremities that have CDCR safety and escape prevention device for skin discoloration, impaired circulation, and skin breakdown. Date initiated July 08, 2022. Check extremities with shackles every 2 hours and as needed. Date initiated July 07, 2022, Monitor, document and report any negative outcome such as skin discoloration, impaired circulation and skin break down. Date initiated July 07, 2022. Notify MD and [Name of state hospital] Medical Services for any changes in condition. Date initiated July 07,2022. During review of Resident 1's medical records under Nurses Progress Notes on August 11, 2022, between 11:14 AM and 11:28 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Resident 1's admission on June 7, 2022, through August 11, 2022. Under the section for the MDS (Minimum Data Set- a computerized assessment tool), there was no documented evidence Resident 1 had been triggered for the use of restraints from July 07, 2022, to August 11, 2022. On Resident 1's Treatment Administration Records (TAR) dated from June 7, 2022, through August 11, 2022, there was no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During an observation of Resident 2 on August 10, 2022, at 2:16 PM, the left ankle was shackled to the bedrail. During an observation of Resident 2 on August 15, 2022, at 2:15 PM, it was noted there was a [NAME] to the left ankle which was attached to the bedrail. During an interview with Resident (2) on August 10, 2022, at 2:16 PM, Resident 2 stated, the corrections officer will release the [NAME] only for showers and when working with Physical Therapy comes, but an officer will remain at Resident 2's side during that time. During a follow-up interview with Resident 2 on August 15, 2022, at 2:15 PM, Resident 2 stated, The nurse does not come and assess my ankle. During review on August 11, 2022, of Resident 2's Admission Record (general demographics),the record indicated the admitted June, 22, 2022, with (DX) of aftercare following joint replacement surgery, anxiety disorder(feeling of worry), presence of right artificial hip joint, chronic obstructive pulmonary disease (difficult to breath), [CONDITION(S)], unspecified, not intractable, without [CONDITION(S)] weakness ([CONDITION(S)] disorder), abnormalities of gait and mobility, [CONDITION(S)] (high cholesterol), extrapyramidal and movement disorder unspecified(uncontrollable movements), [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), vitamin deficiency, [CONDITION(S)] (problems falling asleep), unilateral primary [CONDITION(S)] right hip (breakdown of cartilage in joints), other muscle spasms, essential primary hypertension (high blood pressure), constipation (difficulty emptying bowel), pain, personal history of in-situ neoplasm of cervix uteri(early stage of cervical cancer), personal history of healed traumatic fracture, long term (current) use of anticoagulants(blood thinners), encounter for prophylactic measures unspecified, exposure to COVID-19 ( a contagious respiratory virus). During review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. During review of Care plan indicates, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of state hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. Date Initiated: June 22, 2022, Revision on July 07, 2022, Target Date September 22, 2022. GOAL: Resident will not develop, if possible, skin discoloration, impaired circulation, and skin breakdown QD (every day) X (times) 90 days. Date initiated June 22, 2022, . INTERVENTION: Assessment of skin integrity to extremities that have CDCR safety and escape prevention device for skin discoloration, impaired circulation, and skin breakdown. Date initiated June 22, 2022. Check extremities with shackles every 2 hours and as needed. Date initiated June 22, 2022, Monitor, document and report any negative outcome such as skin discoloration, impaired circulation and skin break down. Date initiated June 22, 2022. Notify MD and [name of state hospital] Medical Services for any changes in condition. Date initiated June 22,2022. During review of Resident 2's medical records under Nurses Progress Notes on August 11, 2022, at 11:14 AM and 11:28 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Resident 2's admitted [DATE], through August 11, 2022. Under the section for the MDS (Minimum Data Set- a computerized assessment tool), there was no documented evidence Resident 2 had been triggered for the use of restraints from June 22, 2022, through August 11, 2022. Review on August 11, 2022, Resident 2's Treatment Administration Records (TAR) no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During observation of Resident 3 on August 10, 2022, at 2:21 PM and August 11, 2022, at 1:21 PM, noted [NAME] to left ankle attached to bedrail. During interview with Resident 3 on August 11, 2022, at 1:21 PM, when asked, how do you feel about the [NAME]? Resident stated, It's normal. During review of Residents 3's Admission Record (general demographics) on August 11, 2022, indicated admitted [DATE], with (DX) of abscess of liver (pus-filled pocket of fluid in the liver), unspecified [CONDITION(S)] not due to a substance or known physiological condition, dependence on supplemental oxygen, [CONDITION(S)] (thought process disorder characterized by hallucinations and delusions), anxiety disorder (feeling of worry), constipation (inability to empty bowel), gastro-[CONDITION(S)] reflux disease without esophagitis (gastric fluid backflows into the esophagus),exposure to COVID-19. During review of Resident 3's on August 11, 2022, at 11:14 AM, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. During review of Care plan indicates, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. Date Initiated: July 19, 2022. GOAL: Resident will not develop, if possible, skin discoloration, impaired circulation, and skin breakdown QD (every day) X (times) 90 days. Date initiated July 19, 2022, Revision on August 03, 2022, Target Date October 19, 2022. INTERVENTION: Assessment of skin integrity to extremities that have CDCR safety and escape prevention device for skin discoloration, impaired circulation, and skin breakdown. Date initiated July 19, 2022. Check extremities with shackles every 2 hours and as needed. Date initiated July 19, 2022, Monitor, document and report any negative outcome such as skin discoloration, impaired circulation and skin break down. Date initiated July 19, 2022. Notify MD and, [name of State Hospital] Medical Services for any changes in condition. Date initiated July 19,2022. During review of Resident 3's medical records under Nurses Progress Notes on August 11, 2022, at 11:14 AM and 11:28 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Resident 3's admitted [DATE], through August 11, 2022. Under the section for the MDS (Minimum Data Set- a computerized assessment tool), there was no documented evidence Resident 3 had been triggered for the use of restraints from July 19, 2022, through August 11, 2022. Review on August 11, 2022, Resident 3's Treatment Administration Records (TAR) had no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During observation of Resident 4 on August 10, 2022, at 2:22 PM and August 17, 2022, at 12:43 PM, noted [NAME] to left ankle attached to bedrail. During review of Residents 4's Admission Record (general demographics) on August 11, 2022, indicated admitted [DATE], with (DX) of end stage renal disease (kidney failure), pneumonia (lung inflammation, bacterial/[CONDITION(S)] infection), encounter for adequacy for hemodialysis (filter waste and water from blood), weakness, other abnormalities of gait and mobility, [CONDITION(S)] (low activity of [CONDITION(S)]), [CONDITION(S)] (low normal red blood cells), [CONDITION(S)] with lower urinary tract symptoms(enlarge prostate), dyspnea (difficulty/labored breathing), [CONDITION(S)] (thought disorder characterized by hallucinations and delusions), essential primary hypertension (high blood pressure), gastro-[CONDITION(S)] reflux disease without esophagitis (gastric fluid backflow into the esophagus),vitamin deficiency, dehydration (loss or reduction of water), dependence on supplemental oxygen, contact with and suspected exposure to COVID-19, long term (current) use of anticoagulants (blood thinners). During review of Resident 4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. During review of care plan indicates, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of state hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. Date Initiated: August 06, 2022. GOAL: Resident will Not develop, if possible, skin discoloration, impaired circulation, and skin breakdown QDX90 days. Date initiated August 06, 2022, Target Date November 04, 2022. INTERVENTION: Assessment of skin integrity to extremities that have CDCR safety and escape prevention device for skin discoloration, impaired circulation, and skin breakdown. Date initiated August 06, 2022. Check extremities with shackles every 2 hours and as needed. Date initiated August 06, 2022, Monitor, document and report any negative outcome such as skin discoloration, impaired circulation and skin break down. Date initiated August 06, 2022. Notify MD and [name of state hospital] Medical Services for any changes in condition. Date initiated August 06, 2022. During review of Resident 4's medical records under Nurses Progress Notes on August 11, 2022, at 11:14 AM and 11:28 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Resident 4's admitted [DATE], through August 11, 2022. Review on August 11, 2022, Resident 4's Treatment Administration Records (TAR) had no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During observation of Resident 5 on August 11, 2022, at 4:14 PM in Red Zone (a separation of Residents who have tested positive for COVID 19 a contagious respiratory virus), Resident 5 was lying in bed unshackled with one end of the [NAME] attached to bedrail. During review of Residents 5's Admission Record (general demographics) on August 11, 2022, indicated admitted [DATE], with (DX) of COVID 19 (acute respiratory illness caused by coronavirus), chronic [CONDITION(S)] [CONDITION(S)] (infection by a virus attacks the liver), [CONDITION(S)] disorder (mental condition, altering elation and depression), chronic obstructive pulmonary disease (difficult to breath), [CONDITION(S)] pneumonia (inflamed due to infection), [CONDITION(S)], unspecified, not intractable, without [CONDITION(S)] weakness ([CONDITION(S)] disorder), supraventricular [CONDITION(S)] (faster than normal heart rate), overactive bladder, vitamin deficiency, essential primary hypertension, (high blood pressure), [CONDITION(S)] (low levels of [CONDITION(S)]), [CONDITION(S)] disorder, [CONDITION(S)] type (psychotic/mood disorder symptoms), major depressive disorder, recurrent (mental disorder persistent feeling of sadness/loss of interest), anxiety disorder(feeling of worry), secondary hypertension (high blood pressure caused by another medical condition), gastro-[CONDITION(S)] reflux disease without esophagitis (gastric fluid backflow into the esophagus),constipation (difficult empty bowel, shortness of breath (difficulty in breathing). During review of Resident 5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. During review of care plan indicates, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of state hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] such as skin discoloration, impaired circulation, and skin break down. Date Initiated: August 08, 2022. Revision on August 08, 2022, GOAL: Resident will Not develop, if possible, skin discoloration, impaired circulation, and skin breakdown QD (every day) X(times) 90 days. Date initiated August 08, 2022, Target Date November 06, 2022. INTERVENTION: Assessment of skin integrity to extremities that have CDCR safety and escape prevention device for skin discoloration, impaired circulation, and skin breakdown. Date initiated August 06, 2022. Check extremities with shackles every 2 hours and as needed. Date initiated August 08, 2022, Monitor, document and report any negative outcome such as skin discoloration, impaired circulation and skin break down. Date initiated August 08, 2022. Notify MD and [name of state hospital] Medical Services for any changes in condition. Date initiated August 08, 2022. During review of Resident 5's medical records under Nurses Progress Notes on August 11, 2022, at 11:14 AM and 11:28 AM, there was no documented evidence of restraint assessments, or skin assessments due to shackles/restraints being done since Resident 5's admitted [DATE], through August 11, 2022. Review on August 11, 2022, Resident 5's Treatment Administration Records (TAR) had no documented evidence the shackles/restraints had been removed and the skin checked as indicated in care plan. During an interview on August 10, 2022, at 2:24 PM, with a Correctional Officer 1 (CO 1), the officer stated, We have officers here 24 hours 7 days a week for these residents. The shackles are on because they are in our custody, per our Policy and Procedure. Because they are under our custody, they have them on. States, it really depends on the resident's behavior, we give (JIR) a courtesy. During an interview on August 10, 2022, at 2:36 PM, with a Certified Nursing Assistant (CNA1), CNA 1 stated, These residents don't go to activities, the most they do is walk the hallways with physical therapy with the C.O. They don't have activities here. These residents are shackled. During an interview on August 10, 2022, 2:41 PM, with a licensed vocational nurse (LVN 2), LVN 2 stated she was not sure how long the justice involved residents (JIR) are shackled for and stated that the COs will unshackle them. LVN 2 indicated only these JIR are shackled in this facility. During interview on August 10, 2022, at 3:01 PM, with the MDS (Minimum data set- a computerized assessment program) Nurse, stated, There is a CO 24/7 (24 hours a day, seven days a week) with these residents. They have shackles on while in bed. The resident can stand on side of bed, [the] chain is long enough. The MDS Nurses further stated, It depends on the CO if they have it [the shackles] on or off. They don ' t go to activities, because they cannot be with other residents, the activities director will give them activities in room, but the CO must go through it. During interview with the Administrator on August 10, 2022, at 3:31 PM, when asked to show the facility's policy on the admission and care of justice involved residents, the administrator stated, I think the State Hospital should have one. During interview with the Director of Nursing (DON) on August 10, 2022, at 3:13 PM, the DON stated, We get these residents from State hospital, court ordered. They could come to us with a CO at bedside and shackles. They are on no gradual dose reduction on psych[iatric] meds(medication) because they might kill. Each of the residents are shackled to the bed. Each resident has an order by doctor for the shackles. It's up to the CO, we have no control over the shackles. When asked for the facility policy and procedure for caring for the use of shackles on resident/inmates, the DON stated, We have never seen a policy and procedure for shackles on inmates. During a follow up interview and concurrent record review of the contract with CDCR, with the MDS Nurse on August 10, 2022, at 3:54PM, the MDS nurse stated, The facility is following policy in the agreement with State hospital. It's in section Exhibit A section S The MDS Nurse continued reading that section in contract agreement. During concurrent interview and record review of the MDS records, Treatment Administration Records (TARs), Restraint Assessments and Nurses Notes for Residents 1,2, 3, 4, and 5 with the MDS Nurse on August 11, 2022, at 11:28 AM, when asked why the section of the MDS was not triggered for restraints on these residents? The MDS nurses stated, Because when I has hired, I was told it (the shackles) not a restraint, it's a court ordered safety device. When asked to review the Treatment Administration Record TAR, Restraint Assessments, and Nurse Notes on shackles/restraints on all 5 of 5 residents. The MDS Nurse stated there was no record of skin assessment regarding shackles. When asked, who was assessing for skin discoloration on these residents? the MDS Nurse stated, It's not documented anywhere, but the Correctional Officers (CO's), Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) will do the assessing on these residents. They check every two hours, but only document if there was a negative outcome as per in the care plan. The shackles/restraints. MDS Nurse stated Restraint Assessments are not done on these [Name of State Hospital] shackled residents. During a follow up interview and concurrent interview of the care plans for Residents 1, 2, 3, 4 and 5 with the DON on August 11, 2022, at 11:38 AM, the DON was shown care plans regarding the use of shackles, and the intervention listed to do assessments every two hours. The DON was unable to provide documented evidence these assessments were being conducted and stated, There is no documentation, because it's not a restraint. That's why it was not triggered on the MDS. I need to stand with the agreement and their policy from [Name of State Hospital]. During an interview on August 11, 2022, at 1:18 PM, with CO 2, when asked, how often do you take off the restraints? CO 2 stated, Technically I can't take it off, but when they need to use the restroom, shower, or care it's removed. When asked how often are the are the nursing staff coming in to check on residents? CO 2 stated, Every hour to two hours, it depends on the resident's medical needs. I can't say how many times they come in a day. During an interview on August 11, 2022, at 1:35 PM with CNA 2, when asked why they do when the COs take off the cuffs, CNA 2 stated, The CO's take off the cuffs. I don't do anything else with the cuffs, I just check on them because they can't go out. During an interview on August 11, 2022, at 1:40 PM, with CNA 3, when asked about the cuffs, CNA 3 stated, I don't do anything with the cuffs. When they first come in, they are in isolation, they are here in the front hall. When asked about if CNA 3 had any in-services or training on Justice involved residents (JIR)? CNA 3 stated, We were taught to treat them like regular people, that's it, no training with the cuffs/shackles. During an interview on August 11, 2022, at 1:52 PM, with a licensed vocational nurse (LVN 1), LVN 1 stated the nurse goes in room for med pass, the CO assess shackles and if there is a change of condition with the skin, the LVN will make a progress note. The CNAS tell the licensed nurses if there was something new with these residents. During an interview on August 11, 2022, at 2:07 PM, with a registered nurse (RN 1), RN 1 stated, We have a standing order on admission for shackles, RN 1 stated she has not received any in-service on these types of residents and has not cared for inmates before or residents with restraints. During a concurrent interview and record review with the Director of Staff Development (DSD) on August 11, 2022, at 2:13 PM, when asked what training was provided for the staff on inmate shackled residents? The DSD stated, We always make sure safety, CO in room always, they [staff] will ask the CO to remove the shackles. When asked, to provide documentation of in-service education specific to inmate shackles/restraint residents? the DSD stated, They are a different cliental, so the training should be different right? The same education, with orientation skills, and there is a check off list. The CO will remove the shackles. A resident with restraint, it would be different. When asked if a [NAME] or cuffs was a restraint? The DSD stated, Yes, but there are still able to move. When asked, if the five residents could walk to the door? The DSD stated, No. The DSD acknowledged the [NAME] would be considered a restraint. The DSD stated that staff were not able to touch the shackles. They could assess the area of the [NAME], but she has not educated staff on restraints, because shackles are not restraints, so we are not training. The DSD could not provide documentation of in-services caring with residents in shackles/restraint completed for 2022. A concurrent interview and record review of the facility's policy and procedure (P&P) titled, Physical Restrain Application dated revised December 2014, with the DON on August 11, 2022, at 3:05 PM, was conducted. The policy physical restraint is defined by the [name of oversight agency] as any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of the movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint. The resident must be physically and cognitively able to self-release devices such as Velcro, lap trays, or tables, seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the device is considered a restraint.) The DON stated. A restraint was restricting movement, and the resident's ability to transfer and to get out of bed, but shackles are not a restraint, because they are not the same resident as the others. After review of the facility's P&P regarding restraints, the DON agreed with definition and stated. They cannot move on restraints. It doesn't apply to these residents. A restraint is a restraint, but they are treated differently. I don't want to agree that it's a restraint. They are incarcerated residents, but its safety for other residents. There was no documented evidence provided to indicate these residents are being monitored or assessed while in shackles. The DON stated that she agreed these were restraints and Residents 1, 2,3,4 and 5 should be monitored and assessed and the findings documented. The DON stated there should be training on how to care for these residents. During an interview on August 15, 2022, at 2:16 PM, with CO 4, stated to the Surveyor, You are not supposed to be asking the inmates any questions. They are not regular residents of this facility. [You] need to contact supervisor from CDCR or State hospital first. During a follow up interview with the DON on August 16, 2022, at 2:23 PM, the DON stated, They are incarcerated, and forensic criminal residents need to be shackled. When they come from State hospital they are shackled or go to another facility they have shackles with CO at bedside. They remain shackled here. When they go to appointments, they are shackled. The consent for shackles is vested in the order from State hospital and our management. The consent is obtained from CDCR, State hospital, our facility, and our doctor. They are aware of the shackles. When asked, if assessments are done initially when the JIR come into the facility, to determine the medically necessity for the restraints? The DON stated, Restraints are necessary for the safety of the residents and staff. It is necessary because it is a court order as well as CDC guidelines. It is not used for discipline or staff convenience or other residents in medical center. The DON restated the shackles were not defined as a [TRUNCATED]

Based on observations, interviews and record reviews, the facility failed to ensure resident's rights were honored for Justice Involved Residents (residents in custody) five of five residents (Residents 1, 2, 3, 4, and 5) and had their needs met consistent with federal regulations ensuring all residents have equal access to care regardless of their diagnoses, when the facility allowed the criminal justice system to deny the same treatment and rights such as participation in activities of their choice and freedom of movement around the facility to these five clients. This failure resulted in Residents 1, 2, 3, 4, and 5 to be shackled by one ankle to the bed frame except for toileting or showering and denied the right to move around their room, participate in activities or to be interviewed by state agency surveyors, which has the potential for severe psychosocial harm. All decisions were made by the correction officers (COs) present with each justice involved resident and superseded the federal regulations regarding providing the same care and privileges to all residents to be followed by the facility. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was initially admitted to the facility on [DATE] with readmission July 7, 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract). During a review of Resident 1's Care Plan related to restraint/[NAME] indicated, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patient is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH-State Hospital contract) Resident is a risk for negative effects of use of [NAME] .Date Initiated: July 07, 2022. During an observation of Resident 2, in her room, on August 10, 2022, at 2:16 PM, the left ankle was shackled to the bedrail. During an observation of Resident 2, on August 15, 2022, at 2:15 PM, it was noted there was a [NAME] to the left ankle which was attached to the bedrail. During an interview with Resident 2, on August 10, 2022, at 2:16 PM, Resident 2 stated, the corrections officer will release the [NAME] only for showers and when working with Physical Therapy when they come. For activities they bring puzzles and coloring to the room, [I]can ' t go out to patio area. During a review of Resident 2's Admission Record (general demographics) dated June 22, 2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Physician Order, dated June 23, 2022, at 11:18 AM, indicated, Resident under the custody of California Department of Correction and Rehabilitation (CDCR, [name of State Hospital] Patients) is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract). During a review of Resident 2's Care Plan related to restraint/[NAME] indicated, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH-State Hospital contract) Resident is a risk for negative effects of use of [NAME] .Date Initiated: June 22, 2022. During observation of Resident 3, in his room, on August 10, 2022, at 2:21 PM and August 11, 2022, at 1:21 PM, Resident 3 had a [NAME] to left ankle which was attached to the bedrail. During interview with Resident 3, on August 10, 2022, at 2:21 PM, Resident 3 stated, Activities are brought to room. We don ' t go to the activities room. During interview with Resident 3, on August 11, 2022, at 1:21 PM, when asked, how do you feel about the [NAME]? Resident 3 stated, It's normal (having use of shackles). During a review of Residents 3's Admission Record (general demographics) document indicated, admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's Physician Order, dated July 19, 2022, at 6:22 PM, indicated, Resident under the custody of California Department of Correction and Rehabilitation (CDCR, [name of State Hospital] Patients) is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of State Hospital] contract) Resident is a risk for negative effects . During a review of Resident 3's Care Plan related to restraint/[NAME] indicated, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH-State Hospital contract) Resident is a risk for negative effects of use of [NAME] .Date Initiated: July 19, 2022. During an observation of Resident 4, in his room, on August 10, 2022, at 2:22 PM and August 17, 2022, at 12:43 PM, Resident 4 had a [NAME] to left ankle which was attached to bedrail. During a review of Residents 4's Admission Record (general demographics) indicated admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's Physician Order, dated August 6, 2022, at 7:16 PM, indicated, Resident under the custody of California Department of Correction and Rehabilitation (CDCR, [name of state hospital] Patients) is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects . During a review of Resident 4's Care Plan related to restraint/[NAME] indicated, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH-State Hospital contract) Resident is a risk for negative effects of use of [NAME] .Date initiated August 06, 2022. During a review of Residents 5's Admission Record (general demographics) indicated admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During review of Resident 5's Physician Order, dated August 8, 2022, at 7:59 AM, indicated, Resident under the custody of California Department of Correction and Rehabilitation (CDCR, [name of state hospital] Patients) is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH- [name of state hospital] contract) Resident is a risk for negative effects of use of [NAME] . During a review of Resident 5's Care Plan related to restraint/[NAME] indicated, FOCUS: Resident under the custody of California Department of Correction and Rehabilitation CDCR, [name of State Hospital] Patients is under jurisdiction of CDCR. CDCR officers may use physical restraints or seclusion strictly for security and protection of patients and staff, and to prevent escape. (Exhibit A section S 2016 DSH-State Hospital contract) Resident is a risk for negative effects of use of [NAME] .Date Initiated: August 08, 2022. During an interview on August 10, 2022, at 2:24 PM, with a Correctional Officer 1 (CO 1), the officer stated, We have officers here 24 hours seven days a week for these residents. The shackles are on because they are in our custody, per our Policy and Procedure. During an interview on August 10,2022, at 2:36 PM, with a Certified Nursing Assistant (CNA 1), stated, These residents don't go to activities. The most they do is walk the hallways with physical therapy with the C.O. They don't participate in activities here. These residents are shackled (restrained). During an interview on August 10, 2022, at 2:41 PM, with a Licensed Vocational Nurse (LVN 2), LVN 2 stated she did not know how long the justice involved residents (JIR) are shackled. LVN 2 further stated, only these JIR (Residents 1, 2, 3, 4 and 5) are shackled (restrained) in this facility. During an interview on August 10, 2022, at 2:43 PM, with Resident 6, in her room, she stated, [name of state hospital] residents are not included in activities, and I have not seen them out in the patio. During interview on August 10, 2022, at 3:01 PM, with the MDS (Minimum Data Set- a computerized assessment program) Nurse, stated,There is a CO 24 hours a day, seven days a week with these residents. They have shackles on while in the bed. The resident can stand on side of bed, the chain is long enough. The MDS Nurses further stated, They don't go to activities, because they cannot be with other residents. During an interview with the Director of Nursing (DON), on August 10, 2022, at 3:13 PM, the DON stated, We get these residents from State hospital, court ordered. They come to us with a CO at bedside and shackles . Each of the residents are shackled to the bed. Each resident has an order by the doctor for the shackles. It's up to the CO, we have no control over the shackles. During an interview on August 11, 2022, at 1:18 PM, with CO 2, when asked, how often do you take off the restraints? CO 2 stated, I can ' t take it off, but when they need to use the restroom, shower, or receive care It ' s removed. During an interview on August 11, 2022, at 1:35 PM with CNA 2, when asked what care is done when the COs take off the cuffs. CNA 2 stated, I don't do anything else with the cuffs. I just check on residents, because they can't go out. During an interview and medical record review with the Director of Staff Development (DSD) on August 11, 2022, at 2:13 PM, when asked if a [NAME] or cuffs was a restraint? The DSD stated, Yes, but there are still able to move. When asked, if the five residents could walk to the door? The DSD stated, No. During an interview with DON on August 11, 2022, at 3:05 PM, DON stated, They cannot move while in restraints. A restraint is a restraint, but they (JIR) are treated differently. They are incarcerated (imprisoned) residents. During an interview on August 15, 2022, at 2:16 PM, with CO 4, stated to the Surveyor, You are not supposed to be asking the inmates any questions. They are not regular residents of this facility. During a follow up interview with the DON on August 16, 2022, at 2:23 PM, the DON stated, They are incarcerated, and criminal residents. When they come from State hospital, they are shackled. They remain shackled here. During a follow up interview with the Administrator AD1 on August 16, 2022, at 2:52 PM, Administrator stated, With inmates, well you know your privileges and liberties are taken away. They follow their sentence here. If they committed a crime, they have no rights. We keep shackles on them. They are inmates because they have committed a crime. When the administrator was asked if the resident gave consent, for the restraints the AD1 stated, No, because of their conviction, their freedom was taken away from them. During an interview with the Administrator on August 17, 2022, at 1:48 PM, AD1 stated, these are inmates they are bound to shackles. This is a court order; they have committed a crime. AD1 stated, How can I remove the shackles? How can I do that? It 's a court order. We must follow the order. During random interview of residents on September 7, 2022, between 9:35AM and 10:05 AM, when asked how they would feel of shackled to the bed or wheelchair and to not be able to participate in activities or move freely around their room or the facility, when other residents were not shackled, they responded as follows: a. 9:35 AM- Resident 6 stated, It would make me feel secluded, pinpointed out. b. 9:55 AM- Resident 7 stated, I would feel like an outsider, the only one with that condition. I would feel alone and isolated. Hopefully I would never get shackled. It would not feel good at all. Treating all residents, the same would be beneficial. c. 10:02 AM- Resident 8 stated, I would feel embarrassed, I would want no one to see me shackled. It would be humiliating. I think all residents should be treated the same way. During an interview with CNA 2, on September 7, 2022, at 10:11 AM, when asked if they were a resident in a facility where they were the only one shackled and not free to participate in activities, or to move freely about the facility, what impact if any, that could have on them, CNA 2 stated, I would feel left out, and different from everyone in the room. I would feel trapped in a room, feel left out. I would feel lonely and questioning why I'm shackled. It would be an overwhelming feeling for me. During an interview with Restorative Nursing Assistant (A certified nursing assistant with training in application of splints and range of motion) RNA 1, on September 7, 2022, at 10:15 AM, when asked if they were a resident in a facility where they were the only one shackled and not free to participate in activities, or to move freely about the facility, what impact if any, that could have on them, RNA 1 stated, I would feel embarrassed if I'm the only one shackled. Low self-esteem, they will ask what I did and why am shackled. I would feel below myself and left out. All resident need to be treated the same and get provided the same care. During a review of the facility's policy and procedure titled, Residents Rights, revised December 2014, The policy and procedure indicated, It is the policy of this facility to inform the resident, and/or responsible party, and/or agent (if any) of the rights of the resident on admission to aid with informing the resident of his/her rights and to exercise the rights to enhance the quality of care and everyday life in the facility. During a concurrent interview and review of S&C (Federal Survey and Certification letter) 16:21 with the Director of Nursing on August 31, 2022, at 10:31 AM, the DON stated she had never seen the document and was very helpful in educating the facility, and she would also review with staff. Per S&C 16:121 section D.Skilled Nursing Facility and Nursing Facilities, dated revised December 23, 2016, the document indicated, .nursing home cannot incorporate into care plans restrictions that violate resident rights and cannot serve as an agent of the pertinent law enforcement or criminal justice supervisory authority by enforcing supervisory conditions or reporting violations of those conditions to officials. Additionally, there can be no integration of the criminal justice. supervisory function into the essential operations or physical environment of the nursing home . It is possible that some DOCs or law enforcement ' s terms of supervision may conflict with CMS(Center for Centers for Medicare and Medicaid Services) requirements, if those terms affect the care and services being provided in the nursing home, or if the nursing home is violating an individual ' s rights by enforcing the terms directly. Under federal requirements, a nursing home cannot incorporate into care plans restrictions that violate resident rights and cannot serve as an agent of the pertinent law enforcement or criminal justice supervisory authority by enforcing supervisory conditions or reporting violations of those conditions to officials. . Nursing homes cannot impose conditions or restrictions that undermine resident rights and protections required by federal law. Facilities cannot require prospective residents to give up their rights as a requirement for admission. Resident rights in the nursing home include, but are not limited to the right to: Be free from physical or chemical restraints imposed for discipline or convenience, and not for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care [and] interact with members of the community both inside and outside the facility; . Personal privacy and confidentiality of his or her personal and clinical records; .Immediate access to any resident by the following: subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and subject to reasonable restrictions and the residen s right to deny or withdraw consent at any time, others who are visiting with the consent of the resident; . Be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Also, nursing home residents must not only be able to exercise their rights as residents of the facility and as citizens of the United States, but also have the right to be free of interference, coercion, discrimination, or reprisal from the facility in exercising those rights.14 .Facility Policies and Practices Some DOC or law enforcement terms of release or placement may conflict with the CMS requirements if the terms affect the care and services provided by the facility or violate the resident's rights. In such a case, if a facility agreed to enforce restrictive law enforcement terms applied to a resident (for example, restricting visitors), the nursing home would not be in compliance with federal requirements and would risk enforcement action and termination from participation if it did so.The facility may not establish policies or impose conditions on the resident that result in restrictions which violate federal law and regulation outlined in 42 CFR Part 483, Subpart B. The facility must promote care for its residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

Based on interviews and record reviews, the facility failed to ensure supervision of one of three residents (Resident A) identified as being an elopement (leaving building without permission from the physician) risk, when the facility discontinued the one on one supervision (one staff remains with resident at all times) due to insurance not paying for the service for this conserved resident (the court appoints a person to manage affairs of another person deemed by the court not competent to do so for themself) who had a history of elopement attempts and of removing his wander guard ( a device that will set off an alarm if a resident attempts to leave through any exit door). This failure resulted in Resident A not being located for two days, and when located he was taken to the general acute care hospital (GACH) were Resident A tested positive for [MEDICATION(S)] (a powerful, highly addictive illegal street drug which affects the central nervous system). Findings: An unannounced visit was made to the facility on [DATE] at 10:35 AM, to investigate a facility reported incident (FRI) regarding Resident A's elopement on December 23, 2021. During an interview with the Administrator (Adm) on December 24, 2021, at 11:15 AM, the ADM stated Resident A was not in the facility at the time of the investigation, and had not been located by the police or the facility. During a review of Resident A's face sheet (a facility's document which contains basic information about Resident A) indicated Resident A was admitted to the facility on [DATE], with diagnoses which included [CONDITION(S)] (a mental disease which caused disorganized thoughts), hypertension (high blood pressure) anxiety disorder (a mental disease which causes excessive worrying), major depressive disorder (a mental disease which causes sadness). Further review of Resident A's face sheet indicated Resident A was under conservatorship. During a review of Resident A's progress notes for the month of August, November and December 2021, it indicated prior to Resident A eloping on December 23, 2021, Resident A had previously eloped on August 25, 2021, August 30, 2021, November 6, 2021, and December 4, 2021. During a review of Resident A nurses' progress notes, the notes indicated Resident A had attempted elopements as follows: A. August 25, 2021, at 3:15 PM, documented, Resident had an attempted elopement this morning. Staff noted the resident at the bus stop across the street. Resident assisted back to the facility safely. Body assessment completed without injury noted. Resident assessed for pain and none noted. Resident able to perform ROM[range of motion- able to move arms and legs] to all extremities within limits without difficulty. Resident A left the facility unsupervised and crossed a busy street to go to the bus stop. B. August 30, 2021, at 7:15 PM, documented, .Staff continues with the search of the resident and resident found at [name of fast food restaurant] on [name of street] and [name of cross street] .Resident noted with 2 abrasions to the left hand, one on the palm of the hand and one on the top of the left hand, bilateral arm redness from the elbow down, redness to the upper chest and face, right knee abrasion and left knee discoloration. At 7:20 PM, MD [medical doctor] made aware of the resident return with findings of abrasions, discolorations and redness . Resident A left the facility unsupervised and crossed a busy street to go to a fast food restaurant and sustained injuries. C. November 6, 2021 at 1:11 PM, documented, This writer was returning from lunch and spotted resident at corner of east [name of street] and [name of cross street]. Resident was alone and unharmed alert and adamant about going to see his mom . Resident A left the facility unsupervised and was found at the corner. D. December 4, 2021 at 3:40 PM, documented, At 2:40 PM received a call from [name of hospital] spoke with nurse [name of the nurse] per nurse stated, 'We have your resident here in the ER (emergency room ). Doctor will see him first and we'll transfer him back to you guys. Resident A left the facility unsupervised and facility staff was unaware until the hospital called the facility and informed the facility staff Resident A was at the hospital in the ER. During a review of the Elopement Risk assessment dated [DATE], indicated Resident A was identified as a high risk for elopement. During a review of the nurses' progress notes dated December 4, 2021, at 2:54 PM, the notes indicated, DON (Director of Nurses), administrator, and all department heads notified of resident leaving the facility without notifying staff and resident is at [name of hospital] at this time. Per DON [nurses] to do full body assessment, check Level of Consciousness (LOC- an assessment to determine the level of alertness), elopement risk, notify conservator that he is on 1 to 1 supervision and needs to be discharge in a lock unit when resident returns. Dr. [name of the doctor] notified. Communicated. During a review of the Physician's order dated December 6, 2021, it indicated, 1 to 1 sitter to be provided by [name of insurance company] while awaiting for a lock[ed] unit transfer secondary to high risk for elopement and endangerment. During a review of the nurses' progress notes dated December 12, 2021, at 2:15 PM, it documented, .Resident removed his wander guard in front of writer and other charge nurses. Immediately intervene with resident, approach not to remove wander guard but unsuccessful, resident walk away from writer. Reapply wander guard to resident but refused, approach resident in a calm voice, encourage to vent feelings. Resident stated, 'I don't want to wear that, get away.' Explained risk and benefits and consequences. Verbalized understanding but still strongly refused. Called [name of sister] left voice message to encourage resident wear wander guard. Awaiting for response. Reality orientation provided, redirect resident. Again, explained the importance of wearing a wander guard and agreed, able to redirect after multiple attempts resident finally agreed to wear a wander guard. Reminded resident not to remove wander guard and verbalized understanding. Responsible party made aware regarding incident . During a review of the Physician's order dated December 13, 2021, at 4:15 PM, it documented, Discontinue one to one sitter to be provided by [name of insurance company] while awaiting for a lock[ed] unit transfer secondary to high risk for elopement and endangerment. During a review of the nurse's progress notes dated December 13, 2021 at 4:16 PM, it documented, Dr. [name of the doctor] made aware, that [name of the insurance company] can not provide a 1 to 1 sitter. Orders discontinued, noted and carried out. HMO [health maintenance organization- a health insurance] coordinator made aware, conservator called, no response. Staff to continue monitoring of residents whereabouts. During a review of Resident A's elopement care plan with an initiation date of July 31, 2021, indicated, Resident A is at risk for elopement as evidenced by ambulates independently, with or without devices, propels self in wheelchair independently, wanders throughout facility. Resident A's elopement care plan indicated an intervention with an initiation date of August 4, 2021, for hourly monitoring for close observation, and close monitoring of resident's whereabouts. There was no documented evidence that new interventions were added after each elopement attempt to try to prevent future attempts. Further review of Resident A's elopement care plan indicated an intervention with an initiation date of December 13, 2021, discontinue 1 to 1 sitter. Continue staff monitoring of residents whereabouts. During a review of nurses' progress notes dated December 23, 2021 at 8:30 PM, documented, CNA (Certified Nursing Assistant) called the Charge nurse, because resident not in his room. Charge nurse ordered to search all rooms, office, bathroom and shower room. Called CODE purple (a code which alerts staff to a missing resident) .charge nurse assigned Licensed Vocational Nurse and Certified Nursing Assistant to search within 5 miles into neighboring, hospital and restaurant and residential area. During a telephone interview with the Social Services Designee (SSD) on December 24, 2021, at 1 PM, the SSD stated, A facility has decided to take him, but not until next week. He eloped while waiting to transfer. He does not belong in this facility. This is not a locked facility. During an interview with a Licensed Vocational Nurse (LVN 4) on December 24, 2021 at 2:25 PM, LVN 4 stated she was the nurse in charge taking care of Resident A on Decemeber 23, 2021. She stated, The CNA reported to me she could not find the resident for his shower. I went looking for him. I did not hear the wander guard alarm go off. The resident has taken his wander guard off before. The LVN 4 further stated, I was busy that night. I had a Change of Condition and an admission. I cannot monitor him all the time. Resident has a history of removing his wander guard. The one to one should not [have] been discontinued. During a telephone interview with Certified Nursing Assistant (CNA 1) on December 24, 2021 at 3:00 PM, CNA 1 stated she was the CNA taking care of Resident A on December 23, 2021. CNA 1 stated, I went looking for him at approximately 8:30 PM, [ on December 23, 2021] because I was going to give him a shower. I could not find him. I reported to my charge nurse. I cannot monitor him all the time. They should have never discontinued the one to one. I have other residents to take care of. The last time I saw the resident was at 7:30 PM. He was going to activities. CNA 1 further stated, I did not hear the wander guard alarm go off. I have heard he has removed his wander guard before. During an interview with Certified Nursing Assistant (CNA 5) on December 24, 2021 at 4:00 PM, CNA 5 stated she has taken care of Resident A before. She further stated, I cannot monitor him all the time. I have other residents to take care of. He goes to activities. We try to keep a close watch on him. CNA 5 further stated, The resident had a one to one sitter. I do not know why it was discontinued. He wanted to get out. During an interview with Certified Nursing Assistant (CNA 6) on December 24, 2021 at 4:20 PM, CNA 6 stated, He [Resident A] calls his family constantly. He [Resident A] wanted to leave. He [Resident A] sits by the door in the sofa. I would check on him all the time. I could not watch him every minute because I have to take care of other residents. He [Resident A] is active. He [Resident A] walks through out the facility. During an interview with Licensed Vocational Nurse (LVN 6) on December 24, 2021 at 4:40 PM, LVN 6 stated, I can't keep him [Resident A] in the line of sight at all times. I have work to do, pass pills, Gastric tube feedings [G-tube- a tube inserted directly into the stomach where medications and food is given]. He [Resident A] had a history of elopement. This is not a locked facility. During an interview with Licensed Vocational Nurse (LVN 3) on December 24, 2021 at 4:45 PM, LVN 3 stated, The resident took off his wander guard and left it in his room. During an observation on December 24, 2021 at 5:00 PM, in the front office, the Director of Nurses brought Resident A's wander guard wrapped in a glove and showed teh surveyor. The DON stated, that the resident had removed the wander guard and the staff found his wander guard in his room. During an interview with the DON on December 27, 2021 at 11 AM, the DON stated, They found the resident on December 26, 2021, at approximately 11 AM. He was at his mother's house. He came back to the facility. He was placed on one to one. The doctor was notified and gave an order to transfer the resident to [name of the hospital] for evaluation. The DON stated, The resident left the facility to the hospital via ambulance at approximately 3: 15 PM. During a follow up interview with the DON on December 27, 2021, at 11:30 AM, the DON stated, The hospital called. The resident tested positive for meth[[MEDICATION(S)]]. During a review of the facility's policy and procedure titled, Elopement Risk Precautions and Procedures, revised February 2018, under section .B. Prevention, indicated, 1. Interventions that may be used for residents identified as high risk for elopement included: a. Frequent monitoring of the resident's whereabouts to assure he or she remains in the facility (e.g., every one half hour check). An Immediate Jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called on December 24, 2021 at 2:15 PM, under 483.25 (d) (2) Each resident receives adequate supervision, when a conserved (court determination of inability to care for oneself) resident (Resident A) who had the one to one staff cancelled due to insurance not paying, eloped. The IJ was called in the presence of the Administrator, Registered Nurse Supervisor, the Staff Developer and the Director of Nursing (who was present by phone). The Corrective Action Plan (CAP) provided by the facility included: Resident will be assessed during admission, quarterly and annually for wandering or history of wandering. Based on assessment wander guard is put in placed. Wander guard are check by license nurses every shift. Each exit door equipped with monitoring system and check by maintenance staff everyday to ensure it is in good working condition. Resident with higher risk of elopement are place in the elopement binder with complete elopement information and staff are educated on prevention of elopement of the residents. If the patient has a tendency of removing the wander guard, patient wander guard placement will be check every hour. Resident will be placed on one on one sitter to further prevent wandering out of the building. One on one sitter will not be discontinued as long resident still in the building. Additional wander guard will placed also under the wheel chair as added safety monitoring pre caution. If resident using wheel chair. All staff will be re-inservice which starts immediately at 3:00 PM, December 24, 2021, and be completed with all staff in 72 hours on wander guard alarm Policies and Procedures and it will be followed accordingly. It will be emphasized that all staff are personally familiar with wandering residents. This correction will be implemented and monitored by administrator, DON, and DSD for continued compliance. Any non compliance findings will be presented to QA committee to assess if plan of correction is effected or not. QA committee will formulate additional corrective actions as needed. Based on observations, interviews, and record review, the corrective action plan had been initiated as evidence by residents being assessed for elopement risk, wander guards in place, one to one sitter, and in-services for all staff. The IJ was lifted on December 27, 2021 at 2:15 PM in the presence of the administrator, Chief Operating Officer (CEO), MDS nurse, Managed Care Coordinator MCC), and Director of Nurses (DON).

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Two of two ice machines were not kept in sanitary condition and put residents at risk for food borne illness. 2. One pan of meat was thawing in the refrigerator and desserts were stored under the meat which is a potential for contamination. 3. One microwave available to heat resident food was not kept in sanitary condition which could be transferred to resident food during reheating. 4. Two drawers and two trays were lined with parchment paper and dirt and debris was visible under the liner, that had the potential to transfer to food. 5. Two lower shelves in the kitchen were dusty and had a sticky residue, which had the potential to contaminate the food and the clean cutting boards stored on the shelves. The facility's failures to ensure a safe and sanitary condition resulted in the likelihood of microorganisms that harbor foodborne pathogens to come in contact with residents' food which would cause food-borne illnesses to a population of 64 of 66 residents who received food from the kitchen and are medically compromised. Findings: 1. During an observation and concurrent interview on June 1, 2021 at 9:53 AM, of the ice machine with the Maintenance Supervisor (MS), the ice machine in the utility room had spotted yellow and black residue in the ice chute where ice leaves the condenser then enters the ice bin. A clear plastic pipe that carries water to make ice was yellowish in color and had a substance that looked like black mold inside. The grates that make ice also had slimy yellowish residue and black spots. The MS stated he cleans the ice machine monthly, so he is not sure how it got like that. During an observation on June 1, 2021 at 10:00 AM, the MS removed the cover to the condenser that was contained inside the smaller ice machine in the kitchen. He removed the tray where water collects, and the surveyor used a white paper napkin to wipe the tray. A black residue was visible on the napkin. During an interview on June 1, at 10:10 AM, with the Dietary Services Supervisor (DSS), she stated that her staff is responsible for cleaning and sanitizing the outside of the ice machine in the kitchen and they are not responsible for cleaning the ice machine in the utility room. She stated her staff does not clean the inside of the ice machine in the kitchen, that is done by the MS. She stated since both ice machines are dirty, she would need to discontinue using the ice machines and purchase ice from an outside source. She stated she would dispose of the ice that they are currently using. During an interview with the MS on June 1, 2021 at 10:21 AM, the MS stated that he cleans the ice machines monthly but does not check for cleanliness in between cleanings. He stated that no one else checks the ice machine for cleanliness besides him. The MS stated that he noticed a there is a yellowish residue inside the ice machine in the utility room, that is hard to remove when he does his monthly cleanings. During an interview on June 1, 2021 at 10:35 AM, with the Infection Preventionist (IP) and the Administrator (Admin), the IP stated that she is not familiar with the interworkings of an ice machine and only checks inside the bin and if the ice scoop container is kept clean. She stated that the ice machine in the utility room is not included in her monthly check off list. The Admin stated that the Registered Dietitian (RD) checks the ice machine but does not record her findings. She stated that the RD does not look inside the condenser. During an interview on June 1, 2021 at 10:40 AM, with the Administrator, she stated that she needed to clarify that the RD only checks the ice machine in the kitchen, not the ice machine in the utility room. During an interview on June 1, 2021 at 3:13 PM, the MS stated that he recently changed the cleaners he was using to clean both ice machines from the brand recommended by the manufacturer to another once because it was not in stock. He thinks this may be why the machines were so dirty. During an observation and concurrent interview on June 2, 2021 at 9:23 AM, of the ice machine in the utility room, after it had been professionally cleaned and with the MS, the ice machine had a few areas that had black stains and was corroded. The MS stated that the ice machines were professionally cleaned. He stated the parts that look dirty are stained and the stain cannot be removed. During an interview with the Registered Dietitian on June 3, 2021 at 8:34 AM, she stated that she was not checking the ice machine in the utility room for cleanliness. She stated for the ice machine in the kitchen, she was not pulling off any parts, she was just using a paper towel to wipe the outside of the water tray and around the lip of the door. During a review of the FDA Federal Food Code 2017, it indicates that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits and similar imperfections, free from sharp internal angles, corners and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. During facility record review of the policy and procedure, titled Ice Machine Cleaning, dated 05/2009 (May 2009), read It is the policy of this facility to establish procedures to properly clean and disinfect the ice machines in order to maintain and assure a safe and sanitary supply of ice During a review of the manufacturer guidelines titled, [Company name], undated, indicated under cleaning . '6) Remove the insulation panel, then pour 14 fluid ounces of Hosizaki Scale Away into the tank. Replace the front insulation panel. Turn the cleaning valve to the left until completely vertical (open).' And for Sanitizing, the guidelines revealed '15) remove the front insulation panel, then pour .78 fl. oz. of an 8.25% sodium hypochlorite solution (chlorine bleach) into the water tank. Review of the facility policy titled, Sanitation, dated 2018, revealed, all utensils, counters, shelves and equipment shall be kept in clean, maintained in good repair, and shall be free from breaks, corrosions, open seam, cracks and chipped areas. Review of the Food and Nutrition Inspection Checklist/Report, dated March 16, 2021, April 29, 2021 and May 27, 2021, the RD put a check mark on the box 92 that read ice Machine is clean (no mold found on dispensing lip) inside ice holding area and within condenser compartment and the motor/condenser area is clean (may need maintenance to open), for the March 16, 2021 check list the RD included motor/condenser area is clean inside- not observed. Review of the facility document titled Order Listing Report. dated June 1, 2021, indicated there were 64 residents on a PO (by mouth) diet. Review of the facility document titled Order Listing Report, dated June 1, 2021,indicated there were two residents on a tube feeding (fed through a tube to the stomach or gut) diet and not receiving food by mouth. An immediate jeopardy (IJ) was called on 483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety, on June 1, 2021 at 12:30 PM, the survey team verbally notified the Administrator of the IJ due to the ice machines not being kept in sanitary condition. Failure to maintain sanitary ice machines had the potential to cause food-borne illness to the highly susceptible residents who received ice from the machines. The Corrective Action Plan (CAP) included the following: 1. Water pitchers were immediately removed from the resident rooms. 2. Ice machines were emptied and placed in non-operational use. 3. Ice and ice chests were purchased, and water was redistributed. 4. Regional maintenance consultant contacted for immediate assistance. 5. Governing board notified of the survey finding. Action plan completed on June 2, 2021. 1. [NAME] was contacted and technician came to professionally clean the identified ice machines. 2. The Regional Maintenance Consultant came with manufacturer's recommended cleaning product and educated the Maintenance Supervisor of proper cleaning procedures. 3. The Maintenance Supervisor completed a return demonstration of cleaning procedures and successfully completed a skills test for the cleaning and the maintenance of the ice machines. 4. The infection control preventionist received training on properly inspecting the ice machines for sanitary compliance. 5. The Nutritional Service Supervisor received training on inspecting the ice machine for safety compliance. 6. The Registered Dietitian inspected the dietary ice machine and added the utility room ice machine on her inspection rounds. 7. The findings of the ice machine maintenance and sanitary compliance was added to the Monthly QAA meeting. The QAA members will review the findings and make recommendations as indicated. 8. The utility room ice machine was taken out of service permanently. Staff was educated that the existing machine was unplugged and out of use awaiting new unit delivery. 9. A new ice machine for the utility room was ordered. The new ice machine was verified to be received and installed on June 3, 2021. During a concurrent interview and observation on June 2, 2021 at 9:23 AM, with the Maintenance supervisor (MS) of the ice machine in the utility room, the ice machine was free of black mold and black and yellow residue. The MS stated that the ice machine was professionally cleaned by (company name) and stated that some parts are stained/discolored and have some corrosion. During an interview and concurrent observation on June 2, 2021 at 9:41 AM, the ice machine in the kitchen was clean. The MS stated that he was trained by the service company on how to clean the machine and the new process for cleaning both machines is more detailed. He stated that the DSS would now also be monitoring the inside of the ice machine in the kitchen for cleanliness. During an interview on June 2, at 9:56 AM, the IP stated she will be inspecting the ice machines for cleanliness bi-weekly and logging her inspections. During an interview on June 2, 2021, at 10:53 AM, the Admin stated that they are going to replace the utility room ice machine with a new one. During a review of facility invoice for (Company Name), dated June 1, 2021, Ice machine Preventative Maintenance was completed. During a review of facility document titled Ice Machine Skill Competency, dated June 1, 2021, read Maintenance Supervisor completed the competency training on June 1, 2021. During an observation on June 3, 2021 at 12:30 PM, the new ice machine was being installed by a technician in the utility room. The IJ was lifted on June 2, 2021 at 11:29 AM, in the presence of the Administrator, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews, and document review. 2. During an observation on June 1, 2021 at 7:30 AM, smoked ham lunch meat was thawing on the second shelf in the walk-in refrigerator. On the third shelf below the meat three pans of key lime pie were stored. During an interview on June 1, 2021 at 9:36 AM, the Dietary Services Supervisor (DSS) stated the dessert should have been on the shelf above the thawing meat. During an interview on June 3, 2021 at 8:34 AM, the Registered Dietitian stated the meat should be on the bottom shelf and ready to eat foods should be stored on the top or second shelf of the refrigerator. During a review of the facility's policy and procedure, titled FOOD PREPARATION THAWING OF MEATS dated 2018, the policy indicated .b. Thaw meat on the bottom shelf below prepared, ready-to-eat foods. 3. During an observation on June 1, 2021 at 9:53 AM, the microwave designated only to heat resident food had a black film on the top inside where food is placed to be warmed. During an interview on June 2, 2021 at 8:59 AM, Charge Nurse 1 stated that when family brings in food for residents, she will use the microwave in the utility room to heat the food. During an interview on June 2, 2021 at 9:56 AM, the Infection Preventionist (IP) stated that housekeeping and the nursing staff are responsible for keeping the microwave to heat resident food clean. She stated they currently do not have a system for monitoring the microwave. Review of the facility policy titled, Sanitation, dated 2018, stated All utensils, counters, shelves and equipment shall be kept in clean, maintained in good repair, and shall be free from breaks, corrosions, open seam, cracks and chipped areas. Review of the facility policy titled, Reheating Resident Food Policy and Procedure, dated May 28, 2001, read Processed food will be reheated in the programmed microwave located in the utility room per manufacturer labeled direction. And Microwave and thermometer will be washed and sanitized after each use and kept in proper container following the label of product used. 4. During an observation on June 1, 2021, at 7:30 AM, two drawers storing clean utensils were lined with parchment paper, two trays in the reach-in refrigerator storing juice and food were lined with parchment paper and dirt and food debris were visible under the paper liner. The DSS acknowledged the debris under the paper liners. During an interview on June 3, 2021, at 8:34 AM, the Registered Dietitian (RD) stated that paper liners should not be used to line drawers or on trays with food. During a review of the facility's policy and procedure titled, PROCEDURES FOR DRY STORAGE: dated 2017, the policy indicated .4. All shelves and storage racks or platforms should be in accordance with state and federal regulations to facilitate air circulation and promote easy and regular cleaning. Shelves and cupboards will not be lined with shelf paper or other liners. 5. During an observation on June 1, 2021, at 7:30 AM, a lower shelf storing clean cutting boards was dusty. The surveyor wiped a hand across the shelf and a layer of black dust was visible. A second shelf storing potatoes and bananas also was dusty to the touch and had a sticky residue. During an interview and concurrent record review on June 2, 2021, at 3:35 PM, with the Dietary Services Supervisor of the cleaning schedule, the DSS stated the shelves should be cleaned daily. She acknowledged that the shelves that were dusty were not on the cleaning schedule. During an interview on June 3, 2021, at 8:34 AM, the Registered Dietitian stated she expects shelves in the kitchen to be cleaned regularly and free of dust. During a review of the facility's policy and procedure, titled SECTION 8 SANITATION dated 2018, the policy indicated .9. All utensils, counters, shelves and equipment shall be kept clean .

Based on interview and record review, the facility failed to ensure the residents right to be free from abuse when a Certified Nursing Assistant (CNA 1) slapped Resident 1 and washed him with cold water against his will. This failure resulted in the physical abuse of Resident 1. Findings: During a review of the clinical record for Resident 1, the admission record indicated Resident 1's admitted was November 19, 2017, with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS; an assessment of resident's functional and health status) dated November 30, 2017, indicated the Brief Interview Mental Status (BIMS - a screening tool used to determine mental status) scored 14. A BIMS score of 13 - 15 indicates a person is cognitively intact (intact mental process). During an interview with the Director of Nursing (DON), on December 7, 2017, at 1:55 PM, she reported, she suspended CNA 1 on December 5, 2017 due to an abuse allegation (a claim that someone has mistreated a person). During an interview with a Licensed Vocational Nurse (LVN 1), on December 7, 2017, at 4:05 PM, she stated, she heard Resident 1 yelling for help from his room. She stated when she entered Resident 1's room, she observed CNA 1 continuing to perform a sponge bath (an all over washing provided in bed, instead of in the bath or shower, using a sponge or washcloth) on Resident 1 while Resident 1 was resisting and yelling for her to stop and to leave him alone. LVN 1 stated she told CNA 1 to stop and to leave the room when CNA 1 said Resident 1 was 'always like this but needed to be cleaned.' During an interview with Resident 1, on December 8, 2017, at 9:25 AM, he stated CNA 1 was giving him a sponge bath with cold water. Resident 1 stated he told CNA 1 the water was cold and told CNA 1 to stop bathing him. He stated CNA 1 told him the water was not cold and continued to bathe him. Resident 1 stated he again told CNA 1 to stop giving him a sponge bath but she did not stop so he grabbed the washcloth at that time and threw it across the room onto the floor. Resident 1 stated, CNA 1 went to pick up the washcloth then came back and slapped me on my forehead with her open hand. Resident 1 stated, CNA 1 continued to wash him with the cold water and he continued to resist, yelling at CNA 1 to stop and to leave him alone several times but CNA 1 would not stop. Resident 1 stated, It really upset me. A review of the clinical record for Resident 1, indicated the following: 1. Nurses Note dated December 5, 2017, at 8:30 PM, indicated, .CNA (CNA 1) stated that when she went to continue washing the resident (Resident 1), the resident (Resident 1) began yelling. The CNA (CNA 1) stated, 'he is always like this' and 'he does this all the time.' 2. Nurses Note dated December 5, 2017, at 9:11 PM, written by LVN 1 indicated, At 8:10 PM, heard resident (Resident 1) yelling out for help from his room. Immediately went to assist and upon entering room noticed CNA (CNA 1) struggling to provide incontinent (inability to control bowel or bladder) care to resident while resident resisting and repeatedly yelling out 'leave me alone.' I asked resident (Resident 1) what happened and he stated 'tell her to leave me alone, she (CNA 1) hit me.' .Resident able to verbalize concern. He (Resident 1) stated that CNA (CNA 1) .got very upset and struck resident (Resident 1) on the forehead with her open palm . During a review of CNA 1's employee file, it indicated CNA 1 received Elderly and Dependent Abuse Prevention and Reporting training upon date of hire, and at least annually thereafter, with the most recent training on November 20, 2016. The facility policy and procedure titled, Abuse and Neglect Prevention Management revised December 2014, indicated, Policy: It is the policy of the facility to ensure our residents safe and free from abuse .Our residents have the right to be free from abuse and neglect by anyone, including staff members .Definitions: Physical abuse includes hitting, slapping .Incident Management .Educate the staff to avoid using phrases like 'they always complain,' or 'he/she always says that' .

Based on observation, interview, and record review, the facility failed to provide and maintain a safe environment free from the possibility of accident hazards. The facility failed to: 1. Monitor and supervise the residents in the facility identified to need supervision during smoking for three of 14 unsampled residents (Residents E, I and J). This failure had the potential for Residents E, I and J to experience burns from cigarettes, and possible exposure to fire, in a universe of 15 residents who smoked in the facility. 2. A dining room chair was found with a detached seat outside the patio door near sampled Resident 2's room. This had the potential for falls and injuries affecting residents, staff and visitors who use the patio. 3. Facility staff smoking in an area not designated for smoking. This failure had the potential risk for fire at the facility, affecting 85 residents, staff, visitors and the surrounding community. Findings: 1. During an observation of the smoking patio on June 15, 2016 at 8:30 AM, Resident I was observed to be smoking in the smoking patio without supervision and without a smoker's apron. During an interview with Resident I on June 15 2016, at 9:30 AM, in the Resident I's room, she stated that she had been smoking without supervision. She stated, I signed a waiver to keep my own cigarettes and lighter. I gave the waiver to the nurses. In a concurrent observation of Resident I's bedside table there were two boxes of cigarettes, with 3 sticks in each, and 1 half-filled lighter. Another box of cigarettes with 2 sticks of cigarettes were on the nightstand. During a concurrent interview with the Certified Nursing Assistant (CNA 11), when speaking with Resident I, she stated, I did not know that Resident I had cigarettes at the bedside. No one told me. She confirmed that Resident I was assigned to her. During an interview with Licensed Vocational Nurse (LVN 3), on June 15 2016 at 9:35 AM in front of Resident I's room, she stated, Resident I is alert and oriented (able to make her own decision), she is allowed to keep her own cigarettes. Social service is responsible for deciding which residents keep their own cigarettes. No one watches her. During an interview with Social Service Designee (SSD), on June 15 2016 at 9:38 AM, she stated that all the cigarettes for the residents who need supervision are being kept in the business office. The Restorative Nurse Assistant (RNA) will give the cigarettes to the residents during scheduled smoking hours. She stated that if the resident is alert and oriented, and signs a waiver, then they can keep their own cigarettes and lighters. During an interview with Director of Nursing (DON) on June 15 2016, at 9:45 AM, she stated, The staff should be watching the residents during smoking, even though they sign the waiver and decides to go out anytime to smoke, we should also keep an eye on them. During a review of the clinical record for Resident I, on June 15 2016, the Smoking Assessment, dated April 27, 2016, indicated Resident I was evaluated as Independent/Unsupervised . Intervention: Facility storage of fire materials only. Assistance with lighting tobacco products only. During a review of the smoking care plan for Resident I, untitled, dated May 18, 2016, indicated, Resident at risk for smoking related injury associated with [DIAGNOSES REDACTED]. Approach: Supervise resident per facility smoking policy while resident is smoking, Provide smoking apron for resident while smoking, Place resident in position to assure direct visual view of ashtray. During a review of the Resident I's Smoking with supervision by the staff during smoking time dated April 28, 2016, indicated, As per re-assessment resident requires to be supervised .Resident insisting that she/he don't need to be supervise and insisting about her/his freedom. During a review of the clinical record for Resident I, the Resident Face Sheet, undated, indicated that Resident I was admitted to the facility with [DIAGNOSES REDACTED]. During an observation of Resident E smoking on June 15, 2016 at 4:00 PM, in the smoking patio, Resident E was observed smoking without staff supervision and without wearing a smoker's apron. Resident E was noted to be flicking ashes to the ground, without ash trays. Resident E was wearing a flannel blanket on her lap. During a concurrent interview with Resident E, she stated that she smoked without supervision whenever she wants, and she throws the cigarette butts on the ground. Resident E stated, Normally, I would have ash trays. During concurrent interview with Certified Nursing Assistant (CNA 4), she stated that certain times, some residents go alone anytime they want. During a review of Resident E's Smoking Assessment dated May 14 2016, indicated, Evaluation: Smokes safely with minimal supervision. Interventions: Smokers apron, Facility storage of fire materials only, Assistance with lighting tobacco products only. A review of Resident E's smoking care plan titled, Smoker under supervision, at risk for injury, dated May 12 2016, indicated, Orient the resident on smoking area, schedule and staff supervision, supervise in smoking by staff. During a review of the clinical records for Resident E, the Resident Face Sheet, undated, indicated that Resident E was admitted to the facility with [DIAGNOSES REDACTED]. During an observation of the smoking patio on June 16, 2016 at 12:25 PM, Resident J was smoking on the outside patio without staff supervision. Resident J did not have a smoking apron. During a concurrent interview with Resident J, he stated that he comes to smoke anytime he wants and does not need supervision. During a review of the Care plan for Resident J, dated December 17, 2014, indicated, Smoker at risk for self injury r/t (related to) shaking episode due to CVA (Stroke), Approach: supervise resident by staff during smoking time for safety, .offer apron for skin protection during smoking. A review of the Smoking Safety Assessment, dated June 11, 2016, indicated, Evaluation: Smokes safely with minimal supervision. A review of the clinical records of Resident J showed a document titled, Resident Face Sheet, undated, which indicated that Resident J was admitted to the facility with [DIAGNOSES REDACTED]. A facility policy and procedure titled, Smoking Policy and Guidelines, undated, indicated, Residents who need staff supervision must smoke only at supervised smoking times If facility staff determines that you have safety risks related to your smoking: You will not be allowed to keep cigarettes, matches, or lighters in your possession, you will only be allowed to smoke at the supervised smoking times under staff supervision. An Immediate Jeopardy was was called on June 16, 2016 at 4:40 PM, in the presence of the Administrator and the Director of Nursing. On June 16, 2016 at 6:25 PM, the facility provided an acceptable corrective action plan which included the following : a. The facility will assign additional staff specific to smoking area, to monitor residents that smokes and will be schedule for 24 hours a day for the next five days until residents that smokes are aware of the smoking policy and guidelines. Staff that is assign to the smoking area will assist lighting up cigarettes and to have apron in place while residents are smoking. Break time assign for the staff will arrange to maintain coverage and a staff on the schedule on the floor will cover that person. Also if the staff needs to use the restroom or a quick break, he or she will notify the nurse on Station B. b. Ordered additional 12 smoking apron. c. In-service will be conducted to all staff starting on today until all active are made aware of the smoking policy. d. Residents who smokes were invited to the emergency council meeting to reiterate smoking agreement upon admission and inform them of the changes in the schedule and implementation of smoking policy. On June 17, 2016 at 3:03 PM, after observation of residents that smoked who needed supervision, interviews were conducted to verify the updated facility and in-services on supervision of residents who smoke to Nursing staff were completed as per the corrective action plan, the IJ was removed in the presence of the Administrator and the Director of Nursing. 2. During an observation on June 14, 2016 at 11:10 AM, with the house keeper (HK 3) and Registered Nurse (RN 3) a chair was noted outside in the patio area near Resident 2's room with its seat completely detached. In a concurrent interview, housekeeper (HK 3) confirmed the finding and stated, she did not know about the chair. She stated, Maybe it was garbage. In a concurrent interview with Registered Nurse (RN 2), she stated she did not know why the chair was left outside the room and that she would call Maintenance. The facility policy and procedure titled, Preventative Maintenance Program, dated November 2004, indicated, It is the policy of this facility to keep all the equipments and property in the greatest condition possible and consistent And .completed on an inspection and repair as necessary basis. 3. During an outdoor environmental tour observation on June 15, 2016, between 8:25 AM and 9:45 AM, with the Maintenance Supervisor (MS), there were findings as follows: a. Cigarette butts along the east wall of the facility in a dry leafy area. During a concurrent interview, the MS stated that the area was not designated for smoking and he was unsure as to who smoked there. b. An overflowing ashtray and cigarette butts on the grounds among paper trash items, surrounding the area outside of the back door of the facility leading into the parking lot. During a concurrent interview, the MS stated that it was a smoking area, but did not know who smoked there. He further stated that cigarette butts should not be on the ground and it is a fire hazard. c. Cigarette butts on the grounds outside of the main kitchen door. d. Cigarette butts on the grounds near the propane tank and emergency generator where trash and dry leaves were noted to be. e. Cigarette butts on the grounds among dry leaves and paper trash items, in the back corner area of the parking lot and around the perimeters of the parking lot. During interviews on June 15, 2016 between 12:55 PM and 1:00 PM, with a Licensed Vocational Nurse (LVN 1), a Certified Nursing Assistant (CNA 4), and a Registered Nurse (RN 1), they stated that the facility staff smoke outside the back patio door leading to the parking lot. The facility policy and procedures titled, Smoking Policy, dated July 2012, and Smoking Policy and Guidelines, undated, did not address staff smoking.

Based on observation, interview, and record review, the facility failed to provide a safe environment for a universe of 85 residents, facility staff and the surrounding community when: 1. The facility placed a gasoline container, propane tank, cleaning solutions, other cleaning materials and landscape equipment that may contain gasoline into two separate outdoor, unventilated large metal storage bins. 2. The facility failed to educate staff on the safe use and storage of chemicals and combustible materials. 3. Cleaning products were left unattended on the bedside table of one of 14 unsampled residents (Resident B). The facility failed to provide a safe environment for a universe of 85 residents, plus facility staff and surrounding community members, when they placed different types of chemicals and combustibles into two separate outdoor, unventilated large metal storage bins. This had the potential to result in an explosion, fire and hazardous materials situation. Findings: 1. During an observation on June 15, 2016 at 9:50 AM, in the outdoor facility parking lot, escorted by the Maintenance Supervisor (MS), there were two large (train car size) metal unventilated storage bins approximately 100 yards from the back of the facility. During a concurrent interview with the MS, when asked what was inside the storage bins, he stated that one bin (Bin 1) had diapers and supplies inside, and the other bin (Bin 2) had activity supplies (supplies such as craft items, decorations ect., used to provide activities for the residents). During an observation on June 15, 2016 at 9:55 AM, inside Bin 1, in the presence of the MS and the Administrator, the bin was noted to be without ventilation and the air was hot. There was no thermometer inside the bin. In addition to the diapers and supplies stored in Bin 1, there were various chemicals and combustibles including but not limited to: a. Two cardboard cases, containing four (one gallon each), plastic containers of Genlabs Orange Deodorant, that indicated, Store in cool dry place at room temperature. b. Three cardboard cases, containing six (one gallon each), Pure Bight Germicidal Ultra Bleach, that indicated, Store in a cool dry area away from heat. c. One cardboard case of Glass Cleaner. The cardboard case had stains from spillage. d. Four oxygen concentrators (equipment designed to hold oxygen). During an observation on June 15, 2016 at 10:05 AM, inside bin 2, in the presence of the MS and the Administrator, the bin was noted to be without ventilation and the air was hot. There was no thermometer inside the bin. A strong odor of gasoline was noted upon opening the bin, and throughout the interior of the bin. In addition to the activity supplies stored in bin 2, there were various chemicals and combustibles including but not limited to: a. One five gallon red plastic container with gasoline inside. b. A lawn mower and other lawn equipment requiring gasoline. c. A propane gas tank (the size and type used for gas barbeques). d. A fire extinguisher in working condition. e. A small plastic container of oil containing petroleum. f. Six plastic containers (one gallon each) of bleach. During a concurrent observation of the facility grounds, near the two storage bins, there were dry leaves, shrubbery and scattered cigarette butts on the ground. During a concurrent interview with the MS, when asked who placed the chemicals inside the bins, he stated, I did. He further stated that the Ecolab representative comes weekly to check the supplies and was aware of their storage. When asked if he received training on the safe use and storage of chemicals, he stated, No. An Immediate Jeopardy was called on June 15, 2016 at 11:43 AM, in the presence of the facility Administrator and the Director of Nursing where details of the findings were discussed. On June 16, 2016 the facility provided an acceptable corrective action plan, which included the following: 1. Maintenance Personnel was immediately instructed by administrator to remove gasoline container, propane tank, all cleaning solutions, other cleaning material and landscaping equipment that may contain gasoline that were stored at the outside containers. Propane tank was returned to vendor. Gasoline power landscaping equipment and gasoline container were removed from the premises and stored at a storage unit. Chemical solutions including but not limited to bleach and degreaser were placed in the facility's newly created chemical storage room. The containers of those chemicals were secured in place and the storage room was also secured with self-locking door knob. The personnel that will have access to the storage room are administrator, maintenance supervisor, and maintenance assistant. A backup key was placed in the emergency key cabinet located in the director of nursing services office. Detergents and non-flammable cleaning solutions were placed in the maintenance storage area. Emergency Quality Assurance meeting was conducted regarding safe storage and handling of chemicals. 2. Area manager, administrator, department heads, and maintenance supervisor immediately conducted rounds within the facility and outside grounds to ensure no other chemicals or gasoline and combustible solutions are improperly stored within facility compound and noted to have roofing patch materials and canister, these were removed immediately. Further rounds and inspection to roof areas were conducted by administrator, area manager, and maintenance assistant to make sure no other materials are unsafely stored and none were found. 3. In-service was conducted by safety consultant on 6/15/16 with regards to safe storage, handling, and proper disposal of chemicals that are used for facility operation to available staff and mandatory in-service on 6/16/16. The in-service will be on going to cover those that are off duty employees until every active employee (except employees under temporary disability) have been educated with safe storage, handling and disposal of chemicals. Employees that returns from vacation and have not been educated with safe storage, handling and proper disposal of chemicals that are used for facility operation will make arrangements to be in-serviced by safety consultant prior to return to normal duties. Newly hired employees will also undergo training of safe storage, handling, and proper disposal of chemicals that are used for facility operation. 4. Maintenance supervisor and personnel will check the chemical storage room daily and as necessary to ensure that chemical solutions are properly and securely stored. Administrator will monitor and check the storage room during the daily rounds. Area manager or safety consultant will check the storage area and perform environmental inspection monthly to make sure compliance and report any issues to the administrator for appropriate corrective actions for the next 3 months or until compliance is achieve. Quality Assurance Committee will meet monthly to discuss any identified problems, possible interventions and to determine effectiveness of system in place. On June 16, 2016 at 2:20 PM, after observations of the storage bins, interviews were conducted to verify the updated facility practices and in-services to all facility staff as per the corrective action plan, the Immediate Jeopardy was removed in the presence of the Administrator and the Director of Nurses. During an observation on June 17, 2016 at 1:15 PM, inside bin 2, with the Maintenance Supervisor (MS), the bin's temperature was measured with a hand- held temperature gauge and noted the bin had an inside air temperature reading of 110 degrees Fahrenheit and the outside air temperature of 89 degrees Fahrenheit. There was a strong gasoline odor noted inside the bin. During an observation on June 16, 2016 at 11:20 AM, next to the chemical storage closet in the hall close to Station B, Dura Shine 29% Floor Finish was observed stored in the closet with instructions that indicated, Wear protective gloves, protective clothing, eye protection and face protection. During an interview on June 16, 2016 at 12:30 PM, with a Maintenance Worker (MW), he stated that when he uses the Dura Shine 29% Floor Finish he wears gloves and mask but not an apron or eye goggles. During an interview on June 17, 2016 at 11:10 AM, with the Field Maintenance Supervisor (FMS), he stated that he did not have any written document for the staff to use as a guide for the safe use of the chemicals that are being used in the facility. The facility Preventative Maintenance Manual policy, titled Room Cleaning, Schedule, dated December 2004, did not indicate what chemicals to use for cleaning, disinfecting, polishing removing mildew, and mopping in resident areas. A review of the facility Material Safety Data Sheets (MSDS, provides comprehensive information about a substance or mixture for use in workplace chemical management): a. In the maintenance room, 11 of 17 different types of chemicals did not have a MSDS. b. In the chemical storage closet in the hall, close to Station B, 6 of 7 different types of chemicals did not have a MSDS. 3. During an observation on June 13, 2016, at 1:30 PM, there were four bottles of cleaning products found on a bedside table of Unsampled Resident B. Resident B was alert and able to verbalize needs. During an interview with Housekeeper 2, on June 13, 2016 at 1:40 PM, she stated, Somebody put it there, no is mine. She verified the cleaning products were not supposed to be left in the resident's room. The facility policy and procedure dated January 9, 2013, titled Housekeeping Policies and Procedures, states Store all housekeeping supplies properly and store all housekeeping equipment in a designated place.

Based on interview and record review, the facility failed to ensure that one of 17 sampled residents (Resident 9), was not moved from her room to another room against her wishes, and without prior notification. This failure resulted in Resident 9 experiencing emotional distress and verbalizing feeling depressed (a feeling of being sad and unhappy), after moving to another room. Findings: During an interview on June 15, 2016 at 1:00 PM, in Resident 9's room, the resident stated, They moved me to this room a few months ago and I did not want to move. My old room-mate passed away and I was still thinking about that, and then they moved me to this room. I prefer my old room. Resident 9 stated that no one told her. She stated, I felt very depressed, and it was very hard for me to take for the first few weeks, I did not leave my room for two weeks because I was very sad that I was moved from my old room. During an interview with the Social Service Designee (SSD) on June 17, 2016 at 4:15 PM, in the social service office, she stated, (Resident 9's name) was in another room, before we moved her to her current room. The Social Service is responsible for notifying the residents of transfer to another room. Usually we tell the residents at least two days ahead of time before we move them.The SSD stated, If the resident refuses to be moved to another room, then we do not move the resident. During a review of Resident 9's clinical record, there was no documentation regarding Resident 9 being informed about the room change or documentation reflecting that resident agreed to be moved to another room. During a concurrent interview with the SSD, she confirmed that they did not document in Resident 9's clinical record regarding the transfer. She stated We are supposed to document the conversation between the social service and the resident and also document the resident's acceptance to move to another room. I don't know why it was not documented. I'm not sure Resident 9 was notified about the move. The facility policy and procedure titled, Policy and Procedure on Room Change, dated July 2012, indicated, Licensed nurse and or/SSD will notify resident or resident's representative or both of the possible room transfer . reasons for propose transfer will be discussed to resident, resident's representative or both.

Based on observation, interview, and record review, the facility failed to ensure that four of 17 sampled residents (Residents 3, 6, 9, and 11), received care and services that are consistent with their comprehensive assessment when: 1 a. Resident 9 was left wet and uncomfortable when she needed incontinence (inability to control urine) care. 1 b. Staff failed to notify the Physician that Resident 9 was refusing her medication order for [MEDICATION NAME] (a medication used to high blood pressure that causes the resident to urinate) 40 mg (milligram) orally daily. 2. The nursing staff could not correctly identify the type of [MEDICAL TREATMENT] (purification of blood), Ash catheter (a tube used to gain access to the resident's circulatory system) access site for Resident 6, and failed to provide adequate assessment and documentation. 3. Resident 11 was not assisted with obtaining upper and lower dentures. 4. Staff failed to notify the Physician that Resident 3 was refusing her [MEDICATION NAME] (medication used for controlling blood sugar levels). These failures had the potential to place four of 17 sampled Residents at risk for experiencing psychological and physical harm. Findings: 1a. During an interview with Resident 9 on June 15, 2016 at 1:00 PM, she stated that a Certified Nursing Assistant (CNA 12) left her wet for 4 hours before changing her incontinence pad. Resident 9 stated, I told her that I needed to be changed. She put me in the bed and left me there. This was about 5:00 in the evening. She did not come back (until) 9:00 in the evening to change me. I felt humiliated and felt very angry. During an interview with CNA 12 on June 16, 2016 at 6:19 PM, she stated, When the resident asks to be changed, you are supposed to change them right away. I remember that day when (Resident's name) told me that she needed to be changed. My charge nurse told me to change 2 other residents. I thought I am supposed to do what my charge nurse told me. I left her there, in bed, and went to change the other residents. She stated, I did not tell the charge nurse that (Resident's name) was waiting for me to change her. (Resident's name) needs assistance to be changed, she is not able to use the bathroom by herself. During a review of Resident 9's Minimum Data Set-MDS (an assessment tool for residents), dated May 2, 2016, indicated, Functional Status: Toilet use/self performance-Extensive Assistance, One person Assist. 1 b. During an interview on June 15, 2016 at 1:00 PM, with Resident 9 in her room, she stated, I take [MEDICATION NAME] (a medication use to flush out fluids from the body) for my high blood pressure. I don't like it because it makes me urinate a lot, so I keep telling them that I don't want to take it , but no one listens to me. She stated, They keep giving it to me and I just throw it away in the trash. I don't know if they know that I throw it away, since they don't call the doctor to tell him. They leave the medication here and walk away and I just throw it away in the trash. During an interview with a licensed vocational nurse (LVN 5), on June 16, 2016 at 10:15 AM, she stated, No I did not call the doctor to tell him that Resident 9 refused her medication. We are supposed to call the doctor when residents refuse their medications and also do a care plan for it. During a review of Resident 9's clinical record, Resident Progress Notes, there were no documentation entries regarding Resident 9 refusing her [MEDICATION NAME] and no documentation of physician notification that Resident 9 was refusing her [MEDICATION NAME]. The nurses documented that Resident 9 has continued to receive her [MEDICATION NAME]. During a review of Resident 9's Minimum Data Sheet (MDS-a resident assessment tool), under section K 0300-Weight, dated May 2, 2016, indicated that Resident 9 had gained 21 pounds (lb.- a unit of measuring weight) between February 1, 2016 and May 2, 2016. If Resident 9 had been taking the prescribed [MEDICATION NAME] to remove excess fluids, this would have prevented some of the weight gain which in turn would assist in stabilizing her blood pressure. During a review of Resident 9's Care Plan, dated May 2, 2016, indicated, Potential for complications related to diuretic (medication that makes resident urinate) medication usage secondary to [DIAGNOSES REDACTED]. Approach: Administer diuretic as prescribed: [MEDICATION NAME] 40 mg (milligram)1 tab . Notify MD (physician) for any change of condition (COC). The facility's policy and procedure titled, Medication Documentation, dated June 2012, indicated, When doses are refused or not given for other reasons .the nurse shall circle her initials and explain reason on the back of medication administration record .Physician should be notified of missed doses, as appropriate. 2. During a review of Resident 6 [MEDICAL TREATMENT] Communication Book (communication book used to communicate information for Resident 6 between the facility and [MEDICAL TREATMENT] Unit) on June 14, 2016 at 11:20 AM, indicated that Bruit/Thrill (Bruit is an abnormal swishing sound heard with a stethoscope (devise used for listening to the internal sounds of the human body) over a blood vessel, thrill is the vibration felt), used to assess an AV (artery and vein) shunt ( a tube placed between an artery and a vein as a bypass) were present on [MEDICAL TREATMENT] days (Tuesdays, Thursdays, Saturday) during the months of May and June 2016, Resident 11 had no AV shunt in place. During review of Resident 6's physician order for [REDACTED]. During an interview on June 14, 2016 a 12:15 PM, with a Registered Nurse (RN 2) she stated, His portal catheter (a port placed under the skin with a tube placed into the vein and allows access to the circulatory system) is in left upper chest. When asked what type of portal catheter was in place, RN 2 stated, I will call the [MEDICAL TREATMENT] Unit to find out. The [MEDICAL TREATMENT] Unit nurse reported to RN 2 the access site is a (Ash Pick Portal Catheter-the nurse cannot check for bruits and thrills) not a portal catheter (the nurse checks for bruits and thrills). During an interview on June 20, 2016 a 10:20 AM, with the Director of Nursing (DON) she stated, (I) do not know why the licensed nurses were documenting the Bruit/Thrill (these cannot be checked on an Ash catheter) or why they were documenting a Portal Catheter, after reviewing Resident 11 [MEDICAL TREATMENT] communication sheets for May and June 2016. She also stated the licensed staff has not received recent training on care for [MEDICAL TREATMENT] residents. A review of the facility policy titled, [MEDICAL TREATMENT] Services dated August 2012, indicated, .g. Management of emergencies and complications which include monitoring of bleeding, hemorrhaging and infection/ bacteremia/ septic shock with immediate notification of physician . Licensed nurses not knowing the type of devise being used an Ash Catheter (a tube used for exchange of blood to and from the [MEDICAL TREATMENT] machine and patient) puts Resident 6 at risk for complications of the access site during an emergency. 3. During an observation on June 17, 2017 at 10:10 AM, in the outdoor patio smoking area, Resident 11 did not have upper or lower teeth. During a concurrent interview, Resident 11, with the Activity Assistant (AA) as a Spanish interpreter, stated that he likes the food but can't chew everything because he doesn't have teeth. He further stated that he had discussed wanting dentures with the Social Worker. Later in the same interview, when asked if he needed any help with activities of daily living, he stated that he doesn't need help to eat, he just needs teeth. During a review of the clinical record for Resident 11, the dentist notes dated June 16, 2015 and June 7, 2016, indicated, Resident 11 Needs Dentures (U) (L) (upper and lower dentures). During an interview on June 17, 2016 at 11:37 AM, with a Social Worker Designee (SSD), she stated that Resident 11 was admitted to the facility on [DATE], and received a dental exam on June 16, 2015. She stated that she did not follow up. Another dental exam occurred on June 7, 2016. She stated that she should have followed up when Resident 11 did not receive his dentures. During a review of the clinical record for Resident 11, the Resident Progress Notes entered on June 15, 2015, by the SSD, indicated, Resident requested for a dental consult and wants to see if he could get a dentures on 6/14/15. During an interview on June 17, 2016 at 2:00 PM, the SSD stated that regarding the dentures, there were no notes by her after June 15, 2015. The facility job description for the SSD dated August 16, 2012, indicated, .12. Refer and assist resident to access when the facility does not provide the services or needs of the resident; i.e., dental . 4. A review of Resident 3's medication administration record (MAR) dated June 2016, indicated Resident 3 was to receive [MEDICATION NAME] (a long-acting insulin to control blood sugar levels) at 9:00 PM, daily. The MAR indicated Resident 3 refused the [MEDICATION NAME], on the following dates: June: 1, 2, 5, 6, 7, 8, 9, 10, 11, and 12 2016. A review of the MAR and nurses progress notes indicated there was no documented evidence that Resident 3's physician was notified for any of the days Resident 3 had refused the insulin. During an interview with a Registered Nurse Supervisor (RN 1) on June 15, 2016 at 9:24 AM, she confirmed there was no documentation that a physician was notified of Patient 3's refusals as documented on the MAR. A review of Resident 3's care plan titled, Noncompliance as evidenced by refusal of [MEDICATION NAME]. At risk for medical illness deterioration, dated September 17, 2014, indicated under approach column: Report noncompliant behavior to MD and responsible party. A review of the facility policy and procedure titled, Medication Documentation, revised June 2012, indicated, Charting .9. Drugs not given as prescribed. a. When doses are refused or not given for other reasons or given at a time other than that prescribed the nurse shall circle her initials and explain reason on back of medication administration record. b. Physician should be notified of missed doses as appropriate .

Based on interview and record review, the facility failed to ensure that one of 17 sampled residents (Resident 10) did not experience an undesirable 9 lb (pound) weight loss in 2 months. The facility also failed to assess Resident 10 after the weight loss. These failures resulted in Resident 10 experiencing a decline in nutritional status, and an undesirable, unplanned weight loss. Findings: During a review of the clinical record for Resident 10, the Resident Face Sheet, undated, indicated that Resident 10 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the Care Plan, ted February 15, 2016, indicated, Significant change in status assessment: 14 lbs weight gained in 6 months, Resident desirable weight gained. During a review of the clinical review for Resident 10, the Monthly weight record, dated March 1, 2016, indicated that Resident 10 was 135 lbs. On April 1, 2016, Resident 10 weighed 130 lbs and on May 1, 2016, Resident 10 weighed 126 lbs. Resident 10 lost a total of 9 lbs in 2 months. During an interview with the Restorative Nurse Assistant (RNA-Staff responsible for weighing residents) on June 15, 2016 at 2:27 PM, in Nurses' Station A, he stated that when a resident loses weight, I notify the charge nurse who then notifies the Director of Nursing (DON). The DON will then contact the RNA to provide nourishment to the resident. During an interview with DON on June 15, 2016 at 2:35 PM, she stated, When a resident loses weight, we notify the Registered Dietician (RD), and then follow the RD's recommendation. She said if there is no RD recommendation, then we contact the Doctor. We also have an Interdisciplinary Team (IDT) weight variance meeting (a meeting where residents that are risk for weight loss are discussed and care planned) once a month. She stated, There are no IDT notes in Resident 10's clinical record. We did not notify the doctor or the dietician. During a review of the clinical record for Resident 10, no notes were found in the Care Plan, nor documentation of the RD regarding weight loss from March 2016 through May 2016. The DON confirmed that there were no nursing notes, assessment notes, no updated plan of care, or physician's documentation noted in Resident 10's clinical record regarding resident 10's unintended weight loss. There were also no interventions put in place to ensure that Resident 10 regained the lost weight or to prevent future weight loss during this time. During a review of the Care plan,dated May 2015, indicated, At risk for significant weight loss of 5% in a month or 10% in 6 months , secondary to dx (diagnosis) of Dementia (condition of significant memory loss). Approach: Monitor weight as ordered, will notify MD (medical doctor) and Resident's responsible party for any significant COC (Change of condition). Review of the facility policy and procedure titled, Weight Assessment and Intervention, dated March 2012, indicated, Any weight change of 5 pounds or 5% or greater within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician and an IDT, then meeting with weight variance will be started .If an unplanned weight loss is identified, and is significant, the IDT will proceed to care plan the weight loss, and analyze the different contributing factors which could result to unplanned weight loss .The attending physician of the subject resident will be notified for the significant weight loss or gain. Review of the facility policy and procedure titled, Resident's Weight, dated July, 2012, indicated, The nursing staff is accountable for identifying the residents with considerable unplanned weight gain/loss and meeting with IDT MEMBERS to discuss significant weight gain/loss interventions. The Physician is also notified of significant gain/loss undesirable weight change.

Based on observation, interview, and record review, the facility failed to ensure Resident A, who was non-verbal and immobile, was free from sexual abuse from Resident B. This failure resulted in Resident A being subjected to sexual abuse when Resident B was found fondling her genitalia, placing her at risk of injury and unable to protect herself from Resident B due to her medical condition. Findings: An unannounced visit was made to the facility on [DATE] at 4:00 PM to investigate an entity reported incident of sexual abuse of Resident A by Resident B. During a review of the clinical record for Resident A, the admission record indicated Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (a progressive loss of brain and muscle function), [MEDICAL CONDITION] (chronically poor airflow),constipation (bowel movements that are hard to pass), and hypertension (high blood pressure), Resident A required total care with two person assist, was a non-verbal, and non-ambulatory female. Resident A was small statured woman, totally dependent on staff for all activities of daily living (ADLs). She was a non-verbal, non-ambulatory, and immobile female. During a review of the clinical record for Resident B, the admission record indicated that Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. of sadness). Resident B was alert with confusion, does not have the capacity to make decisions, ambulatory, and 179 pounds. During a phone interview on November 5, 2015 at 10:34 AM, with the Certified Nurse Assistant (CNA 1),who witnessed Resident B fondling Resident A's genitalia; he described the incident as follows: CNA 1 was doing rounds and walking in the hallway and noticed Resident B was in Resident A's room and was observed fondling Resident A on the genitalia area. CNA 1 told Resident B to get out of the room and escorted Resident B back to his room. Resident B was placed on a 1:1 observation. CNA 1 said that Resident A was quiet, she did not speak, and was confined to bed. During a review of the declaration statement explaining the incident where CNA 1 witnessed Resident B fondling Resident A on the genital area on November 4, 2015 at 6:45 AM, indicated, CNA 1 noticed Resident B's hand on her (Resident A's) private area. Immediately, Resident B was redirected to leave the room. The charge nurse was notified and Resident B was placed on 1 on 1 for close behavioral observation with staff monitoring. A full body assessment was done to Resident A by the charge nurse. Director of Staff Development, the Administrator, and Director of Nursing were notified. During a phone interview on November 5, 2015 at 10:38 AM, with the Certified Nurse Assistant (CNA 2) who was assigned to Resident A, she described the incident as follows: I did not see the incident but I did see (Resident B) entering and exiting several times from the outside patio sliding door leading to (Resident A's room) CNA 2 stated, I reported to the charge nurse and to the CNA (CNA 1)who was assigned to the resident (Resident B) about his behavior. During a review of the declaration statement of CNA 2 who witnessed Resident B entering and exiting (Resident A's room) from the outside patio sliding door on November 4, 2015 (no time was indicated on the statement form) indicated, Witnessed (Resident B) entering and exiting (Resident A's room) outside patio and I told him several times that he couldn't use the sliding door of that room as an entrance or exit. This was reported to his assigned CNA (CNA 1)of Residents (B's) behavior at that time. (CNA 1) witnessed (Resident B) coming out from (Residents A's room) and CNA 1 addressed Resident B and I continued to finish my rounds. During an interview with the Director of Nursing (DON) on November 6, 2015 at 10:55 AM, when asked if CNA 2 closed the sliding door when Resident B was entering from the patio to room [ROOM NUMBER], she said, Yes, but Resident B kept on opening the sliding door. The door was not locked. During a phone interview on November 6, 2015 at 11:34 AM, with the Licensed Vocational Nurse (LVN 1), when asked if Resident A's diaper was open when CNA 1 witnessed Resident B fondle Resident A's genitalia, she said, CNA 1 told her that Resident A's diaper was open and Resident B had his hand on Resident A's genitalia, and Resident B was fully dressed. When asked did CNA 2 notify her regarding Resident B entering through the sliding door coming from the patio to room [ROOM NUMBER] before the incident occurred, LVN 1 said, No. She stated she was told by CNA 1 about him witnessing Resident B fondling Resident A's genitalia. The facility policy and procedure titled,Criteria to Screen Residents for Potential Abuse, undated, indicated,Possible signs of Sexual Abuse: cuts, lacerations, bruises, around genital areas, injuries not compatible with history, flirtations, coyness, etc., as possible indicators of inappropriate sexual relationship, helplessness, hesitation to talk openly, fear, withdrawal, depression, denial, agitation, and fear. The facility policy and procedure titled, Abuse and Neglect Prevention Management, undated, indicated,Screening potential residents will be reviewed for potentially abusive behaviors: the pre-admission screen reviews the residents [DIAGNOSES REDACTED]. The facility makes every effort to ensure residents who have challenging behaviors will receive a psychiatric evaluation for appropriate interventions. The facility failed to ensure Resident A was free from sexual abuse by Resident B, by not preventing Resident B from re-entering Resident A's room uninvited.

Based on interview, and record review, the facility failed to ensure that one (1) of three (3) sampled residents (Resident 1) was free of mental and verbal abuse when the Maintenance Supervisor (MS) responded to Resident 1's request to have his bed repaired, by telling Resident 1,"I will blow your head off." This failure resulted in Resident 1 to verbalize feeling threatened, and unsafe in the facility. Findings: An unannounced visit was made to the facility on [DATE], to investigate an entity reported incident related to resident abuse. The facility's typed summary of their investigation provided with their report of the incident to the California Department of Public Health (CDPH) undated, indicated on August 12, 2014, Resident 1 asked the MS to fix his bed, and the MS replied, "I will blow your head off." Resident 1 verbalized the comment made him feel threatened. During an interview on January 20, 2015 at 1:55 PM, when asked to describe what happened, Resident 1 stated he asked MS to fix his bed that kept hitting the plug on the wall every time the bed goes down. Resident 1 stated MS, who was holding "some kind of a tool," replied with an attitude, "I will blow your head off." MS then gestured, "Bang, bang," using the tool he was holding. Resident 1 stated, "I felt threatened. You don't joke like that; I don't really know the guy." Resident 1 stated this was witnessed by another staff (Housekeeper 1). Resident 1 stated MS never came back to fix his bed; another maintenance staff came a couple days later to fix his bed. During an interview with Housekeeper 1, in the presence of the Director of Nursing (DON) on January 22, 2015 at 8:50 AM, and a concurrent review of her undated statement of the incident, Housekeeper 1 confirmed on August 12, 2014, MS went into Resident 1's room looking for another staff. MS, who had a caulking gun in hand, told Resident 1, "I can blow your head off with this." A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's history and physical examination [REDACTED]." An undated incident investigation signed by the Administrator, was received by the California Department of Public Health (CDPH)on August 26, 2014. The report indicated on August 13, 2014, the day after the incident, the Administrator met with the MS. "The maintenance supervisor was asked about the incident and admitted that he could have said those words but he meant no harm and was only joking and assumes that the resident did not take those words seriously." During an interview with MS, in the presence of the Administrator and the DON on January 20, 2015 at 2:55 PM, when asked what happened, MS stated he was fixing Resident 1's bathroom and he was holding a caulking gun (a hand tool that dispenses a material used to seal a gap or a seam). MS stated, "We used to joke around like normal person. I know I said something as a joke but I don't remember what I said, ...I didn't know he got upset." MS stated on August 13, 2014 (a day after the incident on August 12, 2014), he talked to Resident 1 by himself and explained to Resident 1, "I wasn't trying to hurt your feeling." During an interview on January 20, 2015 at 3:10 PM, the Director of Staff Development/Licensed Vocational Nurse (DSD/LVN) stated on August 12, 2014, a staff member overheard and reported the "threat" to Resident 1 to her. The DSD/LVN and the Social Service Director (SSD) talked to Resident 1, who confirmed the incident. DSD/LVN stated Resident 1, "Felt uncomfortable and didn't feel safe." During an interview on January 20, 2015 at 3:35 PM, SSD confirmed she and DSD/LVN talked to Resident 1, who confirmed the incident. SSD stated Resident 1, "felt threatened." A review of the "Disciplinary Action," form dated August 14, 2014 indicated the MS received notification that he would be, "immediately suspended if he does it to any resident and agreed." A review of a second "Disciplinary Action,"form dated August 28, 2014, indicated the MS had an "allegation of verbal abuse against resident August 12, 2014. " Under, "Corrective action," was listed: "verbal warning/write-up August 14, 2014, Suspension for 3 days for re-investigating the incident." The dates of the suspension were from August 25, 2014 through August 28, 2014." A review of the facility's policy and procedure titled, "Elder Abuse and Dependent Adult Reporting," dated July 2012, indicated, "9. The Administrator and DON are responsible to ensure timely inclusive investigative actions have been completed. Administrative active may include suspension of an employee involved in an incident pending completion of investigation results." The MS was not suspended until 13 days after Resident 1 verbalized he had felt threatened.

Based on interview and record review, the facility failed to report and fully investigate an allegation of verbal abuse according to the facility's policy and procedure, when the Maintenance Supervisor (MS) told one of three sampled residents (Resident 1), who was asking to have his bed fixed, "I will blow your head off." This failure resulted in Resident 1 to feel threatened, and unsafe, and had the potential for all residents to be placed at risk for allegations of abuse to not be investigated, or reported. Findings: An unannounced visit was made to the facility on [DATE] to investigate an entity reported incident related to resident abuse. The report revealed on August 12, 2014, when Resident 1 asked the MS to fix his bed, the MS replied, "I will blow your head off." Resident 1 felt threatened. A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's history and physical examination [REDACTED]." An undated incident investigation signed by the Administrator, was received by the California Department of Public Health (CDPH) on August 26, 2014 (14 days after the incident was reported to the administrator on August 12, 2014). The report revealed, "The maintenance supervisor was asked about the incident and admitted that he could have said those words but he meant no harm and was only joking and assumes that the resident did not take those words seriously." During an interview on January 20, 2015 at 2:15 PM, the Administrator stated the incident was reported to him by the Social Service Director (SSD) on August 12, 2014. He stated he reported the incident to CDPH on August 24, 2014 (14 days after the incident was reported to the administrator on August 12, 2014); "I admit I reported it late." The administrator stated he counseled the MS on August 13, 2014 and made a verbal/written warning on August 14, 2014. The Administrator stated during his interview with the MS, he stated he could have said those words, and he was just joking with Resident 1." The Administrator stated, "It was inappropriate." A concurrent interview with the Administrator on January 20, 2015 at 2:18 PM, and a review of a "DISCIPLINARY ACTION" form, dated August 28, 2014, revealed MS was suspended from work on August 25, 2014 (13 days after the incident was reported to the Administrator on August 12, 2014) to August 28, 2014; "Suspension for 3 day for re-investigating the incident." The Administrator stated that as an Abuse Coordinator, "I'm supposed to suspend the employee immediately as soon as we found out, until the investigation was over." During an interview on January 20, 2015 at 1:55 PM, when asked to describe what happened, Resident 1 stated he asked MS to fix his bed that kept hitting the plug on the wall every time the bed goes down. Resident 1 stated MS, who was holding "some kind of a tool," replied with an attitude, "I will blow your head off." MS then gestured, "Bang, bang," using the tool he was holding. Resident 1 stated, "I felt threatened. You don't joke like that; I don't really know the guy." Resident 1 stated this was witnessed by another staff (Housekeeper 1). Resident 1 stated MS never came back to fix his bed; another maintenance staff came a couple days later to fix his bed. MS came approximately a week or two later and said, "I was just joking." During an interview with MS, in the presence of the Administrator and the Director of Nurses (DON) on January 20, 2015 at 2:55 PM, when asked what happened, MS stated he was fixing Resident 1's bathroom and he was holding a caulking gun (a hand tool that dispenses a material used to seal a gap or a seam). MS stated, "We used to joke around like normal person. I know I said something as a joke but I don't remember what I said... I didn't know he got upset." MS stated on August 13, 2014 (a day after the incident on August 12, 2014), he talked to Resident 1 by himself and explained to Resident 1, "I wasn't trying to hurt your feeling." During an interview on January 20, 2015 at 3:10 PM, Director of Staff Development/Licensed Vocational Nurse (DSD/LVN) stated on August 12, 2014, a staff member overheard and reported the "threat" to her. DSD/LVN and the Social Service Director (SSD) talked to Resident 1, who confirmed the incident. DSD/LVN stated Resident 1, "Felt uncomfortable and didn't feel safe." DSD/LVN then reported the incident to the Administrator on the same day. DSD/LVN stated MS was not suspended during that time; "The person should be suspended until the outcome and I did not see that; he was still here." During an interview on January 20, 2015 at 3:35 PM, SSD confirmed she and DSD/LVN talked to Resident 1, who confirmed the incident. SSD stated Resident 1, "Felt threatened." During a concurrent review of Resident 1's clinical record, SSD confirmed there was no documented evidence Resident 1 was assessed and monitored immediately, and following the incident until August 27, 2014 (15 days after the incident on August 12, 2014). SSD also confirmed there was no documented evidence a "Grievance/Complaint Report" was filled out for the incident. SSD stated there was no grievance/complaint log in place because the facility never received any grievance or complaints from anyone at all. A concurrent review with the SSD of the facility's policy and procedure titled "GRIEVANCES SOCIAL SERVICES ROLE AND RESPONSIBILITIES," Rev. 02/05, revealed, "The Social Service designee is a key person receiving grievance and/or complaints from residents, family members and/or responsible parties. A grievance/complaint may be oral or written. If the Social Services designee receives an oral grievance/complaint, the information is to be documented on the report form. This is to ensure the grievance/complaint has been acknowledged and actions have been taken in resolution of the problem. Reports are to be forwarded and preferably discussed promptly with the Administrator who may direct additional actions by the Social services designee in resolution of the problem. The Social Services designee may also be requested to assist in upgrading the Grievance/Complaint log ...The Social Services designee will also be a primary person responding to the individual making the grievance/complaint. This is to inform the individual the actions taken in resolution of the problem and determine their satisfaction with the facility's efforts..." During an interview on January 20, 2015 at 4 PM, the Administrator stated based on his interview with Resident 1 and the MS during the investigation, MS "was just joking." And since Resident 1 already accepted MS' apology, MS was reinstated on August 28, 2014. He confirmed there was no documented evidence a result of the investigation was reported to CDPH. An interview with Housekeeper in the presence of the DON, and a concurrent review of her undated statement of the incident was conducted on January 22, 2015 at 8:50 AM. Housekeeper confirmed on August 12, 2014, MS went into Resident 1's room looking for another staff. MS, who had a caulking gun in hand, told Resident 1, "I can blow your head off with this." During an interview with the DON on January 22, 2015 at 9:15 AM, and a concurrent review of the clinical record, the DON confirmed there was no documented evidence of the incident, and that Resident 1 was assessed and monitored immediately, and following the incident. DON stated Resident 1 should have been assessed and monitored for 72 hours for any change in condition. A review of the facility's policy and procedure titled "Plan of Care for Resident Concern and/or Change of Condition" Rev. 07/2012, revealed, "It is the policy of the facility to document in the medical records any concern and/or change of condition/accident/incident regarding a resident which may or may not involve an injury ... 4. An assessment of the resident's condition by a licensed nurse including vital signs is to be done at the time of the concern/change of condition or injury and each shift for minimum of seventy-two (72) hour period/or per physician's orders [REDACTED]. A review of the facility's policy and procedure titled "ELDER ABUSE AND DEPENDENT ADULT ABUSE REPORTING" Rev. 07/2012, revealed under Procedure, "...6... The Charge Nurse/Supervisor is to interview and obtain written statements...9. The Administrator and DON are responsible to insure that timely inclusive investigate actions have been completed. Administrative action may include suspension of an employee involved in an incident pending completion of investigation results...11. The Administrator or DON will be responsible to report immediately or as soon as possible or within 24 hours by telephone and to be followed by a written report. SOC 341 should be send (sent) to ombudsman coordinator or to a local law enforcement agency, then to department of public health services..."

Based on observations, interviews, and record reviews, the facility failed to maintain a safe environment that was free of accident hazards as evidenced by: 1. The facility failed to ensure that the spaces/gaps in the side rails for 6 of 86 resident beds had no spaces/gaps large enough to entrap (trap) the head or body parts for residents with fluctuating mental status and/or decreased mobility. A. For Residents' F, G, 4 and 15, there were large spaces/gaps in between the vertical rods supporting the top and bottom rails. Also, the side rails on the beds were collapsible (to fall down easily). Resident G's left arm was observed dangling through the vertical rods of the side rails. B. For Residents' E and H, there were large spaces/gaps in between the bottom of the side rails and the mattresses when the residents were observed in semi/sitting positions. These beds also had horizontal rods in the side rails. Resident H's left arm was observed dangling through the horizontal rods in the side rail. This failure had the potential to cause entrapment (when a resident is caught between the mattress and bed rail or in the bed rail itself due to wide spaces between bars in the bed rails), harm, serious injury, impairment (partial or complete loss of function or body part) or death for at least 6 of 86 residents. Because of the facility's failure to identify the potential for harm/injury/entrapment/or death for Residents' F, G, 4 and 15, with the large spaces/gaps in between the vertical rods supporting the top and bottom rails and the collapsible side rails on the beds; for Residents' E and H, with the large spaces/gaps in between the bottom of the side rails and the mattresses when the residents were observed in semi/sitting positions; Resident G' s left arm that was observed dangling through the vertical rods of the side rails; Resident H's left arm that was observed dangling through the horizontal rods in the side rail; and staff going into the room and assisting both Resident G and H and not identifying the potential danger or repositioning their arms that were dangling through the side rails, Immediate Jeopardy (IJ a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death to a patient/resident) was called on 10/24/12, at 1:29 PM, with the Administrator, Director of Nursing (DON) and the Chief Executive Officer (CEO). 2. The facility failed to ensure that the hot water temperatures were maintained below 120 degrees Fahrenheit for 2 of 8 unsampled Residents (Resident A & B) as evidenced by: A. On 10/22/12, during the initial tour of the facility, the hot water temperature in the bathroom that serviced rooms 39 and 41 was 126.8 degrees Fahrenheit. B. The hot water temperature in the bathroom that serviced rooms 35 and 37 was 124.7 degrees Fahrenheit. This failure had the potential for the residents to sustain burns when the hot water in their bathrooms exceeded 120 degrees Fahrenheit. 3. The facility failed to provide the supervision and interventions necessary to prevent falls/accident for 1 of 18 sampled Residents (Resident 3). The resident fell in his room on 9/10/12, while attempting to go to the bathroom unassisted; sustaining a left hip fracture that required surgical intervention and hospitalization . Findings: 1. On 10/24/12, at approximately 8:20 AM, Residents' F, G, 4 and 15 were observed in beds with side rails that had large spaces/gaps in between the vertical rods supporting the top and bottom side rails. These beds also had collapsible side rails. Resident G's left arm was observed dangling through the spaces/gaps between the vertical rods. Residents' E and H were observed in bed that had large spaces/gaps in between the bottom of the side rails and the mattresses when the residents were observed in semi/sitting positions. These beds also had horizontal rods in the side rails. Resident H's left arm was observed dangling through the horizontal rods in the side rail. On 10/24/12, at 8:40 AM, an inspection was conducted of all the beds in the facility with side rails that were in use. No additional residents with the affected side rails were identified at that time. On 10/24/12, at 8:55 AM, the Administrator was notified of concerns for the 6 residents with large spaces/gaps in between the vertical rods supporting the top and bottom side rails, and the collapsible side rails for Residents' F, G, 4 and 15; the spaces/gaps created between the bottom of the side rails and the mattresses for Residents E and H, when the residents were in semi/sitting positions; and that the staff had not identified and/or repositioned Residents G's left arm that was dangling through the vertical rods in the side rails or Resident H's left arm that was dangling through the horizontal rods in the side rails. An inspection and measurement for the 4 beds with the large spaces/gaps in between the vertical rods supporting the top and bottom side rails with the collapsible bed rails, and the 2 beds with the large spaces/gaps created between the bottom side rails and the mattresses when the residents were in semi/sitting positions, was conducted with the Administrator. The measurements of the spaces/gaps in in between the vertical rods supporting the top and bottom side rails, and spaces/gaps created between the bottom of the side rails and the mattresses when the residents were in semi/sitting positions were: Resident E - The spaces/gaps was greater than 5 inches between the bottom of the side rails and the mattress when the resident was observed in a semi-sitting position in bed. This bed design had horizontal rods in the side rails. Resident F - The spaces/gaps in between the vertical rods supporting the top and bottom of the side rails was 9.5 x 5.5 inches apart for this bed design. The bed side rails were collapsible. Resident G - The spaces/gaps in between the vertical rods supporting the top and bottom of the side rails was 9.2 x 7 inches apart for this bed design. The bed side rails were collapsible. Resident H - The spaces/gaps between the bottom of the side rails and the mattress when the resident was observed in a sitting position was 9 inches (based on the design this particular bed and mattress). This resident's left arm was still dangling through the horizontal rods in the side rails at the time of the measurement. Resident 4 - The spaces/gaps in between the vertical rods supporting the top and bottom of the side rails was 8.5 x 5.5 inches apart. The bed side rails were collapsible. Resident 15 - The spaces/gaps in between the vertical rods supporting the top and bottom of the side rails was 9.25 x 6 inches apart. The bed side rails were collapsible. On 10/24/12, at 9:07 AM, after completion of the measurement of the gaps in the side rails of the 6 affected resident's beds, the Administrator was asked, what was the facility's plan to correct the problem? The Administrator responded, " This is an old building, I will check the policy " . In 1995, the Food and Drug Administration (FDA), issued a safety alert entitled, "Entrapment Hazards with Hospital Bed Side Rails", which included, residents most at risk for entrapment being those who are frail and elderly or those who have conditions such as agitation, confusion, uncontrolled body movement etc., that may cause them to move about the bed and try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and the bed rail or in the bed rail itself. Technical issues such as the proper sizing of mattresses and the integrity of bed rails or other design elements (e.g., wide spaces between bars in the bed rails) can also affect the risk of resident entrapment. Precautions may include following the manufacturer equipment alerts and increasing supervision. In March 9, 2006, The FDA published the guidance, entitled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment", which "identifies special issues associated with hospital bed systems and provides design recommendations for manufacturers of new hospital beds and suggestions for health care facilities on ways to assess existing beds. The guidance characterizes the body parts at risk for entrapment, identifies the location of hospital bed openings that are potential entrapment areas, recommends dimensional criteria for new hospital bed system,.............. Summary of FDA Hospital Bed dimensional Limit Recommendations: Zone 1, within the rail, Zone 2, under the rail, between rail supports or next to a single rail and Zone 3, between rail and mattress < 120 mm or 4.75 inches. Zone 4, under the rail, at the end of the rail < 60 mm or 2 3/8 inches and > 60 degree angle". On 10/24/12, at 9:15 AM, the CEO reported that the facility ordered 6 beds that would be delivered to the facility within 2 weeks. The CEO also stated that the facility had been in the process of replacing the old beds. For example, the beds for unsampled Residents H was recently purchased. On 10/24/12, at 9:25 AM, the CEO reported that the new beds would arrive at the facility on 10/24/12 by 7:00 PM. She stated that all of the residents would be evaluated by the licensed nursing staff and would be assigned 1:1 supervision (one staff assigned to one resident) until all of the residents were out of the affected beds. At 9:40 AM, the CEO stated that the new beds would now arrive at 1:00 PM. She stated that while they were waiting for the new beds, the facility staff would switch out the affected beds from the current vacant beds in the facility. On 10/24/12, from 9:51 AM to 10:01 AM, no staff were observed providing 1:1 supervision for Resident 15. The resident was sleeping in bed. At 9:55 AM, a Certified Nursing Assistant (CNA) was observed going into the room, he pulled the privacy curtain around the resident ' s roommate ' s bed and proceeded to provide care for the roommate. On 10/24/12, at 10:01 AM, an interview was conducted with the DON. The DON verified that Resident 15 was not being supervised. She confirmed that the CNA assisting the roommate was not the CNA assigned to provide the 1:1 supervision for Resident 15. The DON stated that the resident was sleeping and that she would find out who was assigned to provide the 1:1 supervision for the resident until the bed was changed. On 10/24/12, the following affected resident medical records were reviewed to determine their mental and functional capacities: 1. A review of Resident 15's medical record was conducted on 10/24/12. It noted that the resident was admitted to the facility on [DATE], and readmitted on [DATE]. The [DIAGNOSES REDACTED]. The Minimum Data Set (MDS a comprehensive assessment of the resident) completed on 10/10/12, noted that the resident was alert, oriented and able to make needs known. He required extensive assistance with bed mobility and was dependent on staff for transfers and activities of daily living (ADL's). On 10/24/12 the resident was observed to be totally dependent on staff for re-positioning in bed. He was able to use an electric wheel chair to move around the facility. 2. A review of Resident E's medical record was conducted on 10/24/12. It noted that the resident was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. (progressive mental deterioration occurring in middle or old age, due to generalized degeneration of the brain). The MDS completed on 8/8/12, noted that the resident had long and short term memory problems and was dependent on staff for transfers and activities of daily living. On 10/24/12, at 8:59 AM, Resident E was observed lying in bed and appeared to be sleeping. On 10/24/12, at 12:04 PM, an interview was conducted with CNA 1. She stated that Resident E was alert and at times could make her needs known, required assistance with transfer and bed mobility, but that the resident squirmed (moved around) in bed on her own. 3. A review of Resident F's medical record was conducted on 10/24/12. It noted that the resident was admitted to the facility on [DATE], and readmitted on [DATE]. The [DIAGNOSES REDACTED]. The MDS completed on 8/16/12, noted that the resident was alert and oriented and was independent with transfers and ambulated with a walker. On 10/24/12, at approximately 9:01 AM, Resident F was observed lying in bed. She responded to questions and stated that she had no problems with her bed. 4. A review of Resident G's medical record was conducted on 10/24/12. It noted that Resident G was admitted to the facility on [DATE], and readmitted on [DATE]. The [DIAGNOSES REDACTED]. A review of the MDS completed on 7/25/12, noted that Resident G was able to make his needs known. He required extensive assistance with bed mobility and was dependent on staff for transfers and activities of daily living. He had functional limitations in range of motion to the upper extremity (shoulder, elbow, wrist, hand). On 10/24/12, at 8:20 AM, observation was made of Resident G in a semi-sitting position in bed. The resident' s left arm was observed dangling through the horizontal rods of the side rails. The resident was unable to move and reposition his left arm. An interview was conducted on 10/29/12, at 8:25 AM, with Licensed Vocational Nurse (LVN) 1 who was responsible for the supervision of care for Resident G. LVN 1 stated that the resident was unable to move his arms but that he might be able to lift his left arm 2 to 3 inches. The resident was later observed propelling his wheel chair in the hallway, using his legs. 5. A review of Resident H's medical record was conducted on 10/24/12. It noted that the resident was admitted to the facility on [DATE], and readmitted on [DATE]. The [DIAGNOSES REDACTED]. The MDS review completed on 9/25/12, noted that Resident H was not always able to express his needs and had cognitive impairment. He was dependent on staff for bed mobility, transfers and activities of daily living. The resident had functional limitations in range of motion to one side of his upper and lower extremities (hip, knee, ankle and foot). On 10/24/12, from 8:21 AM to 9:03 AM, observation was made of Resident H in a semi-sitting position in bed. The resident's left arm was observed dangling through the horizontal rods in the side rails. The resident was unable to move and reposition his left arm. An interview was conducted on 9/29/12, at 8:30 AM, with LVN 1. She stated that Resident H could move both arms with limitations but had a hard time feeding himself. 6. A review of Resident 4's medical record was conducted on 10/24/12. It noted that the resident was admitted on [DATE], and readmitted on [DATE], and 10/17/12. The [DIAGNOSES REDACTED]. The MDS review completed on 9/13/12, noted that the resident had memory problems and was totally dependent on staff for re-positioning, transfers and activities of daily living. Because of the facility's failure to identify the potential for harm/injury/entrapment/or death due to large vertical gaps in between the top and the bottom side rails and the large gaps between the bottom of the side rails and the mattresses for the 6 residents, Immediate Jeopardy was called on 10/24/12, at 1:29 PM, in the presence of the Administrator, DON and CEO. On 10/24/12 at 2:35 PM, the Administrator submitted a Plan of Correction (POC). At 2:45 PM, the POC was reviewed by the survey team and was not accepted for the following reasons: a. The POC did not include staff training on all types of beds/rails. b. The POC only included in-services for the day shift Certified Nursing Assistants. c. The POC completion was dated 10/24/12, which did not give the facility time to complete in-services for all staff that had contact with the residents while in bed. On 10/24/12, at 3:43 PM, the facility submitted the revised POC which was not accepted for the following reason: The POC did not reflect that all staff would be in-serviced regarding all of the facility's beds, to include the large spaces/gaps in between the vertical rods supporting the top and bottom side rails; the spaces/gaps created between the bottom of the side rails and the mattresses when the head of the bed was elevated and the residents were in semi or sitting positions, or instructions for the staff to adjust those side rails. On 10/24/12, at 3:50 PM, the facility's revised POC was accepted. The POC consisted of the following elements: 1. The 6 affected residents were assessed by the licensed staff and assisted out of bed to the activity room. 2. The beds and or the side rails were changed for the identified beds and were replaced with appropriate side rails and beds that did not have the side rails in question. 3. 6 new beds were ordered and arrived at 12:00 PM. 4. In-services with demonstrations and role playing was started on the appropriateness of the beds, mattresses, side rails and positioning of residents in bed to prevent entrapment/harm or death. The lesson plan included information from the FDA Safety Alert: Entrapment hazards with Hospital Beds Side Rails. The diagrams used showed the 4 locations where all reported entrapment occurred. The lesson plan also covered appropriate side rails adjustment to prevent gaps between the bottom side rails and the mattress when the head portion of the bed was adjusted. 5. Daily monitoring of beds would be completed by administrator, maintenance supervisor or designee. 6. Daily monitoring of residents and beds by the DON, DSD and RN supervisor during routine rounds. 7. Licensed nurses to check resident ' s position while in bed, every shift. 8. The effectiveness of this monitoring would be addressed at the monthly and quarterly Quality Assurance (QA) meetings. 9. All staff would be in-serviced on the appropriateness of bed, side rails, positioning of residents by 10/25/12. On 10/25/12, at 1:45 PM, the survey team met with the Administrator and the DON regarding the facility's implementation of the corrective measures to remove the risk and the prevention of repeat Immediate Jeopardy situations. The facility provided documented evidence that the majority of the staff from all 3 shifts were in-serviced on the potential safety hazards to residents from inappropriate beds, including mattresses, side rails and unsafe positioning of residents in bed. The facility had a plan to in-service the few staff that were not available for the in-services prior to any resident care. On 10/25/12 at 2:10 PM, the survey team informed the Administrator and the DON that the Immediate Jeopardy was abated (lifted). 2. On 10/22/12, at 2:45 PM, during the initial tour of the facility, the hot water temperature in the bathroom that serviced the residents in rooms 39 and 41 was 126.8 degrees Fahrenheit (F). Time and temperature Relationship to Serious Burns: Water Temperature Time required for a 3rd. Degree Burn (penetrates the entire thickness of the skin and permanently destroy tissue) to Occur. 100 degrees F Safe temperatures for bathing (burns can occur below this temperature based on the individual condition and length of exposure. 120 degrees F 5 minutes 124 degrees F 3 minutes 127 degrees F 1 minute An interview was conducted on 10/22/12, at 2:46 PM, with the Minimum Data Set (MDS) Coordinator who confirmed that the hot water temperature was 126.8 degrees Fahrenheit. She proceeded to wash her hands under the hot running water and stated, " This water is very hot". An interview was conducted with the Director of Nursing (DON) on 10/22/12, at 2:55 PM. The DON was notified of the hot water temperature in the bathroom. She stated that she would notify the maintenance supervisor (MS). On 10/22/12, at 3:05 PM, the hot water temperature was checked with the MS in the bathroom that serviced residents in rooms 39 & 41 bathroom. The temperature read 126.5 and 122 degrees Fahrenheit. The MS stated that he had adjusted the hot water in the boiler down to 115 degrees about 10 - 15 minutes earlier when he was notified of the hot water. He also stated that this bathroom was the closest to the boiler and was usually the hottest. On 10/22/12, at 3:09 PM, the hot water temperature in the bathroom that serviced rooms 35 and 37 was checked with the MS. The hot water temperature was 124.7 and 121 degrees Fahrenheit. The MS stated that he would adjust and monitor the hot water temperature. On 10/22/12, at 5:20 PM, the hot water temperature in the affected bathrooms were rechecked with the MS. The hot water temperature in bathroom that serviced rooms 39 and 41 was 118 and 115 degrees Fahrenheit. The hot water temperature in the bathroom that serviced rooms 35 and 37 was 118 and 114 degrees. The MS stated that he routinely tested water temperatures. The temperature log and the policy for checking the water temperature were requested. The temperature log was reviewed, but the facility policy for checking the water temperatures was not received. A. An interview was conducted on 10/22/12, at 5:25 PM, with unsampled Resident A, who used the bathroom that serviced rooms 35 and 37. She stated, "The hot water is always hot, good hot water". She also stated that she used the hot water to make tea at night. On 10/23/12, Resident A' s medical record was reviewed. It noted that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, a comprehensive assessment of the resident) completed on 9/27/12, noted that the resident was alert, oriented and able to make her needs known. She required limited assistance for mobility, transfers and activities of daily living. An interview was conducted on 10/26/12, at 8:29 AM, with CNA 2. She confirmed that Resident A used the sink for hand washing and personal hygiene. B. On 10/23/12, Resident B's medical record was reviewed. It noted that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].). A review of the MDS completed on 8/10/12 noted that the resident was able to make his needs known and was independent with toileting. An interview was conducted on 10/26/12 at 8:30 AM with CNA 2. She confirmed that Resident B went to the bathroom independently and used the sink for personal hygiene. 3. On 10/23/12, Resident 3's medical record was reviewed. It noted that the resident was admitted to the facility on [DATE], and readmitted on [DATE], and 10/15/12. The [DIAGNOSES REDACTED]. functioning), Alzheimer ' s disease (degeneration or loss of nerve cells in the brain) and psychosis (loss of contact with reality that usually includes: False beliefs about what is taking place or who one is (delusions); Seeing or hearing things that aren't there (hallucinations). A review of the MDS completed on 8/8/12, prior to the fall noted, that Resident 3 was alert, oriented and was independent with transfer, ambulation and required limited assistance with dressing, personal hygiene and bathing. The resident had functional limitation in range of motion to one side of the lower extremity (hip, knee, ankle, foot). The resident was always incontinent of urine with occasional incontinence of bowel. A review of the physician annual history and physical completed on 2/12/12, noted that the resident had fluctuating capacity to understand and make decisions due to psychosis. A review of the quarterly "Fall Risk Assessment", completed on 8/8/12, noted that Resident 3 was low risk for fall. The resident was ambulatory and continent of bladder and bowel and only had difficulty while walking through a door way. This contradicted the MDS completed on the same date that noted the resident to be incontinent of urine all the time with occasional incontinent of bowel. A review of the "Fall Risk/ Restraint Assessment", completed by the IDT on 8/8/12, noted that Resident 3 had memory problem, fair safety judgment/awareness, poor balance problem with unsteady gait and had behavioral problem that could contribute to potential fall. The resident had no falls or injury this past quarter. The recommendation was for staff to continue to assist the resident with transfer, mobility and other ADL ' s as needed. This assessment was contrary to the "Fall Risk Assessment", completed on the same date. A review of the quarterly Interdisciplinary (IDT) Progress Notes completed on 8/9/12, noted that Resident 3 was alert with periods of confusion secondary to dementia. He needed limited assistance with dressing, personal hygiene, bathing and supervision with toilet use. The resident was incontinent of urine with occasional incontinent of bowel, was ambulatory but preferred to stay in room. A review of the nurses notes dated 9/8/12, at 3:00 PM, noted that Resident 3 had periods of confusion and was disoriented with no acute distress. Registered Nurse (RN) 1, the day shift supervisor stated that on 9/7/12, the resident was placed on 24 hour monitoring due to abnormal lab results. The staff monitored the resident for fever, abnormal vital signs and generalized weakness. A review of the nurses notes dated 9/10/12, at 7:30 AM, noted that the CNA reported that that Resident 3 was lying on his left side on the floor between the bed and the bathroom. The resident stated that he lost his balance while going to the bathroom and slipped unto the floor. The resident was able to move both upper extremities but complained of pain to the left shoulder and left hip. Tylenol # 3 (a narcotic used to treat pain), 2 tablets was administered for severe pain at 7:35 AM. The resident was lifted to bed using the bed linen with 4 staff. No swelling or discoloration was noted to hip or shoulder. At 8:30 AM, the physician returned the call and orders were received which included transporting the resident to the acute care hospital for evaluation and treatment. A review of the acute care hospital discharged summary dated 9/18/12, noted that Resident 3 was admitted on [DATE], with a left hip fracture and had an ORIF (surgical procedure of open reduction internal fixation) on 9/13/12. The resident was discharged to the acute long term care rehabilitation hospital for further care. A review of the care plan for Resident 3, titled, "At Risk for Further Weakness, Falls/Self Injury", due to history of motor vehicle accident, ORIF of left leg, limping with unsteady gait, refused to use wheel chair or walker dated 2/8/12, (prior to the fall) had the following interventions: a. Notify MD of changes in condition as well as courtesy call to wife per resident approval. b. 6 entries from 2/24/12 to 8/11/12 that the resident was seen and examined by the attending physician. There were no instructions for the staff to follow or no further interventions to this care plan related to the resident fall risk. A review of the care plan titled, "Functional Status ADL's (activities of daily living)", at risk for falls/self-injury, dated 2/8/12, included the following: Keep call light within easy reach and answer promptly. There was no interventions or instructions related to Resident 3's unsteady gait/risk for falls. A review of the facility policy titled, "Fall Risk Assessment and Prevention", revised 7/12, included the following: " 2. Any resident identified as high risk for fall will have a preventative protocol initiated and documented on the care plan". " 4. ... ...Anticipate resident ' s need by asking him/her and assist in toileting management as often as needed". " 6. Observe ambulation and gait stability especially in the morning whereby morning stiffness and discomfort could be experience by the resident". A review of the "Functional Status ADL's", and the "At Risk for Further Weakness, Falls/Self Injury" care plans did not incorporate those interventions. An interview was conducted on 10/22/12, at approximately 6:00 PM, with Resident 3's wife regarding the fall. She stated that Resident 3 was not right in his head (he tried to do things he was not capable of doing), he tried to go to the bathroom on his own, fell and broke his hip. An interview was conducted on 10/23/12, at 1:30 PM, with the Director of Nursing (DON). Resident 3's care plans, nurses notes, nursing assistant daily flow sheets were reviewed prior to the fall. The DON stated that the resident was offered a walker and a wheel chair which he refused. The DON confirmed that there was no documented evidence to show what mechanism was implemented to provide supervision for Resident 3 with ambulation to and from the bathroom. Also, that the MDS, the Fall Risk Assessment, Fall Risk Assessment/Restraint, IDT notes had conflicting documentation as to the resident's continence of bladder and bowel and the need for bathroom supervision prior to the fall. An interview was conducted on 10/23/12, at 2:45 PM, with the Registered Physical Therapist (RPT). She stated that on 8/8/12, the date of the quarterly assessment, Resident 3 had functional limitation with range of motion to his left lower extremity. He was unsteady on his feet and walked around the facility by holding on to the hand rails in the hallway for balance. She stated that the resident needed supervision for ambulation since he refused to use the walker and wheel chair and was unsteady on his feet. She confirmed that this instruction for supervision of resident during ambulation was not on the plan of care. An interview was conducted on 10/24/12, at 3:15 PM, with CNA 3, who was assigned to Resident 3 at the time of the fall. She stated that her shift started at 7:00 AM, and around 7:30 AM, she was notified that the resident had fallen in the room. CNA 3 stated that prior to the fall, the resident was independent with ambulation, walked with a limp and no assistive device. The resident was continent of urine most of the time with occasional incontinence and that he went to the bathroom on his own. An interview was conducted on 10/26/12, at 7:50 AM, with LVN 1, the night nurse who was responsible for the supervision of Resident 3's care at the time of the fall on 9/10/12. She stated that the resident was alert, oriented and able to make his needs known and that the resident was independent with ambulation and walked with a limp. She also stated that occasionally the resident was incontinent of urine and needed assistance. When she arrived at the resident's room on 9/10/12, at 7:30 AM, the resident was lying on the floor on his left side. He complained of pain to the left shoulder and left hip with no visible swelling or discoloration to the areas. The resident was evaluated and assisted to bed. An interview was conducted on 10/26/12, at 9:30 AM, with RN 1, the day shift supervisor. She confirmed that prior to the fall on 9/10/12, the care plan did not accurately reflect Resident 3's functional status. Also, there was no documented evidence of interventions that were in place to address the resident's cognitive impairment, unsteady gait and risk for fall when the resident refused to use the walker and the wheel chair. Therefore, the facility failed to maintain a safe environment that was free of accident hazards for a universe of 86 residents