Every finding on record at Moraga Post Acute

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for residents (1-9), the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). 2. The facility failed to ensure, between 4/1/22-7/31/22, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration), and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).1. During an interview, on 3/19/26 at 11 a.m. the Director of Nursing (DON) and Medical Record Director (MRD) were asked to describe the scheduled medication record system. Their description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation that the scheduled medication was delivered to the facility. They further described that the Shipping Manifests were retained by the facility. They were requested to provide all the scheduled medication Shipping Manifests from 4/1/22 through 7/31/22, CDRs and Automated Dispensing Cabinet (ADC, device to store and dispense medications) dispense reports. During a concurrent observation and interview, on 3/19/26 at 11:40 a.m. Licensed Vocational Nurse (LVN 1) identified medication cart (stores medication) #1. LVN 1 was asked to describe the scheduled medication record system. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The nurse reviewed the scheduled medication and Shipping Manifest for errors. The nurse signed the Shipping Manifest. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medication and the CDR were sent to the DON. Continuing the interview, LVN 1 was asked to describe the ADC (Automated Dispensing Cabinet) process. Her description included that the ADC did not provide a receipt for the scheduled medication dispensed. She further described that the ADC did not provide a CDR for the scheduled medication dispensed. During a concurrent observation and interview, on 3/19/26 at 11:55 a.m. at the nursing station, Licensed Vocational Nurse (LVN 2) was asked to describe the use of the Rx Now ADC. During her description she identified the ADC. The ACD was in a closet across from the nursing station. During a concurrent interview and record review, on 3/20/26 at 10:17 a.m. DON and MRD identified ARxIUM DT Usage (Begin Date: 4/1/2022 End Date: 7/31/2022) (ADC scheduled medication dispensed) report. Inspection of the report showed the following dispenses:Resident 1 6/23/2023 7:20 pm Hydrocodone (hydrocodone, narcotic pain reliever)-Acetaminophen (non-narcotic pain reliever) 10-325 mg (milligram) tab (tablet) #1.Resident 2 7/2/22 5:02 pm Hydrocodone (narcotic pain reliever) w/APAP (acetaminophen, non-narcotic pain reliever) 5/325 mg tab #1.DON and MRD confirmed the ADC dispenses listed above. They were requested to provide documentation that the scheduled medications were administered. They stated the medical records did not document administration, or destruction, of either scheduled medication. During a concurrent interview and record review, on 3/20/26 at 10:25 a.m. DON and MRD identified Resident 3's Shipping Manifest dated 5/1/22 Rx# 3964597 Oxycodone/APAP 5/325 mg tab #90. They stated the facility found CDRs to account for 60, out of 90, tablets. They acknowledged the facility did not have a CDR to account for 30 tablets. During a concurrent interview and medical record review, on 3/20/26 at 10:29 a.m. DON identified the following Shipping Manifests.Resident 1, manifest date 6/23/22, Rx# 4159127 Hydrocodone/APAP 10/325 mg tab #34Resident 4, manifest date 4/1/22, Rx# 3853803 Hydrocodone/APAP 5-325 mg tab #30Resident 5, manifest date 4/16/22, Rx# 3910274 Oxycodone (narcotic pain reliever) 5 mg tab #18Resident 6, manifest date 7/15/22, Rx# 4243475 Oxycodone/APAP 5/325 mg tab #26DON was requested to provide the CDRs for the above Shipping Manifests. She stated that the facility did not have a corresponding CDR for the above shipping manifests. During a concurrent interview and medical record review, on 3/20/26 at 10:43 a.m. DON identified Resident 7's RX# 3954045 Hydrocodone/APAP 5/325 mg tablet #28 CDR. She compared the CDR medication removal against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on 5/10/22 2103. During a concurrent interview and medical record review on 3/20/26 at 10:45 a.m., DON identified Resident 8's RX# 4036730 Hydrocodone/APAP 10/325 mg tablet #28 CDR. She compared the CDR medication removal against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.5/27/22 0600, 01456/1/22 5016/5/22 1600 During a concurrent interview and medical record review on 3/20/26 at 10:50 a.m., DON identified Resident 9's RX# 4019103 Hydrocodone/APAP 5/325 mg tablet #16 CDR. She compared the CDR medication removal against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on 5/17/22 2022. During an interview on 3/20/26 at 11:10 a.m., DON acknowledged the facility did not have the Shipping Manifests and CDRs as documented above. She further acknowledged that information was inaccurate between CDRs and corresponding MARs as documented above. She stated that it was the facility's expectation that all documents were to be complete and accurate. During a concurrent interview and document review on 3/20/26 at 11:15 a.m., DON identified the Policy for Controlled Substances (Revision Date November 2022). She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be accurate (monitored and reconciled). An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled (complete and accurate) to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records. 2. During an interview on 3/19/26 at 11 a.m., the Director of Nursing (DON) and Medical Record Director (MRD) were asked to describe the scheduled medication record system. Their description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation that the scheduled medication was delivered to the facility. They further described that the Shipping Manifests were retained by the facility. They were requested to provide all the scheduled medication Shipping Manifests from 4/1/22 through 7/31/22, CDRs and Automated Dispensing Cabinet (ADC, device to store and dispense medications) dispense reports. During a concurrent observation and interview on 3/19/26 at 11:40 a.m., Licensed Vocational Nurse (LVN 1) identified medication cart (stores medication) #1. LVN 1 was asked to describe the scheduled medication record system. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The nurse reviewed the scheduled medication and Shipping Manifest for errors. The nurse signed the Shipping Manifest. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medication and the CDR were sent to the DON. Continuing the interview, LVN 1 was asked to describe the ADC process. Her description included that the ADC did not provide a receipt for the scheduled medication dispensed. She further described that the ADC did not provide a CDR for the scheduled medication dispensed. During a concurrent observation and interview on 3/19/26 at 11:55 a.m., at the nursing station, Licensed Vocational Nurse (LVN 2) was asked to describe the use of the Rx Now ADC. During her description she identified the ADC. The ACD was in a closet across from the nursing station. During a concurrent interview and record review on 3/20/26 at 10:17 a.m., DON and MRD identified ARxIUM DT Usage (Begin Date: 4/1/2022 End Date: 7/31/2022) (ADC scheduled medication dispensed) report. Inspection of the report showed the following dispenses:Resident 1 6/23/2023 7:20 pm Hydrocodone (hydrocodone, narcotic pain reliever)-Acetaminophen (non-narcotic pain reliever) 10-325 mg (milligram) tab (tablet) #1.Resident 2 7/2/22 5:02 p.m. Hydrocodone (narcotic pain reliever) w/APAP (acetaminophen, non-narcotic pain reliever) 5/325 mg tab #1.DON and MRD confirmed the ADC dispenses listed above. They were requested to provide documentation that the scheduled medications were administered. They stated the medical records did not document administration, or destruction, of either scheduled medication. During a concurrent interview and record review on 3/20/26 at 10:25 a.m., DON and MRD identified Resident 3 Shipping Manifest date 5/1/22 Rx# 3964597 Oxycodone/APAP 5/325 mg tab #90. They stated the facility found CDRs to account for 60, out of 90, tablets. They acknowledged the facility did not have a CDR to account for 30 tablets. During a concurrent interview and medical record review, on 3/20/26 at 10:29 am, DON identified the following Shipping Manifests.Resident 1, manifest date 6/23/22, Rx# 4159127 Hydrocodone/APAP 10/325 mg tab #34Resident 4, manifest date 4/1/22, Rx# 3853803 Hydrocodone/APAP 5-325 mg tab #30Resident 5, manifest date 4/16/22, Rx# 3910274 Oxycodone (narcotic pain reliever) 5 mg tab #18Resident 6, manifest date 7/15/22, Rx# 4243475 Oxycodone/APAP 5/325 mg tab #26DON was requested to provide the CDRs for the above Shipping Manifests. She stated that the facility did not have a corresponding CDR for the above shipping manifests. During a concurrent interview and medical record review on 3/20/26 at 10:43 a.m., DON identified Resident 7's RX# 3954045 Hydrocodone/APAP 5/325 mg tablet #28 CDR. She compared the CDR medication removal against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on 5/10/22 2103. During a concurrent interview and medical record review on 3/20/26 at 10:45 a.m., DON identified Resident 8's RX# 4036730 Hydrocodone/APAP 10/325 mg tablet #28 CDR. She compared the CDR medication removal against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.5/27/22 0600, 01456/1/22 5016/5/22 1600 During a concurrent interview and medical record review on 3/20/26 at 10:50 a.m., DON identified Resident 9's RX# 4019103 Hydrocodone/APAP 5/325 mg tablet #16 CDR. She compared the CDR medication removal against the MAR. DON acknowledged the CDR removal did not have a corresponding MAR administration on 5/17/22 2022. During an interview, on 3/20/26 at 11:10 a.m., DON acknowledged the facility did not have the Shipping Manifests and CDRs as documented above. She further acknowledged that information was inaccurate between CDRs and corresponding MARs as documented above. She stated that it was the facility's expectation that all documents were to be complete and accurate. During a concurrent interview and document review on 3/20/26 at 11:15 a.m., DON identified the Policy for Controlled Substances (Revision Date November 2022). She reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be accurate (monitored and reconciled). During a concurrent interview and record review on 3/20/26 at 11:15 a.m., DON was requested to provide the Pharmacist inspection reports for 4/1/22 through 7/31/22. DON identified the Pharmacist's Medication Regimen Review & Report, Monthly Pharmacy Inspection Report, 5/4/22 and 6/10/22. She inspected the reports and stated they did not document issues with incomplete or inaccurate scheduled medication records. During a concurrent interview and record review on 3/20/26 at 11:15 a.m., DON identified the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019). She reviewed the policy and stated that it was the facility's expectation that issues with scheduled medications should have been identified. An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled (complete and accurate) to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records. An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Policy Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on observation, interview and record review, the facility failed to ensure the social services department was directed and supervised by a qualified social worker according to State regulation for more than 9 years.This failure resulted in all residents receiving social services care from unqualified staff.During an interview on 3/24/26 at 9:45 a.m. with the Social Services Director (SSD), the SSD stated they were the only staff member in the facility's social services department and had worked there for more than 9 years as the social services director. The SSD stated they did not have a bachelor's degree in any field and that their training for the position consisted of a certificate course they completed in 1997. The SSD further stated they had not received any continuing education or additional training since obtaining the certificate in 1997.During a concurrent interview and record review on 3/24/26 at 10:00 a.m. with the Operations Manager (OM), two job descriptions for the SSD, dated 7/2022 and 12/2025, were reviewed. Both job descriptions were signed by the SSD. The job description dated 7/2022 indicated under Qualifications.Education that the position required a Bachelor of Science in Social Work, two years of experience, and noted that an MSW (Master's in Social Work) was preferred. The job description dated 12/2025 indicated under Preferred Qualifications.Education that a Bachelor of Science in Social Work and two years of experience were preferred, and an MSW was also preferred. OM stated the two job descriptions were for the Social Services Director and that the facility removed the education and experience requirements from the newer job description. After reviewing the 12/2025 job description, OM stated there was no minimum education or experience needed for the Social Services Director position.During a concurrent interview and record review on 3/24/26 at 10:15 a.m. with the OM, the SSD's resume dated 1997 was reviewed. The SSD's resume indicated that the highest level of education completed was high school.During a phone interview on 3/24/26 at 11:54 a.m. with the Administrator (ADM), the ADM stated that the SSD was the only staff member in the social services department. The ADM stated there was no qualified social worker who supervised or directed the department. The ADM was aware that the SSD's qualifications did not indicate they were a qualified social worker.During a review of facility policy and procedure (P&P) titled, Social Services, dated 2/2024, the P&P indicated the facility's director of social services was a qualified social worker.During a review of facility's facility assessment titled, [Facility] Facility Assessment, dated 12/27/25, the facility assessment indicated a staffing plan which included Total Number Needed or Average or Range.Social Worker.FULL-TIME on AM and PM shift.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72105, the state regulation indicated a Clinical Social Worker means a person who is a licensed clinical social worker by the Board of Behavioral Sciences.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) to prevent falls and sustained injuries when Resident 1, with history of unwitnessed falls, lost her balance while walking from her bed to room's doorway and fell forward to the ground. This failure resulted in Resident 1 sustaining a laceration to the left frontal part of the head with uncontrolled bleeding, transferred to Acute Care Hospital for follow up care and diagnosed with subarachnoid hemorrhage (a life-threatening condition caused by bleeding into the space surrounding the brain).During a review of Resident 1's admission Record (AR), printed on 2/23/26, AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included abnormalities of gait (a person's manner of walking) and mobility, age related physical debility, osteoarthritis, wedge compression fracture of first lumber vertebra (fractured back) and vascular dementia (memory loss). Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptoms and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). During a review of Resident 1's admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/12/26, the MDS indicated Resident 1's ability to walk at least 10 feet in a room was not attempted due to medical condition or safety concerns. MDS indicated Resident 1 used a walker and wheelchair for mobility (ability to move, walk or change position easily and freely). MDS indicated Resident 1 had functional limitation in range of motion to lower extremity (hip, knee, ankle, foot) that placed Resident 1 at risk of injury. MDS indicated Resident 1 had a fall prior to admission to the facility. MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 08 which indicated moderately impaired mental status. The BIMS score indicated Resident 1 was unable to recall the correct year, month, and day of the week. During an observation on 2/25/26, at 10:25 a.m., in Resident 1's room, Resident 1 lay on her back in bed, awake mumbling with incomprehensible sounds. Resident 1 had a swelling to the left side of forehead with dry lacerated area and no bleeding. Resident 1 had bluish black discoloration around the left eye area. Resident 1's bed was placed next to the wall; bed was in a lower position with floor mat placed on the right side of the bed. During a review of Resident 1's Progress Note (PN), dated 2/23/26, PN indicated that on 2/18/26 at approximately 11:30 a.m., another resident's family member saw Resident 1 ambulating from her bed to room's doorway. Per family member, Resident 1 lost balance and fell forward to the ground, and staff was called to assist Resident 1. Nurse found Resident 1 on the floor. Resident 1 was noted with laceration on left frontal forehead with uncontrolled bleeding. Resident 1 was sent to acute hospital for further evaluation. During a review of Resident 1's PN dated 1/25/26, PN indicated Director of Nursing (DON) asked Resident 1's Responsible Party (RP) if Resident 1's family could provide one on one sitter/caregiver for Resident 1 due to Resident 1 being a fall risk, trying to get out of bed to ambulate with agitation, aggression and hallucinations. According to Resident 1's RP, family cannot afford to hire anybody 24/7. Resident 1's RP stated they would try to come more often to sit with Resident 1 and redirect Resident 1. During a concurrent interview and record review on 2/25/26, at 1:42 p.m., with DON, Resident 1's Fall risk assessments and IDT (interdisciplinary team) progress notes were reviewed. The fall risk assessments dated 1/6/26, 1/15/26 and 1/22/26 had scores 28, 28 and 36 respectively, indicating Resident 1 was at high risk for falling. DON stated Resident 1's family was asked to provide a sitter due to high risk for fall. IDT progress notes indicated that Resident 1 had the following documented falls:On 1/15/26 at 0820 (8:20 a.m.), staff heard screaming which came from Resident 1's room. Staff found Resident 1 on the floor sitting down. Resident 1 could not recall what happened.On 1/22/26 at 1910 (7:10 p.m.), Resident 1 had an unwitnessed fall; a staff member passed by Resident 1's room and heard Resident 1 calling out for help. Licensed Nurse found Resident 1 on the floor. The fall was unwitnessed. Resident 1 stated she struck her head on the floor. On 2/18/26 at 11:30 a.m., family member of another resident saw Resident 1 ambulate from bed to room's doorway, lose her balance and fall forward to the ground. Family member called staff to assist Resident 1. Resident 1 had a laceration on the left frontal scalp/forehead with uncontrolled bleeding. During an interview on 2/25/26, at 11:26 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated she was Resident 1's care giver during the morning shift on 2/18/26. CNA 1 stated Resident 1 was at high risk for fall and frequently tried to get out of bed without assistance. CNA 1 stated she frequently checked on Resident 1. CNA 1 stated she was out on lunch break when Resident 1 fell and transferred to hospital. CNA 1 stated before she went on break, she asked CNA 2 to cover (step in to handle duties and responsibilities during their absence) for CNA 1. CNA 1 stated she also informed Licensed Vocational Nurse (LVN 1) that she was going on break. During an interview on 2/25/26, at 11:38 a.m., with LVN 1, LVN 1 stated she was the charge nurse when Resident 1 fell on 2/18/26. LVN 1 stated Resident 1 was asleep at the start of the shift. LVN 1 stated she assumed Resident 1 tried to walk by herself. LVN 1 stated Resident 1 had a high risk for falling. During an interview on 2/25/26, at 12:05 p.m., with CNA 2, CNA 2 stated she did not know the specific details of what happened with Resident 1's fall incident on 2/18/26. CNA 2 stated CNA 1 informed CNA 2 that CNA 1 was going on lunch break and that CNA 2 would cover for CNA 1. CNA 2 stated CNA 2 provided care in another room transferring a resident from wheelchair to bed and did not hear anything. CNA 2 stated by the time CNA 2 completed care with another resident, an ambulance was already at the facility to take Resident 1 to the hospital. During a concurrent interview and record review on 2/25/26, at 1:42 p.m., with DON, Resident 1's fall care plans were reviewed. Fall care plan initiated 1/6/26, indicated Resident 1 was at risk for falls with or without injury related to altered balance while standing and or walking, decreased muscular coordination, history of falls, unsteady gait, hearing and visual impairment. The interventions included to anticipate and meet needs, educate, and remind Resident 1 to call for assistance, keep bed in low position with brakes locked, keep call light within reach and keep personal items frequently used within reach. Further review of fall care plans dated 1/15/26 and 2/15/26, indicated Resident 1 had unwitnessed falls and was at risk for injury and recurring falls, and care plans were not updated with new interventions. Fall care plan dated 2/18/26 indicated Resident 1 had an unwitnessed fall and was transferred to ED (emergency department) for further evaluation. DON stated nursing staff checked Resident 1 every hour for safety and reminded Resident 1 to call for assistance. DON stated facility discussed 24/7 (at all times), one on one sitter with Resident 1's RP. DON stated Resident 1's RP indicated Resident 1's family could not afford the expense. During an interview on 3/12/26, at 10:45 a.m., with Administrator (Admin) and DON, DON stated facility does not provide one on one sitter/caregiver to watch or monitor fall risk residents. Admin stated facility would negotiate with the family of residents with fall risks to provide a sitter prior to admission. During a review of Resident 1's Hospital Discharge Summary (DS), dated 2/22/26, the DS indicated, Resident 1 presented to the hospital after a fall at the nursing facility. Resident 1 was found to have subarachnoid hemorrhage. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary drugs when:1. Interdisciplinary team (IDT-a group of professionals from different disciplines working together to provide the greatest benefit to the resident, which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person - centered.) did not address Resident 1's angry outbursts and hallucinations (perceptual experiences in the absence of real external sensory stimuli) and identify person-centered non-pharmacological/behavior approaches prior to administering Resident 1 Quetiapine Fumarate (Seroquel), an antipsychotic medication for vascular dementia (a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. There are many types and causes of dementia with varying symptoms and rates of progression. [Adapted from: About Dementia. Alzheimer's Foundation of America. 30]).2. Resident 1 was administered Seroquel for vascular dementia, an inadequate diagnosis for use. (Antipsychotic medications are drugs used to treat psychotic disorders such as schizophrenia and bipolar disorder, serious mental health conditions). 3. Prescribing physician did not obtain informed consent from Resident 1 and or Resident 1's representative prior to administration of Seroquel and Lorazepam (Ativan-antianxiety medication). 4. Facility did not address Resident 1's use of Seroquel and Ativan in Resident 1's care plan with appropriate interventions. These failures had the potential for Resident 1 to receive unnecessary medications and to suffer adverse side effects.During a review of Resident 1's admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/12/26, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status), score was 08 and indicated moderately impaired mental status. The BIMS score indicated Resident 1 was unable to recall the correct year, month, and day of the week. MDS indicated Resident 1 was able to recall recent information with cueing. MDS indicated Resident 1 had no behavioral evidence of an acute change in mental status. MDS indicated Resident 1 had no potential indicator of psychosis, no hallucinations or delusions. MDS indicated Resident 1 had no physical, verbal, or other behavioral symptoms exhibited e.g., hitting, kicking, pushing, screaming, threatening, scratching, wandering or rejection of care. MDS indicated Resident 1's diagnoses included non-Alzheimer's dementia (memory loss) and anxiety disorder. During an observation on 2/25/26, at 10:25 a.m., in Resident 1's room, Resident 1 lay on her back in bed, awake and mumbling with incomprehensible sounds. Resident 1 had a swelling to the left side of forehead with dry lacerated area and no bleeding. Resident 1 had bluish black discoloration around the left eye area. During a review of Resident 1's Order Summary Report (OSR), dated 1/25/26, the OSR indicated Resident 1's physician prescribed Resident 1 Seroquel tablet 25 mg give one tablet by mouth two times a day for vascular dementia manifested by manic behaviors. During a review of Resident 1's Medical Progress Note Skilled Nursing Facility (MPN), dated 2/14/26, the MPN indicated Resident 1 exhibited progressively increasing aggressive outbursts and episodes of confusion as reported by both staff and family. A urinalysis was performed and returned positive (a positive urinalysis for urinary tract infection UTI typically shows elevated white blood cells or bacteria accompanied by symptoms like burning, frequency, or urgency). In response, Resident 1 was initiated on antibiotics for five days. Additionally, the patient's Seroquel dose was increased from 25 mg daily to 25 mg BID (twice a day). During a review of Resident 1's Psychotherapeutic Drug informed Consent Form (IC), for use of Seroquel dated 1/25/26, IC indicated that the prescriber/medical doctor (MD) did not document that informed consent was obtained from Resident 1's representative (RP) prior to Resident 1's use of Seroquel. During a review of Resident 1's Medication Administration Records (MARs), dated 1/25/26 to 2/15/26 indicated Resident 1 was administered Seroquel 25 mg two times a day for vascular dementia manifested by manic behavior. During an interview on 2/25/26, at 10:50 a.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 1 had dementia and was forgetful. During a review of Resident 1's OSR dated 1/8/26, OSR indicated Resident 1's physician prescribed Resident 1 to receive Ativan oral 0.5 mg by mouth nightly as needed (PRN) for anxiety. During a review of Resident 1's MARs dated 1/10/26 to 1/31/26 indicated Resident 1 was administered PRN Ativan tablet 0.5mg by mouth PRN nightly for anxiety on 1/10/26 twice on 1/11/26, 1/12/26, twice on 1/15/26 and 1/16/26 at night for anxiety. During a review of Resident 1's IC for use of Ativan, dated 1/17/26, the IC indicated that the prescriber/MD did not document that informed consent was obtained from Resident 1's RP prior to Resident 1's PRN use of Ativan. During an interview on 2/25/26, at 1:20 p.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated facility process was that when an order for psychotropic medication was received from the physician, licensed nurses will notify resident's family by calling the RP, explain the medication, uses and side effects and ask if it's OK to give resident the medication. If family agrees to administer psychotropic medication, then two nurses will complete and sign IC. If resident's family refused, the licensed nurse would notify the physician. During an interview on 2/25/26, at 1:37 p.m., with Resident 1's Physician (MD), MD stated she did not speak to Resident 1's RP directly regarding obtaining IC for Seroquel and Ativan. MD stated the way it was set up at the facility was for licensed nurses to discuss psychotropic medication order with Resident 1's family/RP and have Resident 1's family/RP sign IC. MD stated except when MD was at the facility, MD did not directly obtain IC from Resident 1/RP. MD stated that licensed nurses obtained IC from Resident 1's RP with option to call the physician if there was need for more clarification. During a concurrent interview and record review on 2/25/26, at 1:42 p.m., with Director of Nursing (DON), Resident 1's care plans, OSR, MARs, IC and PN were reviewed. DON could not provide IDT documentation and care plan that addressed Resident 1's angry outburst with person-centered non-pharmacological approach identified and implemented prior to administration of Seroquel. DON stated Resident 1 was treated for urinary tract infection (UTI) but continued with increased agitation. DON stated facility process for obtaining IC was to call physician and clarify behavior indication for psychotropic medication order when received. DON stated licensed nurse would call resident's representative, explain what the psychotropic medication was for and the side effects. DON stated mostly psychotropic medications were not administered until family verbalized understanding. If the resident representative needed more clarification, the physician would call the resident's family. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic medication are at an increased risk of death. Seroquel was not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g., heart failure, sudden death). [Reference: https://dailymed.nlm.nih.gov/seroquel]. During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, dated 2001, indicated, The IDT will thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: infection; fluid or electrolytes imbalance; pain or discomfort; constipation; change related to medications and or worsening of or complications related to others conditions. During a review of the facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, dated 04/2025, the P&P indicated, Psychoactive (also known as Psychotropic) medications may be administered following federal and state regulations if the medication is necessary to treat a specifically diagnosed condition and is appropriately documented in the medical record. Additionally behavioral interventions, unless contraindicated, will be used to meet the individual needs of the resident. The prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative) for use of a psychotropic medication.

Based on interview, record review, and comprehensive assessment, the facility failed to ensure one of three sampled residents (Resident 1), with occasional incontinence of bladder and bowel, received appropriate care services and assistance to maintain and restore continence to the extent possible. This failure had the potential to place Resident 1 at risk for infections, falls and injuries. During a review of Resident 1's admission Record (AR), printed on 5/6/26, AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included history of falling, muscle wasting and atrophy, age related osteoporosis, and dementia with mood disturbances (memory loss). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/3/26, the MDS indicated Resident 1 had occasional incontinence of bladder and bowel. MDS indicated trial toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) had not been attempted to manage Resident 1's incontinence. MDS indicated Resident 1 needed moderate assistance to walk at least 10 feet in room, corridor, or similar space. MDS indicated Resident 1 used a walker and wheelchair for mobility (ability to move, walk or change position easily and freely). MDS indicated Resident 1 was dependent with toileting hygiene, helper does all the effort. Resident 1 does none of the effort to complete the activity to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 03 which indicated impaired mental status. The BIMS score indicated Resident 1 was unable to recall the correct year, month, and day of the week. MDS indicated Resident 1 had clear speech, usually understood and understand others. During a review of Resident 1's Bowel and Bladder Observation/Assessment (B&B), dated 4/29/26, the B&B indicated Resident 1 was continent of bladder and bowel with occasional incontinence episodes. During a review of Resident 1's Bladder Incontinence care plan (CP), initiated 2/25/26, CP indicated Resident 1 had functional incontinence. (Functional Incontinence refers to loss of urine that occurs in a resident whose urinary tract function is sufficiently intact, that he/she should be able to maintain continence, but who cannot remain continent because of external factors other than inherently abnormal urinary tract function). CP interventions included offer toileting on rounds, upon request, and as needed and provide incontinence care on rounds, upon request and as needed. During an interview on 5/6/26, at 11:55 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 had short term memory loss. LVN 1 stated Resident 1 was impulsive when getting up to use bathroom without calling for assistance. During a concurrent interview and record review on 5/6/26, at 1:48 p.m., with Director of Nursing (DON), DON stated staff offered Resident 1 toilet assistance during nurses' rounds and as needed. DON stated facility did not proceed with toileting program because Resident 1 was not appropriate due to impaired mobility and needed one person assistance for toilet use. DON could not provide facility's policy and procedure for bowel and bladder toileting program.

Based on observation, interview and record review, the facility failed to follow state regulation in ensuring residents were housed in approved areas when the facility allowed one of two sampled residents (Resident 2) to be housed in a conference room without a sink from admission to discharge totaling six weeks.This failure placed Resident 2 at risk for infection when the facility was unable to provide a sink for handwashing and could only provide a commode for toileting.A review of Resident 2's admission record indicated Resident 2 was admitted on [DATE] with a diagnosis of neutropenia (blood disorder which white blood cells count is reduced), hemiplegia (the loss of muscle function on one side of the body), hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body), functional diarrhea and heart failure. The record further indicated Resident 2 discharged on 2/11/26.During a record review of Resident 1's minimum data set (MDS, an assessment tool to guide resident care), dated 1/6/26, the MDS indicated Resident 2 had Brief Interview for Mental Status score of 13 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of 13 to 15 indicates intact cognitive impairment.)During a record review of Resident 1's care plan titled, Care Plan Report, dated 2/13/26, the care plan indicated Resident 2 had a care plan for housing in the conference room. The care plan indicated Resident 2 needed staff to bring in water and soap for handwashing.During an observation on 2/11/26, at 9:40 a.m., Resident 2 was in the conference room on a patient bed. The conference room was directly behind the reception desk at the entrance of the facility. A curtain was partially pulled closed and the conference room door was open.During a concurrent observation and interview on 2/11/26, at 10:54 a.m., with Resident 2, Resident 2 was in the conference room in a patient bed, at the bedside was a commode and bedside table. On the walls of the room were advertising brochures. Resident 2 stated they use a bell to call for help. The conference room had a glass door which could be closed, but an improvised curtain was used to provide privacy. Resident 2 stated at home he was able to walk to the toilet.During a concurrent observation and interview on 2/11/26, at 10:58 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 had entered the conference room which Resident 2 was in. CNA 1 stated they were going to assist Resident 2 with care. CNA 1 stated there was no bathroom or sink in the room and Resident 2 used the commode for bowel movements. CNA 1 closed the curtain but did not shut the door during care.During an interview on 2/11/26, at 12:09 p.m., with CNA 1, CNA 1 stated Resident 2's family wanted Resident 2 to have a private room, and the family selected the conference room. CNA 1 stated the room was primarily separated by a curtain and it was difficult to maintain privacy. CNA 1 stated Resident 1 required one person assist with toileting and getting out of bed.During an interview on 2/11/26, at 1:12 p.m., with Admissions Coordinator (AC), AC stated Resident 2 was directly admitted to the conference room. AC stated the census indicated Resident 2 was in room [ROOM NUMBER]A, but was always in the conference room. AC stated the facility made attempts to have a private room for Resident 2, but Resident 2's family refused. AC stated the conference room had been used in the past for residents.During an interview on 2/11/26, at 1:38 p.m., with the Director of Nursing (DON), the DON stated Resident 2's family requested the conference room prior to admission during a facility tour. The DON stated the conference room was not ideal for patient care because there was no toilet or sink in the room.During an interview on 3/5/26, at 1:38 p.m., with the Administrator (ADM), the ADM stated the facility did not inform the California Department of Public Health prior to admitting Resident 2 into the conference room because there was authorization during the COVID-19 pandemic. The ADM didn't know of the details regarding the authorization from the CDPH and didn't know how long that authorization lasted. ADM stated they assumed their duties at the facility on 9/2025.During an interview on 3/5/26, at 1:49 p.m., with the facility's former administrator (FADM) and ADM, FADM stated between 2020 and 2022, the California Department of Public Health (CDPH) had granted clearance to use the conference room to house residents. FADM did not know the dates this clearance was granted, and stated he was not the administrator during that time period. FADM stated they were giving the facility tour to Resident 2's family at the time and mentioned to the family the room was used in the past for resident housing. ADM stated they had concerns Resident 2's family would make a complaint if they didn't allow Resident 2 to be admitted into the conference room. FADM stated Resident 2 was admitted directly into the conference room.During a review of CDPH program flexibility waivers, no waivers regarding using the conference room as a patient room were found.During a record review of CDPH All Facilities Letters (AFL) titled AFL 20-17, dated 3/3/20, AFL 20-17 indicated facilities could submit program flexibility requests to create alternative spaces on their property. AFL 20-17 further indicated This AFL is no longer in effect and is for historical purposes only.During a record review of CDPH AFL titled AFL 23-13, dated 2/7/23, AFL 23-13 indicated the discontinuation of temporary waivers during the COVID-19 pandemic and indicated all facilities must be in compliance with the statutory and regulatory requirements by 3/1/23.facilities who have a continued need for flexibility beyond the end of the declared COVID-19 emergency may submit a program flexibility request.During a review of California Title 22, Chapter 3 regulations titled, 72607 Patient Capacity, the regulation indicated (b) Patients shall not be housed in areas which have not been approved by the Department for patient housing.except as provided in (a) above.(a) a facility shall not have more patients or beds set up for use than.which it is licensed for except in case of emergency when temporary permission may be granted by the Director or designee.

Based on observation, interview, and record review, the facility failed to ensure the safe labeling, open date, and expiration date of eye drop medication for 2 (Resident 98 and Resident 100) out of 2 residents. These failures had the potential to result in residents being given medication with decreased potency and efficacy. Findings: During an observation of Medication Cart A on 11/4/24, at 11:45 a.m., with Assistant Director of Nursing (ADON), Resident 98's Latanoprost (medication to treat high pressure in the eye caused by glaucoma) Ophthalmic solution label indicated an expiration date of June 2026, to refrigerate until opening and to discard 42 days after opening. No open date was indicated on the label. During an observation of Medication Cart B on 11/4/24, at 12:00 p.m., with ADON, Resident 100's Latanoprost Ophthalmic solution label indicated an expiration date of June 2026, to refrigerate until opening and to discard 42 days after opening. No open date was indicated on the label. During interview on 11/4/24, at 12:05 p.m., with ADON, ADON stated the eye drops should have had an open date to know when the medication needed to be discarded as per instructions. ADON stated using the medication past the discard date may result in giving medication that is less effective. During review of resident 100's face sheet resident has a diagnosis of primary open - angle glaucoma (increase pressure in the eye, resulting in slow progressive vision loss), bilateral (both eyes) indeterminant stage (mid-level). During a review of Resident 98's Physician Orders, dated 10/25/24, indicated one droplet Latanaprost to each eye at bedtime for glaucoma. During a review of Resident 100's Physician Orders, dated 10/29/24, indicated one droplet Latanaprost to each eye at bedtime for glaucoma. During an interview on 11/8/24, at 9:57 a.m., with Pharmacy Consultant Supervisor (PC), PC stated that the eye drops should have an open and use by date to ensure the effectiveness of the medication.

Based on observation, interview, and record review, the facility failed to ensure proper storage of medication when the following was noted: 1. Two bottles of expired 20 milliliters (ml) of lorazepam (a medication used to treat anxiety) for Resident 10 were stored in a dedicated refrigerator for ready to use medications. 2. The lid of black colored Medication Disposal Bin was kept very loosely open in medication storage room. The failure to dispose of expired lorazepam medication, posed a potential risk of utilizing the medication with decreased effectiveness for anxiety to Resident 10. The failure to ensure proper security of the Medication Disposal bin posed a potential authorized/unauthorized access to medications in the bin. Findings: 1. During an observation on [DATE] at 09:57 a.m. in Medication room [ROOM NUMBER], with Licensed Vocational Nurse (LVN) 1, two bottles of 20 ml of lorazepam with expiration date of [DATE] for Resident 10 were kept in a dedicated refrigerator for ready to use medications. LVN 1 stated medications were expired and should not be kept in the refrigerator. During a telephone interview on [DATE] at 11:32 a.m. with the facility's Pharmacist (Pharm), Pharm stated as soon as medications were expired or discontinued, they should be placed in the designated disposal area in medication room [ROOM NUMBER] to be disposed or destroyed. During a record review of Resident 10's Physician orders, dated [DATE], the order indicated Resident 10 had an order for lorazepam give 0.25 milliliters (mls) by mouth every 4 hours as needed for anxiety. A review of the medication administration record indicated, Resident 10 last received a dose of lorazepam on [DATE] at 07:46 p.m. During a review of the facility's policy and procedure titled, Storage of Medications, dated ,d+[DATE], indicated Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. During a concurrent observation and interview on [DATE] at 11:21 a.m. in Medication room [ROOM NUMBER], with the Director of Nursing (DON), a black colored Medication Disposal bin was kept next to the medication refrigerator. The lid to the medication disposal bin was easily removed. The disposal bin had pills, capsules, medication packages, nasal spray bottles, multiple use injection vials, and medication cups were easily accessible from the bin. The DON stated the lid to the medication disposal bin needed to be secured to the bin. The label on the disposal bin indicated, Hazardous Waste Pharmaceuticals: KEEP LID CLOSED, DO NOT REMOVE OR DISPENSE ITEMS FROM THIS CONTAINER . During a review of the facility's policy and procedure titled, Storage of Medications, dated ,d+[DATE], the facility stores all drugs and biologicals in a safe, secure, and orderly manner.

Based on interviews and record review, the facility failed to ensure when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met the federal and state educational qualifications for a dietary manager position. The lack of full-time, qualified oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in malnutrition and/or death. Findings: During an interview on 10/30/23 9:35 a.m., with Dietary Supervisor (DS), DS stated he worked fulltime as the Dietary Supervisor. DS stated he had worked at the facility for one year. During an interview on 10/31/23 at 12:23 p.m., with Registered Dietitian (RD), RD stated he worked at the facility part time. RD stated he was usually at the facility two days a week. During an interview on 11/01/23 at 9:18 a.m., with DS, DS stated he had completed an online training course and had received a Food Manager certification. Review of the document titled, ServSafe Certification, with an examination date of 2/10/21, the document indicated DS had completed a standard training for the Food Protection Manager certification examination. The document indicated, Accredited by the American National Standards Institute-Conference for Food Protection (CFP), an accredited food safety exam that does not require classroom hours or necessarily involve a training program. During an interview and concurrent review on 11/01/23, at 10:29 a.m., with the Administrator (Admin), the DS ServSafe Certification, document was reviewed. The Admin stated the DS ServSafe certificate was not sufficient training to qualify DS for the dietary manager position.

Based on observation, interviews and record review, the facility failed to ensure storage and preparation of food under sanitary conditions when: 1. The facility failed to ensure two of two facility ovens were maintained in safe operating condition to provide cooked meals according to mealtime schedules: oven 1 was unable to cook chicken to the required food safety temperature; oven 2 was inoperable. 2. The facility failed to maintain the physical environment: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration; a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered; a storage cabinet drawer did not fully close. These failures had the potential to result in food borne illnesses for residents who received food from the facility's kitchen. Findings: 1. During an observation on 10/30/23 at 1:15 p.m., with Dietary Supervisor (DS), in the kitchen, oven 2 had plates stored inside the oven. During a concurrent observation and interview on 10/31/23, at 11:23 p.m., with [NAME] (CK), in the kitchen, during lunch preparation, chicken breasts were cooked in oven 1. [NAME] (CK) measured the temperature of a chicken breast in the oven as 140 degrees Fahrenheit (F). The chicken remained in the oven for 15 more minutes, and CK rechecked the temperature of a chicken breast which still measured as 140 degrees F. CK removed the tray of chicken breasts from the oven onto to the top stove and continued cooking the chicken until the chicken breast temperature was measured as 170 degrees F. CK stated oven 1 was the only functioning oven in the facility. CK stated oven 1 delayed timely cooking and serving of residents' meals. CK stated oven 1 had a faulty fan that was not working properly so food trays had to be rotated in the oven for food to reach the necessary temperature to be safe for consumption. CK stated he had informed the Dietary Supervisor (DS) about the faulty ovens about three to six months ago. During an interview on 10/31/23 at 2:39 p.m., DS stated Maintenance Supervisor (MS) was aware of the faulty ovens. DS stated Administrator (Admin) had been informed of the faulty ovens and repairs needed in the kitchen about three to six months ago. During an interview on 10/31/23 at 2:03 p.m., MS stated he was aware of the need for oven replacement and repairs needed in the kitchen. During an interview on 11/01/23 at 9:38 a.m., with Admin and MS, Admin stated he was aware of the need to repair or replace the ovens. During a review of the 2022 Federal Food Code, the Food Code indicated equipment components such as doors and seals are to be kept intact and tight. 2. During an initial kitchen tour on 10/30/23, at 9:35 a.m., with the Dietary Supervisor (DS), the following were observed: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration, a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered. During an observation in the kitchen on 10/30/23, at 1:15 p.m., with DS, the following were observed: a cabinet drawer did not fully close. During an interview on 10/30/23, at 1:20 p.m., with DS, DS stated the Administrator (Admin) and the Maintenance Supervisor (MS) were aware of the need for repairs in the kitchen. During an interview on 10/31/23 at 2:03 p.m., MS stated the facility had plans to replace the kitchen cabinet, ovens, plumbing, floorings and grease trap. During an interview on 11/01/23, at 9:38 a.m., with Admin and MS, Admin stated he was aware of identified concerns in the kitchen. MS stated he was not sure who was responsible for the cleaning the vents. During a review of the facility's policy and procedure titled, Sanitation, revised November 2022, indicated, The food service area is maintained in a clean and sanitary manner . All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects . All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair

Based on interview and record review, the facility failed to ensure the pharmacist provided consultation services to ensure there was a record system for receipt and disposition and reconciliation of all controlled drugs maintained for three years. The failure to maintain records had the potential to result in drug diversion. Findings: During and concurrent interview and record review on 11/1/2,3 at 11:06 a.m., with Director of Nursing (DON), the controlled medication disposition binder was reviewed. The DON stated she had a huge stack of unorganized logs and medications packages for controlled medications which had been sent for disposal on 10/5/23. DON stated she had organized the logs and placed them in the disposition binder; the binder showed the last previous transfer for destruction date was 10/5/22, with no transfer for final disposal of controlled medication between 10/5/2022 to 10/5/2023. The DON stated she and the facility's Pharmacist (Pharm) were responsible to dispose of the controlled medications into the final incinerator container together. The DON stated Pharm had advised her the controlled medication disposal into the incinerator container should be completed on a quarterly basis, however she had not had the time to do so. The DON stated she was unable to find the controlled drug disposition records for the year of 2021. During a phone interview on 11/1/23, at 11:41 a.m., with Pharmacist (Pharm), Pharm stated the DON accumulated all the controlled drugs in need of disposal, then Pharm and the DON would reconcile the log and document any discrepancies. Pharm stated the controlled drugs in need of disposal would be placed in sealable plastic bags with a liquid in the bag, and then the entire plastic bag would be placed in an incinerator container. Pharm stated the incinerator container would go to a contractor for destruction. The Pharm stated controlled medication disposal should be done on a quarterly basis and the disposition documentation/log should be retained for 3 years. During a record review of the facility's policy and procedure titled, Discarding and Destroying Medications, dated 11/2022, completed medication disposition record are kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records. Review of the California Codes for Pharmacy: 72371(c) (1) Patient's drugs supplied by prescription which have been discontinued and those which remain in the facility after discharge of the patient shall be destroyed by the facility in the following manner: (1) Drugs listed in Schedules II, III or IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be destroyed by the facility in the presence of a pharmacist and a registered nurse employed by the facility. The name of the patient, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction and the signatures of the witnesses required above shall be recorded in the patient's health record or in a separate log. Such log shall be retained for at least three years.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate Medical Records for three (Residents 9, 30, and 15) of eleven sampled residents, when: 1. Licensed Vocational Nurse (LVN) 2 failed to immediately document in Resident 9's medical record, the administration of Resident 9's oxycodone (a controlled medication: medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). 2. LVN 2 and Licensed Vocational Nurse 5 (LVN 5) failed to document administration of multiple medications for Resident 30 on 10/6/23, 10/14/23, 10/18/23, 10/19/23. 3. Resident 15's care plan indicated Resident 15 was restricted to her room for infection control reasons since 12/17/20, while observations and interviews indicated Resident 15 had left her room for ambulation therapy outside her room, as well as locomoting in a wheelchair in the lobby and dining areas. The failure to maintain complete and accurate medical records for Resident 30, Resident 9, and Resident 15's had the potential to result in missed or duplicative medication administration, and inappropriate care provision from inaccurate care plans. Findings: 1. During a concurrent observation and interview on 11/1/23, at 12:16 p.m., with LVN 2, at the medication cart, Resident 9's Medication Administration Record (MAR) and Controlled Drug Record (CDR) for oxycodone were reviewed. LVN 2 opened the medication cart and examined Resident 9's oxycodone supply. LVN 2 stated Resident 9 had 23 tablets of nine milligrams (mg) oxycodone myristate available in the medication cart supply. LVN 2 stated Resident 9's CDR indicated there should be 24 tablets available. LVN 2 stated she had administered one tablet of nine mg oxycodone to Resident 9 in the morning today but had not documented the administration on the CDR. LVN 2 stated Resident 9's MAR had no documentation of oxycodone administration for the 11/1/23, at 9 a.m., regularly scheduled nine mg dose of oxycodone. During an interview on 11/1/23, at 2:56 p.m., with the Director of Nursing (DON), the DON stated nurses were expected to document immediately after administration of medication. 2. During review of Resident 30's Admission Record printed 10/31/23, the Admission Record indicated Resident 30 was admitted to the facility in April 2023. During a concurrent interview and record review on 10/31/23, at 3:02 p.m., with the DON, Resident 30's MAR dated October 2023, and nursing progress notes dated 10/6/23 through 10/31/23, were reviewed. The DON stated she was unable to find any documentation in the MAR or the nursing progress notes to indicate nursing staff administered the following medications: 10/6/23 at 9 p.m.: Hydralazine (used for blood pressure) and Lantus Insulin (lowers blood sugar). 10/14/23 at 6:30 a.m.: Levothyroxine (a hormone), Pantoprazole (an antacid), routine Humalog Insulin (lowers blood sugar). 10/18/23 at 9:00 a.m.: Atorvastatin calcium (to lower cholesterol), Eliquis (a blood thinner), furosemide (promotes urination to decrease excess body fluids), Hydralazine, Lexapro (an anti-depressant), Isosorbide Mononitrate (lowers blood pressure), Metoprolol (lowers blood pressure), routine Humalog Insulin, and Ticagrelor (prevents blood clot formation). 10/18/23 at 11:30 a.m.: routine Humalog Insulin. 10/19/23 at 6:30 a.m.: routine Humalog Insulin. 10/19/23 at 11:30 a.m.: routine Humalog Insulin. During an interview on 10/31/23, at 3:18 p.m., with LVN 2, LVN 2 stated she had been Resident 30's charge nurse on 10/18/23 and 10/19/23 and was responsible for Resident 30's medication administration on those days. LVN 2 stated she had failed to document the medication administration on 10/18/23 because she had gotten sidetracked; LVN 2 was unable to provide an explanation for the lack of documentation on 10/19/23. During a phone interview on 11/03/23, at 2:17 p.m., LVN 5 stated she had been responsible for Resident 30's missed entries for 10/6/23 and 10/14/23. During a review of the facility's policy and procedure titled, Documentation of Medication Administration, dated 11/2022, the policy and procedure indicated, administration of medication is documented immediately after it is given and .documentation of medication administration includes, as a minimum reason(s) why a medication was withheld, not administered, or refused (as applicable) . During a review of the facility's policy and procedure titled, Administering Medications, dated 4/2019, medications are administered in accordance with prescriber orders, including any required time frame .the individual administering the medication initials the Resident's MAR on the appropriate line after giving each medication and before administering the next ones . 48616 3. During a review of Resident 15's Admission Record, undated, the record indicated Resident 15 was originally admitted to the facility in 2018 with a medical history of urinary tract infection (bladder infection) and Carrier of Carbapenem-Resistant Enterobacterales (CRE-an antibiotic resistant bacterial infection that can be transmitted by direct contact with an affected individual or indirect contact). During an observation on 10/30/23, at 10 a.m., outside Resident 15's room, the door to the room had signage which indicated, Stop, and Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). During a review of Resident 15's Infection Control care plan initiated 12/17/20, revised on 7/31/23, the care plan indicated, due to the regulatory infection precautions, the resident is remaining in the room. During a concurrent interview and record review on 11/1/23, at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 15's Physician orders for the month of 11/2023 was reviewed. LVN 3 stated the order indicated Resident 15 was to be on Strict Contact Isolation with an order start date of 9/29/23. During a concurrent interview and record review on 11/02/23 at 5:14 p.m. with Restorative Nursing Assistant (RNA), RNA stated during exercise sessions, even though Resident 15 was on contact isolation, RNA provided physical assistance while Resident 15 walked in the hallways and on the outdoor patio. During a concurrent observation and interview on 11/3/23, at 9:19 a.m., with administrator (Admin), facility surveillance videos dated 10/23/23, and 10/25/23, were reviewed. Admin stated the surveillance video dated 10/23/23, showed Resident 15 in the lobby sitting on a wheelchair and chatting with the receptionist. Admin stated the surveillance video dated 10/25/23, showed Resident 15 seated on a wheelchair, wheeling herself in the dining area. 20

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices when Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene during medication administration for Resident 2, Resident 5, and Resident 151. This failure to ensure proper hand hygiene had the potential risk for transmission of infection to Residents 2, 5, 151, and throughout the facility. Findings: During an observation on 10/31/23 at 08:58 a.m., Licensed Vocational Nurse (LVN) 3 prepared Resident 2's morning medications outside his room and put them on a medication tray. Without performing hand hygiene, she put on an isolation gown and a pair of gloves. LVN 3 stated Resident 2 was on Contact Isolation (infection control measures used for a resident with infectious disease that may be spread by touching). LVN 3 went inside Resident 2's bathroom, turned the faucet on, grabbed water for medication administration, poured water in each medicine cup with the same gloved hands. LVN 3 then closed Resident 2's room door by touching the doorknob, picked up a disposable stethoscope (a medical instrument for listening to someone's heart or breathing) and a 30 milliliter (ml) syringe, checked Resident 2's Gastrointestinal feeding Tube (GT, device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) for placement with same gloved hands. LVN 3 then, flushed GT with 30 ml water using the syringe, with same gloved hands. LVN 3 then administered one-by-one morning medications via GT to Resident 2. Without changing gloves and/or performing hand hygiene, LVN 3 then administered an injection of enoxaparin sodium (a medication which lowers risk of getting blood clots) to Resident 2 in the left upper abdomen. During an observation on 10/31/23 at 09:53 a.m., in Resident 151's room, LVN 3 placed morning medications on a medication tray on Resident 151's bedside table, pulled the privacy curtain and without performing hand hygiene, administered morning medications by mouth to Resident 151. LVN 3 then went out of Resident 151's room and wheeled a portable Vital Sign Machine (a medical instrument used to measure temperature, pulse, breathing, and blood pressure) into Resident 151's room. Without performing hand hygiene, she put on a new pair of gloves and checked Resident 151's vital signs. LVN 3 then administered eye drops medications to Resident 151's both eyes. During an interview on 10/31/23 at 09:54 a.m. LVN 3 stated that she should have changed her gloves and do hand hygiene with gel sanitizer or soap and water during medication administration for Resident 2 and Resident 151 to prevent cross contamination. During an observation on 11/01/23 at 11:59 a.m. LVN 3 administered a nebulizer (inhalation) medication treatment to Resident 5. LVN 3 entered Resident 5's room, with gloved hands touched door and side cart near bed. An observation was made of LVN 3 setting up the nebulizer with medication for Resident 5 with the same gloves throughout administration. During an interview on 10/31/23 at 2:44 p.m. with Director of Nursing (DON), the DON stated that hand hygiene was important to prevent infections which could lead to sepsis, rehospitalization , prolonged stay at nursing homes, hindrance in residents' progress and rehabilitation. The DON stated staff was expected to perform hand hygiene in between different routes of medications, before and after administration of medications, and after touching any items in residents' rooms. The DON stated she was working as a DON since 2/2023 in the facility but did not conduct any medication pass observation for licensed nurses. The DON stated facility utilized Nurse Consultant from their contracted pharmacy company for medication administration observations for Licensed Nurses on a quarterly basis. The DON stated Hand Washing was the common concern reported on most recent nurse consultant visits on 5/17/23 and 9/26/23. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 08/2019, the P&P indicated, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, visitors . use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c) before preparing or handling medications .

Based on an interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool used to guide care) functional status on mobility for one of two sampled residents (Resident 15). The MDS assessment inaccurately showed Resident 15 was not able to walk due to health and safety reasons. This failure resulted in an inaccurate reflection of Resident 15's medical condition and placed her at risk for receiving inappropriate care. Findings: During a review of Resident 15's Admission Record, dated October 2023, the record indicated Resident 15 was readmitted to the facility in May 2019. During an interview on 11/02/23 at 5:14 p.m. with Restorative Nursing Assistant (RNA), RNA stated Resident 15 was able to walk with assistance in the hallways and outside on the patio. RNA stated he usually assisted Resident 15 for ambulation for at least three times per week. During a review of Resident 15's RNA Weekly Summary, dated 9/29/23 and 10/6/23 showed Resident 15 received RNA services for walking program three times a week. During a concurrent interview and record review on 11/03/23 at 9:55 a.m. with MDS Coordinator (MDSC), Resident 15's MDS assessment dated [DATE] was reviewed. The MDS assessment under Functional Abilities showed walking was not attempted due to medical condition. However, under Restorative Nursing Programs, the MDS assessment indicated Resident 15 walked for three days in the last seven calendar days. The MDSC stated MDS assessments were based on records and the information from direct care staff such as Nursing Assistants, Charge Nurses, and RNA involved in a resident's care during the look back period. The MDSC also stated it was an item coding error and it should have been coded as moderate assistance for walking. The MDSC also stated it was important to complete the MDS assessment accurately because an inaccurate assessment could affect Resident 15's plan of care. During a review of Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, the manual indicated, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

Based on interview and record review, the facility failed to accurately complete and/or update the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 15) for a period of over four years. This failure resulted in an inaccurate reflection of Resident 15's medical status and had the potential to result in Resident 15 not receiving the care and services appropriate for her condition. Findings: During a review of Resident 15's Admission Record, dated October 2023, the record indicated Resident 15 was originally admitted to the facility in December 2018. During a concurrent interview and record review on 11/3/23 at 11:58 a.m. with Director of Nursing (DON), Resident 15's PASARRs, dated 12/12/18 and 6/7/19 were reviewed. The DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. The DON stated the PASARR dated 12/12/18 was completed one week after Resident 15's admission to the facility and was inaccurately coded as No for Question 28 Has the resident been prescribed psychotropic medications (used to manage mental health conditions)? The DON stated Resident 15's clinical record showed that she received quetiapine (a psychotropic medication) 25 milligrams (mg) for hospital delirium (acute confusion) from 12/5/18 until 12/11/23. The DON stated the PASARR dated 6/7/19 was completed for Resident 15's readmission to the facility on [DATE]. The PASARR dated 6/7/23 showed facility answered Yes to Question:17b Will the resident's stay at your facility likely to require less than 30 days of NF services? The DON stated Resident 15 did not leave and was a long-term resident at the facility. The DON stated the PASARR dated 6/7/23 did not reflect an accurate status of Resident 15. The DON stated the facility did not update and/or complete a new PASARR to reflect the actual status of Resident 15 since 6/7/19. During a concurrent interview and record review on 11/3/23 at 12:33 p.m. with Minimum Data Set Coordinator (MDSC), Resident 15's MDS assessment dated [DATE] was reviewed. The assessment showed Resident 15 had a diagnosis of Schizophrenia (a mental disorder characterized by disconnection from reality), Psychosis (condition that affects the brain processing of information) and had received psychotropic medication, but she was not eligible for Level II PASARR screening. The MDSC stated, Resident 15's mental illness diagnoses could have led her to have Level II PASARR screening, however she overlooked that need when she completed the MDS assessment. During a review of facility's Policy and Procedure (P&P), titled Admission Criteria, dated March 2023, the P&P indicated. all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre- Admission Screening and Resident Review (PASARR) process .If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process.

Based on observation, interview and record review, the facility failed to provide assistance needed for fingernail care for one (Resident 30) of three sampled residents when Resident 30 had long fingernails with blackish material under the nail tips. This failure had the potential for Resident 30 to be injured by long fingernails and develop an infection. Findings: Review of the Minimum Data Set (MDS Resident Assessment tool used to guide care), dated 8/25/23, indicated Resident 30's diagnoses included stroke (brain injury when blood flow to a part of the brain stops) and diabetes mellitus (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood). Resident 30 had clear speech, was able to understand others and be understood. Resident 30 required extensive physical assistance from one-person for personal hygiene, including combing hair, brushing teeth, shaving, washing, and drying face and hands. Review of Resident 30's Activities of Daily Living (ADLs) care plan, dated 8/25/23, indicated Resident 30 required extensive assistance with ADLs for shower, bathing, toilet, and hygiene. During an observation and concurrent interview on 10/30/23 at 10:23 a.m., with Resident 30, Resident 30 lay in bed. Resident 30 had long fingernails with blackish material under the nail tips. Resident 30 stated she would like to have her long fingernails trimmed. During an observation and concurrent interview on 10/30/23 at 10:25 a.m., with Licensed Vocational Nurse/Supervisor (LVN 1), and Resident 30, LVN 1 stated Resident 30's fingernails were long and had blackish material under the nail tips. LVN 1 stated he would ensure Resident 30's assigned licensed nurse trimmed the fingernails. During an interview on 10/30/23 at 10:36 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was Resident 30's assigned nurse. LVN 2 stated she did not know why Resident 30's fingernails were not trimmed. Review of the facility's policy and procedure titled, Fingernails/Toenails, Care of, revised February 2022, indicated: The purpose of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide Resident 1's Representative (RR) with a summary of the baseline care plan. This failure resulted in the lack of information about Resident 1's care. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) need for assistance with personal care, malignant neoplasm (abnormal growth, cancer) of connective and soft tissue, presence of a cardiac pacemaker (small device implanted in the chest to help control the heartbeat), and atrial fibrillation (irregular and very rapid heart rhythm). The record indicated RR as Resident 1's responsible party/representative. During a telephone interview with RR on 2/1/23 at 11:32 a.m., RR stated not having received a summary of Resident 1's care plan or even a telephone call from any facility representative during Resident 1's stay from 2/1/22 through 2/6/22. RR stated of not being informed about the plan of care to be provided by the facility. Review of Resident 1's Patient Care Timeline notes from the hospital dated 2/6/22 indicated, RR stated .No one [at the facility] can tell me what is happening. During a telephone interview and concurrent review of Resident 1's clinical record with the Director of Nursing (DON) 2 ,on 1/31/23 at 4:11 p.m., DON 2 stated the baseline care plan was developed for Resident 1 on 2/122 but the clinical record did not indicate a summary of the care plan was provided to RR. Review of the facility's policy and procedure titled, Care Plans-Baseline, last revised March 2022, indicated the resident and/or representative are provided a written summary of the baseline care plan that includes stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions and any services and treatments to be administered by the facility. The policy also indicated provision of the summary to the resident representative is documented in the clinical record. Review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated 2/2/22 indicated, E. Additional Notes signed and dated by DON 3, had no responses entered to the question if a printed copy of the Baseline Care Plan was provided to Resident 1 or RR.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide treatment and care in accordance with professional standards of practice in caring for the resident with a Foley catheter (a flexible tube that is passed into the bladder to drain urine) when: - Resident 1's urine characteristics (amount, color, odor, transparency) was not assessed and monitored for any changes. - Resident 1's intake and output (the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]) were not monitored per the physician's order. This failure contributed to Resident 1's transfer to the acute hospital and required intravenous (IV) fluids (administration of fluids into the person's veins) for fluid resuscitation (replenishing bodily fluids lost through sweating and bleeding). Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) and need for assistance with personal care. Resident 1 was admitted with a Foley catheter. Review of Resident 1's Order Summary Report for February 2022 indicated a physician order dated 2/1/22 for I & O (intake and output) x 1 month . The report also indicated an order dated 2/1/22 for Resident 1 to receive apixaban tablet (an anticoagulant, prescription medication to prevent blood clots) 5 milligrams (mg) twice daily. During a telephone interview with the Director of Nursing (DON) 1 on 1/31/23 at 4:11 p.m., DON 1 stated for a resident with a Foley catheter, intake and output monitoring would be recorded in the Medication Administration Record (MAR) by the licensed nurse assigned during the shift. Review of Resident 1's MAR for February 2022 did not indicate intake and output record/monitoring was done as ordered by the physician. Review of Resident 1's undated care plan for potential bleeding related to the use of anticoagulant medication indicated for staff to monitor urine for presence of blood. Review of Resident 1's undated Foley catheter care plan indicated for staff to monitor/record/report to MD for signs/symptoms of UTI or urinary tract infection, any infection in the bladder, kidneys or urethra (tube through which urine leaves the body). Another intervention to prevent a catheter associated urinary tract infection (CAUTI), included staff to provide catheter care every shift. Review of the facility's policy and procedure titled, Catheter Care, Urinary, last revised September 2014, for Input/Output, staff must Maintain an accurate record of the resident's daily output, per facility policy and procedure. Also, documentation of the character of urine, such as color, clarity, and odor should be recorded in the resident's medical record. During an interview and concurrent record review with the DON 2 on 9/6/22 at 12:52 p.m., DON 2 stated Resident 1's urine output was not monitored or documented in the medical record. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 9/7/22 at 2:15 p.m., LVN 1 stated, for residents with Foley catheter, if there was a written order for catheter care, it would be documented in the MAR, otherwise one only needed to do something about it if anything out of the ordinary was observed. During a concurrent interview and review of the facility's policy and procedure with DON 4, on 8/1/23 at 10:07 a.m., DON 4 stated intake and output monitoring is done for residents who were admitted with a Foley catheter. The facility's policy and procedure titled, Output, Measuring and Recording, last revised October 2010 indicated, the following information to be recorded on the bedside intake and output and/or in the resident's clinical record; the date and time the resident's urine output was measured and recorded, name and title of the individual who measured and recorded the urine output, amount and character of output, and the signature and title of the person completing the data. Review of Resident 1's Progress Notes indicated the following: -2/1/22 at 7:59 p.m., evening shift, Resident was admitted to the facility with a FC (Foley catheter) intact and draining well to yellow colored urine. -2/3/22 at 2:56 a.m., night shift, there was no documentation of Resident 1's urinary output or urine characteristic assessment. -2/3/22 at 11:44 p.m., no documentation of Resident 1's urinary output or urine character. -2/4/22 at 2:33 p.m., no documentation of Resident 1's urinary output or urine character. -2/4/22 at 9:28 p.m., no documentation of Resident 1's urinary output or urine character. -2/5/22 at 5:56 p.m., no documentation of Resident 1's urinary output or urine character. -2/5/22 at 11:14 p.m., no documentation of Resident 1's urinary output or urine character. -2/6/22 at 7:46 a.m., no documentation of Resident 1's urinary output or urine character. -2/6/22 at 3:58 p.m., Received resident in bed eyes closed. F/C [Foley catheter] intact draining hematuria (blood in urine). Resident 1's family requested for Resident 1 to be transferred to the acute hospital. -2/6/22 at 9:36 p.m., Resident 1 was picked up by ambulance at 5 p.m. and transferred to the hospital. Review of Resident 1's ED Provider Notes dated 2/6/22 indicated the physical exam showed Resident 1's vital signs as follows: blood pressure 80/40 (normal blood pressure is not less than 90/60 or not more than 120/80), pulse rate 130 (normal range 60-100 beats /minute) and respiration of 24 breaths/minute (normal range 12-18 breaths/minute). Review of Resident 1's Patient Care Timeline at the acute hospital dated 2/6/22 indicated Resident 1 arrived at the Emergency Department (ED) at 5:21 p.m. where Resident 1 received IV fluid of normal saline 0.9% 1,000 milliliters (ml) at 5:35 p.m. and another 1,000 ml NS (normal saline 0.9%) at 9:15 p.m. for fluid resuscitation. The timeline documentation also indicated urine analysis was performed that showed more than 180/HPF (high powered field, a technique in microscopy utilized in urine analysis) of RBCs (Red Blood Cell, normal range 0-2), more than 180 HPF of WBCs (White Blood Cell, normal range 0-5) and presence of large amount of bacteria and mucus. Resident 1 received 1 gram of Rocephin (antibiotic for bacterial infections, including severe or life-threatening forms) IV. The Patient Care Timeline also indicated the Resident's Representative (RR) stated .No one [at the facility] can tell me what is happening. I was there [at the facility] yesterday and [Resident 1's] urine was orange and today it was bloody.

Based on interview and record review, for one (Resident 1) of three sampled residents, the facility failed to provide treatment and care in accordance with professional standards of practice when Resident 1's urine output was not monitored after insertion of a Foley catheter (a flexible tube that is passed into the bladder to drain urine) to identify a recurrence of [CONDITION(S)] (inability to urinate or empty the bladder). This failure contributed to Resident 1's transfer to the acute hospital and required intravenous (administration of medication directly into the person's vein) antibiotics to treat a urinary tract infection ([CONDITION(S)]). Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview and concurrent review of Resident 1's Progress Notes with Licensed Vocational Nurse (LVN) 1 on 7/29/22 at 3:03 p.m., LVN 1 stated, on 3/18/22, during the change of shift report with LVN 2, LVN 2 stated Resident 1 had increased confusion, twitching legs and pain. LVN 1 stated LVN 2 was not aware if Resident 1 had urinated during the morning shift. LVN 1 stated Resident 1 was confused and could not say or describe the pain, but had non-verbal cues, like moaning and facial expressions of pain. LVN 1 also stated Resident 1's bladder was very distended, and the physician had ordered a Foley catheter inserted for [CONDITION(S)]. Resident 1's Progress Notes indicated, a total of 2,000 milliliters (ml, equals 2 liters) of urine was drained after the Foley catheter was inserted. Review of Resident 1's Order Summary Report dated 7/21/22 indicated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with LVN 2 on 8/1/22 at 4:38 p.m., LVN 2 stated he did not know if Resident 1 had voided on day shift on 3/18/22 because LVN 2 did not receive a report from CNA 1. LVN 2 also stated, if the urinary output information was monitored and recorded, it would have been documented in Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 1's MAR for March 2022 did not indicate urine output information through 3/21/22. During a telephone interview and concurrent review of Resident 1's Progress Change of Condition dated 3/21/22, with LVN 1 on 7/29/22 at 3:03 p.m., LVN 1 stated, at the start of the evening shift on 3/21/22, three days after LVN 1 inserted the Foley catheter, Resident 1 was noted with Bladder distention [with] thick yellowish cloudy urine slightly flowing [through] foley tubing by gravity. LVN 1 stated she irrigated the catheter with 100 ml of saline but nothing was coming out. LVN 1 stated, Resident 1's foley catheter had to be pulled out and replaced with a new one. The notes indicated Removed Foley catheter, gushing of vaginal discharge mixed [with] yellow thick foul smelling urine noted. LVN 1 stated after the Foley catheter was changed with a new one, the catheter seemed plugged again with no urine draining and Resident 1's bladder was still distended. Resident 1 had shortness of breath, complained of feeling tired, unable to lift legs up and had decreased sensation on both legs. Resident 1 was transferred to the hospital via 911. Review of Resident 1's Order Summary Report for March 2022 indicated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's ED (Emergency Department) Provider Notes dated 3/21/22 indicated Resident 1 had cloudy, thick urine suggestive of urinary tract infection ([CONDITION(S)]). Resident 1 received intravenous antibiotics to treat the [CONDITION(S)]. Review of Resident 1's Progress Notes indicated the following: -3/18/22 at 4:38 p.m., evening shift, written by LVN 1, Resident 1 was noted with bladder distention, a Foley catheter was inserted for [CONDITION(S)], 2,000 ml of urine drained after a Foley catheter was inserted. -3/19/22 at 5:45 a.m., night shift, written by LVN 3, Resident 1 clear urine, monitored Foley catheter for urine output, with a total 350 ml for the shift. -3/19/22 at 1:04 p.m., Weekly Summary Notes, morning shift, written by LVN 2, Resident 1 and signs and symptoms of dehydration, dark amber-colored urine, average 24-hour output in mls: no response entered. -3/19/22 at 5:37 p.m., evening shift, written by LVN 2, Resident 1 was on alert for charting for [CONDITION(S)], indwelling catheter remains patent, urine light amber in color, slightly opaque. No documentation of urine output for the shift. -3/20/22 at 5:45 a.m., night shift, written by LVN 3, Resident 1 was monitored for urine output related to [CONDITION(S)], had total urine output of 350 ml. -3/20/22 at 5:07 p.m., written by LVN 2, Resident 1 was on alert for charting for [CONDITION(S)], indwelling catheter remains patent, urine light amber in color, slightly opaque. No documentation of urine output for the shift. -3/20/22 at 6:12 p.m., written by LVN 4, . No documentation of Resident 1's Foley catheter or amount of urine output for the shift. -3/21/22 at 1:55 a.m., night shift, written by LVN 5, Resident 1 did not show signs of depression and [CONDITION(S)]. There was no documentation of Resident 1's urine output for the shift. -3/21/22 at 11:36 a.m., morning shift, there was no mention of Resident 1's urine output. Review of Resident 1's Foley catheter care plan dated 3/18/22 indicated the goal was for Resident 1 to not show signs and symptoms of [CONDITION(S)]. The interventions included for staff to, Monitor/record/report to MD for signs and symptoms of [CONDITION(S)], pain, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp[temperature], urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The care plan also indicated for staff to monitor and document intake and output per facility policy. During an interview and concurrent review of Resident 1's Documentation Survey Report for March 2022, Bladder Incontinence, with the Certified Nursing Assistant (CNA 1) on 7/21/22 at 11:51 a.m., CNA 1 stated, when documenting Resident 1's urine output information, 0, NA meant Resident 1, during the 8-hour shift, was dry and did not require any brief change. CNA 1 stated, after Resident 1 had the Foley catheter, CNA had to write 3, NA which indicated Resident 1 had a Foley catheter in place. CNA 1 stated CNAs did not record Resident 1's urine output for the entire shift because that was the licensed nurse's responsibility. Review of the facility's policy and procedure titled, Catheter Care, Urinary last revised September 2014 indicated one of the general guidelines included for staff to maintain an accurate record of the resident's daily output, per facility policy. During an interview and concurrent review of Resident 1's clinical record with the Director of Nursing (DON), on 7/21/22 at 1:48 p.m., DON stated, for a resident who has [CONDITION(S)], the facility's policy was for the licensed nurse to check for lower abdominal (bladder) distention, and for the assigned Certified Nursing Assistant (CNA) to report to the licensed nurse how much output the resident had for the shift. DON further stated Resident 1's clinical record had no documentation of Resident 1's Foley catheter urine output. During a telephone interview with DON on 7/29/22 at 2:50 p.m., DON stated the facility had been using a bladder scan since last year (2021) and is used when a resident does not have urine output when a Foley catheter is in place. DON stated the bladder scan would be helpful to assess how much urine is retained in the bladder. DON further stated Resident 1's clinical record did not indicate that a bladder scan was used. In addition, licensed nurses were expected to perform additional assessments for a resident with a Foley catheter because of [CONDITION(S)]. DON stated nursing assessments included; checking for abdominal distention, checking for patency (unobstructed) of the catheter and for CNAs to report the amount of urine output to the licensed nurse. The licensed nurse was to document the amount of urine output in the Progress Notes. During the same telephone interview with LVN 1 on 3/21/22 at 3:03 p.m., LVN 1 stated, urinary output was usually recorded every shift in the binder for I and O (Intake and Output), where the total output for the last 24 hours were recorded at the end of evening shift. LVN 1 stated, at the end of the 7-day monitoring, the document would be placed in the resident's clinical record. LVN 1 also stated, the resident's output is recorded in Point of Care ( electronic record system by the CNAs). LVN 1 stated there was no documentation of Resident 1's urinary output in the facility's electronic medical records.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP - infection control professional) completed specialized training in infection prevention and control. This failure had the potential to result in the IP not being fully knowledgeable with current infection control practices to manage outbreaks of infectious diseases in the facility, including the residents' development of healthcare acquired infections due to exposure, like COVID-19 (virus that is easily spread causing respiratory illness, ranging from mild to severe, including death). Findings: During an interview on 7/6/22, at 10:35 a.m., with the Director of Nursing (DON), DON identified the individual who is the designated IP at the facility. During an interview on 7/6/22, at 11:22 a.m., with IP, IP indicated the infection prevention and control duties are shared with the DON. IP further indicated they had not completed the specialized training in infection control and prevention. During a review of the infection prevention and control documentation for a completion certificate titled, Nursing Home Infection Preventionist Training Course, by The Centers for Disease Control and Prevention (CDC - national public health agency in the United States), dated 11/30/20 by DON, was reviewed. No completion certificate exists for IP.

Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, who was at high risk for falls, was provided adequate supervision and assistance, while he was outside the facility alone attempted to control his wheelchair on an incline and open the door to enter the facility. This failure resulted in Resident 1's fall backwards in his wheelchair, and in immediate transfer to the hospital for a six-day hospitalization for fracture of C7 (a break in the bone in the neck [cervical] the cervical bone allows the neck to bend and twist, fractures at this level typically result from trauma such as falls and could lead to paralysis and even death). Findings: Review of Resident 1's Admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included difficulty walking, cognitive communication deficit, unspecified displaced fracture of second cervical vertebra (C2) and muscle wasting and atrophy (wasting/thinning or loss of muscle tissue). Review of Resident 1's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 8/9/21 indicated Resident had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 4. The BIMS score range is from 0-15, with zero as the most impaired. Resident 1's MDS also indicated Resident 1 required physical assistance of one person with locomotion off unit (how a resident moves to and returns from off-unit locations like areas for dining and activities, how resident moves to and from distant areas on the floor, self-sufficiency if resident is in wheelchair). Review of Resident 1's Progress Notes dated 8/3/21 indicated, on 7/15/21, before Resident 1 was admitted to the facility, Resident 1 was seen by neurosurgery (medical specialty that treats patients with injury to the brain and spine) for neck pain and a fall. Resident 1's Progress Notes also indicated the following problems: - Resident 1's imaging showed fracture of C2-C3. (cervical spine bones in the neck) - Dizziness/vertigo. - Mild Cognitive Impairment. During a telephone interview and concurrent review of Resident 1's Fall Risk assessment dated [DATE] with Nurse Supervisor (NS) 1 on 10/26/21 at 5:06 p.m., NS 1 stated, she did not review Resident 1's health history from the admission reports. NS 1 stated, instead of a score of 12, Resident 1's fall risk assessment score should have been 20, a score that would have indicated Resident 1 a high risk for falls. NS 1 stated, if Resident 1 was assessed a high risk for falls, frequent visual checks should have been performed to monitor Resident 1's whereabouts every 15 minutes. Review of Resident 1's fall care plan dated 8/3/21 indicated, interventions to ensure Resident 1 was free from fall or injury included the following: -Keep close observation during activities to minimize potential for falls. - Orient Resident 1 with environment. - Keep environment free of hazards like small objects on the floor, hot and toxic liquids. Review of Resident 1's Activities of Daily Living (ADL) care plan dated 8/3/2, indicated, Resident 1 will be provided assist with locomotion. During a telephone interview with Director of Rehabilitation (DOR) on 10/15/21 at 10:40 a.m., DOR stated, when indoors, Resident 1 required supervision by a staff when wheeling himself. DOR stated, when outdoors, Resident 1 needed a staff/one person assist to push the wheelchair Review of Resident 1's Progress Notes dated 8/8/21 indicated, Resident 1 had an unwitnessed fall when Resident 1 was found on the floor next to the bed. Review of Resident 1's actual fall care plan dated 8/8/21 indicated, staff would perform frequent checks to ensure Resident 1's safety. During an interview with Director of Nursing (DON) on 9/30/21 at 12:12 p.m., DON stated, frequent checks meant staff had to check Resident 1's whereabouts every 15 to 20 minutes. During a telephone interview on 10/15/21 at 10:32 a.m. with Nursing Supervisor (NS) 2, and concurrent review of Resident 1's Progress Notes dated 9/9/21 NS 2 stated, on 9/9/21 at 12:15 p.m., Resident 1 was up in a wheelchair outside the building by C wing exit door. Resident 1 wheeled himself up an incline to get back into the building when the wheelchair tilted backwards and caused Resident 1 to fall backwards with the wheelchair. The Progress Notes indicated, Resident [1] possibly hit his head on cement where he fell . Immediately after the fall, Resident 1 drooled and made gurgling sounds while Resident 1 tried to breathe. During an interview with Licensed Vocational Nurse (LVN) 1 on 9/30/21 at 1:15 p.m., LVN 1 stated, on 9/9/21 at 9:30 a.m., LVN 1 administered Resident 1 all scheduled morning medications. LVN 1 stated, between 9:30 a.m. and 12:15 p.m., LVN 1 did not know where Resident 1 was. LVN 1 also stated, when LVN 1 saw Resident 1 being wheeled by NS 2 into the building immediately after the fall, LVN 1 noticed Resident 1 did not have the cervical collar on. LVN 1 stated, upon seeing Resident 1, LVN 1 had asked, where is his collar? LVN 1 stated, she did not know Resident 1 was on frequent visual checks. Review of Resident 1's Physician Orders dated 8/3/21 indicated Resident 1 had to have cervical collar when out of bed. During a telephone interview with Certified Nursing Assistant (CNA) 1 on 10/11/21 at 2:24 p.m., CNA 1 stated, on 9/9/21, between 8:30 a.m. to 9 a.m., Resident 1 had a shower and was getting dressed for an activity at the facility's patio. CNA 1 stated, she got distracted and forgot to put on Resident 1's neck brace. CNA 1 stated, at 9:30 a.m., Resident 1 was already dressed up, in his wheelchair inside his room when CNA 1 went on to the next resident on her assignment. CNA 1 stated, at 11:15 a.m., CNA 1 saw Resident 1 at the patio listening to the music entertainment. CNA 1 stated, the next time CNA 1 saw Resident 1 again was around lunch time, after another staff had said Resident 1 fell outside the building. CNA 1 stated, between 11:15 a.m. and around 12 noon, she did not know where Resident 1 was. CNA 1 stated she did not know Resident 1 was on frequent visual checks, and had she known, she would have been watching Resident 1 every 15-20 minutes. Review of Interdisciplinary Team (IDT, a group consisting of individuals from different departments of the facility) Note dated 9/10/21 indicated, Resident 1 was transferred to the hospital via 911 for further evaluation. Review of the Hospitalist Discharge Summary dated 9/14/21 indicated, computed tomography (CT, scan that allows doctors to see inside your body by combining a series of x-ray images with computer processing to create pictures of the bones, blood vessels and soft tissues inside the body) indicated a complex fracture of C7 (a break in the 7th neck bone) with injury to the ligaments that hold the bones in place (neck sprain). During a telephone interview with Attending Physician (AP) on 10/26/21 at 3:40 p.m., AP stated, Resident 1's cervical collar helped to stabilize Resident 1's neck and could have prevented the fracture. AP also stated, while admitted at the acute hospital, Resident 1 was referred to hospice care because of the extent of the new injury Resident sustained from the fall. AP stated, Resident 1 was getting ready to be discharged home few days before the fall. During a telephone interview with Family Member (FM) 1 on 9/30/21 at 8:51 a.m., FM 1 stated, Resident 1 was ready to be discharged home on 9/16/21. FM 1 stated that morning on 9/9/21, Resident 1 had happily called FM 1 and told her to come visit at the facility. FM 1 stated the next telephone call she received was from a staff at the facility about Resident 1 falling outside in the patio. FM 1 stated, Resident 1 was taken to the hospital that same day, where physicians referred Resident 1 to hospice care. FM 1 stated, on 9/14/21, Resident 1 was discharged home and passed that afternoon. During a telephone interview with Director of Rehabilitation (DOR) on 10/15/21 at 10:40 a.m., DOR stated, when indoors, Resident 1 required supervision by a staff when wheeling himself. DOR stated, when outdoors, Resident 1 needed a staff/one person assist to push the wheelchair

Based on interview and record review, the facility failed to provide supervision to prevent an accident for one (Resident 1) of four sampled residents. For Resident 1, Certified Nurse Assistant 1(CNA 1), single-handedly transferred him using a Hoyer lift (a mechanical device used to lift people) from his bed to his wheelchair; hoisting him up by herself, causing Resident 1 to fall onto the floor head first. This deficient practice resulted in Resident 1 sustaining a contusion (bruise) and hematoma (a blood-filled raised bruise) to the left side of his head, warranting a transfer to the emergency room for evaluation and treatment. Findings: Review of the Resident Face Sheet indicated Resident 1 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - an assessment tool used to guide care) dated 12/28/17, indicated Resident 1 was unable to complete a Brief Interview for Mental Status. The MDS also indicated Resident 1 was totally dependent for transfers and required the assistance of two or more persons when transferring to and from bed to his wheelchair. In a telephone interview with Certified Nursing Assistant 1 (CNA 1) on 2/13/18 at 11:45 a.m., CNA 1 stated she transferred Resident 1 by herself using the EZ lift Hoyer (mechanical lift) from the bed to the wheelchair at 10:30 a.m. on 2/3/18. CNA 1 stated she called for help, but staff were busy assisting other residents. CNA 1 stated, while waiting for help she hoisted Resident 1 up by herself to try to position Resident 1 in front of the wheelchair. CNA 1 stated that she called for assistance from staff again, then she saw Resident 1 starting to fall head first. CNA 1 stated she tried to catch Resident 1, but was not able to because he was heavy. CNA 1 stated she was supposed to transfer Resident 1 with another person. Review of the Emergency Department's (ED) Triage Notes, dated 2/3/18 at 11:56 a.m. showed, Hematoma & superficial abrasion (scraping of tissue/skin) to left frontal skull. Review of the ED physician's notes, dated 2/3/18 at 12:35 p.m., showed, Diagnosis: [REDACTED]. Further review of the ED discharge instructions by the ED physician on 2/3/18 at 1:59 p.m., indicated that, Patient requires two person assist with Hoyer lift. Review of the facility's undated policy and procedure titled, Lifting and Transferring of Residents, showed, Residents are lifted and transferred safely in all instances. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. The designated method of lifting and transferring of a resident is indicated in the Plan of Care and MDS. Adjustments are made to the Plan of Care as needed. Review of the facility's undated policy and procedure, titled, Mechanical Lift, revealed, At least two people are present while resident is being transferred with the mechanical lift.