Every finding on record at Oakland Healthcare & Wellness Center

Based on observation, interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM is one aspect of exercise important for increasing or maintaining joint function) for three of four sampled residents (Residents 6, 75, and 26).This failure had the potential to result in further decline in Residents 6, 75, and 26's ROM. 1.A review of Resident 6's admission record (AR), undated, indicated Resident 6 was admitted on [DATE] with diagnoses that included hemiplegia (paralysis affecting one side of the body, often the face arm, leg, usually from brain or spinal cord injury), diabetes, and repeated falls. A review of Resident 6's Minimum Data Set (MDS - an assessment screening tool used to guide care) dated 11/7/25 indicated Resident 6 with functional limitations in range of motion on one side of the upper extremity (shoulder, elbow, wrist, hand) and one side of the lower extremity (hip, knee, ankle, foot). A review of the record of the last Physical Therapy (PT) Evaluation and Plan of Treatment (Evaluation only) dated 7/2/23 indicated date of service 6/23/23 - 6/23/23. There was no documented PT eval after that and no OT (Occupational Therapy) evaluation (eval) record were provided. During an interview on 1/13/26 at 11:25 a.m. with RNA (Restorative Nursing Assistant, a person trained to provide specific treatment to residents to restore and maintain strength, coordination, and skills to perform functional activities of daily living) 2, RNA 2 stated Resident 6 was not on the list of the residents on RNA program (RNA program - exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as range of motion exercises, splint or brace assistance, training and skills practice in bed mobility, transfers, walking, dressing, grooming, eating, communication) as there was no order. During a concurrent record review and interview on 1/14/26 at 9:47 a.m. with MDS Nurse (MDSN) 1, MDSN 1 stated Resident 6 had contractures and was bed bound. During an interview on 1/14/26 at 9:20 a.m. with Treatment Nurse (TN), TN stated Resident 6 was contracted and had wounds on and off on the lower extremities as they heal and then come back. During an observation and concurrent interview on 1/14/26 at around 1:42 p.m. in Resident 6's room, TN had just completed dressing changes of Resident 6's multiple wounds including stage 3 right thigh pressure ulcer and unstageable left palm pressure ulcer. Resident 6's lower extremities appeared very stiff and contracted. TN stated Resident 6 was not able to move his legs and his left arm/hand was also contracted. During a review of Resident 6's care plan dated 11/19/23 indicated Resident 6 is on pain medication therapy related to (r/t) current medical condition (contracture at left arm). There was no evidence that the care plan was updated to address Resident 6's mobility and contractures. 2. A review of Resident 75's AR, undated, indicated Resident 75 was admitted on [DATE] with diagnoses that included chronic kidney disease dependent on renal dialysis and muscle weakness. A review of Resident 75's MDS indicated Resident 75 with functional limitations in range of motion on both sides of the lower extremity (hip, knee, ankle, foot). During a concurrent observation and interview on 1/12/26 at 10:30 a.m. Resident 75 was lying in bed, awake, alert. Resident 75 stated she was not getting therapy anymore because of insurance authorization. She stated she felt she needed more therapy exercises. Resident 75 stated they used the Hoyer lift to get her onto the wheelchair to go to dialysis every other day. During an interview on 1/13/26 at 11:25 a.m. with RNA 2, RNA 2 stated Resident 75 was not on the list of the residents on RNA program as there was no order. A review of the OT (Occupational Therapy) Evaluation Discharge summary dated [DATE] indicated Resident 75 had OT services on 10/23/24 – 12/9/24 with discharge recommendations: To request new authorization. During a review of Resident 75's care plan (CP) dated 2/16/23, revised on 10/8/25, the CP indicated Resident 75 had an ADL self-care performance deficit r/t impaired balance, limited mobility. 3. A review of Resident 26's AR undated, indicated he was initially admitted [DATE] and readmitted on [DATE]. A review of Resident 26's MDS dated [DATE] indicated Resident 26's Basic Interview of mental status (BIMS) score was10 (indicating moderate cognitive impairment). The MDS of Resident 26 indicated limited ROM and impairment on one side of the upper extremity (shoulder, elbow, wrist, hand) and one side of the lower extremity (hip, knee, ankle, foot) The diagnoses included generalized muscle weakness, right (R) hand primary osteoarthritis, left hand primary osteoarthritis. During an interview on 1/13/26 at 11:25 a.m. with RNA 2, RNA 2 stated Resident 26 was not on the list of the residents on RNA program as there was no order. A review of Resident 26's OT Discharge summary dated [DATE] indicated Resident had an OT evaluation/ treatment and was recommended for Restorative ROM, Restorative Splint and Brace program – BUE (both upper extremities) AROM (Active ROM) and R (right) resting hand splint. A review of the Physician order report indicated a PT/OT order dated 6/28/25, the physician ordered PT, OT or ST evaluation and treatment as indicated and an order dated 12/8/21 indicated, Right hand therapy due to contracture. During a review of the CP dated 10/22/21, revised 11/10/25 indicated Resident 26 required extensive to total assistance to turn and reposition in bed as necessary. During an interview on 1/14/26 at 2 p.m. with Rehab Consultant (RC), RC stated when transitioning from skilled to long term care, every resident has opportunity to have an RNA and residents are given an option. She stated they make sure residents are on regular annual evaluation and quarterly for residents with contractures. During an interview on 1/14/25 at 2:51 p.m. with RC, RC stated she was filling in today and for a week. She stated the Assistant Director of Rehab (ADOR) resigned on Friday. RC acknowledged Residents 6, 26, and 75 were supposed to be on the RNA program (exercises or activities designed to maintain or improve residents' abilities to the highest practicable level such as range of motion exercises, splint or brace assistance, training and skills practice in bed mobility, transfers, walking, dressing, grooming, eating, communication) and confirmed evals (evaluations) were not done. RC stated they have now scheduled evals for the patients and would be doing evals now. RC stated the RNA program is important to prevent contractures, decline, also to make sure to maintain skin integrity, minimize hospitalization and for quality of life. During an interview on 1/15/26 at 9:02 a.m. with Resident 26 about his right hand/digits' contracture, Resident 26 stated they used to put a splint on his right hand but they stopped. He stated he could not remember what month they stopped. During an interview on 1/15/25 at 10 a.m. with RNA 1, RNA 1 stated he had not seen Resident 26 with a splint, and they did not have an order. During an interview on 1/15/26 at 1:40 p.m. with Director of Nursing (DON), DON stated Resident 26's PT/OT order was a standing order and not supposed to be active, and they would clarify the order with the physician today. During an interview on 1/15/26 at 2 p.m. with Assistant DON (ADON) stated for the residents (Resident 6, 75, 26) who have limited range of motion, RNA program is important to prevent contractures and declines. ADON stated that the residents, after they graduate from PT/OT, are supposed to be referred to RNA Program and then after 90 days, are reassessed to see if they are cleared from the RNA program or have to renew if needed. During a record review of the facility's policy and procedure (P&P) titled Restorative Nursing Program Guidelines dated September 19, 2019, the P&P indicated, The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and as safely as possible. During a record review of the facility's P&P titled, Range of Motion Exercise Guidelines dated January 1, 2012, indicated, Purpose - To maintain/increase Range of Motion (ROM) of joint, to prevent deformity/reduce deformity (prevent/decrease contractures) . During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning, revised 8/24/23, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety . needs of residents in order to obtain and maintain the highest physical. well-being.

Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: Kitchen staff had uncovered facial hair while in the kitchen.Beyond use by date food items were stored in the kitchen refrigerator.Unlabeled, undated and expired food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for the 97 residents who lived at the facility. During an observation on 1/12/26, at 9:24 a.m., the Dietary Supervisor (DS) had uncovered facial hair while in the facility kitchen. During an observation on 1/12/26, at 9:42 a.m., the kitchen refrigerator had cranberry sauce with a use by date of 12/27/25 and salad dressing with a use by date of 12/30/25. During an observation on 1/12/26, at 10:18 a.m., the resident refrigerator had a smoothie with an expiration date of 1/5/26, one pack of ready to eat chicken not labeled with resident name or date, one unknown food item not labeled with date, and one unknown food item not labeled with resident name or date. During an interview on 1/13/25, at 3:16 p.m., with the Registered Dietician (RD), RD stated kitchen staff with facial hair should have worn a beard guard while in kitchen because hair could have got in the food. RD stated the facility should not have kept food that was beyond their use by date or expired because it was not appropriate for human consumption and should have been thrown out. RD stated staff should have labeled food in the resident refrigerator with the date it was opened or brought in, the use by date, and resident name for food safety and to prevent food borne illnesses. During a review of the facility's policy and procedure (P&P) titled, Dietary Department - Infection Control, revised 2/29/24, the P&P indicated, Cover hair, beard, and mustache, with an effective hair restraint, such as hats, hair coverings, or nets while in the kitchen and food storage areas. During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised 4/24/25, the P&P indicated, Place the food in a food container that is clearly labeled with the resident's name and date received . When refrigerated, it will be labeled, dated and discarded after 48 hours if not consumed. Unopened/ sealed foods must be discarded by the manufacture's printed best by or used by date.

Based on interview and record review, the facility failed to report an unusual occurrence report within 24 hours to the California Department of Public Health (CDPH) when one of two sampled residents (Resident 4) had an unwitnessed fall and sustained lacerations (cuts) on the back of the head after being found and was sent to acute care hospital.This failure delayed regulatory oversight and placed Resident 4 at increased risk of repeated falls and additional injury, while also putting other residents at risk for similar harm. During a review of Resident 4's admission Record printed on 1/15/26, the admission Record indicated Resident 4 was admitted to the facility in November 2025 with diagnoses of right femur fracture (broken leg), abnormalities of gait and mobility and mild cognitive impairment. During an interview on 1/12/26 at 3:23 p.m. with Resident 4, Resident 4 stated experiencing a recent fall that resulted in a laceration to the back of the head requiring two staples (metal clips used to close the wound). Resident 4 stated the fall occurred in the shared bathroom when a family member from the other room suddenly opened the door while holding the doorknob, causing Resident 4 to lose balance and fall. During a record review and interview on 1/15/26 at 12:45 p.m. with the Assistant Director of Nursing (ADON), Resident 4's Electronic Health Record (EHR) was reviewed. ADON stated the incident was not reported because the fall was believed to be witnessed by a family member and therefore did not require reporting to CDPH. However, ADON acknowledged that the EHR documentation indicated Resident 4 sustained an unwitnessed fall resulting in injury. ADON further stated the facility considered Resident 4's head injury to be minor despite the injury requiring two staples to the back of the head. ADON stated if the fall had been identified as unwitnessed, the incident should have been reported as unusual occurrence to ensure thorough investigation from CDPH and to prevent recurrence. During a review of the facility's policy and procedure (P&P), titled, Unusual Occurrence Reporting revised on 5/30/24, the P&P indicated, The facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrence .The facility report the following events by phone and in writing to the appropriate State or Federal agencies: .c. Other Occurrences: ii. Major accidents .2. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and the confirmed in writing .

Based on observation, interview and record review, the facility failed to identify significant weight loss and implement interventions for two out of four sampled residents (Resident 28 and 95).These failures had the potential to result in continuous, unplanned weight loss for Residents 28 and 95.1.During a review of Resident 28's admission Record, dated 1/15/26, the admission Record indicated Resident 1 was admitted in the facility on 12/25/25 with an admission diagnosis of nontraumatic chronic subdural hemorrhage (bleeding under the brain's outer covering, occurring without significant head injury). During an interview on 1/12/26 at 11:46 a.m. with Resident 28, Resident 28 stated having difficulty chewing food and losing weight. During a concurrent interview and record review on 1/15/26 at 9:19 a.m. with Restorative Nursing Assistant (RNA) 1, Resident 28's Weekly Weights, dated 12/29/25 and 1/5/26 were reviewed. The Weekly Weights indicated, Resident 28's weight the week of 12/29/25 was 134.4 pounds (lbs.), and the week of 1/5/26 was 123.2 lbs. RNA 1 stated giving a copy of the Weekly Weights to the charge nurse. RNA 1 stated could not recall the nurse who received the copy of the Weekly Weights. During a concurrent interview and record review on 1/15/26 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 28's Weekly Weights, dated 12/29/25 and 1/5/26 was reviewed. The Weekly Weights indicated, Resident 28's weight the week of 12/29 was 134.4 pounds (lbs.), and the week of 1/5/26 was 123.2 lbs. LVN 1 stated Resident 28 lost 11.2 lbs. in a week and was considered a significant weight loss. LVN 1 stated a change of condition assessment should be performed for a resident with significant weight loss. During a follow-up concurrent interview and record review on 1/15/26 at 9:50 a.m. with LVN 1, Resident 28's Electronic Health Record (EHR), dated 1/5/26 to 1/15/26 was reviewed. Resident 28's EHR did not indicate a change of condition assessment was performed and an intervention was documented for Resident 28's significant weight loss. LVN 1 stated not being aware of Resident 28's significant weight loss. LVN 1 stated the purpose of change of condition assessment for a significant weight loss was to make sure residents would receive the proper diet if a diet change was needed, to evaluate resident's meal consumption, to identify what was causing the weight loss and to provide intervention to prevent further weight loss. During a review of the facility's policy and procedure (P&P) titled, Evaluation of Weight and Nutritional Status, dated 1/25, indicated, 1. Definitions. b. Weight loss. Significant weight loss 5% &/or 5 lbs. in one month. 2. Clinical Evaluation. b. Any resident weight that varies from the previous reporting period by 5% in 30 days. will be evaluated by the interdisciplinary team (IDT) to determine the cause of weight loss and the intervention(s) required. 2. During a review of Resident 95's admission Record (AR), printed on 1/13/25, the AR indicated Resident 95 was admitted to the facility in October 2025 with diagnoses of cerebral infarction (brain tissue dies because it does not get enough blood) and depression (a serious mood disorder causing persistent sadness, loss of interest in enjoyable activities, and impacts daily life). During a review of Resident 95's record, titled, Nutritional Risk Assessment, dated 10/27/26, completed by Registered Dietician (RD), the assessment indicated a recommendation for gradual weight loss of 0.5 to 4 pounds (lbs.) per month. During a review of Resident 95's Care Plan, revised on 10/27/25, the Care Plan indicated Resident 95 had potential nutritional problems related to diagnoses and body weight of 264 lbs. The Care Plan further indicated a goal for Resident 95 to remain within 5% of 264 lbs. and required physician notification if significant weight loss of 5% of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days occurred. During an observation and interview on 1/12/26 at 3:26 p.m. with Resident 95, Resident 95 stated experiencing difficulty chewing and swallowing food related to an ongoing ear infection and further stated experiencing a weight loss of more than 20 lbs. within one week. During a record review and interview on 1/13/26 at 3:26 p.m. with Registered Dietician (RD), Resident 95's Nutritional Risk Assessment and Weights and Vital Summary were reviewed. RD stated there was a physician order for monthly weight monitoring; however, the January 2026 weight had not been completed. RD 1 further stated Resident 95 was only assessed by a dietician upon admission and RD 1 was not aware of reported weight changes or chewing and swallowing difficulties. RD stated if issues with chewing and swallowing had been identified, the RD should have been notified to assess Resident 95 and determine the need for a Speech Therapist evaluation. RD further stated monthly weight monitoring should have been completed to track weight changes and allow for a timely evaluation and intervention. During a record review and interview on 1/14/26 at 11:38 a.m. with Licensed Vocational Nurse (LVN) 2, facility's record, titled, Monthly Weights, dated 1/1/26 was reviewed. LVN 2 stated Resident 95's last documented weight in the Electronic Health Record (EHR) prior to January 2026 was recorded on 12/1/25 as 254.8 lbs. LVN 2 further stated the Monthly Weights record, dated 1/1/26 for Resident 95, reflected a weight of 228.0 lbs., with a re-weigh on the same date of 226.6 lbs. LVN 2 stated the weighing scale may have been inaccurate at the time Resident 95's weight was obtained. During an observation on 1/14/26 at 11:51 a.m. with Resident 95, Resident 95 was assisted onto a weighing scale by a Restorative Nurse Assistant (RNA) 2. While Resident 95 was standing on the scale, the displayed weight was 227.0 lbs., confirming the weight loss. During a follow-up interview on 1/14/26 at 11:55 a.m. with LVN 2, LVN 2 stated an assessment should have been completed, and the physician and RD should have been notified regarding the weight loss. LVN 2 further stated Resident 95's current weight represented a significant weight loss and placed Resident 95 at risk for severe malnutrition (inadequate nutrition) and dehydration (inadequate total body water). During a review of Resident 95's Weights and Vitals Summary, printed on 1/14/26, Weights and Vital Summary showed the following recorded weight for Resident 95: 1/14/26: 227 lbs. 12/1/25: 254.8 lbs. 11/1/25: 256.4 10/24/25: 264 lbs. The Weights and Vitals Summary record showed Resident 95 experienced a total weight loss of 37 lbs., representing approximately 14% body weight loss within less than three months, meeting criteria for a significant weight loss. During an interview on 1/15/26 at 9:30 a.m. with Resident 95, Resident 95 stated there were no plans or discussion regarding the weight loss program. Resident 95 stated the weight loss was unplanned, excessive, and bothersome. Resident 95 further stated the weight loss was drastic that bones felt increasingly prominent. During an interview on 1/15/26 at 2:00 p.m. with the Director of Nursing (DON), weight logs should have been reviewed by the nursing supervisor and entered into the resident's EHR. DON stated if there was a significant change in weight, there should have been an Interdisciplinary Team (IDT, a group of healthcare professionals who coordinate comprehensive resident care) to identify the cause and provide interventions to address the weight loss. During a review of Resident 95's record, titled, After Visit Summary, dated 1/13/26, the record showed Resident 95 was seen in the emergency department (ED) on 1/13/26 with diagnoses of periapical abscess (localized collection of pus at the tip of a tooth's root, usually caused by bacterial infection) with facial involvement, jaw swelling, and dehydration. The After Visit Summary further indicated Resident 95 received a bolus (given all at once) of Lactated Ringer's solution (an intravenous fluid, given through the veins, that's used to replace fluids and electrolytes when someone is dehydrated or needs volume support). During a review of the facility's policy and procedure titled, Evaluation of Weight and Nutritional Status, dated 1/25, indicated, 1. Definitions. b. Weight loss. Significant weight loss 5% &/or 5 lbs. in one month. 2. Clinical Evaluation. b. Any resident weight that varies from the previous reporting period by 5% in 30 days. will be evaluated by the interdisciplinary team (IDT) to determine the cause of weight loss and the intervention(s) required.

Based on observation, interview, and record review, the facility failed to ensure timely assessment and intervention to one of two sampled residents (Resident 95) when Resident 95 had a significant change in condition related to weight loss. This failure placed Resident 95 at risk for malnutrition (body does not receive enough nutrients), dehydration (insufficient body fluid), decline in functional status, and emotional discomfort. During a review of Resident 95's admission Record (AR), printed on 1/13/25, the AR indicated Resident 95 was admitted to the facility in October 2025 with diagnoses of cerebral infarction (brain tissue dies because it doesn't get enough blood) and depression (a serious mood disorder causing persistent sadness, loss of interest in enjoyable activities, and impacts daily life).During a review of Resident 95's Care Plan, revised on 10/27/25, the Care Plan indicated Resident 95 had potential nutritional problems related to diagnoses and body weight of 264 pounds (lbs.). The Care Plan further indicated a goal for Resident 95 to remain within 5% of 264 lbs. and required physician notification if significant weight loss of -5% of body weight in 30 days, -7.5% in 90 days, or -10% in 180 days occurred.During a review of Resident 95's record, titled, Nutritional Risk Assessment, dated 10/27/26, completed by a Registered Dietician (RD), the Nutritional Risk Assessment indicated the RD had a recommendation for Resident 95 to gradually lose 0.5 lbs. to 4 lbs. of weight per month. During a review of Resident 95's Order Summary Report, dated 1/14/26, the Order Summary Report indicated Resident 95 had a physician order to monitor weights monthly that started on 10/24/25.During an observation and interview on 1/12/26 at 3:26 p.m. with Resident 95, Resident 95 stated experiencing difficulty chewing and swallowing food related to an ongoing ear infection. Resident 95 further stated recently experiencing a weight loss of more than 20 lbs. within one week. Resident 95 was observed rubbing the left jaw and stated it was too painful to talk, bite down on food, and swallow. Resident 95 stated the appetite had been affected for some time and expressed feeling helpless about the situation.During a record review and interview on 1/14/26 at 11:38 a.m. with Licensed Vocational Nurse (LVN) 2, facility's record, titled, Monthly Weights, dated 1/1/26 was reviewed. LVN 2 stated Resident 95's last documented weight in the Electronic Health Record (EHR) prior to January 2026 was recorded on 12/1/25 as 254.8 lbs. LVN 2 further stated the Monthly Weights record, dated 1/1/26 for Resident 95 reflected a weight of 228.0 lbs. indicating Resident 95 experienced a weight loss of 26.8 lbs.(-10.91%). within one month. LVN 2 stated the weighing scale may have been inaccurate at the time Resident 95's weight was obtained that's why it was not recorded in Resident 95's EHR. LVN 2 further stated the physician order for monthly weight monitoring should have been obtained and followed.During an observation on 1/14/26 at 11:51 a.m. with Resident 95, Resident 95 was assisted onto a weighing scale by a Restorative Nurse Assistant (RNA) 2. While Resident 95 was standing on the scale, the displayed weight was 227.0 lbs., confirming the weight loss.During a follow-up interview on 1/14/26 at 11:55 a.m. with LVN 2, LVN 2 stated an assessment should have completed, and the physician and RD should have been notified regarding the weight loss that was noted on 1/1/26. LVN 2 stated she was also the case manager for Resident 95 and she was not aware that Resident 95 had a significant weight loss. LVN 2 further stated Resident 95's current weight represented a significant weight loss and placed Resident 95 at risk for severe malnutrition (inadequate nutrition) and dehydration (inadequate total body water). During an interview on 1/15/26 at 2:30 p.m. with the Assistant Director of Nursing (ADON), ADON stated Resident 95's significant weight loss should have been addressed immediately upon identification of weight loss on 1/1/26. ADON stated if there were significant change in weight was identified, the facility should have completed an assessment of Resident 95 and the physician, RD, and responsible party should have been notified. ADON stated the cause of weight loss should have been identified and interventions should have been implemented. ADON stated failure to identify and address the weight loss in a timely manner could place Resident 95 at risk for complications like dehydration and delayed wound healing, as Resident 95 had wounds on the lower extremities.During a review of the facility's policy and procedure (P&P), titled, Re-hospitalization, revised in January 2019, the P&P indicated, The facility will utilize process to aide early identification of a change in condition and a method of providing the healthcare provider with resident specific information about that change. The notification process will facilitate appropriate care interventions to avoid the need for unplanned hospitalization.During a review of the facility's P&P, titled, Evaluation of Weight and Nutritional Status, effective on 2/20/25, the P&P indicated, The facility will maintain an acceptable nutritional status for residents per professional standards .b. Analyzing the assessment information to identify the medical conditions, causes and/or problems related to resident's condition and needs .c. Implementing interventions for maintaining or improving nutritional statis that are consistent with resident's needs, goals, and standards of practice .d. Developing interventions involving resident and/or the resident representative to ensure resident's needs, preferences and goals are accommodated .

Based on observation, interview, and record review, the facility failed to ensure two of 25 sampled residents (Residents 30 and 95) received nail care and shaved in accordance with their preferences.This failure had the potential to cause Residents 30 and 95 to feel embarrassed and undignified. During a review of Resident 30's admission Record, printed 1/15/26, the Record indicated Resident 30 was admitted to the facility in December 2025 with a diagnosis of need for assistance with personal care. During a review of Resident 30's Brief Interview for Mental Status (BIMS, is 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 eight to twelve is an indication of moderate impairment.), dated 12/9/25, the record indicated Resident 30's BIMS score was 12. During a concurrent observation and interview on 1/12/26, at 11:41 a.m., with Resident 30, Resident 30 was observed with facial hair and long dirty finger nails. Resident 30 stated staff did not offer to shave or cut and clean their finger nails. Resident 30 stated their facial hair, and long dirty nails made them feel embarrassed. During a review of Resident 30's Care Plan, revised 12/9/25, the Care Plan indicated, The Resident has a decreased ability to perform self care related to impaired activity intolerance, impaired balance/safety, impaired coordination, pain limiting function, weakness. During a review of Resident 95's admission Record (AR), printed on 1/13/25, the AR indicated Resident 95 was admitted to the facility in October 2025 with diagnoses of cerebral infarction (brain tissue dies because it doesn't get enough blood), depression (a serious mood disorder causing persistent sadness, loss of interest in enjoyable activities, and impacts daily life) and atherosclerosis (thickening or hardening of the arteries) of extremities with gangrene (death of tissue) on bilateral legs. During a review of Resident 95's Care Plan, revised 12/3/25, the Care Plan indicated, The resident has a decreased ability to perform self care related to decreased range of motion (how far a joint can move in different directions) impaired activity intolerance, impaired balance/safety, impaired coordination, weakness. During an observation and interview on 1/14/26 at 10:07 a.m. with Resident 95, Resident 95's fingernails were long, and facial hair was present around the chin and jaw area. Resident 95 stated the nursing staff had not offered assistance with trimming facial hair or fingernails. Resident 95 stated a preference for facial hair to be trimmed due to discomfort of looking like a man and for fingernails to be kept short to prevent scratching the skin, particularly the lower legs with existing wound. Resident 95 further stated a desire to feel clean and look well-groomed. During an observation and interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 95's fingernails were overgrown and needed to clipping. CNA 1 stated the CNAs were responsible for assisting the residents in maintaining their grooming. CNA 1 stated residents' fingernails and facial hair should have been offered to Resident 95. CNA 1 stated unwanted facial hair grooming and nail care should have been offered to residents who needed assistance to promote comfort and self-esteem. During an interview on 1/15/26 at 12:57 p.m. with the Assistant Director of Nursing (ADON), ADON stated unwanted facial hair could negatively affect a female residents' physical appearance and at risk for low self-confidence and could affect their dignity. ADON further stated long finger nails were prone to skin irritation and skin infection. During review of the facility's policy and procedure (P&P), titled, Resident Rights, revised on 1/1/12, the P&P indicated, II. The Facility makes every effort to assist each resident in exercising his/her rights by providing the following services: .A. The Facility's staff encourages residents to participate in planning their daily care routines (including ADLs [Activities of Daily Living]) .III. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: B. Personal care needs, such as bathing methods, grooming styles . During review of the facility's P&P, titled, Grooming, revised on 1/1/12, the P&P indicated, The facility will work with residents to improve their ability to groom him/herself to promote independence, hygiene, comfort, self-esteem and dignity by teaching the resident to groom him/herself with use of assistive device and with appropriate types and amount of assistance .

Based on observation, interview and record review, the facility failed to ensure 90 of 90 sampled residents were prevented from unauthorized visitor entry or resident exit from the facility when facility staff failed to close the alarmed emergency exit back door and arm the emergency exit alarm for 35 minutes during the evening shift. This failure had the potential to result in unauthorized visitor entry and/or unwitnessed resident elopements potentially resulting in resident injury. Findings: During an observation of the alarmed emergency exit back door on 10/17/24, at 1:00 p.m., the alarmed emergency exit back door was opened; there was no audible alarm. The door led to an access ramp with direct access to public streets. The access ramp was closed with an unlocked metal latch. During a continuous observation of the alarmed emergency exit back door on 10/18/24, at 6:40 p.m., the door was opened from 6:40 p.m. to 7:15 p.m.; there was no alarm audible. During a concurrent observation and interview on 12/3/24, at 11:05 a.m., with Certified Nursing Assistant 1 (CNA 1), an alarmed emergency exit door near the nurses' station was inspected. CNA 1 stated the facility emergency exit doors were never locked, but all the emergency exit doors have an alarm to alert staff when the door was opened. CNA 1 stated the alarms could be heard anywhere in the facility. During a concurrent observation and interview on 12/3/24, at 1:15 p.m., with the Director of Nursing (DON) and Housekeeping Supervisor (HS), the alarmed emergency exit back door was inspected. There were two signs affixed to the door. The first sign indicated, Please Keep Door Closed At All Times. The second sign indicated, Emergency Exit After 5:00 p.m. Keep Door Closed. The DON stated the door should always be closed. The HS stated when the door alarm was armed, an audible alarm would sound when the door was opened and would continue until staff reset the alarm. The DON and HS stated the alarm mechanism should be armed after 5:00 p.m. because the reduced staffing during the evening and night shift prevented continuous monitoring of the exit. The DON stated the purpose of the door alarm was to alert staff when the door was opened. The DON stated staff were expected to respond to the alarm when it sounded. During a review of facility policy and procedure (P&P) titled, Wandering & Elopement, Operational Manual - Administrative Policies, dated 1/1/12, the P&P indicated facility staff must also act to ensure their health and safety .facility staff should check all doors to ensure they close properly after each entry/exit .the maintenance department will check the alarm system regularly to ensure it is in good working order. During a record review of facility plan of correction (POC) for the 2022 recertification survey titled, Department of Health and Human Services Centers for Medicare and Medicaid Services Statement of Deficiencies and Plan of Correction, dated 5/9/22, the facility POC indicated, Door marked ' Emergency Exit' are equipped with both door alarms .On 4/20/22 DON instructed all licensed nurses to keep door alarms engaged at all times. Nurses were already familiar with the use of the intuitive and well labeled door alarm system and were previously leaving them disengaged .maintenance supervisor or environmental supervisor will inspect all door alarms daily to ensure they are in the armed position by pressing the alarm test button .when a patient would trip the alarm, a nurse would be required to show up on scene to reset the alarm, thereby being present to intervene on the situation. Nurses would not fail to show up to the scene as the alarm is extremely loud and impossible not to hear in the facility.

Based on interview and record review, the facility failed to assure nursing staff possessed the competencies and skill sets necessary to provide nursing services to meet the residents' care needs safely for one of one sampled resident (Resident 1), when a Licensed Vocational Nurse(LVN), without an intra-venous(IV-a medical technique that involves administering fluids, medications, or nutrients directly into a vein) and blood withdrawal certificate provided care for Resident 1's peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein in the chest). This failure had the potential to result in improper infusion of ordered TPN (Total Parenteral Nutrition-a method of feeding that provides nutrients directly into a vein, bypassing the gastrointestinal tract) and cause infection and complications. During a record review of Resident 1's face sheet, printed on 8/27/24, the face sheet indicated Resident 1 was admitted during May 2024, with diagnoses including: surgical aftercare following surgery on the digestive system, short bowel system, nutritional deficiency, and acquired absence of other specified parts of digestive tract. During a record review of Resident 1's Order Summary Report dated 8/27/24, the report indicated Resident 1's medical orders included: -Change dressing and cap as needed for PICC care when soiled, start date 6/1/24 - no end date. - Cyclic-infuse (method of delivering intravenous nutrient solutions to patients in shorter periods of time) from 1700 to 0900. Taper up over 1 hour -33 mls (milliliters-a unit of measure) rate; then 67 ml for 14 hours continuous. Taper down over 1 hr 33 ml one time a day for TPN (plain) - Dextrose (a type of simple sugar made from corn) -200 GM, Clinisol (an intravenous nutrient solution that provides a variety of amino acids - the raw materials for protein synthesis ) 40 GM, Sodium Chloride (salt) 230 MEQ, Magnesium sulphate (a mineral supplement used to manage and treat multiple clinical conditions) 5 MEQ TPN, start date 5/4/24 - no end date. - Monitor central line for signs/symptoms of infection/bleeding q (every) shift for central line monitoring, start date 5/4/24- no end date. During a concurrent interview and record review on 8/27/24 at 10:30 a.m., with the Director of Nursing (DON), the DON confirmed three specific LVNs documented giving care to Resident 1 during the hours 11:00 p.m. to 7:30 a.m., during the month of August 2024. The DON only provided IV competency certificates for two of the three LVN 's. During a record review of the Board of Vocational Nursing Website Licensing details for Licensed Vocational Nurse 1 (LVN 1), the website indicated LVN 1 did not possess an IV and blood withdrawal certification. During a record review of Resident 1's medication administration record (MAR), dated 8/2024, the MAR indicated LVN 1 provided care and/or monitoring for Resident 1's PICC line on 8/6/24, 8/7/24, 8/19/24, 8/24/24, and 8/25/24. During an email correspondence from the Board of Vocational Nursing and Psychiatric Technicians, dated 8/27/24, the Scope of Practice Consultant advised, in California the only LVN who is Board-certified in Intravenous Therapy can flush those (PICC) lines with normal saline or heparin to maintain patency; can care for the dressings on those line sites; and can discontinue those catheters, and Licensed Vocational Nurses who are Board certified in intravenous therapy can perform site dressing care on central lines. During a phone interview with LVN 1 on 8/29/24 at 7:00 a.m., LVN 1 stated, she did not possess an intravenous therapy and blood withdrawal certificate. During a record review of facility ' s policy and procedure (P & P), titled Criteria for Licensed Nurses Administering Therapy Policy: IV 101, dated 3/2023, the P and P indicated, B. IV Certified LVNs may change the dressing and needles access device of central lines as specified by policy. The LVN must demonstrate competency prior to the independent performance of this procedure .C. The IV Certified LVN may NOT start or titrate any IV, which contains medication. However, the LVN may stop or discontinue such infusions whether due to completion of therapy or complication at site or catheter .E. The IV Certified LVN may monitor all types of IV therapies administered through peripheral, central and subcutaneous lines.

Based on observation, interview, and record review, the facility failed to provide effective pest control for two out of 93 residents. This failure had the potential to result in residents being bothered by roaches. Findings: During an interview on 07/22/24, at 10:18 a.m., Resident 88 stated there was an issue with roaches in her room. Resident 88 stated she noted a roach under her lunch tray several days ago and she notified the MDS Coordinator (MDSC). During an interview on 7/22/24, at 10:49 a.m., MDSC stated that Resident 88 notified her about roaches several days ago and MDSC brought it up in the facility 24 hour meeting and in a group message that included Maintenance Staff (MS) and Environmental Supervisor (ES). During a concurrent observation and interview on 7/22/24, at 11:57 a.m., Resident 55 stated there were roaches in his room, and he had reported them on several occasions to staff members, including to Licensed Vocational Nurse 6 (LVN6). A small live roach, approximately the length of a dime, was observed on the floor in Resident 55's room. During an interview on 7/22/24, at 3:01 p.m., LVN6 stated that Resident 55 had complained of roaches in his room. During an observation on 7/23/24, at 10:10 a.m., in the shared bathroom between the rooms for Resident 55 and Resident 344, two small roaches, about four millimeters long, and one-inch-long dead cockroach were observed on the bathroom floor. A buildup of old dirt in the corners of the bathroom, approximately six inches wide by four inches high, was observed. During an interview on 7/24/24, at 11:40 a.m., MS stated that if a resident reported a cockroach to staff, the staff should record it in the maintenance log. MS stated that if a report is not made in the maintenance log, there is a risk that he could forget. MS stated that cockroaches were recently discussed in the 24 hour meeting and in a group text message. MS stated that after the resident found roaches, the pest elimination company should have been called right away. During a concurrent interview and record review on 7/24/24, at 11:50 a.m., with MS, the Maintenance Log for the past several months was reviewed. MS stated that the Maintenance Log indicated that Resident 88's report of roaches was not recorded. MS stated that the report should have been included in the maintenance log so that it is not missed. During an interview on 7/24/24, at 12:03 p.m., with ES, ES stated that he saw cockroaches in Resident 88's room several days ago and he notified MS. During a phone interview on 7/25/24, at 9:02 a.m., with the Pest Control Technician (PCT) from Matrix Pest Control, PCT stated the facility is scheduled for two pest control visits each month. PCT stated they would have only gone into the rooms listed on the invoice. During a concurrent interview and record review on 7/25/24, at 9:55 a.m., with the Director of Nursing (DON), the pest control invoices from 7/11/24, 6/27/24, 6/14/24, 5/28/24, 5/13/24, 4/25/24, 4/12/24, 3/26/24, 3/14/24, 2/16/24, 2/6/24, 1/19/24, and 1/11/24 were reviewed. The DON stated Resident 55's room was not listed on the invoices. During an interview on 7/25/24, at 10:50 a.m., Resident 55 stated that he had never refused to allow the pest control company to enter his room. Resident 55 stated that he desired to have pest control services provided. During an interview on 7/25/24, at 10:59 a.m., with the Social Services Director (SSD), SSD stated that Resident 55 had repeatedly complained of roaches in his room. During an interview on 7/25/24, at 11:13 a.m., with PCT, PCT stated that all rooms he was requested to service were treated for pests and no residents refused pest control services during his last visit on 7/11/24. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated January 1, 2012, P&P indicated, facility staff will report to the Housekeeping Supervisor any sign of rodents or insects, including ants, in the Facility. The Housekeeping Supervisor takes immediate action to remove the pests from the Facility. If necessary, after informing the Administrator, the Housekeeping Supervisor will call the extermination company for assistance.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared and served in a safe and sanitary manner when: 1. A ,d+[DATE] full container of Teriyaki sauce labeled refrigerate after opening was stored in un-refrigerated dry- goods storage 2. A dry food bin marked polenta was ready for use with an expired use-by date, and dry food bins for flour, thickener and grain rice had no use-by dates 3. Two of five cutting boards had deep white scratches 4. A knife rack had sticky brown residue on top 5. An air conditioner unit had thick grey dust on top, and in the air vents 6. The corner of kitchen floor was unclean with food debris buildup These failures placed the residents at risk for food-borne illnesses. Findings: 1. During an initial observation on [DATE], at 9:15 a.m., in the kitchen, a ,d+[DATE] full container of Teriyaki sauce was observed in the dry-storage food pantry, ready for use. On inspection of the back of container, it indicated refrigerate after opening. During an interview on [DATE], at 1:00 p.m., with the Kitchen Manager (KM) and the Registered Dietitian (RD), the KM stated the cook threw out the container of sauce today. KM stated some un-refrigerated liquids can spoil and cause resident illness. During a review of facility's policy and procedure (P&P) titled, Food Storage and Handling, dated [DATE], P&P indicated, Purpose: to store, thaw and prepare food to avoid foodborne illnesses. 2. During an initial observation on [DATE], at 9:17 a.m., in the kitchen, a dry food storage bin labeled polenta was observed in the dry-storage food pantry ready for use, with an expiry date of [DATE]. In addition, three dry food storage bins labeled flour, thickener and grain rice were observed in the dry-storage food pantry ready for use, labeled with open dates only. There were no use-by dates listed on these three bins. During an interview on [DATE], at 12:50 p.m., with KM and RD, KM stated the expiration dates on food should be checked to prevent resident foodborne sickness and for the best food flavor and quality. KM also stated there should be use-by dates on all food to monitor how old the food is. KM stated old, expired food can cause illness to the facility residents and make food taste bad. According to USDA (U.S. Department of Agriculture) Food Safety and Inspection Service Food Dating https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-product-dating, Microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil .There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which do not cause illness but do cause foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome. When spoilage bacteria have nutrients (food), moisture, time, and favorable temperatures, these conditions will allow the bacteria to grow rapidly and affect the quality of the food. Food spoilage can occur much faster if food is not stored or handled properly. During a review of facility's P&P titled, Food Storage and Handling, datedd [DATE], P&P indicated, Dry Storage Area: label and date all storage products. 3. During an initial observation on [DATE], at 9:17 a.m., in the kitchen, two of five cutting boards were observed with deep white scratches and gashes on them. The cutting boards were in the ready-for-use area next to other clean utensils. During an interview on [DATE], at 12:47 p.m. with KM and RD, RD stated the cutting boards should be changed frequently, and food particles might get into the crevices and cause food-borne illness. A review of the U.S. Food and Drug Administration Federal Food Code 2022 indicated, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. Materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to foods, and under normal use conditions shall be .d. finished to have a smooth, easily cleanable surface; and e. resistant to pitting, chipping crazing, scoring, distortion and decomposition. 4. During a concurrent interview and observation on [DATE], at 9:47 a.m., with KM in the kitchen, a knife-rack on the wall was seen covered in a brown sticky residue. Several of the knives had been removed from the rack. The KM stated the area was unclean, and that dirt and germs may get on the knives, and onto resident food. A review of the U.S. Food and Drug Administration Federal Food Code 2022 indicated, in order to effectively clean and sanitize food contact surfaces, where and when required to satisfy the requirements in Parts ,d+[DATE] and ,d+[DATE] of the Food Code, the surface must be first cleaned properly to remove organic material. In most cases this requires use of detergents or other cleaners such as described in Section ,d+[DATE].14 of the Food Code. After the surface is clean to sight and touch, a sanitizing solution of adequate temperature with the correct chemical concentration should then be applied to the surface. The sanitizing solution must stay on the surface for a specific contact time as specified in this Code and in accordance with the manufacturer's EPA-registered label, as applicable. 5. During an initial observation on [DATE], at 9:20 a.m., in the kitchen, a wall air conditioner unit located opposite the entrance door had grey dust on top and inside all the vents. The air conditioner was blowing air into the kitchen above multiple machines and surfaces. During a concurrent interview and observation on [DATE], at 9:50 a.m., with KM in the kitchen, the air conditioner vents were free of dust. KM stated she had directed staff to clean the dust the day prior, to ensure dust and dirt did not blow onto food or food preparation surfaces. A review of the U.S. Food and Drug Administration Food Code 2022 indicated, Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. 6. During an observation on [DATE], at 8:00 a.m., the kitchen floors were inspected. In one corner, a pest trap and a three-inch area of food and dirt buildup was observed. Directly above this area was a large aluminum countertop, with a ,d+[DATE] inch gap between the right edge of the countertop and the adjacent wall. During a concurrent interview and observation on [DATE], at 9:50 a.m., with KM in the kitchen, the floors were freshly mopped and still wet. The corner area was again seen with the pest-trap and the food/dirt debris. KM stated both the kitchen and the housekeeping/maintenance staff were responsible for cleaning the kitchen, and this area should have been cleaned thoroughly to prevent insects and pest infestation. During are review of facility's P&P titled, Maintenance Service, undated, P&P indicated, as part of their duties, maintenance staff will comply with established infection control precautions. During a review of facility's P&P titled, Cleaning Schedule, undated, P&P indicated, Policy: The dietary staff will maintain a sanitary environment in the dietary department . A review of the U.S. Food and Drug Administration Food Code 2022 indicated, equipment that is fixed because it is not easily moveable shall be installed so that it is: (1) Spaced to allow access for cleaning along the sides, behind, and above the equipment; (2) Spaced from adjoining equipment, walls, and ceilings a distance of not more than 1 millimeter or one thirty-second inch; or (3) sealed to adjoining equipment or walls, if the equipment is exposed to spillage or seepage.

Based on observation, interview, and facility document review, the facility failed to ensure the oversight of food service operations when the facility did not employ a full-time qualified Dietary Services Supervisor, defined as working 35 hours per week, to manage and oversee food operation services for the facility. This failure had the potential to jeopardize the health and well-being of the 92 of 93 residents who received food prepared in the kitchen. Findings: According to the California Code, Health and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. During an interview on 7/22/24, at 9:15 a.m., with [NAME] 1 (CK 1), CK 1 stated the Kitchen Manager (KM) was not onsite for the initial kitchen tour, and that the KM only worked part-time. During an interview on 7/24/24, at 1:00 p.m., with KM, KM stated she was still in school for the Dietary Services Supervisor (DSS) certification. When asked to present proof of education to manage and oversee facility food operation services, KM showed a ServSafe (foodborne illness and food sanitation training accredited by the National Restaurant Association) certification. KM also stated she was a full-time employee of the facility; and worked in the facility 35 to 40 hours each week. During an interview on 7/24/24, at 1:10 p.m., the Registered Dietitian (RD) stated registered dietary staff were physically onsite at the facility two days a week. During a review of untitled timecard report dated 5/24/24 through 7/24/24 for KM, the report indicated that KM worked the following total hours per week for the last eight weeks: 29.45 hours during the week of 5/27/24 through 6/1/24 27.77 hours during the week of 6/2/24 through 6/9/24 29.68 hours during the week of 6/10/24 through 6/16/24 12.82 hours during the week of 6/17/24 through 6/23/24 17.48 hours during the week of 6/24/24 through 6/30/24 31.72 hours during the week of 7/1/24 through 7/7/24 34.99 hours during the week of 7/8/24 through 7/14/24 16.43 hours during the week of 7/15/24 through 7/21/24 During a review of facility's policy and procedure (P&P) titled,Dietary Services Supervisor/Certified Dietary Manager - Job Description, undated, P&P indicated, Qualifications: Graduate of a California State approved DSS course, CDM certification with title 22 coursework bachelor's degree in a related clinical nutrition field. For a complete list see California Safety Code 1265.4. During an interview on 7/25/24, at 11:31 a.m., with the Administrator (ADM), the RD, and the DON, the ADM acknowledged the RD and KM had been working part-time at the facility, and stated awareness that a ServSafe certification did not qualify the KM to oversee the facility's Dietary Services Department.

Based on interview and record review, the facility failed to ensure four (Resident 32, 47, 57 and 67) of five sampled resident's Pre-Admission Screening Resident Review (PASRR) was referred to the appropriate state mental authority for evaluation and determination when; 1. Facility did not resubmit a new Level 1 PASRR screening for Residents 32, 47, 67 that remained in the facility longer than 30 days. 2. Facility did not refer Resident 57 for level 2 PASRR evaluation. These failures had the potential to prevent residents from receiving appropriate required mental health services. Findings: 1. Review of Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 5/22/24, indicated Resident 32 was admitted to the facility on [DATE], the Preadmission Screening and Resident Review (PASRR) was coded zero-meaning, Resident 32 was not considered by the State PASRR process to have a serious mental illness. The MDS indicated Resident 32's diagnoses included undifferentiated schizophrenia ( a mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and a sense of mental fragmentation). Review of the PASRR screening dated 5/11/24 indicated Resident 32 had a serious diagnosed mental disorder such as depression, anxiety disorder, schizophrenia/schizophrenia disorder or symptoms of psychosis, delusional (false beliefs) and or mood disorder. The PASRR indicated if the individual remains in the NF (nursing facility) longer than 30 days, the facility should resubmit a new Level I screening as a Resident Review on the 31st day. Review of MDS, dated [DATE], indicated Resident 67 was admitted to the facility on [DATE], the PASRR was coded zero-meaning, Resident 67 was not considered by the State PASRR process to have a serious mental illness. MDS indicated Resident 32's diagnoses included schizophrenia ( a mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and a sense of mental fragmentation). Review of the PASRR screening dated 6/4/24 indicated Resident 67 had a serious diagnosed mental disorder such as depression, anxiety disorder, schizophrenia/schizophrenia disorder or symptoms of psychosis, delusional (false beliefs) and or mood disorder. PASRR indicated if the individual remains in the NF (nursing facility) longer than 30 days, the facility should resubmit a new Level I screening as a Resident Review on the 31st day. During a concurrent interview and record review on 7/24/24, at 9:12 a.m., with MDS coordinator (MDSC), and Director of Nursing (DON), MDSC stated Resident 32 and 67 were admitted to the facility with Level I PASSAR screening completed from the hospital. MDSC stated she reviewed PASRRs during MDS process. MDSC stated facility had not resubmitted a new Level I screening when residents remained in the facility longer than 30 days . During a review of the facility's policy and procedure (P&P) titled, Pre-Admission Screening Resident Review (PASRR) revised July 2018, indicated The facility MDS Coordinator will be responsible to access and ensure updates to the PASRR is done per MDS guidelines. 36087 A review of Resident 47's Admission Record printed on 7/24/24, indicated resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 47's MDS, dated [DATE], indicated the PASRR was coded zero, meaning Resident 47 was not considered by the State Level II PASRR process to have a serious mental illness. However Resident 47's diagnoses included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows) and Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements. They may also have mental and behavioral changes, sleep problems, depression, and memory difficulties). A review of Resident 47's Order Summary Report, active orders as of 7/25/24, indicated an order for Depakote Extended Release (ER) 24 Hour oral tablet 250 mg, give three tablets for bipolar disorder. A review of Resident 47s medical record indicated Resident 47 did not have a PASRR. During a concurrent interview and record review on 7/24/24, at 9:10 a.m., with the MDSC and DON, Resident 47's clinical records were reviewed. MDSC stated MDSC reviewed PASRRs during the MDS process. However, MDSC confirmed Resident 47's PASRR was not completed, and resident was not referred to the State Mental Authority for specialized mental health services when resident remained in the nursing facility longer than 30 days. A review of the facility's policy and procedure titled, Pre-admission Screening Resident Review (PASRR), revised date July 2018, indicated, To ensure that all facility applicants are screened for mental illness and intellectual disability (ID) or a related condition (RC) prior to admission. The State of California has adopted a process to submit Pre-admission Screening Resident Review (PASRR) electronically. All facilities must complete the PASRR by midnight of the date of admission . 2. A review of Resident 57's Admission Record printed on 7/24/24, indicated resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 57's MDS dated [DATE], indicated resident's diagnoses included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 57's Order Summary Report, active orders as of 7/24/24, indicated an order for Seroquel oral tablet 25 mg, give one tablet for Schizophrenia m/b aggressive behavior towards others. A review of Resident 57s medical record indicated Resident 57 did not have a PASRR Level II referral. During a concurrent interview and record review on 7/23/24, at 9:26 a.m., with the MDSC, Resident 57's clinical records were reviewed. Resident's PASRR Level I was completed on 4/3/23, which showed a result of positive for mental illness and a Level II Mental Health Evaluation Referral was required. MDSC stated Resident 57's medical records did not indicate that a Level II PASRR was completed, nor any follow-up appointment was set up to have the evaluation completed was done. A review of the facility's P&P titled, Pre-admission Screening Resident Review (PASRR), revised date July 2018, indicated, .The facility MDSC Coordinator will be responsible to access and ensure updates to the PASRR is done by MDS guidelines .

Based on observation, interview, and record review, the facility failed to ensure maintenance services to maintain a comfortable, sanitary, and homelike environment when: 1. For Resident 39, room had a missing window covering. 2. For Resident 41, bathroom sink hot water knob was not in good working condition. 3. For Resident 58, room window could not be closed completely. 4. Multiple rooms (Rooms 5, 6, 10, 11,1 2, 16, and 19) had unclean and unpleasant bathroom environments. These failures to ensure a homelike environment had the potential to decrease residents' quality of life, comfort, and well-being. Findings: 1. A review of Resident 39's Admission Record printed on 7/24/24, indicated Resident 39 was admitted to the facility on [DATE]. A review of Resident 39's Minimum Data Set (MDS, an assessment tool used to provide care), dated 7/12/24, indicated Resident 39 had a Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time and capacity to remember. The BIMS score ranges from 0-15, with 15 as an indication of intact skills) score of 15 who had clear speech, was understood, and was able to understand. During a concurrent observation and interview on 7/22/24, at 9:25 a.m., with Resident 39, inside the resident's room, right panel of the window did not have a window covering. Resident 39 stated he had asked multiple times from several staff members to tell Maintenance to put blinds or some sort of window covering for resident's privacy and protection from outside heat especially with the recent heat wave. Resident stated it had been two weeks since he was admitted to the facility, yet the other panel of the window remained without blinds. During an interview on 7/22/24, at 10:00 AM, with Maintenance Supervisor (MS), MS stated he had been made aware of Resident 39's request for the resident's room window covering, however, MS was unable to find the time to install the blinds. MS stated the blinds were in the storage room available for installation. 2. A review of Resident 41's Admission Record printed on 7/24/24, indicated Resident 41 was admitted to the facility in 2019. A review of Resident 41's MDS Assessment, dated 5/17/24, indicated Resident 41 had no speech, was rarely/never understood, and was rarely/never able to understand. During an observation on 7/23/24, at 11:36 a.m., inside Resident 41's room, the bathroom sink hot water knob when turned loose was without water flow. During a concurrent observation, interview, and record review, on 7/23/24, at 11:47 a.m., with the Registered Nurse 1 (RN 1), inside Resident 41's bathroom, RN 1 turned the sink hot water knob open and stated it was not working. RN 1 stated if something needed fixing or there was a maintenance issue, depending on the urgency, would report to Maintenance immediately, either verbally or written in the Maintenance Logbook located at the Nurses Station. When RN 1 checked the Maintenance Logbook in Nurses' Station 3, the issue regarding faucet in Resident 41's room was not documented. During an interview on 7/23/24, at 11:58 a.m., with CNA 1, CNA 1 confirmed hot water faucet knob to Resident 41's room had not been working in the last three days. CNA 1 stated she had reported this problem to the license nurse (LN) three days ago. CNA 1 further stated she had been going to the Nurses Station to get hot water for Resident 41's activities of daily living (ADL, the basic self-care tasks an individual does on a day-to-day basis) care. During a concurrent observation and interview on 7/23/24, at 12:01 p.m., with MS, inside Resident 41's bathroom, MS confirmed water did not flow when hot water knob was turned loose. MS stated the hot water valve was closed due to a loud screeching sound when knob was turned loose. MS stated this problem was verbally reported to him by a CNA, but MS was unable to take care of the problem up to this time. A review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, revised date January 1, 2012, indicated, The facility provides residents with a safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences . 49091 3. During a concurrent observation and interview on 7/22/24, at 10:00 a.m., with Resident 58 and Resident 58's family member, the family member stated Resident 58's bedroom window would not close properly. When it was attempted to close the window completely, a 1/4 inch gap was left open to the outside, between the window and the window frame. The family member stated this caused hot and cold air, as well as cigarette smoke from the courtyard smoking area to come into Resident 58's room. The family member stated they were worried about Resident 58's health because of this, and Resident 58 had also complained about cigarette smoke smell. During a concurrent observation and interview on 7/23/24, at 1:36 p.m., with the Infection Prevention Nurse (IPN) in the facility courtyard/smoking area, smoking ashtrays were located approximately 20 feet from Resident 58's and other residents' bedroom windows. A large blue shade awning was also located in the courtyard, with the nearest part of the awning measuring approximately 15 feet from resident bedroom windows. The IPN stated facility residents were allowed to smoke during certain times during the day accompanied by activity staff, and smokers were encouraged to stay far away from facility bedroom windows. During a record review of Smoking Schedule for Residents, undated, the schedule indicated, smoking times are 8:30 a.m., 11:00 a.m., 1:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m. During an observation on 7/24/24, at 10:30 a.m., in the facility's smoking area/courtyard, a resident in a wheelchair was smoking. The resident was under the large blue shade awning. During an observation on 7/24/24, at 12:30 p.m., in the facility's smoking area/courtyard, two residents were smoking in between the ashtray station and the large blue shade awning. During an interview on 7/25/24 at 10:40 a.m. with the Director of Nursing (DON), the DON stated risks of second-hand smoke inhalation include cancer and respiratory problems, and residents should not be exposed to it. During a review of facility's policy and procedure (P&P) titled, Smoking by Residents, effective 8/18/23, P&P indicated, facilities that accommodate residents who smoke will take reasonable precautions by providing a safe environment and protecting the non-smoking residents. In an interview on 7/24/24, at 11:35 a.m., with the Maintenance Supervisor (MS), the MS stated he was aware of Resident 58's window issue. MS stated Resident 58's window would not close, for maybe a month or more. MS stated the facility had tried to find ways to repair the window in-house, and since that didn't work, the facility contacted S.F. Atlas Glass company today for an estimate, and now the plan was to replace Resident 58's window completely. In a review of facility P&P titled, Maintenance Service, undated, P&P indicated, The maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .maintaining the building in good repair and free from hazards . During a record review of SF Atlas Glass invoice #2024225, dated 7/24/24, the invoice indicated two 48 x 48 windows/screens, and one 45 x 45 window/screen would be ordered and installed, and lead time is 4-6 weeks. During an interview with MS on 7/24/24, at 3:30 p.m., MS explained the information printed on S.F. Atlas Glass' invoice, lead time is 4-6 weeks, meant that the work would be started after the parts arrived in 4 to 6 weeks' time. MS stated temporary sealing and taping of the window would be done to ensure that Resident 58's window would close until the whole window could be replaced. 36593 4. During an observation on 7/23/24, at 11:05 a.m., with Maintenance Staff (MS) and Administrator In Training (AIT), Residents' rooms 5, 6, 10, 11,12, 16 and 19 bathroom flooring had cracks and blackish discoloration on floors, toilet bowl with blackish strip marks on the rims, and blackish material around the base of toilet bowl. During a concurrent observation and interview on 7/23/24, at 11:43 a.m., Resident 85 was seated up in wheelchair outside room [ROOM NUMBER]. Resident 85 stated he resided in room [ROOM NUMBER] and used the bathroom. Resident 85 stated he was uncomfortable using the bathroom sometimes. Resident 85 stated when he asked for the bathroom floor to be cleaned, staff did not listen. During an interview on 7/24/24, at 11:39 a.m., with Environmental Supervisor (ES), ES stated facility was aware of cracked flooring, blackish material and discoloration around the toilet in residents' bathrooms. During a review of the facility's policy and procedure (P&P) titled, Resident Rooms and Environment, revised January 01, 2012, the P&P indicated, The facility provides residents with a safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.

Based on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for one of 40 sampled residents (Resident 41) when Resident 41's Hospice Care (a medical care for people focused on palliation [focused on providing relief from pain and other symptoms of a serious illness] of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) Notes were not readily accessible and Hospice Care Visits/Assessments were not accurately documented in resident's electronic medical record. These deficient practices had the potential for Resident 41 to not receive the needed care, services, and treatments due to lack of availability of information to facilitate communication among the Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patients). Findings: A review of Resident 41's Admission Record printed on 7/24/24, indicated Resident 41 was admitted to the facility in 2019. A review of Resident 41's Physician's Order indicated resident was admitted to hospice care on 5/10/24 for terminal diagnosis of Cerebrovascular Disease (a condition that affects flow of blood in the brain and spine). A review of Resident 41's electronic medical record did not indicate any documentation of Hospice Visits/Assessments. During a concurrent interview and record review on 7/23/24, at 10:40 a.m., with Licensed Vocational Nurse 1 (LVN 1), Hospice Communication Binder (HC Binder) revealed a total of five Hospice Notes documentations dated 5/17/24, 5/24/24, 5/30/24, 6/6/24, 6/28/24, and 7/23/24. LVN 1 stated Hospice Nurse visited the resident in the facility on Mondays, Wednesdays, and Fridays, and documented on their tablet (a small portable computer), later signed digitally by the facility nurse on duty. LVN 1 stated there were no Progress Notes entered by facility nurses on resident's electronic medical record. During a concurrent telephone interview and record review on 7/25/24, at 10:27 a.m., with the Hospice Clinical Director (HCD), facility's Hospice Communication Binder (HC Binder) was discussed via the telephone. HCD stated Resident 41 should have Hospice Notes available in the HC Binder. HCD further stated Hospice Nurses were expected to write notes of each resident visit on the HC Binder and facility could request copies of Hospice Progress notes via fax thru the Hospice Medical Records (HMR). A review of the facility's policy and procedure (P&P) titled, Hospice Care of Residents, revised date January 1, 2012, indicated, Documentation .Hospice Notes will be included in the Facility Progress Notes .All documentation concerning hospice services will be maintained in the resident's medical record.

Based on observation, interview, and record review the facility failed to ensure necessary treatment and care services in accordance with professional standards of practice, comprehensive assessment and care plan for two of two sampled residents (Resident 41 and Resident 85) when: 1. For Resident 41, license nurse (LN) did not assess or offer pain medication before wound dressing change was performed. 2. Resident 85 did not receive pain medication as ordered by the physician. License nurses did not reassess routine use of as needed pain medication. These failures had the potential for Resident 41 and Resident 85 to suffer from unnecessary pain and emotional distress, and to not receive the necessary care and services to ensure effective pain management. Findings: 1. A review of Resident 41's Admission Record printed on 7/24/24, indicated Resident 41 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a brain condition that causes a progressive decline in memory, thinking, learning, and organizing skills), hemiplegia (muscle weakness on one side of the body), and pressure ulcer (an injury that breaks down the skin and underlying tissues) of the sacrum (bottom of the spine or just above the tailbone). It also indicated Resident 41 was on palliative care (a specialized medical care focused on providing relief from pain and other symptoms of a serious illness). A review of Resident 41's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 5/17/24, indicated Resident 41 had no speech, was rarely/never understood, and was rarely/never able to understand. The MDS also indicated Resident 41 required substantial/maximal assist (helper does more than half the effort) to dependent assist (helper does all of the effort to complete the activity with the assistance of two or more helpers required for the resident to complete the activity) during his activities of daily living, (ADLs, the basic self-care tasks an individual does on a day-to-day basis). A review of Resident 41's Order Summary Report, order date range 7/1/24-7/31/24, indicated: 1. 7/20/24 Morphine Sulfate 20 milligram (mg)/milliliter (ml), give 0.25 ml by mouth every one hour as needed for pain. 2. 7/19/24 Sacrum - cleanse wound with normal saline or sterile water pat dry apply calcium Alginate (AG) to wound bed and dry dressing. Every day shift for wound care and as needed for wound care. A review of Resident 41's Care Plan focused on, The resident is at risk for pain, dated 9/22/21, indicated, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain . During a concurrent wound dressing change observation on 7/23/24, at 10:34 a.m., with the Treatment Nurse 1 (TN 1) and Licensed Vocational Nurse 1 (LVN 1), inside Resident 41's room, Resident 41 was positioned lying in bed on his right side, with the sacral wound exposed for wound treatment. Resident 41 was observed tensed and guarded. When TN 1 cleansed Resident 41's sacral wound with normal saline, resident moved his lower body part away with a sudden jerk. During a follow-up interview on 7/23/24, at 10:45 a.m., with TN 1, TN 1 stated she did not assess Resident 41's pain level nor asked the Charge Nurse (CN) if the resident had received pain medication prior to wound treatment. TN 1 stated she would normally ask the CN to give the resident pain medication 30 minutes before wound treatment. During an interview on 7/25/24, at 8:47 a.m., with the Registered Nurse Supervisor (RNS), RNS stated a resident must be assessed for pain and offered pain medication 30 minutes prior to wound treatment, and assessed for the effectiveness of the pain medication before the wound treatment was performed. A review of the facility's policy and procedure (P&P) titled, Pain Management, revised date 5/25/23, indicated, .Pain Assessment .If the resident cannot verbalize the intensity of their pain, the Licensed Nurse will evaluate the resident's pain based on non-verbal cues (Examples of non-verbal cues to include but are not limited to: .guarding of a body part .Pain Management .The Licensed Nurse will assess the resident for pain and document results on the Medication Administration Record (MAR) . 36593 2. During a review of Resident 85's Admission Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/29/24, the MDS indicated Resident 85'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 15 and indicated intact mental status. The MDS indicated Resident 85 was able to recall the correct year, month, and day of the week. MDS indicated Resident 85 had facial expression of pain (e.g. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth). Resident 85 had protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). Resident 85 complained or showed evidence of pain or possible pain frequency of 1 to 2 days. The MDS indicated Resident 85 had diagnoses that included cellulitis of right lower limb ( a common and potential serious bacterial skin infection), bilateral osteoarthritis of knee ( a degenerative joint disease) and other chronic pain. During a concurrent observation and interview on 7/23/24, at 9:40 a.m., Resident 85 laid in bed in his room, awake and verbally responsive. Resident 85 stated his pain medication was not relieving his leg pain, and he could not sleep well overnight. Resident 85 stated he received medication every 6 hours as needed for pain and continued to have pain on his knees and legs. During a review of Resident 85's Pain Evaluation, dated 7/22/24, indicated for pain intensity ask resident to rate worst pain on a 0-10 scale, with 0 being no pain and 10 being the worst pain imaginable. Resident 85's pain level was scored at 5. (The pain scale helps the doctor keep track of how well your treatment plan is working to reduce your pain and help you do daily tasks. Most pain scales use numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain you have ever felt) Reference : https://www.healthline.com . During a review of Resident 85's order summary report (physician orders), dated 5/23/24, indicated physician prescribed Acetaminophen (Tylenol) oral tablet 500 mg give 2 tablet by mouth every 6 hours as needed for mild pain (1-4) not to exceed 3 gm in 24 hours. Further review of Resident 85's physician order dated 5/23/24, indicated the physician prescribed hydrocodone-acetaminophen (Norco) oral tablet 10-325 mg give one tablet by mouth every 4 hours as needed for moderate to severe pain (5-9) not to exceed 3 gm of Tylenol in 24 hours. During a review of Resident 85's Medication Administration Record (MAR), dated June 2024 , the MAR indicated Resident 85 was administered Tylenol 500 mg two tablets on 6/17/24 and 6/22/24 for pain score of 5. Further review of June 2024 MAR indicated Resident 85 was administered Norco one tablet by mouth on 6/1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 17, 19, 20, 21, 23/2024. for pain score of 1 to 3. During a review of Resident 85's MAR dated July 2024, Resident 85 was administered Tylenol 500 mg two tablets on 7/4, 5, 9, 10, 14, 15, 20, 22/2024 for pain score of 6. Further review of Resident 85's MARs dated June and July 2024 indicated Resident 85 received as needed Norco oral tablet pain medication one tablet by mouth 2 to 5 times daily. During a concurrent interview and record review on 7/24/24, at 9:26 a.m., with Licensed Vocational Nurse (LVN 2), Resident 85's MAR dated July 2024 was reviewed. LVN2 stated Resident 85 frequently complained of general pain. LVN 2 stated when resident frequently asks for pain medication, we notify the physician. LVN 2 stated for pain level 6 Resident 85 needed to receive Norco not Tylenol. LVN 2 stated she would call the physician to reevaluate Resident 85's pain. During a concurrent interview and review of Resident 85's MAR dated June and July 2024, on 7/24/24, at 10:16 a.m., with LVN 3, LVN 3 stated when resident received as needed pain medication routinely, license nurse would reassess resident and notify the physician to reevaluate resident's pain medication. During a concurrent interview and review of Resident 85's physician orders and MARs dated June and July 2024, on 7/24/24, at 11:34 a.m., with Director of Nursing (DON), DON stated licensed nurses are expected to notify the physician to reevaluate resident pain status when as needed pain medications are routinely administered. DON stated Resident 85's physician would be notified. During a concurrent interview and review of Resident 85's MAR dated June and July 2024, on 7/25/24, at 8:57 a.m., with Registered Nurse (RN 2), RN 2 stated the expectation was to follow the physician order of pain level parameter before medication administration. RN 2 stated Tylenol was not given per pain scale level indicated on the physician order. During an interview on 7/25/24, at 9:58 a.m., DON stated the expectation was for licensed nurses to follow physician order and administer pain medication as ordered. During a telephone interview on 7/25/24, at 12:33 p.m., with Licensed Vocational Nurse (LVN6), LVN 6 stated he was Resident 85's on duty nurse in June 2024. LVN 6 stated he was on duty evening and night shift. LVN 6 stated Resident 85 consistently complained of lower leg pain. LVN 6 stated Resident 85 said that his pain level was at 10 when asked. LVN 6 stated he documented Resident 85's pain level as 1 on MAR on 6/1, 2, 4, 5, 6, 8, 10, 11, 12, 13, 14, 16, 17, 20, 23, 24, 25, 26/2024 because LVN 6 stated he felt Resident 85 just wanted the pills and did not have pain. During a review of the facility's policy and procedure (P&P) titled, Administration of Pain Medication, date revised November 2016, indicated, The Licensed Nurse will only administer pain medications according to the physician's order. Review the physician order and administer the pain medications as ordered. Some physician orders may have different medications indicated for different levels of pain.

Based on observation, interview, and record review, the facility failed to ensure drugs were stored and disposed of in the proper manner. Three boxes of rectal suppositories were expired, and one emergency medication kit was left open and not replaced. These failures had the potential to result in residents receiving ineffective medication. Findings: During an observation on [DATE], at 1:41 p.m., the medication storage room was observed by two Health Facilities Evaluators (HFEs). During the observation, one emergency medication kit (e-kit) was observed as having been opened. The kit contained controlled substances, insulin, and temperature-sensitive suppositories. Further along the observation, three boxes of Bisacodyl suppositories were observed as having an expiration date of ,d+[DATE]. This was confirmed with Licensed Vocational Nurse (LVN) 1. The expired medication was placed with the rest of the over-the-counter medications used by the facility. LVN 1 then checked the reorder log for the e-kits, which revealed a reorder date of [DATE] for the e-kit. LVN 1 stated the expired medication placed residents at a risk of receiving medication that would be ineffective at treating their conditions. During a review of the policy and procedure (P&P) titled, Medication Storage in the Facility, dated [DATE], the policy indicated Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy .

Based on observation, interview, and record review, the facility failed to ensure that two of three sampled residents (Residents 54 and 58) were administered medication to meet their needs. Resident 54 was not given two medications as ordered during an observed medication pass and Resident 58 was not giving prescribed eye drops for two days. These failures had the potential to result in residents' medical conditions worsening. Findings: A review of the Admission Record (a document containing the most pertinent information for a resident) for Resident 54, undated, indicated the resident was admitted on ,d+[DATE] with a diagnosis of heart failure. A review of the Physician's Orders for Resident 54, dated July 2024, indicated the resident had orders for Minoxidil 10 milligrams (mg) once daily for hypertension, and Potassium Chloride 20 milliequivalents (mEq) once daily for supplement. A review of the Admission Record for Resident 58, undated, indicated Resident 58 was admitted on ,d+[DATE]. A review of the Physician's Orders for Resident 58, dated March 2024, indicated Resident 58 had an order for Latanoprost Ophthalmic Solution 0.005 % Instill 1 drop in both eyes at bedtime for Glaucoma OU, primary open angle. During a concurrent observation and interview on 7/24/24, at 9:05 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed passing medication to Resident 54. Resident 54 was noted with an order for potassium chloride (a medication designed to increase a person's potassium). LVN 3 looked through the medication cart and storage area and was unable to locate the potassium chloride. LVN 3 stated the medication was ordered from the pharmacy and had not arrived yet, so LVN 3 was unable to administer the medication to the resident. LVN 3 then completed the rest of the medication preparation and administered the medications to Resident 54. During a concurrent interview and record review on 7/24/24, at 10:30 a.m., with LVN 3, Resident 54's medication orders for the observed medication pass were reviewed. Resident 54 was noted as having an order for Minoxidil (a medication designed to lower blood pressure). This medication was not observed as being passed to the resident. LVN 3 confirmed that the Minoxidil was not administered to the resident. During a concurrent interview and record review on 7/25/24, at 9:41 a.m., with the Director of Nursing (DON), Resident 58's Medication Administration Record (MAR) for March 2024 was reviewed. During the review, the DON stated the MAR indicated Resident 58 did not receive Latanoprost eye drops on 3/29 and 3/30, with two progress notes attached stating that the medication was not available at the time of administration. The DON stated this was a medication error and that all residents should receive medications as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure it maintained a medication error rate of five percent or less. The facility medication error rate was 8.1%, with three errors observed during 37 opportunities. This failure had the potential to result in residents' medical conditions worsening. Findings: During a concurrent observation and interview on 7/24/24, at 9:05 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed passing medication to Resident 54. Resident 54 was noted with an order for potassium chloride (a medication designed to increase a person's potassium). LVN 3 looked through the medication cart and storage area and was unable to locate the potassium chloride. LVN 3 stated the medication was ordered from the pharmacy and had not arrived yet, so LVN 3 was unable to administer the medication to the resident. Continuing the medication pass, LVN 3 prepared two tablets of Vitamin D3 (a medication designed to strengthen bones) 1000 units to administer to Resident 54. LVN 3 then completed the rest of the medication preparation and administered the medications to Resident 54. During a concurrent interview and record review on 7/24/24, at 10:30 a.m., with LVN 3, Resident 54's medication orders for the observed medication pass were reviewed. Resident 54 was noted as having an order for Vitamin D3 2000 [units] 0.5 tab, which is equivalent to 1000 units. LVN 3 stated he believed he had only put one tablet of Vitamin D3 in the medication cup. The surveyor informed LVN 3 that two tablets were observed by both the writer and the consulting pharmacist during observation. Resident 54 was noted as having an order for Minoxidil (a medication designed to lower blood pressure). This medication was not observed as being passed to the resident. LVN 3 confirmed that the Minoxidil was not administered to the resident. LVN 3 stated that not administering medications as ordered to a resident placed them at risk of getting sicker or having a change in condition.

Based on interview and record review, the facility failed to ensure that one of 3 sampled residents (Resident 1) was free from unnecessary drugs when blood pressure (BP, the pressure of blood pushing against the walls of arteries-carry blood from the heart to other parts of the body) was not monitored prior to administration of a medication for regulation of blood pressure (Midodrine) according to physician orders. This failure had the potential to result in Resident 1 receiving an inadequate or excessive amount of medication for her blood pressure treatment. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated that Resident 1 was initially admitted in 2018. Resident 1's diagnoses included diastolic congestive heart failure (condition where lower left chamber of the heart is not able to fill properly with blood), end stage renal disease (condition in which the kidney's cease to function on a permanent basis), and dependence on renal dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly.) During a review of Resident 1's Order Recap Report, dated 12/01/2022-12/31/2022, the Order Recap Report indicated, Resident 1 had an order for Midodrine HCl tablet (medication used to treat low blood pressure) 10 milligrams (mg), give 1 tablet by mouth three times a day for hypotension (low blood pressure), hold if systolic blood pressure >150 (SBP, top number in BP reading, an indication of the pressure exerted on the blood vessel walls when the heart beats). During a concurrent interview and record review, on 2/22/23 at 6:25 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's electronic Medication Administration Record (e-MAR), dated 11/1/2022-11/30/2022 was reviewed. The e-MAR indicated each dose of Midodrine: 9 a.m., 1:30 p.m., and 5 p.m., had a row labeled, ' BP.' All the e-MAR Midodrine BP boxes were marked with an ' x' for the entire month of November 2022. LVN 1 stated the Midodrine BP boxes were for staff documentation of the BP reading for the associated Midodrine administration time. During a concurrent interview and record review, on 2/22/23 at 8:48 a.m., with Director of Nursing (DON), Resident 1's e-MAR, dated 12/1/2022-12/31/2022, and progress notes were reviewed. The DON stated the row ' BP' on the e-MAR should have the BP reading for the Midodrine administration time recorded prior to administration of the medication. The DON stated the December 2022 e-MAR indicated there were no BP entries on the Midodrine BP row for December 2022. The DON provided documentation of some BP readings, but was unable to provide documentation for a total of nine missing entries for 9 a.m.; eight missing entries for 1:30 p.m., , and nine missing entries for 5 p.m. During a review of the facility's policy and procedure (P&P) titled, Medication-Administration, dated January 01, 2012, the P&P indicated, Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e., BP, pulse, finger stick blood glucose monitoring etc.

Based on observations and interviews, the facility failed to secure one of two ice coolers (IC 1) for resident use. This failure resulted in Resident 1 to access ice cubes in IC 1, in an unsanitary manner, potentially contaminating with bacteria causing illness for 89 residents who ingest ice. Findings: During an observation on 2/2/23 at 11:40 a.m., in the hallway, Resident 1, walking independently with his walker, stopped at IC 1, stored in the hallway, adjacent to the kitchen door, that was not in the view of the nursing station. Resident 1 opened the lid and scooped ice into a cup using unclean hands. Two facility staff walked the hall with Resident 1 in site, and neither one acknowledged Resident 1's action. IC 2 was located at a second nursing station. During an interview on 2/2/23 at 11:48 a.m., Resident 1 stated he kept the disposable cup the medication nurse gave him. Resident 1 stated he got ice from IC 1 because staff were not always available or busy. Resident 1 stated he did not want to bother staff or get yelled at when he requested ice and stated they take a long time. Resident 1 stated it was essential to have ice water because he needs to relieve his throat from being dry and painful. During an interview on 2/2/23 at 11:41 a.m., the Activity Assistant (AA) stated kitchen staff places the ice chest into the hallway. The AA stated residents are not allowed to get ice from the ice chest because they can spread germs. The AA stated residents are supposed to ask staff for ice. During an interview on 2/2/23 at 11/44 a.m., the Certified Nurse Assistant (CNA) stated residents should ask nursing staff to collect ice for them to prevent the spread of infection. During an interview on 2/2/23 at 2:20 p.m., the Infection Control Nurse (ICN) stated ice water was distributed in the mornings by the night shift CNAs before their shift ended and at 2 p.m. The ICN stated kitchen staff fill the ice chests and roll them outside the kitchen for nursing staff to bring near the nursing stations. The ICN stated nursing staff had difficulty distributing ice water to residents because the facility was short of staff. The ICN stated residents can be sneaky to get their own ice even if they know to ask. The ICN stated persons need to have clean hands to scoop ice to prevent the spread of infection. The ICN stated that residents handling the ice from the cooler was not appropriate because we don't know where they've [residents] been .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a safe and orderly discharge from the facility when the facility failed to provide and document the orientation and preparations for Resident 1's discharge needs to a legally responsible party, before discharging Resident 1. The attending physician had determined Resident 1 did not have capacity to make healthcare decisions due to dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and required a responsible party to make healthcare decisions. These failures resulted in Resident 1 signing himself out of the facility Against Medical Advice (AMA), without advance notice and joining a woman who alleged a familial relationship but provided no documentary proof of the relationship. This had the potential to result in physical, emotional, or psychological abuse/neglect for Resident 1 and for any resident without legal capacity and without a responsible party, who was allowed to sign themselves out of the facility AMA. An immediate jeopardy (IJ, means a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified and called due to the failure of the facility to protect Resident 1 from leaving the facility without a legally responsible party and a plan to meet identified discharge needs. The Administrator (ADM), Director of Nursing (DON), Social Worker (SW) and [NAME] president of the corporation (VP) were verbally notified of the IJ on 3/30/22 at 6:46 p.m. During an onsite visit on 4/7/22, through observation, interview, and record review, the facility demonstrated they had initiated the plan of action to prevent residents without legal capacity and responsible parties to be allowed to leave the facility by signing themselves out AMA, and the IJ was lifted on 4/7/22 at 2:19 p.m. After removal of the IJ, the facility noncompliance remained at a D level. Findings: A review of Resident 1's Admission Record, undated, indicated Resident 1 was admitted to the facility on [DATE] as his own responsible party, with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 2/3/22, reflected a score of three on the Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired; a score of three is an indication of severe cognitive impairment.) During a concurrent interview and record review on 3/30/22 at 2:38 p.m., with the Social Worker (SW), Resident 1's Baseline care plan, dated 2/3/22, was reviewed. SW stated he was responsible for resident discharge care planning, and there had been no updates to the Baseline care plan since 2/3/22. SW stated Resident 1's Baseline care plan, had a discharge goal of, return to the community, with no listed interventions or further planning. A review of Resident 1's physician Capacity Evaluation dated 3/3/22, signed by the physician, indicated, . No, resident does not have capacity to make medical decisions . During an interview on 3/30/22 at 2:39 p.m., with the Social Worker (SW), SW stated a woman visitor (VIS) arrived at the facility on 3/22/22. SW stated VIS claimed she was Resident 1's daughter, and VIS had been searching for Resident 1 for years. SW stated he had not received any documentation to indicate there was a familial relationship between Resident 1 and VIS. SW stated on 3/22/22, VIS said she wanted to take Resident 1 home with her to live in Texas. SW stated VIS had visited Resident 1 in the facility daily from 3/22/22 until 3/28/22. SW stated on 3/28/22, VIS said she was going home to Texas that day and wanted Resident 1 to go home with her. SW stated, after he spoke with VIS on 3/28/22, SW had informed the Administrator (ADM) and called the ombudsman to inform them of VIS's desire to have Resident 1 accompany her to Texas that day. During an interview on 3/30/22 at 2:13 p.m., with the ADM, the ADM stated she had spoken to her boss about VIS's request to leave with Resident 1. The ADM stated her boss called back and said Resident 1 could leave with VIS. The ADM stated she had never received any documentation to establish a familial connection between Resident 1 and VIS, despite ADM asking for VIS to show documentation to demonstrate a familial connection. The ADM stated she had spoken with Resident 1's physician (PHYS) before Resident 1 left the facility, and PHYS had said Resident 1 did not have capacity to sign himself out AMA, and Resident 1 should not be discharged to VIS's care. During a telephone interview on 3/30/22 at 3:33 p.m., with PHYS, PHYS stated he had spoken with ADM and told the ADM Resident 1 could not sign the form for discharge AMA because Resident 1 had dementia and was not able to make medical decisions for himself. PHYS stated he stated he did not want Resident 1 discharged into the care of the person who alleged she was Resident 1's daughter because there was no evidence to show the alleged relationship existed. PHYS stated he had verbally ordered the DON to not allow Resident 1 to discharge AMA. During an interview on 3/30/22 at 6:00 p.m., with the DON, the DON stated PHYS had given her a verbal order to not discharge Resident 1. The DON stated she had not documented the verbal order and had allowed Resident 1 to leave the facility because an order for discharge was not necessary for a discharge AMA. The DON stated she had been present at the time of Resident 1's discharge and he had not been provided any medications for post-discharge needs because he left AMA. During an interview on 4/13/22 at 11:25 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the ADM and SW had asked her to give the AMA form to Resident 1 to sign. LVN 1 stated the ADM, SW, VIS, and Resident 1 were present in the same room when she gave Resident 1 the AMA form. LVN 1 stated Resident 1 said he wanted to go to Texas with VIS, and he signed the form and left. During an interview on 3/30/22 at 4:55 p.m., with the ADM, the ADM stated she had been present when Resident 1 signed the AMA form and left the facility. The ADM stated she saw VIS and Resident 1 walk to a car, get inside the car, and VIS drove away with Resident 1 in the car. A review of the facility document titled, Discharge Against Medical Advice Form, indicated, The resident is advised to contact his/her responsible party, go to an emergency room , or call 911 for further instructions on medical care and treatment, followed by two lines with entries for, Date: 3/28/22, and Time: 6:10 p.m. The document indicated, This is to certify that I am leaving the facility, [facility name], at my own insistence and against the advice of my physicians and the facility. I have been advised of the risk involved and of possible dangers to my life or health from this departure and I hereby assume the risks and consequences involved. I release my physician, [physician name], the facility and all facility staff members from any liability in connection with my leaving the facility against their advice. Payment in full is hereby guaranteed for all services provided by the Facility, up to and including the day of leaving the Facility. The document indicated entries for, Resident name: Resident 1's name, Signature of Resident: Resident 1's signature, Witness: LVN 1. The document had no entries in the areas which indicated, If resident is unable to consent by reason of age or some other actor, state reason(s), and, If Discharge is requested by the Resident's Legal Representative or Responsible Party:, Name:, Signature:, Relationship to Resident. A review of the facility policy and procedure, Discharge against medical advice, dated 12/1/14, indicated, . if the resident /representative's is still determined to leave against medical advice, the licensed nurse will obtain a physician's order for resident to leave AMA. The policy and procedure did not indicate what the facility actions should be when a resident without capacity and without a legal representative wanted to leave the facility AMA.

Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to ensure Resident 1 was free of a medication error that jeopardized his health. Registered Nurse (RN) 1 gave Resident 1 [MEDICATION NAME] (an opioid narcotic used to treat pain or to help with detoxification in people with opioid dependence) intended for another resident. This failure resulted in Resident 1 vomiting and experiencing an altered level of consciousness that required a five day hospital stay and treatment with [MEDICATION NAME] (a medication for the emergency treatment of [REDACTED]. Findings: Review of Resident 1's face sheet (a document that gives resident information at a quick glance), dated 7/14/17, indicated Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment notes, dated 6/22/17, indicated Resident 1 needed PT services to improve his leg muscle strength, standing balance, activity tolerance and safety awareness to assist with transfers (i.e. moving from sitting to standing) and walking. During an interview with Physical Therapy Assistant (PTA) 1 on 8/24/17, at 3:36 p.m., PTA 1 stated that on 7/24/17 during the 3 o'clock hour, Resident 1 did not receive physical therapy at all because Resident 1 was sick and vomited. Review of Resident 1's Nurse's Notes, dated 7/24/17 at 7:45 p.m., indicated Resident 1 vomited three times in a large amount during physical therapy and also refused dinner. Review of Resident 1's Medication Administration Record [REDACTED] According to Resident 1's Physician's Order, dated July 2017, there was no physician's order for [MEDICATION NAME]. Review of Resident 1's Medication Administration Record [REDACTED]. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR - a technique used to facilitate prompt and appropriate communication), dated 7/25/17 at 10 a.m., indicated Resident 1 had a decreased level of consciousness. Review of Resident 1's Physician's Telephone Orders, dated 7/25/17 at 10:30 a.m., indicated Resident 1 had a physician's order to be sent to the emergency room for evaluation and treatment. Review of the facility's investigation follow up, dated 8/3/17, indicated the facility received a phone call from the hospital on [DATE] during the evening shift that Resident 1 had [MEDICATION NAME] in his system. The investigation follow up also indicated RN 1 called the DON on 7/28/17 and admitted she made a mistake and gave medication to the wrong resident. During an interview with RN 1 on 8/28/17, at 7:33 a.m., RN 1 stated that during the day shift on 7/24/17, a CNA approached her at 11 a.m. and told her a resident in the room adjacent to Resident 1 was in pain and asked RN 1 give him pain medication. RN 1 stated she prepared [MEDICATION NAME] solution and proceeded to give the medication to Resident 1 without checking for any identification. RN 1 stated she gave Resident 1 15 milliliters (150 milligrams) of [MEDICATION NAME]. RN 1 also stated that after she gave the [MEDICATION NAME], she realized it was the wrong resident after she checked the MAR. Review of the drug reference website, Lexicomp, indicated the maximum normal initial dose of [MEDICATION NAME] is 30 milligrams (mg). Further review of Lexicomp indicated .accidental ingestion of even one dose of [MEDICATION NAME] .can result in a fatal overdose of [MEDICATION NAME] . (Reference: www.lexicomponline.com). Review of Resident 1's Emergency Department Note (ED Note), dated 7/25/17 at 11:53 a.m., indicated Resident 1 was admitted to the emergency department with an altered level of consciousness that required a sternal rub (a painful stimulus) to arouse the resident. The ED Note also indicated Resident 1's lab test was positive for [MEDICATION NAME]. The ED Note also indicated Resident 1 received [MEDICATION NAME] two times while in the ED. The ED Note further indicated Resident 1 had a [DIAGNOSES REDACTED]. Review of Resident 1's Hospital Discharge Summary, dated 7/29/17, indicated Resident 1 was admitted to the hospital and had a five day (7/25/17 to 7/29/17) hospital stay for treatment of [REDACTED]. Review of the facility's policy and procedure titled Preparation and General Guidelines, effective April 2008, indicated .Medication Administration Administration-General Guidelines .B. Administration .7). Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record c. If necessary, verifying resident identification with other facility personnel .12). Medications supplied for one resident are never administered to another resident

Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to provide nursing services that met professional standards of quality. Registered Nurse (RN) 1 did not verify Resident 1's identity before she gave Resident 1 [MEDICATION NAME] (an opioid narcotic used to treat pain or to help with detoxification in people with opioid dependence (addiction)) intended for another resident. This failure resulted in Resident 1 vomiting and experiencing an altered level of consciousness that required a five day hospital stay and treatment with [MEDICATION NAME] (a medication for the emergency treatment of [REDACTED]. Findings: Review of Resident 1's face sheet (a document that gives resident information at a quick glance), dated 7/14/17, indicated Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an interview with RN 1 on 8/28/17, at 7:33 a.m., RN 1 stated that during the day shift on 7/24/17, a CNA approached her at 11 a.m. and told her a resident in the room adjacent to Resident 1 was in pain and asked RN 1 give him pain medication. RN 1 stated she prepared [MEDICATION NAME] solution and proceeded to give the medication to Resident 1 without checking for any identification. RN 1 stated she gave Resident 1 15 milliliters (150 milligrams) of [MEDICATION NAME]. RN 1 also stated that after she gave the [MEDICATION NAME], she realized it was the wrong resident after she checked the MAR. Review of the facility's investigation follow up, dated 8/3/17, indicated the facility received a phone call from the hospital on [DATE] during the evening shift that Resident 1 had [MEDICATION NAME] in his system. The investigation follow up also indicated RN 1 called the DON on 7/28/17 and admitted she made a mistake and gave medication to the wrong resident. According to Resident 1's Physician's Order, dated July 2017, there was no physician's order for [MEDICATION NAME]. Review of Resident 1's Medication Administration Record [REDACTED]. Review of the facility's policy and procedure titled Preparation and General Guidelines, effective April 2008, indicated .Medication Administration Administration-General Guidelines .B. Administration .7). Residents are identified before medication is administered. Methods of identification include: a. Checking identification band b. Checking photograph attached to medical record c. If necessary, verifying resident identification with other facility personnel .12). Medications supplied for one resident are never administered to another resident Review of the facility's policy and procedure titled Medication-Errors, last revised 1/1/12, indicated .Policy: I. All errors related to the administration of medications of treatments will be reported to the Director of Nursing Services, the attending physician and the Administrator immediately .II. Medication Error means the administration of medication: A. To the wrong resident .C. At the wrong dose .E. Which is not currently prescribed .Procedure I. Upon discovery of an error, the DON and the Administrator will be immediately notified. II. The Licensed Nurse will make an immediate assessment of the resident in relation to the nature of the error and continue to monitor the resident closely for any adverse effects from the medication. III. If the error is potentially life-threatening, the error and the assessment should be immediately communicated to the Attending Physician. IV. A medication error report should be completed for all medication errors. V. The medication in error is documented in the MAR. VI. Follow-up notes are written if any adverse effect is noted See F333 for additional information regarding Resident 1.

Based on observation, interview and record review, the facility failed to provide a safe environment free of accident hazards for one (1) of three sampled residents, when a housekeeper (HK 1) opened a metal gate, adjacent to an outdoor smoking area, and lifted the 1-7/8 inch by 2-3/8 inch steel box track bar from the ground to move supplies down a ramp leading to the garage. HK 1 failed to use another employee to assist in closing the gate as he moved the supplies to the garage. Resident 1 was in the smoking area sitting in his wheelchair and gained access to the ramp through the open, unattended gate. He rolled down to the bottom and hit a concrete wall. This accident resulted in Resident 1 sustaining multiple injuries that included broken bones in his face and abrasions (scraping of the skin) on his left knee and forehead. Findings: The facility reported that Resident 1 sustained a nasal bone fracture due to an inability to stop his wheel chair from going down a ramp at 2:40 p.m. on 12/22/15. According to Resident 1's Face Sheet dated 7/9/14, he had [DIAGNOSES REDACTED]. Review of the undated Transfer Summary signed by the medical doctor on 12/23/15 at 3:27 p.m., revealed Resident 1 was admitted to the acute care hospital trauma service following a fall from a wheelchair into a glass door, and had injuries that included a nasal fracture, right zygomatic (bone that forms the prominent part of the cheek and outer side of the eye socket) fracture, left knee abrasion and forehead abrasion. During an observation of the smoking area on 1/6/16 at 8 a.m., the smoking area was located in an alley at side the building beside the garage entry way. The garage entry had a metal gate that blocked the entry way and a 2-3/8 inch high steel track bar on the ground. It led to a descending walkway with a concrete wall at the end of the walkway and a door at right wall that led to the garage. During an interview with Housekeeping 1 (HK 1) on 1/6/16 at 10:15 a.m., HK 1 stated on 12/22/15 he was moving supplies from the ground floor to the garage using a pallet jack (a tool used to lift and move pallets which are low portable platforms on which goods are placed for storage). HK 1 saw Resident 1 in the smoking area and he moved Resident 1 close to the building door so he could pass with the pallet jack. HK 1 proceeded to open the metal gate and removed a metal bar on the ground to access the descending walkway leading to the garage. HK 1 left the gate open and did not replace the steel track bar on the ground. Approximately five minutes later, HK 1 heard a noise and immediately checked the walkway. He saw Resident 1's face with blood against the concrete wall while sitting in his wheelchair. He said the metal bar should have been put back before leaving and not left open and unattended. During an interview with the House Keeping Supervisor (HK SUP) on 1/6/16 at 10:40 a.m., HK SUP stated the metal gate should always be closed and there should be two persons when moving supplies to the garage, one person pushes the pallet jack and the other to close the gate. During an interview with the facility's Administrator on 2/3/16 at 10:50 a.m., she stated the metal gate was built several years ago for safety and security purposes.

Based on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 1), was free from physical restraints. Resident 1 was restrained in a merry walker (wheeled walker), which had been tied to the hallway handrail by a certified nursing assistant (CNA) 2, to prevent the resident from walking throughout the facility while the staff provided care to other residents during the night shift. This failure resulted in the Resident 1's inability to move freely about the facility. (Merry Walker: An enclosed framed wheeled walker, made with white [MEDICATION NAME] chloride (PVC) pipe. It is enclosed on three sides and has a front latching hand rail, a rear seat, and an approximately two inch wide safety strap, that extends from beneath the seat and attaches to the hand rail. It is used for residents who are weak and require a place to sit while walking). Findings: Record review, done 11/26/12 at 3 p.m., indicated Resident 1 had a [DIAGNOSES REDACTED]. His primary language was Farsi. Resident 1 had difficulty with long and short term memory, required cues about body placement, was restless and unable to be still for long periods of time in bed, in a chair or in the merry walker. On 8/30/12, 10/22/12 and 11/12/12, he was assessed as being at high risk for falls although he was able to ambulate with close supervision. During the day and night, Resident 1, slept for short periods of time and when not asleep was very active. During an observation, 11/27/12 at approximately 6:45 a.m., Resident 1 was awake and getting out of bed. He was shaky while in bed and when standing. When asked where he was going, he indicated the bathroom with a nod of his head and pointed. Staff came to standby closely while he ambulated to and from the bathroom on his own. He went back to bed without difficulty and went to sleep. In an interview with licensed vocational nurse (LVN) 1and concurrent interview and observation with Resident 1, on 11/28/12 at 10:30 a.m., Resident 1 was standing in the merry walker in his room with the front strap in place. Resident 1 was able to ambulate without difficulty and sat down periodically on the seat. He was cooperative with LVN 1. Additional observations on 11/27/12, 11/28/12, 11/29/12 and 11/30/12 showed Resident 1 sleeping quietly in his bed after breakfast, a family member arrived, sitting up on the side of the bed talking with his family member in his native language, smiling and relating with staff, ambulating in the merry walker with his wife and staff, smiling and participating in a music program, group activities and following gentle direction and redirection without resistance. During an interview on 11/27/12 at 12:10 p.m., the administrator (ADM) stated she had been notified by the charge nurse, registered nurse (RN) 1, on 11/17/13 at approximately 2 p.m., by telephone that Resident 1's merry walker had been tied to the railing while Resident 1 was in it during the night shift. The ADM stated she advised RN 1 she would address the report when she returned to the office on 11/19/12. The ADM attempted to call the night staff but was unable to reach them. She stated she did call the family over the weekend. The family called the local police who came in the night of 11/17/13 at approximately 11:30 p.m., to interview staff. In an interview, 11/28/12 at 2:40 p.m., RN 2 identified himself as the weekend supervisor for 11/17/12 and LVN 1, identified herself as the day time charge nurse on 11/17/12. When RN 2 arrived for work, about 10:30 a.m. on 11/17/12, LVN 1 advised him that Resident 2 told everyone, including staff, that a night staff member had tied Resident 1 to a railing in the hallway with a blanket during the night shift. RN 2 stated Resident 1's family member was informed by Resident 2 and said, " My (relative) is not a dog. How could they do this to him? " When asked, "When did you hear about the incident? " RN 1 stated it was during stand-up, the morning of 11/17/12 that Resident 2 came up and said, "Resident 1 was tied to the rail during the night. " RN 1 stated LVN 1 was one of the other nurses at stand up. (Resident 2 had been admitted to the facility for rehabilitation post a surgically replaced hip. MDS indicated Resident 2's cognitive status as intact; no memory/ recall ability deficit or impairments). RN 1 stated when she heard about the incident she was, "Shocked, surprised. We don't do that here. "We always redirect him. "I'm very clear, we don't do restraints. " When asked what she did when she heard Resident 2's comments, RN 1 did not answer. Asked if she made calls, she stated she did not. The certified nursing assistants (CNAs) had left so she did not talk with them. She planned to report to the DON but did not remember if she actually reported to the DON. In an interview, 11/29/12 at 12:20 p.m., LVN 1 stated that Resident 2 approached her, on 11/17/12 between 9:30 a.m. and 10 a.m., to relate she had been up late smoking and had seen Resident 1 in his merry walker and that it had been tied to the rail, by the south side patio door, during the night shift. The south side patio door is in an alcove next to room [ROOM NUMBER] and faced the south side nurses ' station. In an interview with Resident 1's family member, on 11/30/12 at 1:30 p.m., she stated she came in on 11/17/12 about 11:30 a.m. Resident 2 and Resident 3 came to tell her that between midnight and 4 a.m. Resident 1 was tied to the rails by the south station. He was sleeping in the merry walker that was tied to the rail, at 4 a.m., when they went out to smoke. She stated Resident 1 had bruises on his right arm in two places and a cut on his forehead. Resident 1's family member stated she felt fearful and upset that this, " maybe not first time. This time they got caught. Sometimes they call me at night. He gets restless. I come and stay and walk with him. I did not get a call." In an interview, on 12/5/12 at 10:50 a.m., Resident 2, who was receiving rehabilitation after hip surgery, stated she stayed up late and smoked each night, on the south patio across from the south nurses ' station, between 11 p.m. and 5 a.m. She stated the patio door was never locked and didn't close well. Resident 2 stated that many times Resident 3 was up as well. On 11/17/12 at approximately 12:45 a.m. to 1 a.m., Resident 2 said she saw Resident 1 in his merry walker with a sheet or blanket that was wrapped tightly around the arm of the merry walker and tied to the hallway handrail in the corner by the south nurses' station door. Resident 1 was unable to move the walker. At 2:30 a.m., Resident 1 was asleep sitting in the merry walker that was tied to the rail. At 4:05 a.m., Resident 2 saw Resident 1 awake in the merry walker and that it was still tied to the rail. Resident 2 stated she asked CNA 2 why he was still tied up and that she would tell the administrator. Resident 2 stated Resident 1 was whining and when she asked him if he wanted to go to bed he nodded. She stated she tried to untie the merry walker but was unable. Resident 2 stated Resident 1 was tied three to four hours that night. Resident 2 stated that it was cold and raining that night and Resident 1 was tied by the door. She stated she told RN 1 about the situation at 2:30 a.m. and 4:05 a.m. In an interview, 12/7/12 at 12:15 p.m., Resident 3, who was in the facility for wound care, stated he and Resident 2, " kept going back and forth to smoke, on 11/17/12 after midnight. He stated Resident 1 was in his "stroller" and walking around. Resident 1 opened the door by room [ROOM NUMBER]; the alarm went off but he didn't go out. CNA 2 tied Resident 1's chair "to the wall in front of the south nurses' station with RN 1's assistance. Five minutes later he was untied, then 30 minutes later Resident 3 saw Resident 1 was tied again when he went out to smoke. Resident 3 stated that about 4:30 a.m., he and Resident 2 saw Resident 1 was still tied up. He stated that Resident 3 told RN 1 and CNA 2 that it was against the law but they still did not untie Resident 1. Resident 3 stated the binding was " too tight to get Resident 1 loose. " At 5:30 a.m. Resident 1 was still not untied. "It wasn't right to tie him like that." Resident 3 stated he went out to smoke, on 11/17/12 at approximately 12:30 a.m., 2:30 a.m., 3:30 a.m., 4:30 a.m. and Resident 1 was, "tied up off and on, one time for a couple of hours. " In an interview, 12/4/12 at 4:50 p.m., CNA 2 stated that he was assigned to care for Resident 1 during the night shift beginning at 11 p.m., of 11/16/12 to through to 7 a.m., on the morning hours of 11/17/12, CNA 2 stated Resident 1 was, "always trying to go everywhere, he needs 1:1, " supervision because he was confused at night. He (Resident 1) "usually never sleeps. " CNA 2 stated Resident 1 was strong and if the merry walker brakes were put on the Resident 1 would just pick it up and walk. There were, "lots of call lights that night, " and Resident 1 was "going anywhere, any room ...opened emergency door two times and disturbed most of the patients with going around. " CNA 2 stated his usual assignment was approximately 18 residents per shift. CNA 2 also stated that on, 11/17/12 between 2 a.m. and 3 a.m., CNA 1 was busy and he (CNA 2) had three to four call lights to answer. CNA 2 stated he tied Resident 1, who was in merry walker, to the hallway hand rail with a sheet, for 10 to 20 minutes one time then untied him. CNA 2 said he took his break from 2:30 a.m. to 3 a.m., and tied the merry walker, with Resident 1 in it, to the hallway hand- rail near the front desk and which was near Resident 1 ' s room door. CNA 2 said he asked CNA 1 to take care of him while he was on his break. CNA 2 stated RN 1 was charting at the nurses' station during this time. CNA 2 stated, between 4 a.m. and 4:30 a.m., he again tied the merry walker to the rail, with Resident 1 in it, for five to 10 minutes during the second "diaper change." CNA 2 stated Resident 2 and Resident 3 were alert and oriented and were, "going out all night to smoke. " CNA 2 stated " they (were) making (a) big deal," it was, "just for the safe of him. I try my best." CNA 2 asked, "Who (do) I take care of first, one patient, or 17 patients?" CNA 2 summed up the interview stating he tied Resident 1 with his merry walker to the rail two times on 11/17/12. One time was to answer call lights and have his break and once to do rounds. On 12/4/12, review of the facility ' s policy and procedure titled, Restraints dated, 1/1/12 indicated, " Policy: The facility honors the resident ' s right to be free from any restraints that are imposed for reasons other than that of treatment of [REDACTED]. Review of the facility ' s policy and procedure, titled Resident Abuse - Recognizing Signs and Symptoms, dated 5/15, 11 indicated: Policy: The Facility does not condone any form of resident abuse, neglect, or mistreatment and ensures that all personnel are trained to recognized and report signs and symptoms of resident abuse and neglect and mistreatment to the appropriate individuals. Procedure: Facility staff must report any suspected abuse or neglect of residents to their supervisors or to the Director of Nursing Services immediately. 1. Through staff training, the Facility ensures all personnel are aware of the following signs and symptoms of resident abuse and neglect: A. Actual Physical abuse: Improper use of restraints Review of the most recent dated 11/19/12 Elder Abuse Prevention in-service, which included training about the use of restraints dated 11/19/12, listed CNA 1, and CNA 2 as attendees. In addition, CNA 1 and CNA 2 where listed as attendee for the same restraint in-service on Restraint training was included with the 9/12/12, and 2/17/12.