Every finding on record at Oceanview Post Acute

Based on interviews and record review, the facility failed to ensure three out of 13 sampled residents (Resident 30, Resident 9, and Resident 10) are free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 30 received Depakote (it can be used to treat mood disorders, such as manic episodes in bipolar disorder, as well as seizures and migraines.) without target behavior monitoring, and there was no side effect monitoring. 2. Resident 9 received Trazodone (anti-depressant medication) without monitoring for number of hours of sleep. 3. Resident 10 received Depakote without target behavior monitoring. These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents physical mental and psychosocial well-being. 1. During a review of Resident 30's clinical record titled, admission Record, dated 12/11/25, indicated Resident 30 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) unspecified and essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition). During a review of Resident 30's order summary report, dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg (milligram) to give two capsules by mouth at bedtime for mood disorder, dated 8/30/2025. During a review of Resident 30's Medication Administration Record (MAR, a record of medications given) for month of November 2025 and December 11,2025, indicated there was no monitoring for the target behavior of mood disorder and there was no documentation of side effect monitoring for Depakote. During a concurrent interview and record review on 12/11/25 at 3:41 p.m., with the Director of Nursing (DON), the DON reviewed Resident 30's physician's order. The DON confirmed there was no target behavior monitoring and there was no side effect monitoring for Resident 30's Depakote. The DON further stated psychotropic medication (used to treat mental disorders; a medication used to control behavior or to treat thought disorder processes) they need target behavior. 2. During a review of Resident 9's clinical record titled, admission Record, dated 12/11/25, indicated Resident 9 was admitted to the facility with diagnoses including COPD unspecified and essential (primary) hypertension. During a review of Resident 9's order summary report, dated 12/11/25, indicated an order for trazodone (used to treat depression) 50 mg, to give one tablet by mouth in the evening for insomnia (inability to sleep) , dated 6/19/25. During a review of Resident 9's MAR for month of September 18,2025, October 2025, November 2025, and December 11, 2025, it indicated the nursing staff did not monitor the actual number of hours that Resident 9 slept for pm and night shift since 9/18/25. During a concurrent interview and record review on 12/11/25 at 4:05 p.m., with the DON, the DON reviewed Resident 9's physician's order and the MAR. The DON confirmed there was no number of hours of sleep on Resident 9's MAR. The DON stated she would fix it to see the actual hours of sleep. 3. During a review of Resident 10's clinical record titled, admission Record, dated 12/11/25, indicated Resident 10 was admitted to the facility with diagnoses including depression (loss of pleasure or interest in activities for long periods of time) and essential (primary) hypertension. During a review of Resident 10's order summary report dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg Give 2 capsule by mouth two times a day for mood disorder, dated 8/21/2025. During a review of Resident 10's MAR November and December 11, 2025, it indicated that there was no target behavioral monitoring for use of Depakote. During a concurrent interview and record review on 12/12/25 at 10:34 a.m., with the DON, the DON reviewed Resident 10's physician's order and the MAR for Depakote. The DON stated there was no monitoring for behavior target prior from 12/11/25 and they updated yesterday. During a review of the facility's P&P titled Psychotropic Medication Use, dated 7/2022, indicated, 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications. 11. Residents receiving psychotropic medications are monitored for adverse consequences. 15. Tally/Summarize Behavior at least monthly.

Based on observation, interview and record review, the facility failed to ensure palatability of cooked foods were maintained when five of forty-six facility residents (Residents 7, 32, 4, 41 and 46), receiving food from the kitchen, complained that the food had no taste or tasted bland (lacking taste or flavor) as verified during the test tray meal tasting. This failure of decreased food palatability or no taste could lead to decreased food consumption by residents which could result in decreased nutrient intake for the forty-six facility residents getting foods from the kitchen.1.During an interview on 12/08/2025 at 12:03 p.m., with Resident 7 inside the room, Resident 7 stated the food taste is horrible. During a review of Resident 7's clinical record it indicated Resident 7 was admitted to the facility with diagnosis including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making) unspecified. Review of the order summary report of Resident 7 dated 12/11/25 indicated, Resident 7 had an order of regular texture (standard, unrestricted diet with normal foods), thin consistency (liquids that flow easily, low viscosity and pour quickly from a container), ordered and started on 11/16/23. 2.During an interview on 12/9/2025 at 10:36 a.m., with Resident 32, he stated the food taste was not good. During a review of Resident 32's clinical record, it indicated Resident 32 was admitted to the facility with diagnosis including essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) unspecified. Review of the order summary report of Resident 32 dated 12/11/25 indicated, Resident 2 had an order of Regular diet, SB6 (Soft and Bite Sized) texture, thin consistency, soft bread okay., ordered and started on 12/4/25. 3. During the concurrent observation and interview of Resident 4 on 12/9/25 at 11:42 a.m., Resident 4 was laying in his bed, alert, oriented, calm, comfortable and verbally responsive. Resident 4 stated that his food did not taste good or tasted bland. The cooked rice was hard and did not taste good as well. Review of Resident 4's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 4 was readmitted to the facility on [DATE] with the principal diagnosis of end stage renal disease (also known as kidney failure, is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Review of the order summary report of Resident 4 dated 12/11/25 indicated, Resident 4 had an order of renal diet (kidney-friendly eating plan for those with kidney disease, focusing on limiting sodium, phosphorus, potassium, and sometimes protein and fluids to reduce waste buildup in the blood), regular texture (standard, unrestricted diet with normal foods), thin consistency (liquids that flow easily, low viscosity and pours quickly from a container), two grams (fundamental metric unit of mass) potassium (K, mineral needed by the body that helps nerves to function and muscles to contract), no salt packet and low phosphorus (mineral that is vital for building strong bones and teeth, producing energy and repairing cells), ordered and started on 9/25/25. 4. During the concurrent observation and interview of Resident 41 on 12/8/25 at 12:25 p.m., Resident 41 was in her wheelchair eating lunch in the dining room. She's alert, oriented and verbally responsive. Resident 41 verbalized that the food did not taste good or tasted bland at times. Review of Resident 41's admission record indicated, Resident 41 was admitted to the facility on [DATE] with the principal diagnosis of Parkinson's disease (progressive neurological disorder, primarily affecting movement due to the loss of neurotransmitter or dopamine-producing brain cells) with dyskinesia (involuntary, erratic muscle movements that could not be controlled), with fluctuations (symptoms are unpredictable or changing throughout the day). Review of Resident 41's order summary report dated 12/11/25 indicated, Resident 41 had an order of regular diet (normal, balanced meal without special restrictions), regular texture, thin liquids consistency, ordered and started on 5/28/25. 5. During the concurrent observation and interview of Resident 46 on 12/8/25 at 11:43 a.m., Resident 46 was laying in her bed, alert, oriented, comfortable and verbally responsive. Resident 46 verbalized that the food tasted horrible, did not taste good or tasted bland. Review of the admission record of Resident 46 indicated, Resident 46 was admitted to the facility on [DATE] with the principal diagnosis of nontraumatic intracerebral hemorrhage (ICH, bleeding directly into the brain tissue), in hemisphere, subcortical (refers to brain structures deep within each cerebral hemisphere or the largest part of the vertebrate brain, beneath the cortex or outer layer of the brain). Review of the order summary report of Resident 46 dated 12/11/25 indicated, Resident 46 had an order of regular diet, regular texture, regular consistency (non-restrictive and flows freely), no salt packet with all meals, ordered and started on 10/15/25. During the test tray observation and tasting with kitchen supervisor (KS) and the administrator in-charge (ADMIC) on 12/10/25 from 12:54 p.m. to 1:09 p.m., two test trays were brought and tasted. One of the test trays contained regular potatoes, carrots, rice and fish. The second tray contained mashed potatoes, pureed carrots and pureed fish. Tasted the tray with the regular foods and the regular potatoes and regular carrots did not have taste or tasted bland. The rice was hard and tasted bland as well. Tasted the second tray with mashed potatoes and pureed foods and the mashed potatoes and pureed carrots also tasted bland. During the concurrent interviews with KS and the ADMIC after they tasted the first test tray with regular foods, on 12/10/25 at 1:11 p.m., KS and ADMIC verified that the regular potatoes and carrots did not have taste or tasted bland. They further verified that the rice was hard and tasted bland as well and would check on these concerns. During another concurrent interviews with KS and the ADMIC after they tasted the second test tray with pureed foods, on 12/10/25 at 1:15 p.m., KS and ADMIC verified that the mashed potatoes and pureed carrots also tasted bland and would follow up on that. During the interview with registered dietitian (RD), on 12/10/25 at 2:58 p.m., RD acknowledged that foods served by the facility kitchen should have been palatable, not bland in taste and would check the above concerns. During the interview with the director of nursing (DON) on 12/12/25 from 11:25 a.m. to 11:29 a.m., DON verified the foods should have been palatable to residents and not bland in taste. Review of the facility's policy titled, Food and Nutrition Services, revised October 2017 indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional or special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview, and record review, the facility failed to ensure food items were stored and prepared in accordance with professional standards for food safety when there were unsanitary baking equipment in the kitchen.This failure had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the forty-six residents who received foods from the facility kitchen.Findings: During the initial kitchen tour observation with kitchen supervisor (KS), on 12/8/25 at 9:51 a.m., observed four baking pans with blackish discolorations and brownish spots in them. During the interview with KS on 12/8/25 at 9:52 a.m., KS acknowledged that the four baking pans had brownish to blackish discolorations, rusty spots, and should have the unsanitary baking pans replaced. During the interview with the registered dietitian (RD), on 12/10/25 at 2:58 p.m., RD verified that the unsanitary baking pans should not be kept in the kitchen and no longer used it. Review of the facility's policy and procedure titled, Sanitation, revised October 2008 indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.

Based on interview and record review, the facility failed to ensure that they maintain the documentation records related to the staffs' coronavirus disease 2019 (COVID-19, an infectious disease caused by the SARS-CoV-2 virus or severe acute respiratory syndrome coronavirus 2) vaccinations for seven out of seven facility staffs reviewed when these staffs did not have records on file regarding their COVID-19 vaccination status. This failure had the potential to jeopardize the health and safety of the staffs and the forty-six residents residing in the facility.Findings: During the concurrent review of the facility's employee files and interview with the director of staff development (DSD) on 12/12/25 from 9:31 a.m. to 1:40 p.m., reviewed the employee files of seven staffs with the DSD. Checked the records of certified nursing assistant (CNA) A, CNA B, CNA C, registered nurse D (RN D), licensed vocational nurse E (LVN E), director of rehabilitation (DOR) and current facility administrator (CFADM). DSD acknowledged that there were no records on file for the seven staffs reviewed regarding their COVID-19 vaccination status and whether the staffs were provided with education regarding the benefits and potential risks associated with COVID-19 vaccine. During the interview with the director of nursing (DON) on 12/12/25 at 1:42 p.m., DON verified the above concern and she further verified that she would have the employee files updated with their COVID-19 vaccination records. Review of the facility's policy titled, Personnel Records revised January 2008 indicated, Our facility maintains certain records for each employee which are directly related to his/her employment. Review of the Centers for Medicare and Medicaid Services (CMS, United States federal agency managing Medicare, Medicaid, Children's Health Insurance Program or CHIP and the health insurance marketplace) State Operations Manual (SOM, provides federal rules, guidelines and procedures from CMS), Appendix PP, Guidance to Surveyors for Long Term Care Facilities, issued 7/3/25 indicated, .The facility maintains documentation related to staff COVID-19 vaccination that includes at a minimum, the following: (A) That staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; (B) Staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and (C) The COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

Based on observation, interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 33) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). This failure had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability, or related conditions. Findings:1. Review of Resident 33's clinical indicated she was admitted to the facility with diagnoses including bipolar disorder (mental health condition characterized by mood swings that range from the lows of depression to elevated periods of emotional highs). Review of Resident 33's preadmission PASRR Level 1 screening, dated 10/24/25 indicated Resident 33 had a positive Level I screening which indicated she should have a Level II Mental Health Evaluation. Review of Resident 33's letter from the California Department of Health Care Services (DHCS) with a subject, Notice of Attempted Evaluation, dated 10/29/25, indicated a Level II evaluation was not completed. It indicated a Level II evaluation was not scheduled for the following reason: Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. During an interview on 12/11/2025 at 1:44 p.m., Admissions/Marketing (AM) stated Resident 33 Level II evaluation fell through the cracks. Review of the facility's policy, admission Criteria, revised 3/2019 indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) . The facility conducts a Level I PASARR screen . If the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluations and determination) screening process . The social worker is responsible for making referrals to the appropriate state-designated authority .

Based on interview and record review, the facility failed to develop care plan for two of 13 sampled residents (Resident 30 and Resident 10) when there was no care plan develop for Depakote black box warning (BBW, also known as a boxed warning, is the strongest warning the Food and Drug Administration [FDA-it is a federal agency responsible for protecting and promoting public health by regulating and supervising food safety, medications, medical devices, cosmetics, and other products] gives for prescription drugs). The failures had the potential for the residents not attaining their highest practicable physical, mental, and psychosocial well-being. 1. During a review of Resident 30's clinical record titled, admission Record, dated 12/11/25, indicated Resident 30 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe) unspecified and essential (primary) hypertension (abnormally high blood pressure that's not the result of a medical condition.) During a review of Resident 30's order summary report, dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex Sodium) Give 2 capsule by mouth at bedtime for mood disorder, dated 8/30/2025. During a review of Resident 30's care plan indicated there was no care plan developed for Depakote BBW. During a concurrent interview and record review on 12/11/25 at 4:02 p.m., with the Director of Nursing (DON), the DON reviewed Resident 30's care plan, the DON stated she did found the care plan for Depakote BBW. The DON further stated they should have a care plan for boxed warning. 2. During a review of Resident 10's clinical record titled, admission Record, dated 12/11/25, indicated Resident 10 was admitted to the facility with diagnoses including depression (loss of pleasure or interest in activities for long periods of time) and essential (primary) hypertension. During a review of Resident 10's order summary report, dated 12/11/25, indicated an order for Depakote sprinkles oral capsule delayed release sprinkle 125 mg (divalproex Sodium) to give two capsule by mouth two times a day for mood disorder, dated 8/21/2025. During a review of Resident 10's care plan indicated there was no care plan developed for Depakote BBW. During a concurrent interview and record review on 12/12/25 at 10:40 a.m., with the DON, the DON reviewed Resident 10's care plan, the DON confirmed that there was no care plan from yesterday 12/11/25 for Resident 10's Depakote BBW. During a review of the facility's P&P titled Goals and Objectives, Care Plans, dated 4/2009, indicated, 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem. 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved .

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when there were no Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes.) signage posted and there was no available PPE (Personal Protective Equipment, refers to specialized gear like gloves, gowns, masks, and eye protection that creates a barrier to shield healthcare workers from infectious materials, preventing disease transmission to themselves, patients, and others by stopping contact with germs, blood, or body fluids) outside Resident 7's room. The failure had the potential to spread infections to residents, staff, and visitors.During an observation on 12/10/2025 at 11:44 a.m., outside Resident 7's entrance door indicated there was no signage of EBP posted and there was no available PPE outside Resident 7's room. During a review of Resident 7's clinical record it indicated Resident 7 was admitted to the facility with diagnosis including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) without complications and bipolar disorder (mental disorder characterized by periods of elevated mood and depression, often with poor decision-making) unspecified. During a review of Resident 7 physician's order, dated 10/3/2025, indicated an order EBP: FYI (for your information)- Enhanced barrier precautions due to risk of MDRO acquisition due to presence of wounds. Every shift. During a review of Resident 7 physician's order, dated 11/25/25, indicated an order for Tx: (treatment) left hip NPCU (non-pressure chronic ulcer): cleanse with normal saline, pat dry apply triad (triad, designed to help maintain an optimal wound healing environment) cream to wound and peri wound every day and evening shift for NPCU. During a concurrent interview and record review on 12/11/2025 at 3:18 p.m., with the Wound Nurse (WN), the WN reviewed Resident 7 physician's order she stated resident 7 had a NPCU to lift hip and another wound on top on the wound on 12/9/25. During an observation outside Resident 7's room on 12/11/2025 at 3:32 p.m., with the WN she confirmed there was no EBP signage posted and there was no PPE cart outside Resident 7's room. During an interview on 12/11/25 at 3:37 p.m., with Director of Staff Development (DSD) and the Director of Nursing (DON), the DSD stated EBP is for residents with pressure injury, blistering and open skin. The DON stated Resident 7 has a chronic wound and needs enhanced barrier precautions. During a review of the facility's policy and procedures titled, Enhanced Standard/Barrier Precautions, updated 6/18/24, indicated, PURPOSE: To provide guidance and recommendations for implementing Enhanced Barrier Precautions (EBP) to include the use of glove and gown during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status. 1. Implementation When implementing EBP, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the required PPE (e.g., gown and gloves). For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. Make PPE, including gowns and gloves, available immediately outside of the resident room.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 55) received the appropriate pneumococcal (infections caused by common bacteria that can affect different parts of the body) vaccination. This failure had the potential for residents to have inadequate immunity to pneumococcal infections (caused by bacteria, which can lead to illnesses such as pneumonia [infection in the lung] and meningitis [inflammation around the brain and spinal cord).Findings:Review of Resident 55's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and a foot wound. Review of Resident 55's Informed Consent for Pneumococcal Vaccine, dated 12/3/25 indicated the patient gave the facility permission to administer a pneumococcal vaccination.Review of Resident 55's Immunization Record indicated he had a history of getting the pneumococcal polysaccharide vaccine 23 (PPSV23, one of the two types of pneumococcal vaccines that can prevent pneumococcal disease) on 11/25/2014 and 3/23/2019. There was no documentation that indicated Resident 55 received a pneumococcal conjugate vaccine (PCV, another type of pneumococcal vaccine, which include PCV15, PCV20, and PCV21; each protect against specific types of pneumococcal bacteria)Review of Resident 55's Medication Administration Record for 12/2025 indicated he received PPSV23 on 12/11/25 at 7:31 a.m. During a concurrent interview and record review on 12//2025 at 11:28 a.m., the Director of Staff Development/Infection Preventionist (DSD) reviewed Resident 55's immunization records and clinical record. The DSD confirmed Resident 55 was [AGE] years old and received the PPSV23 on 11/25/2014 and 3/23/2019. The DSD stated they gave him PPSV23 again because that's what he's been getting. The DSD stated the facility followed Centers for Disease Control and Prevention (CDC) guidelines to determine which pneumococcal vaccine to give and at what age.Review of the CDC's Pneumococcal Vaccine Recommendations, dated 10/26/24 indicated, Administer PCV15, PCV20, or PCV21 for all adults 50 years or older who have never received any pneumococcal conjugate vaccine [PCV].Review of the CDC's job aid, Pneumococcal Vaccine Timing for Adults, dated March 2025 indicated for adults 50 years or older who have only received PPSV23, give 1 dose of PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended.

Based on observation, interview, and document review, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.The resident room measurements were as follows:Room Number/ Bed Capacity/ Square Feet Per Resident1 2 72.002 3 66.123 2 79.254 3 68.455 2 74.296 3 75.037 3 75.0310 3 74.2011 2 72.0012 2 72.0014 2 72.0017 4 69.7018 2 72.0019 2 72.0020 2 78.0022 3 76.00During the survey, residents were observed in their rooms. Nursing care and services were not impacted by the shortage of space. The closets and storage were sufficient to accommodate the needs of the residents.Residents were interviewed and stated they did not have any concerns regarding room size, provision of care, or privacy and they can easily navigate inside the room.Staff members were interviewed and stated they were able to safely provide care to the residents, even in rooms with less than 80 square feet per resident.Recommend continuance of room waiver.

Based on interview and record review the facility failed to ensure continuity of care when staff did not provide a transportation driver instructions for dropping off a resident to an appointment for one of three sampled resident (Resident 1). This failure resulted in the resident not being met by a family member at the appointment location and resulted to fall.Findings:During an interview on 8/28/25 at 1:37 p.m., a family member stated Resident 1 had dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life and had a hard time walking. The family member stated when he arrived at the doctor's office on 8/14/25 at 7:50 a.m. the office was not open and while waiting he received a call from a construction worker who informed him the resident rolled down a hill, hit her head and landed in dirt and bushes. He further stated facility staff said it was the driver's fault and the transportation company said the facility should have sent someone to accompany the resident. Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/30/25, indicated the resident's brief interview for mental status (BIMS) scored 5, indicating she had memory problems and severe difficulty in daily-decision making skills.Resident 1 had a physician's order, dated 7/27/25, indicating the resident was not capable of understanding her rights and responsibilities.Review of Resident 1's Physician Certification Statement of Medical Necessity for Non-Emergency Medical Transport form, dated 8/5/25, indicated wheelchair transportation was requested for reasons including the resident was unable to self-transfer into public or private conveyance and her medical condition precluded the resident being able to reasonably ambulate to and from and to board a vehicle. The undated Transportation Services Request Form indicated Resident 1 had a physician's appointment on 8/14/25 at 8 a.m., and specified no attendant and use of a wheelchair. The Alliance Explanation Remarks form, dated 8/6/25, indicated transportation was being arranged for 8/14/25 7:30 a.m. pick up and return at 9 a.m. During an interview on 8/29/25 at 12:50 p.m., the director of nurses (DON) described Resident 1 to have confusion, was able to walk and usually used a wheelchair. The DON stated on the day of appointment a nurse was informed from a telephone call the resident was found down (fallen) by a construction worker, the driver thought the resident was dropped off at the front of the building but it was the back and a family member was waiting at the front.During an interview on 8/29/25 at 1 p.m., the receptionist (RCP) whose duties included arranging resident transportation. RCP stated if a resident had concerns such as confusion she would speak with a nurse but she did not recall what nurse she discussed with.Review of a Nurse's Note, dated 8/14/25 at 8:50 a.m., indicated the facility was informed Resident 1 fell while at the doctor's office and was transported to a hospital emergency department by a family member. During an interview on 9/24/25 at 12:40 p.m., the social services director (SSD) stated when making transportation arrangements the insurance assigns the transportation company and facility staff do not speak with the driver.During a follow-up interview on 9/24/25 at 1:53 p.m., the RCP stated facility staff did not provide any instructions to the driver.During an interview on 9/24/25 at 1:10 p.m., the DON stated there was no policy addressing making transportation arrangement or accidents.Review of Resident 1's acute hospital after visit summary, dated 8/14/25, indicated the resident was seen in the emergency department after a fall. The Computed Tomography (CT scan, medical imaging test used to diagnose and monitor a wide range of conditions) did not demonstrate any evidence of traumatic injury. It indicated to please ensure the patient is escorted into the building for any of her appointments.

Based on interview and record review, the facility failed to ensure, they had designated an infection preventionist (IP) that had completed the specialized training in infection prevention and control when the facility did not have an IP with a completion certificate of infection prevention and control training. This failure had the potential for the facility programs and activities to prevent and control infections, not properly implemented that could affect the forty-eight residents currently residing in the facility. Findings: During the interview with the interim director of nursing (IDON) on 2/11/25 at 3:20 p.m., IDON acknowledged that the facility did not have an infection preventionist (IP) right now that had a certificate of infection prevention and control training or had completed the training. During the interview with the director of staff development (DSD) on 2/11/25 at 3:35 p.m., DSD also verified that the facility did not have an IP right now that had a certificate of infection prevention and control training or had completed the training. During an interview with the former administrator (FADM), on 2/24/25 at 10:25 a.m., he acknowledged that their IP now, did not have the certificate of infection prevention and control training yet and still had to complete the training. During an interview with the current designated infection preventionist (CDIP) on 3/13/25 at 4:06 p.m., CDIP verified that she did not have a certificate yet of infection prevention and control training and still had to complete the training. CDIP stated that she will finish the training as soon as possible. Review of the facility's report provided by the current acting administrator (CAADM) on 4/2/25 at 4:04 p.m. indicated, that the facility did not have an IP that had a certificate of infection prevention and control training or had completed the training since 2/1/2025. During the interview with the IDON on 4/10/25 at 3:40 p.m., IDON acknowledged that the CDIP started working at the facility last November, 2024 as DSD and then worked as the facility's infection preventionist last 2/1/25. Review of the facility's policy and procedure titled, Infection Prevention and Control Program revised October 2018, indicated, An infection prevention and control program (IPCP), is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist) Review of the All Facilities Letter (AFL, a letter from the Center for Health Care Quality, Licensing and Certification Program to health facilities that are licensed or certified) 20-84 of the Health and Human Services Agency, California Department of Public Health (CDPH), titled, CDPH Recommendations for Infection Prevention and Control: Training and Continuing Education, dated November 4, 2020 indicated, It is important that each skilled nursing facility's IP have training in fundamental infection prevention and control principles to effectively perform the IP duties. Ongoing education is necessary to remain aware of new information, trends, best practices, and to refresh existing knowledge. The designated IP, who is an existing skilled nursing facility employee and was designated to the IP role, must complete their initial IP training within 30 calendar days of designation

Based on observation, interview and record review, the facility failed to ensure personal privacy were provided for three (Resident 1, Resident 2, and Resident 3) out of three sampled residents when privacy curtains were not provided. This failure had the potential to put residents in physical, social and emotional distress. Findings: During a concurrent observation and interview on 2/24/25 at 3:12 p.m. with the Administrator (ADM), the ADM stated, he received a call round 11 p.m. on 2/21/25 about the car crash incident in the facility. The affected room had a signage on the door that indicated, Unsafe to Occupy. A yellow tape labeled with Caution was in the middle of the room. No residents were observed inside the affected room. The ADM stated, the three residents who occupied the affected room were not injured and were transferred to the Day Room (activity/rehab room) due to unavailable other beds/rooms. In the Day Room, three beds were noted. Resident 1 was lying in the bed. There were no privacy curtains in between Resident 1, Resident 2 and Resident 3. There were thin drapes hung to cover the windows to the outside street. There was a uncovered big window on the right side of the Day Room, where the lobby/reception/visitor could seen Resident 1, Resident 2 and Resident 3 inside the room. A review of Resident 1's medical record indicated diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety,(the loss of cognitive functioning, thinking, remembering, and reasoning, to such extent that it interferes with a person's daily life and activities) and Other recurrent depressive disorders. (mental health conditions characterized by persistent sadness, loss of interest, and difficulty functioning, impacting daily life and relationships) A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/31/25, indicated a brief interview for mental status score of 4 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of Resident 2's medical record indicated diagnoses of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Unspecified hearing loss, Need for assistance with personal care, Mild cognitive impairment of uncertain or unknown etiology. (mild memory or thinking difficulties, but not severe enough to interfere with daily life and cause is unclear) A review of Resident 2's Nurse's Note by Licensed Vocational Nurse (LVN) A dated 2/22/25 at 1:36 p.m. indicated, Res [resident] is currently housed in dining hall A review of Resident 2's Nurse's Note by Interim Director of Nursing (IDON) dated 2/24/25 at 3:41 p.m. indicated .resident with Autism and deaf . During an interview on 2/26/25 at 11:05 a.m. with LVN B, LVN B stated, It was around 9 p.m. when she heard a loud noise coming from Nurse Station 1. I heard a CNA [Certified Nurse Aide] asking to call 911 because a car crashed into the building. Another nurse with me checked the residents and when checked there was a person inside the car. LVN B stated, Resident 2 was outside the room and Resident 1 and Resident 3 were inside the room. LVN B also stated, Resident 3 was lying in her bed and wheeled herself out of the room after we checked her vital signs. LVN B also stated, Resident 1 was bed ridden and was confused. LVN B stated, Resident 1, Resident 2, and Resident 3 stayed in the dining room on their beds on the night of 2/21/25 after the incident. A review of Resident 3's medical record indicated diagnoses of Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and Anxiety disorder. (a mental condition characterized by excessive and persistent worry, fear, and unease that can significantly interfere with daily life) A review of Resident 3's Minimum Data Set (MDS, an assessment tool), dated 12/23/24, indicated a brief interview for mental status score of 9 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. A review of facility's policy and procedure (P&P) entitled, Dignity indicated, .6. Residents' private space and property are respected at all times

Based on observation, interview and record review, the facility failed to ensure the safety and proper monitoring of resident funds for one of three residents investigated, Resident 1, when Resident 1 lost money in his personal bank account. This failure had the potential to affect the resident's psychosocial and general well-being. Findings: During a concurrent observation and interview of Resident 1 on 8/13/24 at 4:20 p.m., Resident 1 was laying in his bed, alert and verbally responsive. He appears calm and comfortable. Resident 1 stated that the previous business office manager (PBOM), who was no longer working with the facility, had taken money from his bank account. Review of Resident 1's clinical records indicated, he was admitted to the facility on [DATE] with diagnoses including unspecified chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), essential primary hypertension (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles in the blood). Resident 1's brief interview for mental status (BIMS, an assessment used in long-term care facilities to monitor cognition) score was 10, dated 7/26/24, which suggests moderately impaired cognition. Review of the facility's investigation report dated 8/15/24 indicated, that PBOM was arrested by police. The police department reported this to the administrator of the facility. During an interview with the administrator (ADM), on 8/22/24 at 4:00 p.m., ADM verified that Resident 1 reported to them that PBOM had taken money from his bank account. ADM stated that the facility received copies of the account of Resident 1 and forwarded them to law enforcement. ADM further verified that they should have initiated checks and balance system for business office practices to safeguard resident funds and prevent this incident to happen because the personal money of Resident 1 was not protected. During an interview with the director of nursing (DON), on 9/24/24 at 3:15 p.m., DON verified that resident funds should be safe and protected. DON further verified that there should be checks and balance system for business office practices to protect resident funds, including Resident 1's money. Review of the facility's policy titled, Resident Rights, revised, December 2016 indicated, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident's right to be free from abuse misappropriation of property, and exploitation

Based on observation, interview and record review, the facility failed to ensure that the resident receive proper foot care and treatment for one of three residents investigated, Resident 2, when Resident 2 did not get an immediate appointment to see a podiatrist. This failure had the potential to affect the resident's foot condition, general health and well-being. Findings: During a concurrent observation and interview with Resident 2 on 8/13/24 at 4:30 p.m., Resident 2 was laying in his bed, calm, alert, oriented and verbally responsive. Resident 2 stated that he told the nurses that he wanted to see a podiatrist for his toenails, a few months ago but until now, he was never seen by a podiatrist. His toenails were long and uncut. During another concurrent observation and interview with Resident 2 on 8/22/24 at 4:20 p.m., Resident 2's toenails remained uncut and long. Resident 2 stated that no podiatrist had seen him until this time. During an interview with the minimum data set coordinator (MDSC, collects data related to residents in order to develop and evaluate a comprehensive care plan) on 8/22/24 at 4:25 p.m., MDSC verified that Resident 2 was not seen by a podiatrist yet because it was not covered by his insurance. MDSC further verified that the previous administrator had not approved, for the facility to pay Resident 2's appointment with a podiatrist. During the interview with the administrator (ADM) on 8/22/24 at 4:30 p.m., ADM verified that Resident 2 had not seen a podiatrist yet but was scheduled to see one already. Review of Resident 2' clinical records indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including nondisplaced fracture (broken bone where the pieces remain aligned) of base of neck of right femur (the region just below the ball of the right hip joint), subsequent encounter for closed fracture (resident is receiving routine care for a condition after the active treatment phase) with routine healing, generalized muscle weakness (decrease in muscle strength that can make it harder to move the body) and unspecified obesity (a disorder that involves having too much body fat). Resident 2's brief interview for mental status (BIMS, an assessment used in long-term care facilities to monitor cognition) score was 15, taken on 8/15/24, which suggests cognitively intact. Review of Resident 2's order summary report, dated 8/22/24 indicated, that Resident 2 had an order for referral to in house podiatrist on 3/31/24. During a concurrent record review of Resident 2's clinical records and interview with the director of nursing (DON) on 9/24/24 at 2:30 p.m., DON verified that Resident 2 had a referral order to in house podiatrist on 3/31/24 but was not seen, until recently. DON further verified that Resident 2 just had an appointment with the podiatrist on 9/4/24. During an interview with the social services director (SSD) on 9/24/24 at 2:40 p.m., SSD verified that Resident 2's delayed appointment with the podiatrist was because, it was not covered by his insurance and the previous administrator did not approve, for the facility to pay for the coverage. Review of the facility's policy titled, Physician Services, revised April 2013 indicated, Physician orders and progress notes shall be maintained in accordance with current Omnibus Budget Reconciliation Act (OBRA, primary purpose was to improve the quality of care provided by long-term care facilities and to enhance the quality of life of the residents) regulations and facility policy Review of the facility's policy titled, Referrals, Social Services, revised December 2008 indicated, Social services personnel shall coordinate most resident referrals with outside agencies Referrals for medical services must be based on physician evaluation of resident need and a related physician order

Based on an interview and record review the facility failed to ensure to follow their policy and procedure (P&P) for quality assurance and performance improvement (QAPI: a program to enhance the quality of care provided to residents in healthcare facilities) committee meeting attendees. This failure had the potential to result in to identify, monitor, implement and enhance the quality of facility wide system for infection prevention and control practices. Findings: Review of documents for QAPI Committee Minutes dated 1/24/2024 and 4/24/2024 indicated there was no infection preventionist (IP: a healthcare specialist who make sure healthcare workers and residents are doing all things they should to prevent infections in facility)'s signature under Attendees Present for quarterly QAPI meeting on 1/24/2024 and 4/24/2024. During an interview with minimum data set coordinator (MDSC: clinical and functional assessment tool coordinator) on 8/28/2024 at 2:00 p.m., MDSC stated she attended QAPI meetings on 1/24/2024 and 4/24/2024 but she was not certified for IP. During an interview with facility's director of nursing (DON) on 8/14/2024 at 3:30 pm., DON confirmed IP or designee did not attend QAPI quarterly meetings on 1/24/2024 and 4/24/2024. During a concurrent interview and record review on 8/14/2024 at 3:34 pm., with facility's administrator (ADMN), facility's QAPI Committee Minutes, dated 1/24/2024 and 4/24/2024 were reviewed. ADMN confirmed there was no IP signature on both meetings for list of attendees. ADMN stated IP must attend all QAPI meetings. ADMN also stated IP should have attended these meetings and discussed infection control concerns during meetings with other attendees. Review of facility's P&P titled, Quality Assurance and Performance Improvident (QAPI) Program-Governance and Leadership, revised March 2020, the P&P indicated, 6. The following individuals serve on the committee: a. Administrator, or a designee who is in a leadership role; b. Director of Nursing Services; c. Medical Director; d. Infection Preventionist

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control practices when: 1. Wet wash cloth (a small,soft and absorbent cloth that used for washing face and body) on sink and dry wash cloth on the floor in bathroom; 2. Medical doctor (MD) did not use required contact precautions (used for infections, diseases, or germs that spread by touching residents or resident's environment) personal protective equipment (PPE: any piece of clothing or equipment that is worn by healthcare workers to mitigate contracting the infections between residents and staff); 3. Laundry aide did not use required contact precautions PPE. These failures had the potential to result in transmission of infection among residents. Findings: 1.During an initial facility tour on 8/5/2024 at 11:50 a.m., observed one wet wash cloth on laying on sink and another dry washcloth on floor in resident room [ROOM NUMBER]'s bathroom. During an interview with certified nursing assistant A (CNA A) on 8/5/2024 at 1:00 p.m., CNA A confirmed wet wash cloth on sink and dry wash cloth on floor in Resident room [ROOM NUMBER] bathroom. CNA A stated wet wash cloth was placed on sink after use, and dry wash cloth was unused and fell on floo. CNA A also stated staff should not have placed used wash cloth on sink after use. CNA A further stated staff should have sent used and unused wash clothes to laundry for washing to maintain infection control practices. 2.During an observation on 8/5/2024 at 11:55 a.m., noted posting on the wall outside Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] for contact precautions. This posting indicated all staff and visitors must put on gloves and gown before room entry, discard gloves and gown before room exit. During an observation along with facility's director of nursing (DON) on 8/5/2024 at 1:22 pm., noted facility's medical doctor (MD) placed gloves, no gown on, walked into Resident room [ROOM NUMBER], and came out to hallway after few minutes with gloves on for both hands. During an interview with MD on 8/5/2024 at 1:26 pm., MD confirmed he did not wear gown before went to Resident room [ROOM NUMBER]. MD stated he should have worn gown along with gloves before entering to room and removed gloves before came out of the room to follow contact precautions. 3.During an observation on 8/5/2024 at 1:30 pm., noted facility's laundry aid (LA) walked into Resident room [ROOM NUMBER] without gloves and gown, and came out of the room after few minutes later. During an interview with LA on 8/5/2024 at 1:35 p.m., LA confirmed she forgot to wear gloves and gown before entered to Resident room [ROOM NUMBER] as posted for contact precautions for this room. LA stated she should have worn gloves and gown before entered to room and removed before came out and washed hands for infection control. During an interview with license vocational nurse B (LVN B) on 8/5/2024 at 1:40 pm., LVN B stated all staff should have worn gloves and gown before entering into resident rooms with contact precautions posting for infection control. During an interview with DON on 8/5/2024 at 2:15 p.m., DON stated facility following CDC nursing staff should not have left used wash cloth in bathroom sink and on the floor, they both should have sent for laundry for washing. DON also stated MD should have followed contact precautions for PPE before entered to resident room [ROOM NUMBER]. DON further stated all staff should have followed required PPE for contact precautions before entering to resident rooms with contact precautions posting on the wall for infection control practice. During a review of facility's policy and procedure (P&P) titled, Transmission-Based Precautions, revised August 2016, the P&P indicated, Contact Precautions: Wear gloves when contact with resident environment. Wear gown if you anticipate that your clothing may become contaminated. During a review of facility's P&P titled, Personal Protective Equipment, revised October 2018, the P&P indicated, PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed.

Based on interview, and record review, the facility failed to ensure interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals to their residents) quarterly care conference meeting arranged, conducted, and documented for two out of two sampled residents (Resident 1and 2). This failure had the potential for Resident/resident responsible party (RP: healthcare or financial decision maker for resident) to participate in the development and implement of person-centered plan of care decisions for Resident 1 and 2. Findings: Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted on [DATE]. Resident 1's FS also indicated Resident 1 was self-responsible for daily decision making. Review of Resident 1's custom IDT care conference forms indicated there was no documented evidence for quarterly IDT care conference was arranged, conducted, and documented for 6/2023, 12/2023, and 7/2024 for 3 quarters. Review of Resident 2's FS indicated Resident 2 was admitted to facility on 10/11/2023. Resident 2's FS also indicated Resident 2's significant family member was assigned as Resident 2's RP. Review of Resident 2's clinical documentation indicated there was no documented evidence for custom IDT care conference was arranged, conducted, and documented after Resident 2 admitted to facility on 10/11/2023 for 3 quarters in a row. During an interview with facility's director of nursing (DON) on 8/14/2024 at 12:10 p.m., DON confirmed quarterly IDT care plan meeting and documentation was not completed for Resident 1 and 2 on quarterly basis. DON stated facility's social service director (SSD) was responsible to arrange, conduct, and document IDT care conferences every quarter, and as needed all residents. During an interview with facility's SSD on 8/14/2024 at 12:43 p.m., SSD confirmed social service department was responsible to arrange, conduct and document for quarterly care conferences for residents. SSD also acknowledged facility was non-complainant with quarterly care conferences and documentation for residents. SSD stated she identified this concern, auditing for all residents and she will submit the audit report to quality assurance and performance improvement program (QAPI: data driven, proactive approach to improving the quality of life, care, and services for residents). SSD also stated social service staff should have arranged quarterly care plan meeting, documented every quarter, and as needed for all residents in the facility. During an interview with DON on 8/14/2024 at 12:55 p.m., DON stated SSD should have arranged quarterly IDT care conference with resident/RP and documented for all residents. Review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, revised September 2013, the P&P indicated, Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face-to-face, teleconference, written communication, etc.) is at the discretion of the Care Planning Committee. Review of the facility's P&P titled, Social Worker, revised October 2020, the P&P indicated, Involve the resident/family in planning individualized objectives and goals for the resident.

Based on an observation, interview and record review, the facility failed to ensure medications were administered as ordered by the medical doctor (MD) for 2 of 2 sampled Residents (Resident 1and 2). This failure had the potential to adversely affects the health and well- being of Resident 1 and 2. Findings: A Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated Resident was admitted with diagnoses included dementia (loss of ability to think, remember, and reason to levels that affect daily life and activities), and anxiety (persistent and excessive worry and fear about active daily living situations). Review of Resident 1's physician's medication orders indicated quetiapine (antipsychotic medication to treat mental illness) 25 mg (mg: milligrams, unit of measurement of mass equal to a thousandth of a gram) 0.5 tablet one time a day, and before lunch for dementia ordered on 6/11/2024. Review of Resident 1's electronic medication administration record (EMAR: a legal document for medication administration record) for July 2024 indicated on 7/2, 7/3, 7/4, 7/7, 7/8, 7/9, 7/13, 7/14, 7/15, 7/18, 7/20, 7/21, 7/22, 7/25, 7/26, 7/27, 7/28, and 7/31, total 19 of 31 doses of quetiapine administration documented as 9 (EMAR chart codes for 9= Other/See Progress Notes) at 11:30 a.m., and on 7/1, 7/9, 7/13, 7/16, 7/17, 7/20, 7/23, and 7/24, total 8 doses documented as 9 for quetiapine administration at 9:00 p.m. During the record review of Resident 2's FS indicated Resident 2 was admitted to facility on 8/7/2024. Review of Resident 2's FS indicated she was admitted with diagnoses included diabetes type 2 (a condition when body unable to regulates and uses sugar as a fuel), hypertension (a condition in which the force of the blood against the blood vessels wall), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 2's documentation for brief interview for mental status (BIMS) dated 8/12/2024 indicated Resident 2's BIMS score of 15 of 15 (score of 0-7: severe impaired cognition, 8-12: moderately impaired cognition, 13-15: intact cognition). Review of Resident 2's physician medication orders indicated potassium chloride (used to treat hypertension) ER 10 meq (milliequivalent: a unit of measurement used to express the amount of substance in a solution) one time a day, ordered on 8/7/2024. Medication tizepatide (to treat diabetes type 2) 2.5 mg/0.5 ml (milliliter: a unit of volume that measures the capacity of a liquid) inject subcutaneously (insertion of medication just under the skin) one time a day every 7 days ordered on 8/7/2024. Medication rosuvastatin (used to treat to lower cholesterol [fat like substance in the blood]) 10 mg one time a day, ordered on 8/8/2024. Review of Resident 2's EMAR for August 2024 indicated medication rosuvastatin 10 mg administered on 8/8, 8/9, 8/10, 8/11, 8/12, and 8/13 at 9:00 p.m., total 6 doses administered to Resident 2. Further review of EMAR documented as 9 for tirzepatide administration on 8/8/2024 at 9:00 a.m., and potassium chloride 20 meq medication administration documented at 9:00 a.m., as 9 on 8/8, 8/9, 8/10, 8/11, 8/12, 8/13, and 8/14, total 7 doses. During an interview with Resident 2 on 8/14/2024 at 11:22 a.m., Resident 2 stated she did not receive cholesterol medication 2 nights in row. Resident 2 also stated did not receive potassium and injection for diabetes since admitted to facility. Resident 2 also stated Resident 2 was told by charge nurse that the medications were not available and waiting for pharmacy to deliver. During on observation of medication cart (storage, secure, reliable and transport of medications to residents) 1 along with license vocational nurse A (LVN A) on 8/14/2024 at 12:15 p.m., for physician ordered medications supply for Resident 2, LVN A confirmed there was no supply of potassium chloride and tirzepatide in medication cart 1 or in medication supply room (drug preparation and storage room). LVN A also confirmed medication rosuvastatin 10 mg, 4 doses were given from supply of 15 tablets received from pharmacy since Resident 2 admitted on [DATE]. During an interview with LVN A on 8/14/2024 at 12:25 p.m., the RN A reviewed EMAR for Resident 2, acknowledged EMAR documentation of 9 means medications not administered. RN A confirmed potassium chloride, and tirzepatide were not given to Resident due to medications were not available to administer. RN A also confirmed Resident 2 received rosuvastatin 4 doses only based on tablets taken to administered from supply not administered 6 does as documented in EMAR. RN A stated license staff should have called pharmacy when medications were not available to administer to Resident 2. RN A also stated Resident 2 should have received medications as ordered. RN A further stated will call pharmacy today for these two medications. During an interview with RN A on 8/14/2024 at 12:35 p.m., RN A reviewed Resident 1' EMAR for June 2024, acknowledged medication quetiapine 25 mg was not administered for above dates due to unavailability of medication. RN A stated license nurses should have followed up with pharmacy for supply of quetiapine, received medication from pharmacy and administered to Resident 1 as ordered by MD. During an interview with facility's director nursing on 8/14/2024 at 12:58 p.m. DON confirmed Residents 1 and 2 did not receive medications as ordered. DON stated license staff should have followed up with pharmacy when medications were not available, received supply of medications and administered to Resident 1 and 2 as ordered by MD without missing doses of medications. DON also stated license staff should not have documented as administered medication rosuvastatin without giving to Resident 2. Review of facility's P&P titled, Administering Medications, revised April 2019, the P&P indicated, Medications are administered in according with prescriber orders, including nay required time frame. The individual administering the medication must initial the resident's MAR (medication administration record) on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview, and record review the facility failed to ensure to follow their policy and procedure (P&P) for activity assessments and preferred activities for one of two sample resident (Resident 1). This failure had the potential to affect to maintain and improve health, functional, cognitive, and emotional well-being for Resident 1. Findings: Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated diagnoses included schizoid personality disorder (a condition in which people avoid social activities and interacting with others), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in daily activities), anxiety (excessive, and persistent worry and fear about situations) and cerebral infarction (disrupted blood flow to brain). Review of Resident 1's assessments for activities-quarterly/annual indicated there were no assessments for activities for four quarters in a row. Last activities quarterly assessment was completed on 6/25/2023. Review of this assessment for Resident 1's preferences and participation level with activities indicated, resident sometimes sits in a chair outside his room and converse with staff and other residents. Review of Resident 1's activity notes for June 2024 and July 2024 indicated there was no evidence of documentation for preferred activities were provided to Resident 1. During multiple observations for Resident 1 on 7/5/2024 between 12:05 p.m., to 3:30 pm., Resident 1 observed sitting on bed, facing ceiling and no inside room or outdoor activities provided to Resident 1. During an interview with Resident 1 on 7/5/2024 at 1:19 pm, Resident 1 stated I like my activity to sit outside and get sunlight in the patio. Resident 1 also stated activity staff rarely offering activities to Resident 1. During an interview with certified nursing assistant A (CNA A) on 7/5/2024 at 1:28 pm., CNA A stated Resident 1 likes to sit outside in patio and talks to other residents. CNA A also stated activity staff were not taking Resident 1 out to patio. During an interview with license vocational nurse B (LVN B) on 7/5/2024 at 1:55 pm., LVN B stated Resident 1's favorite activity of sitting outside in the patio was not happening as it should be. LVN B also stated activity staff should have been provided to Resident 1 at least once a week when weather permits. During a concurrent interview and record review on 7/5/2024 at 2:05 pm., with director of nursing (DON), Resident 1's Activities-Quarterly/Annual, assessments and activity notes were reviewed. DON acknowledged there were no activities quarterly/annual assessments for four quarters since 6/25/2023 for Resident 1. DON also confirmed Resident 1' preferred activity of sitting outside patio was not happening on routine basis and there was no documentation for 1:1 room activities for Resident 1. DON stated currently there were no group activities, only 1:1 in room activity for all residents due to Covid-19 (contagious viral infection) outbreak (sudden increase) in the facility. DON also stated activity assessments should have been completed every quarter. DON further stated activity staff should have completed activities assessment every quarter and Resident 1's preferred activities should have been provided on routine basis. During a review of facility's P&P titled, Activity Evaluation, revised June 2018, the P&P indicated, The resident's activity evaluation is conducted by Activity Department personnel, in conjunction with other staff who evaluate related factors such as functional level, cognition and medical conditions that may affect activities participation. The completed activity evaluation is part of the resident's medical record and is updated as necessary, but at least quarterly. The activity evaluation is used to develop an individual activities care plan that will allow the resident to participate in activities of his/her choice and interest.

Based on observation, interview, and record review, the facility had a medication error rate of 12% when three medication errors occurred out of 25 opportunities during the medication administration for two residents (Residents 98 and 41): 1. Licensed vocational nurse A (LVN A) did not give Resident 98 a medication as scheduled; 2. Licensed Vocational Nurse B (LVN B) did not give Resident 41 the full dose of two ordered medications. Also, LVN B crushed a medication for Resident 41 that cannot be crushed. These failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications. Findings: 1. Review of Resident 98 clinical record indicated he was admitted to the facility with diagnoses including respiratory failure (condition in which lungs cannot get adequate oxygen into the blood) with hypoxia (low levels of oxygen in the body) and chronic obstructive pulmonary disease (COPD, a disease that affects airflow in the lungs and makes it difficult to breathe). Resident 98 had a physician order for Dulera Inhalation Aerosol (breathing traetment) 200-5 micrograms per actuation(mcg/act, unit of measurement per puff) two puffs orally one time a day for COPD, dated 5/20/24. Review of Resident 41's medication administration record (MAR, record of medications given) indicated the Dulera inhaler was scheduled to be given at 9 a.m. During a medication pass observation on 5/21/24 at 8:47 a.m., LVN A prepared medications for Resident 98 and removed oral medications (pills) and the Dulera inhaler from the medication cart. LVN A entered Resident 98's room with the oral medications and the Dulera inhaler. Resident 98 was in the bathroom and LVN A stated she will wait in the hallway. LVN A walked to the medication cart and put the Dulera inhaler back into the medication cart. LVN A returned to Resident 98's room with the pills and checked on Resident 98 in the bathroom. After Resident 98 returned to his bed, LVN A gave Resident 98 the pills. LVN A did not give Resident 98 the Dulera inhaler. During an interview on 5/21/24 at 10:49 a.m., LVN A stated she was done with medication pass. During an interview on 5/21/24 at 11:07 a.m., LVN A was asked if she gave Resident 98 the Dulera inhaler. LVN A confirmed she did not give Resident 98 the Dulera inhaler. LVN A stated she should have give the Dulera inhaler to Resident 98 and document that it was given late. 2. Review of Resident 41's clinical record indicated he was admitted to the facility with diagnoses of liver cell carcinoma (liver cancer). The record indicated Resident 41 had the following physician orders: - Oxycodone HCl (OxyContin) extended release oral tablet 10 mg give one tablet by mouth two times a day for pain, dated 1/2/24 -Lorazepam oral tablet 1 mg give one mg by mounth three times a day for anxiety, dated 4/11/24. During a medication pass observation and concurrent interview on 5/21/24 at 4:25 p.m., LVN B prepared medications for Resident 41. She prepared lorazepam 1 mg tablet and OxyContin CR (controlled release) 10 mg tablet. LVN B began crushing the two tablets in a pill crusher. LVN B stated the OxyContin CR medication was difficult to crush. She stated it takes a while. After crushing the medications, LVN B poured the crushed tablets into a medication cup. Some of the crushed tablets fell on the medication cart. LVN B put hand sanitizer on a tissue, wiped up the crushed medication on the cart, and threw away the tissue. LVN B added applesauce to the medication cup and administered the medication to Resident 41. During an interview on 5/21/24 at 4:41 p.m., LVN B looked at the OxyContin medication card and confirmed it indicated, Swallow whole. Do not chew or crush. LVN B confirmed some medication fell on to the medication cart and Resident 41 did not get the full dose of the medications. During an interview on 5/22/24 at 11:25 a.m., registered nurse D (RN D) stated Resident 41 was able to swallow his medications as whole pills and she should not crush his medication. During an interview on 5/23/24 at 11:02 a.m., the consultant pharmacist (CP) stated extended release (ER) and controlled release (CR) are equivalent. The CP stated that ER and CR medications are not normally crushed. The CP stated if a CR medication was crushed, the effect of continuous release no longer occurs. Review of the facility's policy, Administering Medications, revised 4/2019 indicated medications are administered in accordance with prescribers orders, including any required time frame and medications are administered within one hour of their prescribed time.

Based on interview, and record review, the facility failed to develop and implement interventions for fall care plan to prevent accidents for one of three sampled residents (Resident 1). The facility failed to initiate a fall care plan when Resident 1 was admitted with high fall risk and did not develop care plan for fall after subsequent falls at the facility. This failure resulted in Resident 1's fall with right wrist fracture (broken bone). Findings: Review of Resident 1's Admission Record, it indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, right side, unspecified injury of head, wedge compression fracture of thoracic vertebra (bone at the midback), paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and dementia (decline in mental capacity affecting daily function). Review of Resident 1's hospital record titled, Clinical Decision Unit [CDU] Discharge/Transfer Summary, dated 3/17/2023, indicated, Resident 1, who presented with mechanical fall resulting in right sided rib fractures .CDU Impression/Plan: 1. Closed head injury and mechanical fall . 2. Right rib fractures with pneumothorax (air in the lungs) and pulmonary contusion (bruise caused by blow) on the right fourth sixth ribs . Review of Resident 1's Fall Risk Assessment, dated 3/17/2023, indicated a score of 20 (HIGH RISK score of 16-42), it means Resident 1 was high risk of falling. The Fall Risk Assessment indicated Resident 1 had history of falls. Review of Resident 1's admission minimum data set (MDS, assessment tool) dated 3/23/2023, indicated brief interview for mental status (BIMS, cognition [includes memory, problem solving, and thinking skills] level) score was 05 (05 suggests severe impairment). Resident 1 requires extensive assistance (staff provide weight-bearing support) with two-person physical assist for bed mobility, toilet use, dressing and personal hygiene. Resident 1 was not walking yet during the assessment. Further review of the MDS, indicated Resident 1 had a fracture related to a fall prior to entry at the facility. Review of Resident 1's physical therapist's note, dated 3/27/2023, indicated Resident 1 was able to take 5-6 steps forward and back from the end of bed, with the used of two wheeled walker, and required minimal one person physical assistance (only 25 % support needed). Another review of Resident 1's physical therapist's note, dated 4/11/2023, indicated Resident 1 walked 300 feet without assistive device. Both notes reviewed, indicated, Precautions: Fall risk, Confusion and HTN (hypertension-high blood pressure). Review of Resident 1's Change in Condition Evaluation, dated 3/27/2023, indicated Resident 1 had a fall in the afternoon and did not sustain an injury. Further review indicated, Patient was noted to be on the floor, sitting on her bottom . There were no fall care plan interventions develop to prevent fall for Resident 1's fall on 3/27/2023. Review of Resident 1's Nurse's note, dated 4/15/2023, indicated, resident found sitting on floor [on 4/14/2023] beside her bed. resident unable to describe what happened. denies any pain. Neuro checks started. all parties notified . There were no fall care plan interventions develop related to the fall on 4/14/2023. Review of Resident 1's Change in Condition Evaluation, dated 4/16/2023, it indicated Resident 1 had another fall in the morning. Further review indicated, resident looks weak, and unsteady, witnessed fall on the floor with right hand support fell on her back, no head injury .rt (right) hand pain. no swollen noted, right hand light red . During a concurrent interview and record review with the nurse supervisor (NS) on 7/7/2023 at 11:30 a.m., NS reviewed Resident 1's discharge summary from the hospital, fall risk assessment and care plans. NS confirmed the following: Resident 1 had a fall at home and sustained right rib fracture prior to admission to the facility, had a fall risk for fall assessment with a score of 20 and had no fall risk care plan in placed upon admission. NS stated Resident 1 should have a fall risk care plan for staff to know the interventions needed to prevent the fall. NS confirmed Resident 1 fell on [DATE] and 4/14/2023 and there was no interdisciplinary team (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) meeting initiated related to the falls. NS stated IDT meeting was important for the team to discuss the contributing factors of Resident 1's falls, and developed a plan of care to prevent further falls or injuries. NS confirmed Resident 1 fell again on 4/16/2023 and sustained a right broken wrist. During a concurrent interview and record review with the licensed vocational nurse A (LVN A) on 7/7/2023 at 12:04 p.m., LVN A reviewed Resident 1's fall risk assessment and care plans. LVN A confirmed she took care of Resident 1 when Resident 1 was still at the facility. LVN A stated Resident 1 was oriented to self only and walked along the facility without a walker. LVN A confirmed Resident 1 was a fall risk upon admission and there was no fall risk care plan developed upon admission. LVN A stated it was important to develop a risk for fall care plan and an actual fall care plan for each falls to prevent further injuries. During an interview with the minimum data set nurse (MDSN) on 7/7/2023 at 1:30 p.m., MDSN confirmed nurses should have initiated a fall risk care plan upon admission when resident was identified a fall risk. MDSN stated an actual fall care plan should have been developed or updated every time a resident fall in the facility. MDSN confirmed she was also responsible to update the fall care plan once triggered in the MDS Care Area Assessment (CAA). Review of Resident 1's MDS CAA about Falls dated 3/23/2023, indicated, This area was triggered because a resident noted a balance problem when moving from seated to standing position, walking, turning around, moving on and off toilet and surface to surface transfer. Factors to consider on this trigger are: effects of medications, pain, poor safety awareness, medical condition and limitation of movement. At risk for injury and potential decline in ADLs (activities of daily living - activities related to personal care such as bathing or showering, dressing, walking, using the toilet, eating, and getting in and out of chair or bed) self-performance. Will proceed to CP (care plan) to prevent risk and keep res safe. Staff are anticipating and addressing needs to help prevent falls . Review of Resident 1's IDT Note - Fall dated 4/17/2023 at 10:24 a.m., indicated, Resident reported to have witnessed fall on 4/16/2023 .Resident was sent to emergency room for evaluation and treatment of right FA (forearm) swelling per MD (medical doctor), RP (responsible party) notified . Review of Resident 1's Nurse's Note, dated 4/17/2023 at 11:23 a.m., indicated, resident right hand swollen, c/o [complained of] pain prn [pro re nata - as needed] tylenol [brand name for acetaminophen, pain medication] given, ineffective . Further review indicated, the nurse called the doctor and received an order to send out Resident 1 to the acute hospital emergency room (ER) to get an x-ray. Resident was sent out to the acute hospitalER on [DATE] at 11:00 a.m. Review of Resident 1's acute hospital record titled, ED (Emergency Department) Provider Notes, dated 4/17/2023, indicated, Post-procedure Diagnoses: 1. Wrist fracture, right, closed, initial encounter . Review of Resident 1's Nurse's Note, dated 4/17/2023 at 5:26 p.m., indicated, resident arrived at 1715 (5:15 p.m.) via wheelchair .resident had broken right wrist .do not use right arm, it should be non-weight bearing[LI10] [do not put weight or carry heavy objects to broken part of the body] . During a review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, date revised March 2018, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls; 2. If a systemic evaluations of resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions .; 5. If fall recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . During a review of the facility's policy and procedure titled, Falls - Clinical Protocol, date revised March 2018, indicated, For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .

Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 2) with a safe and orderly discharge, when Resident 2 who was assessed to be cognitively impaired with at risk for elopement (who is incapable of adequately protecting herself and who departs the health care facility unsupervised), was allowed to leave the facility against medical advice (AMA, resident chooses to leave before the physician recommends discharge) on 2/16/2020 at 3:45 p.m. This resulted in Resident 2 being located four hours later when the police found her on 2/16/2020 at 8:15 p.m., sitting on a bench with complaint of weakness, knee pain, feeling very cold and shaking. Findings: During review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 2's minimum data set (MDS, resident tool assessment) dated 12/08/19, indicated Resident 2 was severely cognitively impaired and required extensive assistance with one-person physical assist during transfers. Review of Resident 2's elopement - wandering (traveling aimlessly from place to place) risk scale dated 3/11/19, score indicated 9 (at risk to wander). During a review of Resident 2's progress notes dated 2/16/2020, indicated at 3:45 p.m., the licensed nurse heard the alarm go off at the front door and seen Resident 2 exit the facility. The licensed nurse tried to convince her to return inside the facility but Resident 2 did not want to return. The nurse asked Resident 2 to sign the AMA form and then allowed Resident 2 to leave the facility as she headed towards the ocean on the sidewalk. At 5:30 p.m., two certified nursing assistants (CNAs) were sent to search for the resident but they could not find her. At 8:15 p.m., the licensed nurse received a telephone call from the police that Resident 2 was found and she was sent to the hospital for an evaluation. Review of Resident 2's hospital history of present illness (H&P) dated 2/16/2020, indicated Resident 2 was admitted for elevated troponin (group of proteins found in skeletal and heart (cardiac) muscle fibers that regulate muscular contraction, measure the level of cardiac-specific troponin in the blood to help detect heart injury), altered mental status which could be from her dementia (memory loss) versus infection. Resident 2 was found wandering in the streets. Apparently, she signed out against medical advice despite having a wander anklet (alarmed anklet, to protect those wander-prone person leaving the facility unattended) on the left. She had no home, and walked 5 miles and became very cold and weak. She was found sitting on a bench complaining of weakness, left knee pain, feeling very cold and shaking. During an interview with the social worker (SW) on 3/12/20 at 1:56 p.m., the SW stated the licensed nurse should not have allowed Resident 2 to sign out AMA because the resident was demented and it was not a safe discharge.

Based on interview and record review, the facility failed to implement care plan to prevent fall for one of two residents reviewed (Resident 49) who was assessed for fall high risk. Resident 49 had a fall on 12/19/19, hit her head and sustained a hematoma (blood leaks from blood vessel). Findings: During review of Resident 49's clinical record, indicated Resident 49 was admitted on [DATE], with [DIAGNOSES REDACTED]. During review of Resident 49's minimum data set (MDS, resident tool assessment) dated 12/20/19, the MDS indicated Resident 49 was severely cognitively impaired and required supervision with two-person physical assist during transfer. During review of Resident 49's fall risk assessment dated [DATE], score indicated 22, which means high risk for fall. During review of Resident 49's situation, background, assessment and, recommendation (SBAR, form of prompt communication) note dated 12/19/19, indicated at 12:32 a.m., three staff witnessed Resident 49 got out of bed and fell while walking in the hallway near other resident's room, with no apparent injury noted. Recommendations: landing mat in place and resident to monitor closely with one to one person. During review of Resident 49's SBAR note dated 12/19/19, indicated Unwitnessed fall at 7:45 p.m., the Nurse Practitioner (NP) heard a thump (as in was hit heavily), then found Resident 49 on floor on her knees next to her bed. The NP and another staff assisted transfer Resident 49 back to bed, sustained 3 X (by) 3 centimeters (cm, metric unit of length) hematoma on right forehead. During review of Resident 49's transfer to hospital summary note dated 12/20/19, Resident 49's daughter requested transfer Resident 49 to hospital for further evaluation due to Resident 49's history of head injury. The Physician (MD) was notified and Resident 49 was sent to hospital at noon time. During an interview with certified nursing assistant B (CNA B) on 03/04/2020 at 3:00 p.m., CNA B stated she did not provide one to one close monitoring with Resident 49 because she had other residents assigned with her to care for. During review of the facility's CNA assignment sheet dated 12/19/19, indicated there was no CNA assigned to provide one to one close monitoring for Resident 49. During an interview with the administrator (Admin) and licensed vocational nurse A (LVN A) on 03/05/2020 at 9:02 a.m., they stated they were not able to provide close monitoring for Resident 49. During review of Resident 49's fall care plan dated 12/18/19, indicated Monitor closely with one on one possibly male orderly if available. Provide assistance as identified in transfer and mobility. During a review of the facility's policy and procedure (P&P), Falls and fall Risk, managing, revised 2007, the P&P indicated 4. If falling recurs, despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.