Every finding on record at Ojai Health & Rehabilitation

Based on record review and interview, the facility failed to ensure staff provided resident care and services in accordance with professional standards of nursing practice when physician medication order and instructions were not followed for one of three residents (Resident 1).This failure had the potential to result in unsafe nursing care practices which could compromise the health and safety of Resident 1.During a review of Resident 1's admission Record (AR) dated 7/30/26, the AR indicated, Resident 1 is a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that includes Hemiplegia and Hemiparesis Following Cerebral Infarction (paralysis and weakness on one side of the body because of stroke cut off blood flow to part of the brain), Wedge Compression Fracture of First Lumbar Vertebra (one of the main block-like bones in upper lower back has cracked and squished down in the front), Dysphagia following Cerebral Infarction (trouble swallowing after having a stroke), Intervertebral Disc Degeneration Lumbosacral Region (natural wear and tear on the disc located in lower back and where spine meets your tailbone), Type 2 Diabetes Mellitus with Diabetic Neuropathy (long-term high blood sugar from Type 2 diabetes has damaged body's nerves).During a review of Resident 1's Physician Order (PO) dated 4/14/24 indicated:Insulin Regular Human Solution 100 Unit/ML inject as per sliding scale:If 0 - 150 = no insulin needed151 - 200 = 4 units;201 - 250 = 5 units;251 - 350 = 6 units;351+ = 8 units 351 and over give 8 units plus,Subcutaneously before meals for diabetesDuring a review of Resident 1's Medication Administration Records (MARs), for the month of July 2026, the staff administration documentation under medication order, Insulin Regular Human Solution. Were reviewed. The review indicated that staff failed to follow medication order instructions when blood sugar was not checked and insulin was not administered on the morning of 7/8/26.During a concurrent interview and record review on 7/30/26 at 1:45 p.m. with the Registered Nurse Supervisor (RNS), Resident 1's MARs, for the month of July 2026, specific to staff administration documentation of the medication Insulin Regular Human Solution were reviewed. DON verified the discrepancy found and acknowledged that staff did not follow physician orders to check and administer insulin on the morning of 7/8/26.During a concurrent interview and record review on 7/30/26 at 2:05 p.m. with the Administrator (ADM), Resident 1's MARs, for the month of July 2026, specific to staff administration documentation of the medication Insulin Regular Human Solution were reviewed. ADM verified the discrepancy found and acknowledged that staff did not follow physician orders to check and administer insulin on the morning of 7/8/26.During a review of the facility's policy and procedures (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated in part, Policy Statement . Medications are administered in a safe and timely manner and as prescribed. The P&P further indicated, Policy Interpretation and Implementation . 4) Medications are administered in accordance with prescriber orders, including any required time frame.A review of [NAME] and Perry's 7th Edition of Mosby's Fundamentals of Nursing, on page 419 under the section titled Legal Implications in Nursing Practice, it is stated that Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients.

Based on interview and record review, the facility failed to ensure physician's orders for restorative nursing assignments (RNA - targeted care tasks assigned to nursing staff to help patients maintain or improve their physical, mental, and functional independence) were consistently provided to four of four sampled residents (Resident 1, 2, 3, and 4). This failure has the potential for residents to experience functional decline.The facility policy and procedure (P&P) titled: Activities of Daily Living (ADL), Supporting, dated March 2018, indicates in part, .Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.b. Unavoidable decline may occur if he or she:.(3) refuses care and treatments to restore or maintain functional abilities and: a) the resident and or representative has been informed of the risk and benefits of the proposed care or treatment; and b) he or she has been offered alternative interventions to minimize further decline; and c) the refusal and information are documented in the resident's clinical record. During review of Resident 1's medical records, the admission Record (AR), dated 7/28/26, indicates Resident 1 was admitted to the facility with diagnoses that include fracture of lower end of left humerus (a break in the lower portion of the upper arm bone on the left side, where it meets the forearm bones to form the elbow joint), muscle wasting and atrophy (the shrinking and loss of muscle mass), lack of coordination, and difficulty walking. The Order Summary (OS), dated 7/28/26, indicates the following RNA orders:Ambulation (walk) for 50-100 feet or as tolerated for maintenance of mobility, AROM (active range of motion- exercises done by the patient using their own muscle power) exercises of BLE (bilateral lower extremities - both legs and feet) to maintain MMS (maximum muscular strength or mobility), PROM (passive range of motion - moving the joints gently without the resident's active physical participation) of LUE (left upper extremity - left arm, shoulder, elbow, wrist, and hand), and AROM of RUE (right upper extremity - right arm, wrist, and hand) 3x/wk.(three times per week) or as tolerated.Further review of the RNA Daily Logs (a form used as an internal communication to record the dates the residents received RNA services, the RNA services that were rendered, and who performed the RNA tasks), dated April 19, 2026, thru July 11, 2026, indicated Resident 1 did not receive the physician ordered RNA services on the following weeks: April 19-25, 2026, April 26-May 2, 2026, May 3-9, 2026, May 10-17, 2026, May 17-23, 2026, May 24-30, 2026, May 31 - June 6, 2026, June 7-13, 2026, June 21-27, 2026, June 28-July 4, 2026, and July 5-11, 2026. Review of Resident 1's medical record showed no evidence on the reason(s) the services were not provided. During a review of Resident 2's medical records, the AR dated 7/28/26 indicates Resident 2 was admitted to the facility following an intracerebral hemorrhage (a burst blood vessel) affecting the left dominant side with hemiplegia (paralysis) and hemiparesis (weakness). The OS dated 7/28/26 indicates the following RNA orders:Transfer Program sit-to-stand with use of hallway rails or gym parallel bars and ambulation with use of bar for 20 feet 3x/wk. or as toleratedAROM of RUE/RLE (right upper extremity/right lower extremity) to maintain ROM (range of motion) and PROM of LUE/LLE (left upper extremity/left lower extremity) 3x/wk. or as toleratedFurther review of the RNA Daily Logs dated April 19, 2026, through July 11, 2026, indicated Resident 2 did not receive the physician ordered RNA services the weeks of April 19-25, 2026, May 3-9, 2026, May 10-17, 2026, May 17-23, 2026, May 24-30, 2026, May 31 - June 6, 2026, June 7-13, 2026, June 14-20, 2026, June 21-27, 2026, June 28-July 4, 2026, and July 5-11, 2026. Review of Resident 2's medical record showed no evidence on the reason(s) the services were not provided. During a review of Resident 3's medical records, the AR dated 7/28/26, indicates Resident 3 was admitted to the facility following a cerebral infarction (narrowing or blockage of cerebral blood vessels in the brain that is deprived of blood supply and causes tissue death) that affected the left dominant side with hemiplegia and hemiparesis. The OS dated 7/28/26 indicates the following RNA orders:PROM to LUE/LLE and AROM to RUE/RLE 3x/wk. or as toleratedFurther review of the RNA Daily Logs dated April 19, 2026, through July 11, 2026, indicated Resident 3 did not receive the physician ordered RNA services the weeks of April 19-25, 2026, April 26th-May 2nd, 2026, May 3-9, 2026, May 10-17, 2026, May 24-30, 2026, May 31 - June 6, 2026, June 7-13, 2026, June 14-20, 2026, and July 5-11, 2026. Review of Resident 3's medical record showed no evidence on the reason(s) the services were not provided. During a review of Resident 4's medical records, the AR dated 7/28/26 indicates Resident 4 was admitted to the facility following obstructive and reflux uropathy (blockage causing urine to back up, harming the kidneys), muscle weakness, and difficulty walking. The OS dated 7/28/26 indicates the following RNA orders:Ambulation 5x/wk. (five times a week) or as tolerated for 100 feet or as tolerated.BLE ROM (bilateral lower extremity range of motion) and BUE (bilateral upper extremities) ROM 3x/wk. or as tolerated to maintain MMS.Further review of the RNA Daily Logs dated April 19, 2026, through July 11, 2026, indicated Resident 4 did not receive the physician ordered RNA services on none of those weeks, Review of Resident 4's medical record showed no evidence on the reason(s) the services were not provided. During a concurrent interview and review on 7/15/26 at 11:01 a.m. with Restorative Nursing Assistant (RNA 1), the weekly RNA logs were reviewed. RNA 1 stated the RNAs are sometimes pulled from performing RNA duties to cover for Certified Nursing Assistants (CNAs) sick calls or staffing shortages. RNA 1 acknowledged no RNA services are rendered to the residents when the RNAs are pulled to cover CNA staffing. RNA stated the charge nurse is verbally notified when a resident refuses RNA services and resident's functional mobility progress is documented in the RNA weekly summaries that is reviewed by the charge nurse. RNA acknowledged the charge nurses reviewing the weekly summaries varied and on occasion were agency nursing staff. During an interview on 7/15/26 at 4:30 p.m. with Director of Staff Development (DSD), the RNA logs were reviewed. DSD acknowledged RNA staff are pulled from RNA duties to cover for CNA staffing shortage when a CNA shift is not filled with agency staff. DSD confirmed the weekly RNA summaries were reviewed by the charge nurse, sometimes it was an agency nurse, with no follow-up action if residents were refusing or not receiving the ordered RNA services.During a subsequent interview and review on 7/15/26 at 5:00 p.m., the electronic medical records (EMR) for Resident's 1 through 4 were reviewed and compared against the RNA Weekly Logs. DSD acknowledged the EMR entries did not match the information documented on the RNA daily logs on multiple occasions and that the residents were not consistently receiving the ordered RNA services. During an interview on 7/28/26 at 2:09 p.m. with Director of Rehabilitation (DOR), DOR indicated that a resident's RNA progress is monitored by the RNAs, DSD, and DOR. DOR explained that the RNAs verbally communicate a resident's ROM changes (improvement or decline) during weekly meetings. When DOR was asked about the RNA daily logs and the EMR's, DOR stated having nothing to do with the daily RNA logs, weekly RNA summaries, or the RNA services documented in the EMR. During an interview on 7/28/26 at 3:10 p.m. with Director of Nursing (DON), DON indicated not being involved with tasks related to RNA services and not knowing that residents were not consistently receiving RNA services as ordered by the physician. DON acknowledged there was no documentation in resident EMR on refusing RNA services, informing residents or their responsible party of the risks involved for not participating or alternative interventions to accommodate and/or encourage resident participation.

Based on observations, interviews and record review, the facility failed to adequately maintain a homelike environment when:1. Four out of six residents (Resident 1, Resident 3, Resident 5, Resident 6) stated their rooms were too hot.2. One air conditioning unit (unit 2) was in disrepair.3. The Physical Therapy gym was 84 (degrees) Fahrenheit (F - unit of measurement for temperature).These facility failures had the potential to negatively impact residents.During an interview on 7/15/26 at 10:21 a.m., in Resident 3's room, Resident 3 stated this room is too hot, but if windows are opened it lets all the hot air in, so I keep it closed. During a concurrent observation and interview on 7/15/26 at 10:30 a.m., in Resident 5's room, the room was noticeably warmer than the hallway. A thermometer in Resident 5's room read 26 C (Celsius - unit of measurement for temperature). Resident 5 stated it's been awful. It's very hot in this room. Resident 5 verbalized I told [name] (Director of Maintenance) a couple of weeks ago, and [he/she] has come in and messed with the TV and clock but not the temperature. During an interview on 7/15/26 at 10:50 a.m., with Resident 6, Resident 6 stated the temperature in this room has gotten too hot before, so I open my window. Resident 6 verbalized I've told everyone and nothing's been done, and it's every day. Resident 6 further stated It seems hot twenty-four hours a day. During an interview on 7/15/26 beginning at 11:28 a.m., with Director of Maintenance (DOM), the DOM stated I use a thermometer to check rooms, and room temperatures are checked only in the morning. The DOM verbalized the temperature range in residents' rooms should be 70-85 Fahrenheit. The DOM further stated I was told that this is the range by the old supervisor, but I haven't looked at a policy for this, and I did not review any policies upon hire. The DOM verbalized there are fans in residents' rooms because not all of the air conditioning system is working. The DOM verbalized DOM did not know the federal regulations for temperature range in residents' rooms. During a review of facility's maintenance logs (ML) for year 2026, ML dated 5/10 indicated Location 10B needs a fan she is hot, and ML dated 6/6 indicated Location 18B room too hot needs fan family asked. During a review of (facility name) Air Temperature (AT) log, dated 6/5/26, AT indicated Location (room) 5 temperature 82 . During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revision date 2/2021, the P&P indicated, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.h. comfortable and safe temperatures (71 F - 81 F). 2) During a concurrent observation and interview on 7/15/26 at 11:49 with the DOM, unit 2 air conditioner fan was not moving as confirmed by the DOM. The DOM stated this has been an ongoing issue with the air conditioning not working. The DOM further stated the unit (unit 2) went out in June and it's for resident rooms 10, 8, 6, 4, and 2 and the DON office. During an interview on 7/15/26 at 1200 with DOM, the DOM stated when the air conditioning unit 2 went out, I checked the residents' rooms which were in range between 7:30am and 8:00am, and I can't check the rooms more than one time a day. The DOM further stated I work eleven hours a day, and I feel hot sometimes. During an interview on 7/15/26 at 1:43 p.m., with the Director of Nursing (DON) the DON stated the temperature reading checks haven't been increased, from the one check in the morning, to make sure residents are comfortable in their rooms throughout the day and night and this should be happening. The DON further stated the facility feels too hot during the day, and we have to tell the residents to shut the windows. During a concurrent interview and record review on 7/15/26 at 2:07 p.m., with the DOM, (Company Name) invoice, dated Jun 10, 2026, was reviewed. The (Company Name) invoice indicated, C/U #2 has a failed compressor that needs to be replaced.We propose to replace the compressor for this unit.The technician will check proper operations and ensure that the unit is restored to normal operating conditions. The DOM verbalized the unit 2 air conditioner has not been working for over one month. During an interview on 7/15/26 at 2:50 p.m., with Licensed Nurse Supervisor (LNS), the LNS stated it's been getting hot here. LNS verbalized when I did (Resident 1's) admission it was hot in (his/her) room where I did it, and (he/she) said it was hot. The LNS stated I sent a message to maintenance that (he/she) needs an air conditioning unit in there. LNS stated I told maintenance yesterday that it was hot. LNS verbalized there was one room where it was so hot, room [ROOM NUMBER], so I took my ac from my work area and put it in there. During an interview on 7/15/26 at 4:10 p.m., with Certified Nursing Assistant (CNA 1), the CNA 1 verbalized I remember bringing a fan to the resident (Resident 1) this week. CNA 1 stated (he/she) said it was hot, so I got the fan. During a review of (Company Name) invoice, dated Jun 22, 2026, the (Company Name) invoice indicated, in part, CU two only started the condenser fan. Further inspection revealed that CU two had a blown-off plug harness and a hole in the compressor shell, rendering it inoperable.Fifty percent of the equipment for the one side of the hall is operational. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, revision date 12/2009, the P&P indicated, 1) The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. 2) a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.d. maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. 3. During a concurrent observation and interview on 7/15/26 at 11:49 p.m., with DOM inside the Physical Therapy gym, the DOM used a Milwaukee laser gun (device used to read temperatures) to check the temperature and confirmed a reading of 84 F. During an interview on 7/15/26 at 11:54 p.m., with Rehabilitation Aide (RA) in the Physical Therapy gym, the RA verbalized the temperature is as cold as we can get it in here. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, revision date 2/2021, the P&P indicated, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.h. comfortable and safe temperatures (71 F - 81 F).

Based on interview and record review, the facility failed to ensure informed consent (a communication process where a healthcare provider educates a patient about the risks, benefits, and alternatives of a proposed treatment or procedure and patient acknowledges to have treatment or procedure done) was obtained when the dose increased for administration of psychotropic medication use for one of two residents (Resident 34).This failure resulted with the responsible party (RP) not having autonomy in medical decision-making before the resident received the medication. Findings:During a review of the admission Record (AR), admission date 3/25/26, the AR indicated Resident 34 is a [AGE] year old female with diagnoses including hemiplegia affecting left nondominant side (paralysis or severe weakness affecting the entire left side of the body), malignant neoplasm of brain (abnormal growth of cells that forms a tumor), epilepsy (a brain disorder that causes repeated, unprovoked seizures) major depressive disorder (mood disorder that causes persistent feelings of sadness, hopelessness, and a loss of interest in activities you once enjoyed), bipolar disorder (mental health condition that causes extreme, uncontrollable shifts in mood, energy, and activity levels), anxiety disorder (an emotion characterized by feelings of tension and worried thoughts).During a review of Resident 34's Order Summary Report (OSR), dated 6/11/26, the OSR indicated, the medication order Ativan Solution (medication to treat anxiety) 2 milligram (mg) per milliliter (ml) inject 1 mg intramuscularly every eight (8) hours as needed for thirty days with an order date of 5/19/26.Further review of Resident 34's electronic medical record indicated no informed consent was obtained from Resident 34's representative for the increase dose of Ativan.During a concurrent interview and record review conducted on 6/11/26 at 11:40 a.m. with the Director of Nursing (DON), the DON reviewed Resident 34's medical record and confirmed that Ativan had been administered to Resident 34 since 5/19/26. The DON acknowledged that informed consent for the use of Ativan had not been obtained.During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, revision date January 2026, the P&P indicated in part, Policy Statement. Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record. The P&P further indicated, Policy Interpretation and Implementation: Informed Consent or Refusal.1) Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal.a) non pharmacological alternatives.b) the indications and rationale for the recommendation.c) the potential risk and benefits (including possible side effects, adverse consequences, and black box warnings).d) the resident's/representative's right to accept or decline the treatment.

Based on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care for scabies rash like skin condition was formulated for one of two (2) sampled residents (Resident 17). This failure had the potential to hinder continuity of care and not to address all aspects of residents' condition and required responses without the comprehensive information of the care plan.Findings:During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, dated 5/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.8. The comprehensive, person-centered care plan will.g. Incorporate identified problem areas.k. Reflect treatment goals, timetables and objectives in measurable outcomes.m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels.Reflect currently recognized standards of practice for problem areas and conditions.11. Care plan interventions.are careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's conditions change.During a review of Resident 17 clinical record (CR), the CR was reviewed. Resident 17's CR indicated that Resident 17 was admitted to the facility on [DATE] with the following medical conditions: Diabetes (abnormal blood sugar level), Dementia (loss of brain function that affects memory, thinking, language and reasoning), Hypertension (abnormal blood pressure), and Osteoarthritis (OA - a type of joint disease that affects joint cushion). Resident 17's Brief Interview for Mental Status (BIMS - a standardized score system for mental status) was 03 (indicates severe mental impairment). Resident 17's nursing documentation on 5/11 indicated that Resident 17 was reported to have scabies like rash (a contagious skin condition caused by bugs that live under the skin and lay eggs causing an allergic reaction resulting in intense itchy rash) on Resident 17's lower back area. Further review of Resident 17's CR also indicated that oral medication, skin treatment and skin scraping test for scabies was ordered by the physician. Nursing documentation indicated that Resident 17 was placed on contact isolation precautions. Further review of Resident's CR, the care plan for skin condition was reviewed.During an interview from 6/8 to 6/11 with the Infection Preventionist (IP 1), IP 1 verbalized that residents in room [ROOM NUMBER] (Resident 17 & 50) was placed on contact isolation precaution in May 2026 due to Resident 17's suspicion of scabies rash in her back. The physician ordered a skin scraping to test for scabies for Resident 17, and both residents were treated with medication cream. The medication was left on residents' skin for 8-12 hours; they were given a shower and were provided with clean clothing, and the room was deep cleaned. All soiled linens were placed in a plastic bag, in a dark area to kill the bugs, and were stored in room [ROOM NUMBER]'s bathroom until the skin test result was received. IP 1 further verbalized that skin scraping test result was received afternoon on 5/18. Contact isolation precautions were lifted, the accumulated soiled linens from the resident's room were sent to the laundry and washed using hot water during the final laundry cycle.During a concurrent record review and interview on 6/11/26 at 10:15 a.m. with the IP 2, Resident 17's plan of care for skin rash, dated 5/11, was reviewed. IP 2 was unable to provide further information regarding the details of the care plan when Resident 17 was suspected of having scabies. IP 2 acknowledged that the incomplete care plan and failed to fully document Resident 17's treatment plan, including the necessary interventions.During an interview on 6/11/26 at 10:45 a.m. with the Director of Nursing (DON), the DON acknowledged that the care plan for Resident 17 did not adequately document the details of the specific interventions that were implemented when Resident 17 was suspected of having a rash consistent with scabies.

Based on record review and staff interviews, the facility failed to ensure compliance with the required 3.5 direct care hours per patient day (DHPPD), resulting in insufficient staffing on 11 of 26 weekend days. This facility failure has the potential to result to unmet care and needs to residents. Findings:During a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report fiscal year (FY), Quarter one 2025 (October 1 -December 31), the report indicated fiscal year quarter one .Excessively Low Weekend Staffing .A review of the facility's Internal Nursing Home Per Patient Day (NHPPD) Audit Report generated date 6/10/26, showed the following Direct Care Hours Per Patient Day (DHPPD) for weekend days from 10/4/25 through 12/28/25: 10/5/25 - 3.44 hours 10/12/25 - 3.17 hours 10/18/25 - 3.19 hours 10/19/25 - 3.12 hours 10/26/25 - 3.15 hours 11/2/25 - 3.30 hours 11/16/25 - 3.38 hours 12/7/25 - 3.49 hours 12/13/25 - 3.48 hours 12/14/25 - 3.18 hours 12/28/25 - 3.26 hoursThe Internal NHPPD Audit Report confirmed that the facility failed to meet the 3.5 DHPPD minimum requirement on 11 of the 26 weekend days reviewed.During a concurrent record review and interview on 6/11/26 at 10:35 a.m. with the Human Resources Coordinator (HRC), facility's Internal NHPPD audit report dated 6/10/26 was reviewed. The Internal NHPPD Audit Report indicated that the facility failed to meet the 3.5 DHPPD minimum requirement on 11 of the 26 weekend days. HRC acknowledged the staffing variances but did not provide additional details.During an interview on 6/11/26 at 10:52 a.m. with the Director of Nursing (DON), the DON stated being aware of the 3.5 DHPPD staffing requirement but was not aware that the facility failed to meet the 3.5 DHPPD minimum requirement on 11 of the 26 weekend days for the months of October, November, and December 2025.During an interview on 6/11/26 at 11:00 a.m. with the Administrator (ADM), ADM acknowledged the facility failed to meet the 3.5 DHPPD minimum requirement on 11 of the 26 weekend days for the months of October, November, and December 2025.A review of the facility's program waiver for staffing, dated June 2, 2025, (A program waiver for staffing is an authorized exception that allows healthcare facilities to operate below minimum mandatory staffing ratios due to workforce shortages.) Indicated, This letter is in response to the request submitted by Ojai Health & Rehabilitation for a workforce shortage waiver pursuant to Health and Safety Code section 1276.65(l) and in accordance with AFL 18 16. Your request is approved only as applicable to the required 2.4 CNA staffing standard, valid from July 1, 2025, until June 30, 2026, under the following conditions:2. The facility shall provide no less than 3.5 direct care service hours per patient day.3. The facility shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all applicable state and federal staffing requirements.The waiver expressly confirms that the facility remains required to provide the mandated 3.5 DHPPD.

Based on observation, interview, and record review, the facility failed to follow it's policy and procedures (P&P) for disposition (process for destroying unused medications) and reconciling (system of recordkeeping that ensures an accurate inventory of medications) of controlled medications (medications with a high potential for abuse and addiction) when:Two opened vials of Lorazepam (controlled medication used to treat anxiety) stored in medication cart 1 were not destroyed appropriately.One count sheet for Morphine (controlled medication used for pain) was incorrect for one out of 17 sampled residents (Resident 6). This failure had the potential to result in drug diversion (the illegal distribution or abuse of controlled prescription drugs) of controlled medications.1. During a concurrent observation and interview on 6/10/26 at 2:26 p.m. with the Director of Staff Development (DSD), two opened, single use vials of Lorazepam were observed stored in medication cart 1 with liquid medication remaining in the vials. One vial was observed stored in the right far back section of the first drawer, not double locked. The second vial was observed stored in the narcotic drawer. DSD stated both vials of Lorazepam are opened and are single use vials. DSD confirmed that the used vials of Lorazepam should have been destroyed and they were not. During an interview on 6/10/26 at 4:03 p.m., with Infection Preventionist (IP) 2, IP 2 stated he was unaware that one vial of Lorazepam was stored in the first drawer and it should not be stored there. IP 2 explained he administered one dose of Lorazepam to one unsampled resident in the morning and did not use the entire contents of the vial. IP 2 further stated that after administration, he stored the unused portion of the vial in the narcotic drawer. IP 2 confirmed that the unused portion of the Lorazepam was not destroyed. During an interview on 6/10/26 at 4:10 p.m., with the Director of Nursing (DON), the DON stated two licensed nurses should waste unused controlled medications at the time that it was administered. DON stated the two vials of Lorazepam should have been destroyed by two licensed nurses immediately after the medication was administered and they were not. During a review of the facility's policy and procedure titled IE1: Controlled Substance Disposal dated May 2022 indicated, B. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It is destroyed in the presence of two licensed nurses. the same process applies to the disposal of .unused portions of single dose ampules. 2. During a concurrent observation, interview, and record review on 6/10/26 at 3:06 p.m., with the DSD, the narcotic count sheets were reviewed for cart 1. The Morphine narcotic count sheet for Resident 6 did not match the actual Morphine bottle contents. One bottle of liquid morphine was observed that indicated 15 milliliters (ml) of total liquid was dispensed from the pharmacy. DSD stated there was about 12mL of liquid Morphine in the bottle. The count sheet indicated there should be 15.75 ml. DSD explained that it is not possible because the total contents of the morphine bottle is 15mL. DSD further explained that the count sheet was started wrong. DSD confirmed the count sheet is inaccurate. During a review of the facility's policy and procedure titled IIA7: Controlled Substance dated May 2022 indicated, E. Accurate accountability of the inventory of all controlled drugs is maintained at all times.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when:Expired medications were stored in medication cart 1.Resident 34's prescription medication was stored in the medication supply room with unopened over the counter medications.Two vials of Furosemide (medication used for fluid retention) stored in medication cart 2 were unlabeled. These facility failures had the potential to result in administering expired and ineffective medications to residents and had potential for medication administration errors.1. During a concurrent observation and interview on 6/10/26 at 2:44 p.m., with Director of Staff Development (DSD), two opened foil packets of DuoNeb (medication used to treat breathing issues) were observed stored in medication cart 1. One foil packet was dated 5/19/26 and one foil packet was undated. DSD stated there is no way to know when the foil package was opened and is considered expired. DSD confirmed the two DuoNeb foil packets were expired. During a concurrent interview and record review on 6/10/26 at 2:47 p.m., with the DSD, the manufacturer's instructions printed on the DuoNeb foil packet indicated, Unit-dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. DSD stated the medication should have been discarded after 2 weeks of being opened. DSD confirmed the expired foil packets should have been discarded and they were not. During a review of the facility's policy and procedure (P&P) titled ID1: Storage of Medications dated May 2022, indicated, G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. 2. During a concurrent observation and interview on 6/10/26 at 2:03 p.m., with the Director of Nursing (DON) in the medication supply room, one opened medication bottle of Lamotrigine (medication used for seizures) for Resident 34 was observed stored with unopened bottles of over-the-counter medication. DON stated resident's personal medications should not have been stored there. DON further explained there is a designated locked cabinet at the nurse's station where resident's personal home medications are stored. During a review of the facility's policy and procedure titled ID1: Storage of Medications dated May 2022 indicated, F. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart. 3. During a concurrent observation and interview on 6/10/26 at 3:23 p.m., with the DSD, two vials of liquid Furosemide (used to treat fluid retention (edema) were observed stored in the top drawer of medication cart 2 without a label. DSD stated she does not know who it belongged to and acknowledged medications should have pharmacy label but they do not. During a review of the facility's policy and procedure titled ID1: Storage of Medications dated May 2022 indicated, C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label.

Based on observation, interview, and record review the facility failed to ensure a kitchen staff member was wearing a beard covering in the kitchen during meal preparation. This failure had the potential to result in Foodborne illness (commonly known as known as food poisoning, refers to any sickness caused by eating or drinking foods or beverages contaminated with harmful bacteria, viruses, parasites, or toxic chemicals). During a concurrent observation and interview on 6/8/26 at 12:01 PM with the Registered Dietician (RD) and the Dietary Supervisor (DS), in the kitchen, a Dietary Aid (DA1) was observed placing items on a shelf near the area where hot foods were being prepared for lunch service with a full facial beard that was not covered by a beard restraint (a hair net that covers facial hair). RD and DS both agreed according to facility policy, DA1 should be wearing a net over his beard to prevent contamination of food for residents. During a review of the facility's policy and procedure titled, Dress Code dated 2023, indicated If applicable, beards and mustaches (any facial hair) must wear beard restraint.

Based on observation, interview, and record review, the facility failed to ensure the medical record of one of 17 sampled residents (resident 11), contained documentation of oxygen given as needed (PRN). This failure had the potential to result in an incomplete medical record as well as the ability to evaluate Resident 11's respiratory (breathing) status and effectiveness of treatment.During a review of the admission Record (AR), admission date 12/11/17, the AR indicated Resident 11 was a [AGE] year-old female with diagnosis including atherosclerotic heart disease (hardening and narrowing of blood vessels), hypertension (high blood pressure), dementia (decline in mental ability severe enough to interfere in daily life), and palliative care (medical care for anyone living with a serious illness focused on providing relief from symptoms). During an observation on 6/8/26 at 10:30 AM in the room of Resident 11, Resident 11 is observed with eyes closed, wearing a nasal cannula (tubing used to deliver oxygen directly through nostrils) attached to oxygen concentrator (medical device used to deliver concentrated oxygen) set at 3 liters per minute (3L/min). During an observation on 6/9/26 at 10:56 AM in the room of Resident 11, Resident 11 is observed with eyes closed, wearing a nasal cannula (tubing used to deliver oxygen directly through nostrils) attached to oxygen concentrator (medical device used to deliver concentrated oxygen) set at 3 liters per minute (3L/min). During a concurrent interview and record review on 6/9/26 at 11:05 AM with licensed nurse (LN2) the Medication Administration Record (MAR), dated 6/1/26-6/30/26 for Resident 11 was reviewed. The MAR indicated a physician's order of Administer oxygen inhalation @ 3L/min via nasal cannula as needed for dyspnea (shortness of breath or difficulty breathing). The MAR further indicated by blank spaces, no oxygen was administered on 6/8/26 or 6/9/26. LN2 agreed the use of the prn oxygen for Resident 11 should be documented on the MAR and was not. During an interview on 06/09/2026 at 2:37 PM with the Director of Nursing (DON), DON agrees prn oxygen use as observed should be documented when administered per policy and procedure on the MAR per facility policy and procedure. During a review of the facility's policy and procedure titled Administering Medications, dated 2001, indicated 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of the administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

Based on record review and interview, the facility failed to adhere to its own policy and procedure (P&P) on handling soiled linen when two (2) out of 17 sampled residents (Resident 17 & 50) were placed on contact isolation precautions from 5/11/26 to 5/18/26 due to a skin rash resembling scabies observed in Resident 17. Despite this precaution, the facility failed to implement the proper protocol regarding the management and storage of contaminated linen as outlined in their infection control guidelines. This failure placed both the staff and residents' health and safety at risk by storing multiple plastic bags of contaminated linen inside the residents' room for seven (7) consecutive days thereby exposing both staff and residents to possible spread of infections in the facility.Findings:During a review of the facility's P&P titled, Infectious Disease Threat, Infection Control Measures, During, dated 5/2026, the P&P indicated, When an infectious disease threat in the geographic region of the facility, aggressive infection control measures will be implemented to prevent introduction of the pathogen to resident, staff and visitors. 1. The following infection prevention and control measures may be implemented to prevent or contain an infectious disease threat in the facility: a. Training clinical staff in the mode of transmission of the pathogen; b. Training resident, families and non-clinical staff on the early symptoms of disease; c. Training staff, residents and visitors on the importance of standard infection control precautions (e.g. hand washing, respiratory hygiene.etc); .e. Surveillance and early detection of infection in the facility; f. Treatment of infected individuals, according to current clinical practice guidelines; g. Strict adherence to appropriate transmission based precautions; .Displaying signs and/or posters.During a review of the P&P titled, Scabies Identification, Treatment and Environmental Cleaning, dated 5/2026, the P&P indicated, The purpose this procedure is to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent spread of scabies to other residents and staff.6. Scabies is spread by skin to skin with the infected area, or through contact with bedding, clothing, privacy curtains and some furniture.Environmental Control 1. Place residents.on contact precautions.4. Place bed linens, towels and clothing used by an affected person during the 4 days prior to initiation of treatment in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for 10-20 minutes. 5. Use the hot cycle of the dryer for at least 10-20 minutes.Further review of the P&P titled, Laundry and Bedding, Soiled, dated 5/2026, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Handling 1. All used laundry is handled as potentially contaminated using standard precautions.a. Contaminated laundry is bagged or contained at the point of collection (location where it was used) .Transport.2. There are no additional requirements (i.e. double bagging or categorizing as biohazard) for transporting linen from rooms where transmission-based precautions are in effect.Storage.3. Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination.During a review of the facility census (FS) on 5/11/26, the FS confirmed that there were 2 residents assigned to room [ROOM NUMBER]: Resident 17 and Resident 50.During a review of Resident 17 and Resident 50's clinical record (CR), the CR was reviewed. Resident 17's CR indicated that Resident 17 was admitted to the facility on [DATE] with the following medical conditions: Diabetes (abnormal blood sugar level), Dementia (loss of brain function that affects memory, thinking, language and reasoning), Hypertension (abnormal blood pressure), and Osteoarthritis (OA - a type of joint disease that affects joint cushion). Resident 17's Brief Interview for Mental Status (BIMS - a standardized score system for mental status) was 03 (severe mental impairment). Resident 17's nursing documentation on 5/11/26, indicated that Resident 17 was reported to have scabies like rash (a contagious skin condition caused by bugs that live under the skin and lay eggs causing an allergic reaction resulting in intense itchy rash) on the lower back area. Further documentation indicated that medication and treatment including skin scraping to test for scabies was ordered by the physician. On the other hand, Resident 50's CR indicated that Resident 50 was admitted on [DATE] had a diagnosis of Multiple Sclerosis (a chronic condition where the body's immune system mistakenly attacks heathy nerve cells), OA, Chronic Obstructive Pulmonary Disease (COPD - lung condition). Both Resident 17 & 50 were placed on contact isolation precautions.During an interview on 6/9/26 at 2:59 PM with Certified Nursing Assistant (CNA 1), the CNA 1 verbalized that room [ROOM NUMBER] was placed on contact isolation due to Resident 17's rash. Both Resident 17 & 50 were placed on contact isolation precaution and was treated as if they had scabies. The Infection Preventionist (IP 1) instructed the staff to place soiled linen in a plastic bag and store in resident's bathroom until the skin test result was obtained. CNA 1 further verbalized that the plastic bags were kept inside the room for several days.During a phone interview on 6/10/26 at 2:18 p.m. with the facility housekeeper (HK 1). The HK 1 verbalized receiving infection control precaution education from IP 1 related to room [ROOM NUMBER]'s contact isolation precaution due to Resident 17's skin rash. HK 1 confirmed observing five (5) to six (6) plastic bags of soiled linen stored in room [ROOM NUMBER]'s bathroom on 5/11 and more plastic bags were observed on 5/18.During an interview on 6/10/26 at 2:36 p.m. with the housekeeper on duty (HK 2) from 5/12 to 5/17, HK 2 verbalized that the accumulated plastic bags were on the floor of room [ROOM NUMBER]'s bathroom had foul odor. HK 2 further verbalized that no restrictions or additional instructions were provided regarding bathroom access during the period of contact isolation. Staff members were permitted to use the bathroom at any time, without limitations or special protocols related to the isolation status.During an interview on 6/10/26 at 3:03 p.m. with the Director of Maintenance, Laundry & Housekeeping (DMLH), the DMLH verbalized visiting room [ROOM NUMBER] on 5/13, observed the accumulated plastic bags in the bathroom now starting to have foul odor. DMLH further verbalized not having encountered this practice before, addressed the concern to IP 1 and the Director of Nursing (DON). DMLH was told not to do anything and that they were waiting for Resident 17's skin test result.During an interview on 6/10/26 at 3:22 p.m. with the Laundry Personnel (LP), LP stated that DMLH informed them of the multiple plastic bags of soiled linen that required laundering. LP further stated that they were instructed to laundry the linens by washing them during the final laundry cycle using hot water. During an interview from 6/8 to 6/11 with the IP 1, IP 1 verbalized that room [ROOM NUMBER] was placed on contact isolation in May 2026 due to Resident 17's skin rash in her back. The physician ordered a skin scraping to test for scabies, both residents were treated with a medication cream. The medication was left on resident's skin for 8-12 hours. The residents were given a shower and were provided with clean clothing. All soiled linens were placed in a plastic bag, in a dark area to kill the bugs, and were stored in room [ROOM NUMBER]'s bathroom until the skin test result was received. IP 1 further verbalized that skin scraping test result was received afternoon on 5/18. Contact isolation precautions were lifted, the accumulated soiled linens from the resident's room were sent to the laundry and washed using hot water during the final laundry cycle.During a concurrent record review and interview on 6/11/26 at 10:45 a.m. with the DON, P&P for Laundry and Bedding, Soiled, P&P for Scabies Identification, Treatment and Environmental Cleaning and P&P on Infection Control Measures were reviewed. The DON acknowledged the deficient practice of failing to properly isolate and launder contaminated linens for residents with suspected scabies, which did not adhere to the facility's infection control guidelines. The DON further stated that corrective actions will be implemented, including providing additional staff training on proper linen handling procedures, to ensure future compliance with infection control standards.

Based on record review and interviews, the facility failed to notify the California Department of Public Health (CDPH) of an unusual occurrence involving a resident who was found to have a fracture of the outer ankle bone of the left leg. Requiring transfer to the emergency room for further evaluation and treatment.The facility's failure to notify CDPH had the potential to delay regulatory oversight of a significant injury and to inhibit external evaluation of resident safety practices.Findings:During a review of the residents Nursing Progress Notes dated 3/25/26 - 4/6/26 indicated:On 04/04/26, resident had a behavioral outburst requiring de escalation interventions; during assessment afterward, staff identified left ankle pain and discoloration.X ray on 04/05/26 showed a fracture involving the lateral malleolus with displacement. (Broken piece of the bone shifted out of normal alignment.)emergency room evaluation on 04/05/2026 confirmed an acute, comminuted distal fibular diaphyseal fracture. (Fracture of the outer ankle bone of the left leg.)During an interview on 4/28/26 at 3:00 p.m. with the Director of Nursing (DON), DON verbalized, because we knew the cause of the fracture, this was not an unusual event for us, that's the reason why we did not deem it to be reportable.During a review of facilities policies and procedure titled Unusual Occurrence Reporting, dated 2001, indicated:Our facility will report the following events to appropriate agencies Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors.Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four {24) hours of such incident or as otherwise required by federal and state regulations.A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. No documentation of CDPH notification, and no evidence of submission of an Unusual Occurrence Report were provided by facility.

Based on observation, interview, and record review the facility failed to ensure staff followed physician ordered parameters when administering as needed pain medication for 2 of 3 sampled residents (Resident 1 and 2). This facility failure had the potential to cause the resident ineffective pain relief and decreased quality of life.During a review of Resident 1's admission Record (AD), the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), hemiplegia and hemiparesis (complete paralysis and weakness) affecting right dominant side, generalized muscle weakness, and depression (persistent sadness, loss of interest in activities, and low energy). During an observation and interview on 4/8/26 at 11:22 a.m., with Resident 1, Resident 1 was observed sitting in the hallway outside his room. Resident 1 stated he has experienced constant pain for the past year and feels miserable. During a review of Resident 1's Order Summary Report, dated 4/8/26, indicated physician's orders with the following orders:-Pain Monitoring Scale: Monitor Pain Level 0-10: 0=no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain, 10+ worst pain every shift- acetaminophen tablet (an over-the-counter pain reliever) 325 mg (milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain 1 to 3, dated 10/10/25- ibuprofen tablet (an over-the-counter pain reliever) 600 mg give 1 tablet by mouth every 8 hours as needed for pain moderate pain 3 to 5, dated 3/1/26- oxycodone tablet (a prescription, narcotic pain reliever) 15 mg give 1 tablet by mouth every 6 hours as needed for severe pain 7 to 10, dated 3/18/26 During a review of Resident 1's Medication Administration Record (MAR) for February and March 2026, the MAR indicated acetaminophen was administered on:- 2/3/26 at 11:30 p.m. for pain level of 9- 2/11/26 at 9:03 p.m. for pain level of 9- 2/25/26 at 5:51 a.m. for pain level of 8- 2/26/26 at 4:49 a.m. for pain level of 8- 3/10/26 at 10:03 a.m. for pain level of 4- 3/10/26 at 3:51 p.m. for pain level of 5- 3/11/26 at 3:50 a.m. for pain level of 8- 3/12/26 at 5:13 a.m. for pain level of 7- 3/15/26 at 7:50 p.m. for pain level of 7- 3/16/26 at 8:15 p.m. for pain level of 7- 3/24/26 at 9:27 p.m. for pain level of 4- 3/26/26 at 1:33 a.m. for pain level of 9- 3/26/26 at 6:28 a.m. for pain level of 7During an interview on 4/9/26 at 12:27 p.m., with Licensed Nurse (LN) 3, LN3 stated being familiar with Resident 1 administered medications to Resident 1 on some of the above mentioned dates. LN 3 explained that Resident 1 takes oxycodone, but when he complains of pain and it's not time yet for the next dose of oxycodone, she administers Tylenol (brand name for acetaminophen) or he will just go back to bed. LN 3 acknowledged that Tylenol is ordered for mild pain 1 to 3 scale and confirmed that she administered the Tylenol outside of the physician ordered parameters. During an interview on 4/9/26 at 10:05 a.m., with the Pain Management Doctor (PMD), the PMD confirmed that Tylenol is ordered for mild pain. Stated he would expect the nurses to notify him if Resident 1 is experiencing moderate to severe pain not relieved by oxycodone. During a review of Resident 3's admission Record (AD), the AD indicated Resident 3 was admitted on [DATE] with diagnoses that includes osteomyelitis of lumbar vertebrae (infection of the bones in the lower spine), generalized muscle weakness, and low back pain. During an observation and interview on 4/8/26 at 12:06 p.m., with Resident 3, Resident 3 was observed sitting on the bed leaning against pillows propped on the wall. Resident 3 stated he had 8/10 pain in his lower back and stated that sitting in that position helps alleviate his back pain. During a review of Resident 3's Order Summary Report, dated 4/8/26, indicated the following physician's orders:- acetaminophen 500 mg give 2 tablets by mouth every 6 hours as needed for mild pain 1 to 3, dated 1/20/26- oxycodone 10 mg give one tablet by mouth every six hours as needed for severe pain 7 to 10, dated 3/2/26During a review of Resident 3's Medication Administration Record (MAR) for February and March 2026 , the MAR indicated acetaminophen was administered on:- 3/9/26 at 5:43 p.m. for pain level of 4- 3/10/26 at 9:17 p.m. for pain level of 7- 3/11/26 at 8:30 p.m. for pain level of 7- 3/16/26 at 2:14 p.m. for pain level of 5- 3/26/26 at 1:20 a.m. for pain level of 9During a concurrent interview and record review on 4/9/26 at 4:23 p.m. with the Director of Nursing(DON), DON confirmed that Tylenol was administered outside of the physician ordered instructions for both Resident 1 and Resident 3 and should not have been given for pain scale greater than 3. Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe the orders are in error or would harm clients. During a review of the facility's policy and procedure (P&P) titled Pain Assessment and Management, dated October 2022, the P&P indicated, 5. During the pain assessment gather the following information as indicated form the resident: . characteristics of pain: . intensity of pain (as measured on a standardized pain scale) . 6. The medication regimen is implemented as ordered.

Based on interview and record review, facility failed to ensure Resident 1's drug regimen was free from unnecessary medications when Resident 1's physician order for lidocaine patch (a topical medication that delivers local anesthetic directly to the skin to provide temporary relief for localized muscle, joint, or nerve pain) exceeded manufacturer's instructions. This failure had the potential for Resident 1 to receive more than the recommended dose per manufacturer's recommendations. During a review of Resident 1's admission Record (AD), the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), hemiplegia and hemiparesis (complete paralysis and weakness) affecting right dominant side, generalized muscle weakness, and depression (persistent sadness, loss of interest in activities, and low energy). During a review of Resident 1's Order Summary Report, dated 4/8/26, indicated physician's orders with the following orders:- Lidocaine Patch 5 % (percent) apply to right shoulder topically every 12 hours for pain, started on 1/19/26- Lidoderm Patch (brand name for lidocaine) 5% apply to back topically every 12 hours for Back pain, started on 1/19/26 During a concurrent interview 4/9/26 at 11:21 a.m., with Licensed Nurse (LN) 2, LN 2 confirmed being familiar with Resident 1 and stated that Resident 1 has physician orders for lidocaine patches to be applied twice a day at 9 a.m. and 9 p.m. During an interview on 4/9/26 at 12:38 p.m., with the Pharmacist (PHAR) stated lidocaine patches should only be worn 12 hours on and 12 hours off based off manufacturer's instructions. PHAR further explained that if an order indicated the application of more than once a day, the order should have been clarified to be only applied once a day and to be removed after 12 hours. During an interview on 4/9/26 at 2:02 p.m. with the Director of Nursing (DON), the DON stated Resident 1's lidocaine order is ambiguous, should have been clarified and it was not. During a review of the manufacturer's recommendations printed on the Lidocaine packaging indicated, Directions for use . Apply the prescribed number of patches, only once for up to 12 hours within a 24-hour period.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) for pain was updated to reflect the resident's current care needs and interventions for one of three sampled residents (Resident 1). This failure had the potential to result in inadequate pain management and could negatively impact Resident 1's psychosocial wellbeing.During a review of Resident 1's admission Record (AD), the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), hemiplegia and hemiparesis (complete paralysis and weakness) affecting right dominant side, generalized muscle weakness, and depression (persistent sadness, loss of interest in activities, and low energy).During an observation and interview on 4/8/26 at 11:22 a.m., with Resident 1, Resident 1 was observed sitting in the hallway outside his room. Resident 1 stated he has experienced constant pain for the past year and feels miserable.During a review of Resident 1's Order Summary Report, dated 4/8/26, indicated physician's orders with the following orders for pain medications:- acetaminophen tablet (an over-the-counter pain reliever) 325 mg (milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain 1 to 3 (pain scale 1 to 10 with 1 being mild and 10 being most severe), dated 10/10/25- ibuprofen tablet (an over-the-counter pain reliever) 600 mg give 1 tablet by mouth every 8 hours as needed for pain moderate pain 3 to 5, dated 3/1/26- oxycodone tablet (a prescription, narcotic pain reliever) 15 mg give 1 tablet by mouth every 6 hours as needed for severe pain 7 to 10, dated 3/18/26- Gabapentin capsule (prescription medication for nerve pain) 300 mg give 1 capsule by mouth three times a day for Neuropathy (damage to the nerves often causing numbness, tingling, weakness, or burning pain) dated 3/12/26- Lidocaine Patch (a topical medication used for pain) 5 % (percent) apply to Right shoulder topically every 12 hours for pain, dated 1/19/26- Lidoderm Patch (brand name for lidocaine) 5% apply to back topically every 12 hours for Back pain, dated 1/19/26 During a concurrent interview and record review on 4/9/26 at 1:27 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1's CPs were reviewed. Resident 1's CP for pain last revised on: 04/08/2026 indicated the following interventions: oxycodone oral tablet 10 mg give 1 tablet by mouth every 6 hours as needed for pain management severe pain 6-10 pain scale (PS) dated 10/8/24 and oxycodone oral tablet 5 mg give 1 tablet by mouth every 6 hours as needed for pain management mild to moderate pain 1-5 PS dated 10/8/24. MDSC confirmed that Resident 1's CP does not accurately reflect the current pain medication regimen, should have been updated and it wasn't. MDSC further stated that the inaccurate CP can cause disruption in care of the residents. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated March 2022, the P&P indicated 11. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 2) to ensure the resident maintained the highest physical well-being; when there were no Physician's Orders that addressed hospice care (program that gives special care to people who are near the end of life), the use and care of a urinary catheter (a flexible tube that collects urine form the bladder and collected in a drainage bag), and use, care, discontinuation, and monitoring for a Peripherally Inserted Central Catheter (PICC- a long, thin tube that's inserted through a vein in the arm). This failure had the potential to result in Resident 2 not receiving necessary care and services consistent with their health status.During a review of Resident 2's Clinical Record (CR) indicated Resident 2 was admitted to the facility on [DATE] under hospice with diagnoses that include cerebral infarction (the death of brain tissue as a result of reduced or blocked blood flow), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), dementia (a progressive state of decline in mental abilities), chronic viral hepatitis C (a lifelong liver infection caused by the hepatitis C virus). During an observation on 4/8/26 at 11:51 a.m., Resident 2 was observed lying in bed with a PICC line to right arm and a foley catheter bag secured to the bed draining yellow colored urine. During a review of Resident 2's Comprehensive Skin Evaluation/Assessment dated 4/3/26, indicated noted with the following: PICC line to right upper arm. F/C (foley catheter). During a concurrent interview and record review on 4/9/26 at 1:00 p.m., with Licensed Nurse (4), Resident 2's current orders were reviewed. LN4 stated Resident 2 was readmitted recently on hospice with a foley catheter and a PICC line. There were no current orders in place for hospice, foley catheter or PICC line. LN4 stated I don't see any orders and confirmed that the orders should have been placed on admission and they were not. During a concurrent interview and record review on 4/9/26 at 2:02 p.m. with the Director of Nursing (DON), Resident 2's clinical record was reviewed. The DON stated Resident 2's PICC line was discontinued on 4/8/26 by one of the licensed nurses. Review of Resident 2's orders indicated there is no physician order for the removal of the PICC line, further review of progress notes indicate there is no documentation of the removal of the PICC line. At 2:31 p.m., Resident 1 was observed lying in bed with a dressing (clean pad applied over a wound to protect it) on the upper right arm. DON confirmed the PICC line was not there and was removed without a physician's order. DON confirmed that there were no orders in place for hospice, foley catheter, the use, monitoring, and removal of the PICC line and there should be. During a review of the facility's policy and procedure (P&P) titled Removal of Central Line and Midline Catheters, dated May 2022, the P&P indicated A licensed practitioner must write an order for the CVAD (Central Venous Access Devices, including PICC lines) to be removed. The following should be documented in the resident's medical record: a. date, time of procedure, and resident tolerance. b. location of catheter that was removed. C. reason for removal of catheter. d. any complications and interventions taken. E. any communication with Physician or oncoming shift. F. any instruction given to the patient. During a review of the facility's P&P titled Physician Services dated February 2021, indicated Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician.

Based on record review and staff interview, the facility failed to ensure compliance with the required 3.5 direct care hours per patient day, resulting in insufficient staffing on 2 of 28 days reviewed.This failure had the potential to result in unmet care needs, inadequate supervision, delayed response to changes in condition, and avoidable adverse outcomes for residents. A review of the facility's Direct Care Hours Per Patient Day (DHPPD) staffing logs for the month of 2/1/26 - 2/28/26 , showed the facility reported the following direct care hours: 2/2/26 - 3.40 hours 2/8/26 - 3.46 hoursThe records confirmed that 2 of 28 days reviewed, the facility failed to meet the staffing minimum of 3.5 DHPPD.During an interview on 4/2/26 at 11:40 a.m. with Director of Nursing (DON), stated to be aware of the 3.5 DHPPD staffing requirement, but were not aware that the facility did not the staffing minimum of 3.5 DHPPD requirement for the month of February 2026. A review of the facility's program waiver for staffing, dated June 2, 2025, (A program waiver for staffing is an authorized exception that allows healthcare facilities to operate below minimum mandatory staffing ratios due to workforce shortages.) Indicated, This letter is in response to the request submitted by Ojai Health & Rehabilitation for a workforce shortage waiver pursuant to Health and Safety Code section 1276.65(l) and in accordance with AFL 18 16. Your request is approved only as applicable to the required 2.4 CNA staffing standard, valid from July 1, 2025, until June 30, 2026, under the following conditions: The facility shall provide no less than 3.5 direct care service hours per patient day. The waiver expressly confirms that the facility remains required to provide the mandated 3.5 DHPPD.

Based on interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 was identified as at risk for elopement, left facility without knowledge of staff, and was found a block from the facility.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 verbalized, heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until the fire department showed up.During an interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC), the FC stated, When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of the facility and another bracelet on one of his legs (wander guard). After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first.quickly ran inside and the staff did not know he was missing. The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed.During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated, Resident 1 was given medication at approximately 9 a.m. and that was the time the resident was last noted in the facility.During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7: indicate severe cognitive impairment). During a review of Resident 1's Care Plan (CP), dated 7/8/25, the CP indicated, Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors.During a review of Resident 1's Order Summary Report (OSR), dated 11/10/25, the OSR indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area.

Based on observation, interview and record review, the facility failed to comply with the state requirement of unusual occurrence by not reporting to the Department (State Agency) for one of two sampled residents (Resident 1). When a Resident with a history of dementia left the care facility without knowledge to staff, fell and was transported to emergency department.This deficient practice resulted in a delayed investigation by the Department.Findings:During an interview on 9/25/25 at 1 p.m. with the director of nursing (DON), the DON stated, We didn't realize Resident 1 was missing until the fire department brought him back. He wasn't gone from the facility that long, so we didn't think reporting to CDPH was necessary. During an interview on 9/25/25 at approx. 1:30 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA verbalized, they heard the wander guard alarm sound, checked the back door of the facility, did not see any residents, assumed it was a false alarm and did not realize a resident was missing until the fire department showed up.During an interview on 10/8/25 at 8 a.m. with [NAME] County Fire Captain (FC), the FC stated, When we arrived on scene there was a gentleman lying just off the ramp into the road in front of a home approximately a block from the facility. He had a hospital bracelet on that had the name of the facility and another bracelet on one of his legs (wander guard). After doing an assessment we helped him up, he was not talking, his blood pressure was pretty low. We stopped at the facility first.quickly ran inside and the staff did not know he was missing. The facility was able to pull up that he had medication around 9 a.m., the call went out about 10 a.m., so sometime in between he left the facility. He could have been missing from the facility for an hour and nobody would have noticed.During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated, Resident 1 was given medication at approximately 9 a.m. and that was the time the resident was last noted in the facility.During a review of Resident 1's Minimum Data Set (MDS) a standardized assessment tool used in nursing homes to evaluate residents' health and functional status, dated 7/15/25, the MDS indicated, a Brief Interview for Mental Status (BIMS) score of 5 on admission (Scores of 0-7: indicate severe cognitive impairment). During a review of Resident 1's Care Plan (CP), dated 7/8/25, the CP indicated, Resident is at risk for elopement, exit seeking/wandering related to communication deficits, difficult to redirect, exit seeking behaviors.During a review of Resident 1's Order Summary Report (OSR), dated 11/10/25, the OSR indicated, Resident 1 was to wear a Wander Guard, a wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated December 2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.

Based on interview and record review, the facility failed to: 1. Ensure four employees working as Certified Nursing Assistants (CNAs 1, 2, 3, and 4) had valid and up-to-date CNA certifications. 2. Ensure two employee personnel files (CNAs 1and 3) were complete and up to date.These failures resulted in unlicensed CNAs providing direct care to residents without proper certification and placed residents' safety at risk.1. During an interview on [DATE] at 10:05 a.m. with the Director of Staff Development (DSD), DSD stated the CNA is responsible for maintaining up to date certification and I double check with the files. DSD further stated we had to check three or four months ago and knew the CNAs who were about to expire and reminded them to get it done and that they can't be on the schedule, it's paper tracking and we keep a schedule of who is due. We will let them know when it will expire and prompt them again and when they get the certification, they will bring it in. We only go online to verify if it's expiring or if they don't have the certification handy with them, we will check it. All new CNAs certifications are checked upon hire. During a concurrent interview and record review on [DATE] at 12:40 p.m. with the Director of Nursing (DON), CNA 1's personnel file was reviewed and indicated, Application for employment, dated [DATE]. DON verbalized was unable to locate verification of CNA 1's CNA certification from the California Department of Public Health (CDPH) Licensing and Certification (L&C) website in CNA 1's personnel file.During a concurrent interview and record review on [DATE] at 1:58 p.m. with the DSD, CNA 1's personnel file was reviewed. DSD was unable to locate CNA 1's CNA certification and stated, We tried to look online and it's not showing. It's not in the file from when (CNA 1) was hired .We usually print it out, but we didn't for this one.At the moment there's no proof CNA 1 has a CNA license.We should have printed it out, and I'm not sure if we just verified it and didn't put it in the file.During a review of CNA 1's Human Resources Workday (HRWD), print outs (work hours clocked for payroll), the HRWD indicated, Worker (CNA 1). Job Profile CNA-H and dates worked indicated, CNA 1 worked the following days, 14 days in [DATE] days in [DATE] days in May, 19 days in [DATE], and 7 days in [DATE], for a total of 67 days worked without a CNA certification.During a review of CNA 1's Application for employment, dated [DATE], the Application for employment, indicated, Job Applied to CNA/FT (full time), Question - If applying for a position that requires a medical license or certification, please enter the license number and state. If not, enter NA, Answer is blank, and Offer details - Hire Date [DATE]. Job Profile CNA-H. Business Title CNA. Scheduled Weekly Hours 40.During a concurrent interview and record review on [DATE] at 3:03 p.m. with the DON and Administrator (ADM), the facility's policies and procedures (P&P) titled, Compliance Risks - Resident Quality of Care and Quality of Life, dated [DATE], and Staffing, Sufficient and Competent Nursing, dated [DATE], were reviewed. In addition, Job Description: Certified Nursing Assistant, dated 02/2024 and (facility) CNA schedule dated [DATE] through [DATE] were also reviewed. P&P titled, Compliance Risks - Resident Quality of Care and Quality of Life, indicated, .Sufficient staffing (1) Staffing is provided in sufficient numbers and with staff who have appropriate clinical training, licensure, and/or expertise to meet the needs of residents.Staff screening (1) Background screening and investigations are conducted prior to employment or engagement to ensure that staff, contractors, and/or volunteers meet at least the following criteria: (a) current licensure (if applicable) is in good standing in the state of practice; (b) education, certifications, and training have been verified. P&P titled, Staffing, Sufficient and Competent Nursing, indicated, .Competent staff (2) All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. The Job Description: Certified Nursing Assistant, indicated, .Must be a licensed Certified Nursing Assistant in accordance with laws of the state. DON and ADM confirmed both P&Ps and CNA Job Description were not followed. DON and ADM confirmed CNA 1 was listed on (facility) CNA schedule, and worked multiple days each month from [DATE] through [DATE], CNA 1's CNA certification was not in CNA 1's personnel file, and CNA 1 worked these shifts without verification of CNA certification.During a concurrent interview and record review on [DATE] at 2:55 p.m. with the ADM, CNA 2's personnel file and CNA schedules, dated October and [DATE] were reviewed. CNA 2's personnel file indicated, CNA 2's certification date of [DATE], expiration date [DATE], and a second certification, effective date [DATE], expiration date [DATE], verified by the CDPH L&C website. CNA 2 did not have a valid CNA certification from [DATE] through [DATE]. Review of the CNA schedules indicated, CNA 2 worked 5 days in [DATE] from [DATE] to [DATE] and 12 days in [DATE] from [DATE] through [DATE]. ADM was unable to locate CNA 2's valid CNA certification from [DATE] through [DATE]. The ADM confirmed CNA 2 worked the dates as noted above without a valid CNA certificate.During a concurrent interview and record review on [DATE] at 3 p.m. with the DON, CNA 2's personnel file was reviewed. DON verbalized CNAs would not be here at that time while CNA certification is processing and further stated, We are supposed to check each staff to make sure their CNA certification is current and valid and make sure that everything is current. DON confirmed CNA 2's CNA certification was expired from [DATE] through [DATE], and CNA 2 was not certified while working as a CNA during that timeframe.During an interview on [DATE] at 3:51 p.m. with the DSD, DSD stated, We didn't have a process in place to ensure (CNA 1) renewed their CNA certification. We didn't have the right process.During a concurrent interview and record review on [DATE] at 4:34 p.m. with the DSD, CNA 3's personnel file undated, and Nursing Staff Daily Assignment & Sign-In Sheet, dated 2/16 and [DATE], and HRWD print outs were reviewed. CNA 3's personnel file indicated, Certified Nursing Assistant Certification.Effective Date [DATE]. Expiration Date [DATE], and Effective Date [DATE]. Expiration Date [DATE]. Verified by the CDPH L&C website. Nursing Staff Daily Assignment & Sign-In Sheet, dated [DATE] and [DATE] indicated, CNA 3's signature next to CNA 3's name. HRWD print outs indicated, CNA 3 worked 2/16 and [DATE]. DSD confirmed CNA 3 worked on [DATE] and [DATE] without an active CNA certification.During a concurrent telephone interview and record review on [DATE] at 3:25 p.m. with the ADM, CNA 4's personnel file and CNA 4's HRWD print outs were reviewed. CNA 4's personnel file indicated, Certified Nursing Assistant Certification Effective Date [DATE]. Expiration Date [DATE], and Effective Date [DATE]. Expiration Date [DATE], verified by CDPH L&C website. HRWD print outs indicated, CNA 4 worked four days in July from [DATE], through [DATE] and ten days in August from [DATE] through [DATE]. ADM confirmed accuracy of all records reviewed and stated, According to these documents (CNA 4) was not actively certified while working these dates.During a review of the facility's Policy and Procedure (P&P) titled, Credentialing of Nursing Service Personnel, dated [DATE], the P&P indicated, Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license or certification prior to or upon employment. 1) Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the director of nursing services prior to or upon employment. 2) Nursing personnel requiring a license/certification are not permitted to perform direct resident care until all licensing/background checks have been completed. 3)a) contact the appropriate state licensing board(s) to obtain a letter of verification/computer printout of such license/certification.4) A copy of all documents obtained during the verification and background check are filed in the employee's personnel file.6) Should the investigation reveal the applicant does not hold a valid license or certification, appropriate state licensing boards and authorities will be notified of the applicant's attempt to practice without a license/certification .9) Inquiries concerning credentialing should be referred to the administrator or the director of nursing services.2. During a concurrent interview and record review on [DATE] at 3:25 p.m. with the DON and Administrator (ADM), CNA 1's personnel file was reviewed. The DON and ADM verbalized they were unable to locate CNA 1's signed job description and CNA 1's personnel file was incomplete.During a concurrent interview and record review on [DATE] at 2:40 p.m. with the DSD, CNA 3's personnel file was reviewed. DSD verbalized CNA 3's start date was [DATE]. When asked if CNA 3's personnel file contained verification of CNA 3's CNA certification back in 2023, DSD stated we don't have the old one, just the most recent, we should get a printed copy and put it in their file, but this file was created before me. DSD further stated we can't search online for previous CNA certifications, and it's missing from when CNA 3 was hired.During a review of the facility's Policy and Procedure (P&P) titled, Personnel Records, dated [DATE], P&P indicated, 1. Federal and state regulations require that our facility maintain an individual personnel record for each employee. However, it shall be the employee's responsibility to provide the HR director with the required data. This responsibility also entails notifying, in writing, the HR director of any change in the required data.3) Personnel records contain, as each may apply, the following data.(c) Job description(s).(l) Copy of current licenses (as applicable).15) Personnel records shall be retained for a period of not less than five (5) years unless otherwise required by federal or state laws.During a review of the facility's Personnel File - Required Checklist - Physical and Workday, dated [DATE], Personnel File - Required Checklist - Physical and Workday, indicated, Employment/Onboarding Items.Education verification (licensure uploaded to in Workday under Career, for monthly monitoring).License required for position (Upload copy into Workday).Job description (it needs to be employee acknowledged; it is assigned in Workday).

Based on observation, interview and record review, the facility failed to ensure an environment free of accident hazards when one of three sampled residents (Resident 1), wheeled self out to the patio and opened an unlocked gate. This failure resulted in Resident 1 falling eight steps in her wheelchair and sustaining a broken left wrist, two broken bones of the spine, and a rotator cuff tear (a rip in the group of four muscles and tendons that stabilize your shoulder joint and let you lift and rotate your arm) to her left shoulder. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was [AGE] years old and originally admitted on [DATE] with diagnoses including but not limited to, vascular dementia (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage), Alzheimer's disease (progressive type of dementia beginning with mild memory loss), and sarcopenia (age related, involuntary loss of skeletal mass and strength) During a review of Resident 1's Minimum Data Set, (MDS - a standardized assessment tool that measures health status in nursing home residents), dated 11/15/22, the MDS indicated, Resident 1 was usually understood and usually understood others, vision was moderately impaired (limited vision but can identify objects), had a Brief Interview for Mental Status - BIMS, score of 3 (The BIMS test is used to get a quick snapshot of how well a resident is functioning cognitively at the moment and ranges from 0 - 15. A score of 3 indicates Severe cognitive impact). Resident 1 required extensive assistance of one person for bed mobility, transferring, toilet use and personal hygiene. Resident 1 was not able to walk, used a wheelchair and was able to wheel self. During a review of Resident 1's Treatment Administration Record, (TAR -is a report detailing treatment administered to a resident by health facility), dated January 2023 and February 2023, the TAR indicated, during the month of January 2023, Resident 1 had 45 episodes of leaving facility without assistance and 91 episodes of wandering around facility and into other resident's rooms. During February 1, 2023 through February 4, 2023, Resident 1 had 10 episodes of leaving facility without assistance and 7 episodes of wandering around facility and into other resident's rooms. During a review of Resident 1's Physician Progress Note, from the acute hospital, dated 2/8/23, the Progress Note indicated, resident is confirmed to have a closed fracture of left distal radius (broken wrist), rotator cuff tear, Compression fracture of L1 vertebra, and Compression fracture of T6 vertebra (two broken bones of the spine). During a concurrent observation and interview on 2/7/23, at 12 p.m., with the Director of Nursing (DON), the patio was observed where Resident 1 was found after a fall on 2/4/23 around 12:50 p.m. The patio had a gate with eight steps leading to the back parking alley. The doorway to the patio currently is outfitted with an alarm when the door is opened, and the gate currently has a lock on it. DON stated, At the time of the fall on 2/4/23 there was no door alarm, and the gate was always closed but there was no lock on it. The facility took those measures after the incident. Resident 1 had two wander guards (lightweight bracelet device used when a resident lingers near an exit or attempts to leave, an alarm alerts staff), one on the wheelchair and one on the resident's ankle. Resident 1 also had a removable Velcro lap belt, which sounded an alarm when the resident fell . Licensed Nurse (LN 1) heard the alarm and Resident 1 calling for help and found Resident 1 at the bottom of the stairs that lead to the back parking lot, still attached to the wheelchair. Resident 1 had moderate bleeding from the forehead and a skin tear to right forearm. (Resident 1) complained of everything spinning, 911 was called immediately. During an observation of the patio, the patio was measured by the surveyor. The patio is 11 feet, 5 inches to the gate, the gate is 3 feet, 2.3 inches in width with an unlocked latch Resident 1 was able to reach and open. There are 8 stairs, 8 feet, 6 inches long. Resident 1 had opened the exit door at station 2 that led out to the patio, while in her wheelchair. The exit door was unlocked without a working Wanderguard alarm. During an interview on 2/7/23, at 1 p.m., with Licensed Nurse (LN 1), LN 1 stated, on day of the accident LN 1 was alerted to the sounds of Resident 1 calling out for help and the sound of her self-release Velcro wheelchair seat belt alarm. Resident 1 was found lying on the concrete, head facing the stairs on her left side in fetal position still attached to her wheelchair with the seat belt detached. During an interview on 4/3/23 at 1:48 p.m., with Licensed Nurse (LN 1), LN 1 stated, Resident 1 is notably more of an exit seeker, constantly goes to the front looking for her mom, she is extensive assist with her activities of daily living, she's redirectable but can be more restless than usual. Will curse in Spanish if agitated, will go into other residents' rooms, and take belongings, tries to get out of bed or wheelchair by herself. On the day of the fall, there was nothing out of the ordinary, Resident 1 woke up before noon and began her day with roaming around the facility in her wheelchair. LN 1 stated, she went on break around 12:45 and came back 5-10 minutes later when she took a phone call at the nurse's station when she heard the alarm from the outside. During an interview on 4/3/23, at 10:30 a.m., with Administrator (ADM), ADM stated, there were no working alarms at the patio exit by station 2 prior to the accident. ADM stated, In retrospect, yes there should have been an alarm or working Wanderguards on the exit by station 2 to prevent the accident. During an interview on 4/3/23, at 2:03 p.m., with Licensed Nurse (LN 2), LN 2 stated, on the day of the accident, she witnessed Resident 1 trying to go out of the front door, her favorite exit seeking door. Resident 1 constantly requires redirection. She is also known to go into other people's room. LN 2 stated she ran outside after hearing the commotion and saw Resident 1 at the bottom of the stairs. During an interview on 4/4/23, at 1:30 p.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated, she is regularly assigned to Resident 1's care and she likes to wander, can be difficult to redirect at times as she can start cursing in Spanish at staff. Once up in her wheelchair she goes around the entire facility, trying to exit, and goes into other resident's rooms. We know to keep our eyes on her at all times, I'm already familiar with her behavior but the Charge Nurses remind us as well. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated March 2018, under the section titled, Monitoring and Follow-up the P&P indicated, 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. During a review of the facility's P&P titled, WANDERGUARD, Code alert etc. Resident Monitoring System, undated, The P&P indicated, Policy: It is the policy of this facility to provide a safe and secure environment to ensure the safety of any resident attempting to elope from the facility. It is our policy once an elopement risk evaluation has identified a resident at risk; the following steps are implemented in conjunction with the Elopement Prevention Policy. Procedure: 1. The Nurse, Social Services IDT, or designee determines if resident needs to be placed on a monitoring device system .5. The Nursing Department or designee tests the monitoring device wore on resident at least weekly or as determined by the facility .6. The Maintenance Department or designee tests the monitoring system at identified exit points at least weekly using the testing equipment/device provided by the manufacturer to ensure proper working condition and will document testing on the Monitoring Device testing log .8. Nursing staff or designee will notify administrator and/or DON of the system failure. Then the facility begins back up procedures to safeguard against elopements. (Conduct visual checks for residents with monitoring devices and record checks utilizing the POC CNAs task). The facility was unable to provide a P&P for accidents and supervision.

Based on observation, interview, and record review, the facility failed to ensure the front outdoor iron gate was secured and supervision was provided to prevent one of six sampled residents (Resident 1) from falling down the steps and sustaining injuries. The facility failed to: *provide a secure and safe environment by failing to ensure the outdoor iron gate was securely latched and preventing resident access to concrete steps. *provide supervision when Resident 1 was out on the front porch. As a result of these failures, Resident 1 (wheelchair bound) was able to open an unlatched gate and fell down six concrete steps, leading to the sidewalk and paved roadway sustaining a 6 cm (centimeters) x 2 cm x 4 cm laceration above his left eyebrow; 25 cm vertical laceration to muscle over right shin; 10 cm laceration through to subcutaneous (beneath the skin) fat with 10 cm continuation of skin tear to right dorsal (back of) forearm; and right upper outer arm skin tear. A passer-by found Resident 1 at the bottom of the six (6) concrete steps bleeding and complaining pain and notified the facility. These failures placed residents at risk for injuries and death as a result of an unsecured gate and lack of supervision. Immediate jeopardy (IJ) was called on 9/8/14 at 7 p.m., with the facility Administrator and the Director of Nursing (DON). On 9/8/14 at 8:30 p.m., the facility provided an acceptable plan of correction. The plan of correction included the following: * Securing the front entrance gate leading to the six concrete steps by locking it with a padlock. * Posted a sign redirecting residents and visitors to use the handicapped access. * Initiated increased supervision of confused residents at the main entry / exit door by providing a staff member seated directly by the front entrance while residents are up and awake. The Department accepted the plan of correction and abated the the IJ on 9/8/14 at 8:30 p.m. with the Administrator and the DON. Findings: During an observation on 9/8/14 at 5:30 p.m., the iron gate at the top of six concrete steps leading into and exiting the facility was noted to be unlatched. At 5:33 p.m., Resident 2 and 3, who were identified by staff to be confused, were propelling themselves, each in a wheelchair, in the lobby eight to ten feet away from the unlatched iron gate and concrete steps. Resident 2 was observed attempting to exit the main entrance to the facility which would provide immediate access to the unlatched iron gate and concrete steps. There were no staff within eyesight supervising these residents. Record review on 9/8/14 revealed Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. The facility's comprehensive assessment dated [DATE] indicated Resident 1 had both short term and long term memory problems, and required limited assistance with locomotion (able to propel himself) on the unit, and extensive assistance with walking, eating, and toilet use. During an interview on 9/8/14 at 6:40 pm, the director of nurses (DON) indicated Resident 1's daughter comes to the facility almost every day to have meals with Resident 1 on the front porch of the facility and next to the iron gate that leads to the concrete steps. During an interview on 9/10/14 at 3 pm, a certified nurses' assistant (CNA 1) confirmed Resident 1 eats most evening meals with his daughter on the front porch. Resident 1's usual habits were described, on a daily basis and especially in the evenings, to propel himself in a wheelchair to the facility main entrance. Resident 1 was further described to, at times, attempt to open the main door to go out to the front porch, in search of his daughter. Review of the facility's plan of care dated 3/21/14, Resident 1 is assisted to eat evening meals by his daughter and Resident 1 "looks for daughter during evening for meal time." The facility's interventions to the plan of care included making sure Resident 1 was in a "safe area on the porch." During review of the facility surveillance video on 9/10/14 at 2 pm, revealed on 9/7/14 at 6:30 p.m., Resident 1 was observed exiting the facility front entrance door by propelling himself while seated in his wheelchair. Resident 1 was observed sitting in his wheelchair on the porch (where he often sat with his daughter for evening meals), however this time he was alone and unsupervised. Resident 1 opened the unlatched iron gate at the top of the concrete steps leading to the sidewalk, tumbled down the steps while still in his wheelchair, head first, and landed at the base of the sixth step next to the sidewalk and paved road. The video showed Resident 1 lying on the ground bleeding for over five (5) minutes without assistance. A passerby driving down the roadway saw Resident 1 lying, tumbled over in his wheelchair, on the sidewalk. The passerby stopped the vehicle and ran into the facility. Review of the facility's nursing progress notes indicated on 9/7/14 at 6:30 pm, a passer-by entered the facility and notified the staff Resident 1 had left the facility, fallen down the steps, and was lying on the sidewalk bleeding and in pain. A physician ordered the facility to transfer Resident 1 to an acute care hospital for evaluation of the injuries from the fall. At the acute care hospital, Resident 1 was diagnosed with [REDACTED]." Resident 1 was admitted to the hospital's Direct Observation Unit for continued observation, neurological assessment, and a repair of the lacerations.