Every finding on record at Orinda Care Center, LLC

Based on observation, interview, and record review, the facility failed to protect personal belongings of four sampled residents (Resident 1, 2, 3, 4) and did not follow their policy to ensure the residents' personal property were properly logged upon admission and as necessary when:1. Resident 1's clothes and personal items were reported missing and not all were found.2. Residents 2, 3, and 4 had claimed they were missing clothes and personal items that were not reported.3. Residents losing their clothes was one of the concerns discussed in the Resident council meeting on 4/23/26 and there was no evidence that it was resolved.4. There was no evidence that the personal belongings for Resident 2 and 4 were inventoried upon admission and no evidence that they were updated subsequently for Residents 2 and 3.This failure had compromised the rights of residents to retain personal possessions.1. A review of the admission record for Resident 1 indicated Resident 1 was originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included stroke with hemiparesis and hemiplegia, dementia, and depression.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 4/21/26 indicates a Brief Interview Mental Status (BIMS, a brief test to help detect cognitive impairment) score of 00 indicating severely impaired cognition.During a telephone interview on 5/l27/26 at 8:33 a.m. with Resident 1's Responsible party (RP), RP stated there are so many things that are missing for Resident 1 and she had to go to the store and buy stuff because Resident 1 did no have it. RP stated she did not have the list at hand now. She stated she sent the list of the clothes/items missing to the social worker (SW) but had not heard anything from the social worker.During an interview on 5/27/26 at 2:25 pm with Certified Nursing Assistant (CNA) 1, CNA 1 stated if a resident is missing their clothes, the process is to go downstairs to the laundry to search for it. If they are unable to find it, they inform the laundry staff of the resident's name and a description of the missing items. The CNAs and laundry staff also report it to the SW.During a review of the printed electronic document titled, Personal Effects Inventory for Resident 1 dated 3/22/26, it indicated - 3 new t-shirts, 3 new pants, photos, pictures, books, other.During a concurrent interview and review on 5/28/26 at 4:05 p.m. with Social Services Director (SSD), the grievance log was reviewed. SSD stated nobody has stolen Resident 1's clothes and just got misplaced. SSD stated she found Resident 1's green blanket and it got missing again. SSD stated she found a couple of Resident 1's shirts. She stated the other missing clothes/items would turn up and she would keep looking for them.During a review of the Resident Council Meeting document dated 4/3/26, it indicated under Maintenance/Housekeeping, Laundry issues - residents don't get the right clothes after laundry with Activity Director (AD)'s comment - addressed with housekeeping department.During an interview on 5/28/26 at around 5:45 p.m. with AD, when asked what actions were taken regarding the concerns noted about laundry in the Resident council meeting minutes she provided, AD stated she contacted the department involved and they stated it was resolved.During a concurrent interview and review on 5/28/26 at 5:50 p.m. with SSD, the document titled, Grievance /Complaint Report form and Follow - up Investigation Report for Resident 1 dated 4/28/26 was reviewed. The document indicated, . the grievance was not resolved as not all items have been found - will continue to search and return as found or replaced if needed.During a review of Resident 1's inventory provided by MRD on 5/28/26 at 6 p.m. titled, Articles acquired after admission, the document indicated multiple items on the list handwritten with multiple dates 5/14/23, 9/22/23, 12/15/24, 4/13/25, 8/3/25 on the first page and on the second page of the sheet, it indicated, (Missing List) with the following items dated 8/3/25 - 2 blankets missing, 2 pink pants, 1 red & black stretch pants, 1 pink sweatshirt, 1 gray blanket, 1 green T-shirt, 1 white T-shirt; and a list of items dated 12/28/25 - 1 grey electric blanket, 1 grey sweatshirt w/[NAME] name in the front; and a list of items dated 2/12/26 - 1 pair of pink socks, 1 pair of Zac and [NAME] long sleeve shirt (orange, gray, blue), and 1 gray Nike Jogger's pants. Provided, was a third document (plain sheet) handwritten that indicated found list - [NAME] Christmas blanket, grey blanket, peace blanket call mom floral pants, pink T-shirt, dark Gray pants. Not found list - winter hats, light pink pants, pink sweatshirt, grey shirt, lights grey pants, socks.During a concurrent observation and interview on 5/29/26 at around 12:55 p.m. outside the laundry room in the basement, with Laundry attendant (LA), Housekeeping/Laundry Supervisor HKLD, and Housekeeping staff (HKS), there were many personal clothes placed on a moving cart and couple of personal pillows placed on the clean linen cart. HKLD translated for LA as she could not understand English. HKLD stated the clothes belong to residents but have no names/labels and they are not able to know the specific residents they belong to. HKLD, HKS acknowledged there were HKLD, HKS acknowledged there were still issues with residents' personal clothing. HKS stated nobody is putting on name labels on residents' clothes. When asked, HKS stated social services are supposed to put the labels. HKLD stated sometimes they find soiled towels and personal clothes in the garbage.2. A review of Resident 2's admission record (AR), AR indicated she was originally admitted [DATE] and readmitted [DATE].A review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 2/20/26 indicates a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 13 indicating no cognitive impairment.During an interview on 5/27/26 at 4:03 p.m. with Resident 2, Resident 2 was lying in bed, alert. She was wearing a hospital gown. Resident 2 stated she was missing a lot of personal clothes, they looked for them, maybe in the laundry, but couldn't find them, so she stopped wearing dresses because she did not want anything stolen. Resident 2 stated she just wore gown and a sweatshirt when outside. Resident 2 stated her daughter replaced them and the second set of clothes were also stolen but she didn't report them.During an interview on 5/29/26 at around 3:40 p.m. with Medical Record Director (MRD), MRD confirmed there was no inventory record for Resident 2. MRD stated he searched for Resident 2's inventory and could not find any in the electronic record or in the hard chart.3. A review of Resident 3's admission record (AR), AR indicated he was originally admitted [DATE] and readmitted [DATE].A review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 4/16/26 indicated a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 13 indicating no cognitive impairment.During an interview on 5/28/26 at 1:47 p.m. with Resident 3, resident 3 stated he was missing his clipper, but he did not report it to anyone.During a follow up interview on 5/29/26 at 12:07 p.m. with Resident 3, Resident 3 stated his hair clipper was in a black case [NAME] brand and missing few weeks ago before May 1st.During an interview on 5/29/26 at 3:40 p.m. with Medical Record Director (MRD), MRD provided the inventory record for Resident 3 dated 4/10/26 but the hair clipper was not on the admission inventory nor was the inventory updated.4. A review of Resident 4's admission record (AR), AR indicated he was admitted [DATE].A review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 3/18/26 indicated a Brief Interview and Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicating no cognitive impairment.During an interview on 5/28/26 at 5:22 p.m. with Resident 4, Resident 4 stated the concern about residents losing their clothes was brought up in the resident council meeting. When asked if the concern among others was resolved, Resident 4 stated, no resolution. Resident 4 stated he was missing his socks that never came back from laundry. He did not say if it was labeled or not. When asked, Resident 4 stated he did not report it and it has been weeks, and waiting for it to come back.During an interview on 5/29/26 at around 3:40 p.m. with Medical Record Director (MRD), MRD provided the inventory record for Resident 4 dated 6/17/25, the inventory upon admission was not provided.During an interview on 5/29/26 at 4:20 p.m. with SSD, SSD was informed that other residents beside Resident 1 were missing their clothes that was not reported but brought up as a general concern in the resident council meeting; and there were many residents' clothes in the laundry with no names on them. SSD acknowledged residents have a right to have their garments washed and returned to them, and whatever belongings they have. SSD stated they have the obligations to the rights of the residents to have their personal belongings and it is a team effort and an obligation to ensure that happens.During a review of the facility's policy and procedure (P&P) titled, Personal Property, revised date August 2022, the P&P indicated Residents are permitted to retain and use personal possessions, including . clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents.The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.A review of the facility's P&P titled, Resident Rights, revised date February 2021, indicated, . retain and use personal possessions to the maximum extent that space and safety permit.

Based on interview and record review, the facility did not secure the belongings of one of three sampled residents (Resident 1) when Resident 1 ' s had some of her clothing items and money gone missing and facility staff did not create inventory, track, or replace the missing items. This failure resulted in Resident 1 expressing feeling, Frustrating which could affect Resident 1 ' s overall well-being. Findings: During a record review of Resident 1 ' s clinical document, Admission Record, the document showed, the facility admitted Resident 1 in May 2025. Diagnoses included post-polio syndrome. (muscle weakness that can develop in someone who previously had polio). Record review of Resident 1 ' s clinical document, MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 (resident assessment) showed, Resident 1 was oriented to the day, month, and year and could accurately recall words presented to her. During an interview on 4/22/2025 at 9:35 a.m. with Resident 1, Resident 1 stated she had underwear and other clothes Stolen and that she had reported this to Everyone including the social worker. Resident 1 stated staff had made a Half ditched effort to find the items. She stated she also lost $53 which had been stored in her bedside table. Resident 1 stated staff said they would Check the inventory of her belongings when she was admitted . But found the facility had not completed one. Resident found the situation Frustrating. During an interview on 4/22/2025 at 10:20 a.m. with Social Services Director (SSD), SSD stated, she was made aware of Resident 1 ' s missing clothes and money. The SSD stated they had found some of the clothing items and returned them and stated she was Not sure if she had been reimbursed for the money or if the items had been checked on the admission inventory list. Record review of the medical record showed no inventory of Resident 1 ' s belongings on admission. During an interview on 4/22/2025 at 12:05 p.m. with the SSD, SSD confirmed, there was no documented inventory list in the clinical record for Resident 1. During a record review of the facility ' s Policy and Procedure (P&P) document titled, Lost and Found dated 2008, the P&P indicated, Our facility shall assist all personnel and residents in safeguarding their personal property. During a record review of the facility ' s Policy and Procedure (P &P) document titled, Personal Property dated 2022, the P&P indicated, The president ' s personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

Based on observation, interview and record review, the skilled nursing licensed staff did not notify the physician for a change in condition for one of three sampled residents (Resident 1). Resident 1 had a change in mentation and was hallucinating. This resulted in Resident 1 feeling it was a Horrible Experience with a possible unnecessary hospital stay. Findings: During a record review of Resident 1 ' s clinical document, Admission Record, the document indicated the facility admitted Resident 1 in May 2023. Diagnoses included post-polio syndrome. (muscle weakness that can develop in someone who previously had polio). Record review of Resident 1 ' s clinical document, the document MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 (resident assessment) showed Resident 1 was oriented to the day, month, and year and could accurately recall words presented to her. During an interview on 4/22/2025 at 9:35 a.m. with Resident 1, Resident 1 stated she had been Hallucinating and had asked the staff for a test and was Ignored. Resident 1 stated it had been a Horrible experience. Record review of Resident 1 ' s clinical documents Progress Notes showed the following: 2/5/2025: Resident 1 left the facility for an appointment at 11 a.m. At the time she was alert and responsive. 2/5/2025: Resident returned to the facility at 12:17 p.m. and was alert and oriented. 2/5/2025: At 10:45 p.m. Resident 1 told staff there were Snakes under her bed. 2/8/2025: From 11:30 p.m. (2/7/25 )to 1:30 a.m (/2/8/25). Resident 1 tried to elope from the facility and was hallucinating . There was no documentation in the clinical record which showed the doctor had been notified. During an interview on 4/22/2025 at 12:50 p.m., with Director of Nursing (DON), DON confirmed, staff had not notified the doctor regarding Resident 1 ' s change in condition. The DON stated the hallucinations can be a sign of an infection and without treatment, the symptoms can get worse. Record review of Resident 1 ' s clinical document, Progress Note dated 2/8/2025, showed Resident 1 tried to leave the facility as she believed her room was in another building and bugs were crawling All over her room. The MD was notified, and Resident 1 was sent to the hospital. Record review of the document Hospitalist Discharge Summary dated 2/11/2025, showed Resident 1 was admitted into the hospital for two days due to hallucinations. Resident 1 was seen by Psychiatry and prescribed medications. Record review of the document Acute condition Changes - Clinical Protocol dated 2001, showed .the nurse shall assess and document/report the following baseline information: Vital signs; Neurological status; Current level of pain, and any recent changes in pain level; Level of consciousness; Cognitive and emotional status .

Based on interview and record review the skilled nursing facility did not provide services to support dental health and the ability to live independently for one of three sampled Residents (Resident 1) when: 1.Dentist recommendation following a dental exam of Resident 1 to be scheduled as soon as possible for an abscess biopsy was never ordered and carried out. 2. Resident 1 was not provided the assistance she needed to live independently. This failure resulted in the potential for pain and infection, and contributed to Resident 1 feeling Frustrated, thereby negatively impacting their overall well-being, autonomy, and quality of life. Finding: 1.During a record review of Resident 1 ' s clinical document, Admission Record, the document showed, the facility admitted Resident 1 in May 2023. Diagnoses included post-polio syndrome (muscle weakness that can develop in someone who previously had polio). Record review of Resident 1 ' s clinical document, MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 (resident assessment), the document indicated, Resident 1 was oriented to the day, month, and year and could accurately recall words presented to her. Record review of Resident 1 ' s clinical document titled, Lumina Healthcare and Dental dated 7/24/2023, showed Resident 1 had been evaluated by a dentist. Under the section Treatment Recommendation it showed Biopsy ASAP. In a concurrent interview on 4/22/2025 at 12:05 p.m. the Social Services Director (SSD) was asked if the biopsy had been ordered. The SSD stated she was not sure. There was no documentation in the clinical record which showed the biopsy had been ordered. During an interview on 4/22/2025 at 12:20 p.m. with Resident 1 , Resident 1 stated, the biopsy had never been completed. During an interview on 4/22/2025 at 12:50 p.m. with Director of Nursing (DON), DON confirmed there was nothing in the record which showed the biopsy had been done. The DON stated the potential outcome was infection. 2. During an interview on 4/22/2025 at 9:35 a.m. with Resident 1, Resident 1 stated she was Frustrated because she wanted to transition to live independently. In order for that to happen she needed to obtain a new identification card. Resident 1 stated facility staff were not assisting her in obtaining the new card as she has difficulty using her hands due to her medical condition. Record review of the Resident 1 ' s clinical document, Psychosocial Note dated 6/28/2024 showed, SSD had met with Resident 1 to assist her in obtaining a driver ' s license replacement and had made an appointment at the local DMV. During an interview on 4/22/2025 at 10:40 a.m. with SSD, SSD stated the Identification Card issue had been fixed. During an interview on 4/22/2025 at 11:45 a.m. with Resident 1, resident 1 stated she still did not have a new ID card, and it was Frustrating. During an interview on 4/22/2025 at 12 noon with Minimum Data Set nurse (MDS RN), MDS (RN) stated, he had assisted Resident 1 in obtaining a new ID but ran into problems as it required a birth certificate which she did not have. It also required her to take a driving test which she physically was unable to do. The MDS RN stated he reported this to the SSD. Record review of the document Progress Notes dated 3/31/2025 confirmed the MDS RN had assisted Resident 1. The MDS RN documented I attempted to get her a real ID, but she will need a certified copy of her birth certificate or passport of which she had none and that the lack of documents .Complicates things but that the SSD can help her further. The MDS RN documented Resident 1 was left Upset and crying. During an interview on 4/22/2025 at 12:02 p.m. the SSD confirmed she had not followed up regarding the ID card. Record review of the document Job Description dated 3/22/2021, showed the Social Services Director Directs the overall operation of the Social Services Department in accordance with current federal, state, and local standards, guidelines and regulations and Company policies and procedures to assist each resident and family adjust to placement, illness and plan of care so as to attain the highest practicable level of functioning. Duties and Responsibilities included Ensures ongoing evaluations for dental, vision and mental health exams and follow up.

Based on observation, interview and record review, the facility failed to ensure a clean, orderly homelike environment when: -Resident rooms had build-up of white crumbs on the floor and personal items like disposable briefs and pillows were piled on a chair at the bedside. -There was insufficient supply of bath towels, face towels, and bed linens available for residents to use. Based on observation, interview and record review, the facility failed to ensure a clean, orderly homelike environment when: -Resident rooms had build-up of white crumbs on the floor and personal items like disposable briefs and pillows were piled on a chair at the bedside. -There was insufficient supply of bath towels, face towels, and bed linens available for residents to use. This failure had resulted in unsanitary and uncomfortable environment for residents and negatively impact their dignity, comfort and safety. Findings: During a concurrent observation and interview on 3/20/25 at 10:32 a.m. with Resident 3, Resident 3 stated there were not enough supplies at the facility. There were white crumbs on the floor, three pillows and a disposable brief piled on a regular chair at Resident 3's bedside rather than stored appropriately or used for resident comfort. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/14/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen is an indication of intact cognitive status) score of 15. A BIMS score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 3/20/25 at 12:25 p.m. with Resident 3, Resident 3 stated they have not cleaned the room yet. The lunch trays were at the bedside, there was still a pile of pillows and disposable brief in the chair. During an interview on 4/9/25 at 11:19 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated there has been shortage of linens and towels since December 2024. CNA 1 stated using disposable dry wipes to dry the residents after shower. She also stated finding mattress covers for eight of her residents was also a challenge, and out of the eight beds she had to make today, CNA 1 stated only three beds were made. During an observation on 4/9/25 at 11:24 a.m., the clean linen closet had several gowns, three pillowcases, three mattress covers, and several top sheets but there were no towels. During an interview on 4/9/25 at 11:32 a.m. with Director of Staff Development (DSD), DSD stated the CNAs have been complaining of not having enough supplies like towels. DSD stated some scheduled showers were moved to the pm shift and pm shift CNAs have complained they did not have enough towels to use for the residents. During a concurrent observation and joint interview and review of monthly inventory on 4/9/25 at 11:42 a.m. with Laundry Aide (LA) and Housekeeping Manager (HM), HM stated there were four scheduled laundry delivery for the resident care areas, first three at 7 a.m., 9:00 a.m., 11 a.m. for the morning shift, and 2 p.m. for the pm shift. LA stated there were no bath and face towels delivered at 7 a.m., 9 a.m., and 11 a.m. because she did not have anything in the laundry. There were two clean, folded bath towels on the folding table, LA stated that was all she had in addition to whatever was in the drier. LA then pulled out the clean and dried laundry from the drier and found four bath towels and two face towels. LA stated she would have 6 bath towels and 2 face towels to deliver to the resident care areas. Review of the Monthly Linen Inventory dated 4/1/25 indicated, for a resident census of 46, the facility needed: 276 bath towels, the facility had total of only 14 towels; 460 wash cloths, facility had 109 wash cloths; 92 bedspreads, facility had 6 bed spreads; 92 blankets, facility had 66 blankets; 138 bath blankets, facility had 62 bath blankets.

Based on interview and record review, for one of three sampled residents (Resident 2), the facility failed to develop and implement an effective discharge planning process that focuses on resident's effective transition to post-discharge care when Resident 2 was discharged to a friend's home without the friend's consent. This failure had led to Resident 2 going to a homeless shelter after police were called to remove Resident 2 from the friend's home. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility in June 2017. The admission Record indicated the name and contact number of Friend (FR) who was listed as other. There was no diagnosis information in the admission Record. During a review of Resident 2's discharge care plan initiated on 11/15/24, the care plan indicated Resident discharged is unknown or uncertain this time, and the following interventions included: Resident will continue in long term care .IDT (interdisciplinary team, a group composed of individuals representing different departments of the facility) will re-evaluate DC (discharge) plan and discuss with resident/family every 3 months or as needed . The care plan did not indicate it was ever revised to reflect updates on Resident 2's discharge location. During a concurrent interview and record review on 4/8/25 at 11:13 a.m. with Social Services Director (SSD), Resident 2's clinical record was reviewed. SSD stated Resident 2 has not been paying his share of cost (SOC, a monthly amount a beneficiary is required to pay towards their medical expenses before Medi-Cal begins covering costs. This is essentially a deductible for Medi-Cal beneficiaries, similar to a private insurance plan's out-of-pocket deductible.) since before September 2024. SSD stated several options of Board and Care were offered to Resident 2. SSD also stated Resident 2 had a friend, FR, who would come to visit Resident 2 at the facility. SSD stated, as Resident 2's discharge date approached, the plan was for Resident 2 to be discharged to FR's home. SSD stated she did not discuss the plan with FR but assumed FR was agreeable to it. SSD stated Resident 2 was dropped off at FR's home on [DATE] via the facility's van. During a review of Resident 2's Psychosocial Note, the Psychosocial Note indicated documentation that included the following. - 11/27/24 SSD provided a copy of 30-day eviction notice to Resident 2 due to Resident 2 not paying for stay in the facility. SSD will assist Resident 2 and provide resources in finding placement. -12/10/24, SSD asked Resident 2 if he had a place to go home to by 12/27/24, Resident 2 stated I don't know .I have credit card to pay. -12/24/24, Social Worker (SW) wrote, Wrote down 3 options for resident .has three options with dedicated bed and ready on 12/27 . The note indicated SW presented three addresses that included FR's home address, Resident 2 was out of the building at the time, options were discussed via phone, Resident 2 hung up. -12/27/24, Met with resident to discuss [discharge] today, Resident said no. Again, emphasized with resident that [Resident 2] has been accepted to two facilities and is within reason and within [Resident 2's] budget. Resident refused to listen. Transportation has been arranged for resident to be picked up at 1 pm. -12/27/24, Resident 2 Agreeing to go to [FR's] house .also gave resident resource for shelter through [Core of Contra [NAME]]. Was told that if [Resident 2] calls the number at 4 pm they will pick [Resident 2] up and take him to shelter that has availability. Number written on post it for [Resident 2] on [discharge] paperwork. -12/27/24, Resident discharge today .to home with a friend [FR] .Resident was [dropped off] by the facility driver via van . During a telephone interview on 4/8/25 at 11:25 a.m. with FR, FR stated not being told by staff that Resident 2 was going to be dropped off at FR's home. FR stated visiting Resident 2 a month prior to being discharged from the facility and this idea has never been brought up. FR stated she was surprised to find Resident 2 in the home's garage without prior notice, prompting FR to call law enforcement. Police arrived at the home, took Resident 2, but after few hours, Resident 2 returned to FR's home. Police were called again and escorted Resident 2 out of the property. FR stated Resident 2 spent a night in jail before being taken to a homeless shelter. FR stated Resident 2 did not have a garage door opener, the garage door was left unlocked, and Resident 2 was able to open it. During a review of the facility's policy and procedure (P&P) titled Transfer or Discharge, Facility-Initiated last revised October 2022, the P&P indicated, For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the changes (s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning. During a review of Resident 2's Discharge Instruction Form dated 12/24/24, the Discharge Instruction Form did not indicate emergency contact information/numbers and symptoms for which to call the doctor, housing arrangements, primary physician and pharmacy information.

Based on interview and record review, for one of three sampled residents (Resident 2) the facility failed to complete a discharge summary that included the following information: A recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of Resident 2's stay that includes diagnoses, course of illness/treatment or therapy, pertinent laboratory, radiology and consultation results. A final summary of Resident 2's status at the time of discharge and reconciliation of all pre-discharge medications with the resident's post-discharge medications. This failure had the potential to result in the lack of information affecting continuity of care. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility in June 2017. There was no diagnosis information in the admission Record. During a review of Resident 2's discharge care plan initiated on 11/15/24, the care plan indicated Resident discharged is unknown or uncertain this time, and the following interventions included Resident will continue in long term care .IDT (interdisciplinary team, a group composed of individuals representing different departments of the facility) will re-evaluate DC (discharge) plan and discuss with resident/family every 3 months or as needed . The care plan did not indicate it was ever revised to reflect updates on Resident 2's discharge location. During a concurrent interview and record review on 4/8/25 at 11:13 a.m. with Social Services Director (SSD), Resident 2's clinical record was reviewed. SSD stated, as Resident 2's discharge date approached, the facility's plan was for Resident 2 to be discharged to FR's (Friend) home. SSD stated she did not discuss the plan with FR but assumed FR was agreeable to it. SSD stated Resident 2 was dropped off at FR's home on [DATE] via the facility's van. During a review of Resident 2's Psychosocial Note, the Psychosocial Note indicated documentation that included the following: -11/27/24 SSD provided a copy of 30-day eviction notice to Resident 2 due to Resident 2 not paying for stay in the facility. SSD will assist Resident 2 and provide resources in finding placement. -12/27/24, Resident discharge today .to home with a friend [FR] .Resident was [dropped off] by the facility driver via van . During a review of Resident 2's Discharge Summary signed and dated 12/30/24, the Discharge Summary indicated Resident 2's discharge date as 12/27/24, and indicated the following admitting diagnoses: aphasia (a language disorder that impairs a person's ability to communicate due to brain damage), cardiomyopathy (a disease that affects the heart muscle, making it harder for the heart to pump blood to the rest of the body), CHF (Congestive Heart Failure, a condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other parts of the body), Paroxysmal Afib (atrial fibrillation, an intermittent type of irregular heartbeat in the upper chambers of the heart), hypertension (a condition where the force of blood pushing against the artery walls is consistently too high), fatty liver (a condition where excess fat accumulates in the liver, often with no symptoms, but can lead to complications like cirrhosis and liver cancer if left untreated), hyperlipidemia (a condition characterized by abnormally high levels of fats (lipids) in the blood, including cholesterol and triglycerides), morbid obesity and benign prostatic hyperplasia (BPH, refers to the non-cancerous enlargement of the prostate gland). The Discharge Summary also indicated the following information: COURSE in SNF: Other: Home with friend, Discharge Status: Home, Discharge Diagnosis: Same as above. The facility was not able to show documentation of post-discharge plan. During a review of the facility's policy and procedure (P&P) titled Discharge Summary and Plan last revised December 2016, the P&P indicated when the facility anticipates to discharge a resident to a private residence, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The discharge summary will include a recapitulation of the resident's stay at the facility and shall include course of illness/treatment since entering the facility, physical and mental functional status.

Based on interview and record review, for one of three sampled residents (Resident 3), the facility failed to ensure Resident 2 received treatment and care in accordance with professional standards of practice when: -A stage 2 pressure ulcer (also known as bedsores or pressure sores, are localized skin and soft tissue injuries caused by prolonged pressure, often over bony areas, resulting in reduced blood flow and potential tissue damage) on a bony prominence (a part of the skeleton where a bone is close to the surface of the skin) was assessed as a skin tear. This failure had the potential to result in delayed management of the wound. -Resident 2's foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) was changed from F16 to F18 (Foley catheters are sized using the French (Fr) system, F18 catheter is larger than a F16 catheter) without a physician's order. This failure had the potential to result in unnecessary tissue trauma. Findings: During a review of Resident 3's Admission Record, the Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included cord compression (occurs when pressure is applied to the spinal cord, the central nervous system pathway connecting the brain to the rest of the body) and benign neoplasm of pituitary gland (a noncancerous growth, also known as a pituitary adenoma, on the pituitary gland. These tumors are extremely common and usually don't spread beyond the pituitary gland). During a review of Resident 3's Braden Scale for Predicting Pressure Sore Risk dated 2/17/25 indicated a score of 13. A score of 13 is an indication of moderate risk to develop pressure sore. During an interview on 3/20/25 at 2:23 p.m. with Treatment Nurse (TN), TN stated, on 2/18/25, a Certified Nursing Assistant (CNA) told her Resident 3 had a wound on the coccyx. TN stated, at the time, the skin on the area appeared thin and had darkened area surrounding the wound, TN thought it was a skin tear. TN stated, two days later, the wound doctor was in the facility and assessed Resident 3's wound as a stage 2 pressure ulcer. During a review of Resident 3's Health Status Note dated 2/18/25, the Health Status Note indicated Resident 3 had a skin tear on the coccyx that measured 7 centimeters (cm) x 7 cm. During a review of Resident 3's Skin & Wound Evaluation dated 3/14/25 (almost 4 weeks later), the Skin & Wound Evaluation indicated Resident 3's coccyx (tailbone) pressure ulcer was a Stage 4 that measured 5.7 cm x 5.7 cm. During an interview on 3/20/25 at 1:29 p.m. with Director of Nursing (DON), DON stated there was no care plan to address Resident 3's risk for development of a pressure ulcer despite the moderate risk and Resident 3's limited mobility. DON also stated the stage 2 pressure ulcer that developed on Resident 3's coccyx was incorrectly identified as a skin tear. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/14/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen is an indication of intact cognitive status) score of 15. A BIMS score of 13-15 is an indication of intact cognitive status. During an interview on 3/20/25 at 11:54 a.m. with Resident 3, Resident 3 stated feeling concerned about the staff not being able to care for Resident 3's foley catheter. Resident 3 stated the licensed staff did not seem to know what to do with the foley catheter that Resident 3 had to be transferred to the hospital catheter issues. During a joint interview on 4/8/25 at 2:45 p.m. with DON and TN, TN stated when she came to work on 2/25/25, Resident 3's foley catheter was a different size than what was ordered. TN stated a Progress Note dated 2/22/25 indicated, the foley catheter change to a F18 was ordered by a Nurse Practitioner (NP) who was in the facility. TN stated writing the order for F18 and transcribed in the Treatment Administration Record (TAR). Review of the TAR for February 2025 indicated both F16 and F18 foley catheter were signed off every shift by licensed nurses. DON stated there was no written physician's order for the change in foley catheter size in the clinical record. DON also stated the order for F16 should have been discontinued and should have been reflected in the TAR. DON stated having two orders of different sizes of foley catheter could be confusing because licensed nurses would not know which one to use the next time the foley catheter had to be changed. During a telephone interview on 4/10/25 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the NP told Resident 3 that the foley catheter would be changed to F18. LVN 1 confirmed changing Resident 3's foley catheter to a F18 but could not recall how she wrote the verbal order, or if it was written and transcribed at all. LVN 1 stated she did not discontinue the previous order because she did not think the order needed to be discontinued. LVN also stated she did not clarify the order because the NP was Rushing to leave.

Based on observation, interview, and record review, the facility failed to follow food safety standards: 1. Cook1 did not wear beard net while preparing desert, when he had about an inch long beard. 2. Five bowls with dry cereal and one bowl with white granulated powder were left unlabeled and undated in the kitchen cabinet. These failures posed a potential risk for food safety and placed facility's residents at risk for food borne illnesses. Findings: During a concurrent observation and interview with [NAME] 1 and Dietary Services Supervisor (DSS) on 1/21/25 at 9:42 a.m., in the kitchen, [NAME] 1 was preparing desert that needed to be served during lunch on that day. [NAME] 1 had a surgical mask on his face, with about one-inch-long uncovered beard visible on both sides of the face, and did not have a beard net on. When asked if facility provided beard nets, Cook1 asked if he needed to wear beard net even with face mask on. During a review of facility's Policy and Procedure (P&P) titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated 11/2022, the P&P indicated, Hair net or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. During a concurrent observation and interview with DSS and [NAME] 1 on 1/21/25 at 9:53 a.m., in the kitchen, there were five bowls with dry cereal covered with a clear plastic wrap; and one small bowl with white granulated powder covered with plastic lid in a closed cabinet, with other clean utensils. Both cereal bowls and bowl with white powder were not labeled and dated. [NAME] 1 stated the cereal in the bowls were poured that morning and Evening [NAME] was responsible for adding the label onto the cereal bowls. DSS then stated any food should be labeled and always dated. DSS stated the white granulated powder was food thickener and needed to be labeled as well. During a review of facility's P&P titled Food Receiving and Storage dated 11/2022, the P&P indicated, Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date).

Based on interview and record review, for eight of 31 sampled residents (Residents 2, 11, 14, 18, 37, 38, 46 and 249), the facility failed to offer or ensure an advance directive (a written instruction for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) was on file, when the facility did not offer to locate or help the residents/representatives complete the document. This failure had the potential for Residents 2, 11, 14, 18, 37, 38, 46, and 249's wishes regarding provision of health care to not be honored. Findings: During a record review of the Resident 2's Admission Record, printed 1/23/25, it indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), paranoid schizophrenia (a mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), epilepsy (a brain disorder in which a person has repeated seizures over time. Seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements), amnestic disorder (a condition that causes memory loss, making it difficult to learn new information or recall past events), and cognitive communication deficit (a difficulty with communication caused by an impaired thinking). Review of Resident 2's clinical record indicated there was no documentation that Resident 2 or her representative were asked about the existence of any advance directives. During a record review of Resident 14's Admission Record, printed 1/23/25, it indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including epilepsy, hypertensive heart disease (heart conditions caused by long-term high blood pressure. It occurs when the heart must work harder to pump blood through narrowed arteries, which can thicken the heart muscle over time), delusional disorders (a mental health condition that involves having fixed false beliefs that are not based in reality. People with delusional disorder can have delusions about their relationships, their bodies, or the world around them), dementia, and congestive heart failure (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs). Review of Resident 14's clinical record indicated there was no documentation that Resident 14 or his representative were asked about the existence of any advance directives. During a record review of Resident 37's Admission Record, printed 1/23/25, it indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including multiple rib fractures (broken bones), depression (a mental disorder that involves a long-lasting low mood and loss of interest in activities. It can affect how a person feels, thinks, and behaves), psychoactive substance abuse (the harmful or hazardous use of mind-altering substances, including alcohol and illicit drugs), and alcohol abuse. Review of Resident 37's clinical record indicated there was no documentation that Resident 37 or his representative were asked about the existence of any advance directives. During a record review of Resident 46's Admission Record, printed 1/23/25, it indicated Resident 46 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), hypertension (a chronic condition where the force of blood in your arteries is consistently too high), suicidal ideations (thoughts of suicide or taking your own life), and anxiety. Review of Resident 46's clinical record indicated there was no documentation that Resident 46 or his representative were asked about the existence of any advance directives. During an interview on 1/23/25 at 1:00 p.m., Medical Records (MR) staff stated the facility does not have advance directives on file for Residents 2, 14, 37, and 46. During a phone interview on 1/24/25 at 8:39 a.m., Resident 14's responsible party (RP) stated since the facility did not have an advance directive on file, the RP felt worried because the facility might not care for Resident 14 appropriately if there was a sudden health decline. During an interview on 1/24/25 at 9:56 a.m., the Social Services Director (SSD) stated both the admitting nurse and the SSD are responsible for ensuring advance-[NAME] directives are on file, or residents are offered help in making one. The SSD stated this issue should also be reviewed at each interdisciplinary team (IDT- refers to a meeting where healthcare professionals from different disciplines within a long-term care facility, such as doctors, nurses, physical therapists, social workers, and nutritionists, come together to discuss and coordinate the care plan of a resident, considering their holistic needs including physical, mental, and social aspects, to ensure the best possible care delivery) conference, and should be documented in the residents record to prove it was done. The SSD stated if the resident did not have an advance directive, their wishes may not be followed in case of incapacitation. During a record review of the facility's policy and procedure titled, Advanced Directives, revised 2013, it indicated, 1. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including right to accept or refuse medical or surgical treatment, and the right to formulate advanced directives .5.If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. The resident will be given the option to accept or decline the assistance, and the care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist, and the resident's decision to accept or decline. 2. a. During a review of Resident 11's admission record, dated 1/23/25, indicated Resident 11 was admitted to the facility on [DATE]. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated assessment tool) dated, 12/27/24, indicated Resident had multiple diagnoses that included, Asthma (lung condition that causes inflammation and narrowing of airways), Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause long-term breathing problem). b. During a review of Resident 18's admission record, dated, 1/23/25, the admission record indicated Resident 18 was admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of Resident 18's MDS, dated [DATE], indicated, Resident 18 had multiple diagnoses which included progressive neurological conditions (type of illness that affects the nervous system like brain, spinal cord, or nerves and gets worse over time) that included cerebral palsy (condition that affects posture and movement) quadriplegia [(condition characterized by the loss of impairment of movement and sensation in all four limbs (arms and legs)] seizure or epilepsy (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, loss of consciousness), muscle wasting and atrophy (loss of muscle mass and strength). During a concurrent interview and record review on 1/23/25 at 10:34 a.m. with Medical Records (MR), MR stated there was no Physician Orders for Life-Sustaining Treatment (POLST, medical order that provide clear instructions to healthcare providers about the medical treatments a patient wants or does not want to receive in the event of a serious illness or medical emergency) or advance directive in Resident 11 and Resident 18's Electronic Health Records (EHR) and record chart. MR further added, she was responsible for ensuring POLST form and Advance Directive was in resident chart. During a concurrent interview and record review on 1/23/25 at 3:25 p.m. with Social Service Director (SSD), in SSD's office, SSD stated, Resident 11 and 18 did not have POLST in their chart. SSD further stated, POLST was important for staff to know if there was advance directive in place so that treatment preference can be carried out in case anything happens, or in emergency situation. 49091 3) During a record review of the Admission Record, the record indicated Resident 38 was admitted to the facility 10/11/2024. During a record review of the Admission Record, the record indicated Resident 249 was admitted to the facility 1/2/2025. During a record review on 1/21/2025 at 5:37 p.m., Resident 38 and Resident 249's Electronic Health Record (EHR) were reviewed, and no Advanced Directives (AD) was found. During an interview on 1/22/2025 at 11:09 a.m. with Social Service Director (SSD), when asked for Advance Directives for Resident 38 and Resident 249, SSD stated she needed time to look for that information. During a concurrent interview and record review on 1/24/2025 at 10:02 a.m. with Director of Nursing (DON), DON stated facility did not have or had reached out to Resident 249 and Resident 38 and/or their family representatives to offer them resources to have Advance Directives on their files until 1/22/2025. During a review of the facility's policy and procedure (P&P) titled Advance Directives, dated 12/16, the Advance Directive indicated, 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family member and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. During a review of facility's Policy and Procedure (P&P) titled Requesting, Refusing and/or Discontinuing Care or Treatment dated 2/2021, the P&P indicated, Residents/representatives are informed of his or her rights to formulate an advance directive. 51636

Based on observation, interview and record review, the facility failed to accurately assess two of three sampled residents (Resident 13 and Resident 23) for tobacco use status on comprehensive Minimum Data Set (MDS, an assessment used to guide care). Facility inaccurately coded NO to Current Tobacco Use for Resident 13 and Resident 23 who were smoking daily. The failure resulted in inaccurate reflection of Resident 13 and Resident 23's clinical status and placed them at risk for not receiving person-centered care. Findings: During a record review of Resident 13's Admission Record, printed on 1/24/25, the record indicated Resident 13 was admitted to the facility on [DATE]. During a record review of Resident 23's Admission Record, printed on 1/24/25, the record indicated Resident 23 was admitted to the facility on [DATE]. During an observation on 1/22/25, 1/23/25, 1/24/25 at 10:10 a.m., 1:19 a.m., and 10:16 a.m. respectively, Resident 13 and Resident 23 were observed smoking at facility's patio. During an interview on 1/23/25 at 11:42 a.m., Resident 13 stated he started smoking when he was teenager, and never quit smoking since then. During an interview on 1/24/25 at 10:00 a.m., Resident 23 stated she has been smoking since her 20's without a quitting period. During an interview on 1/24/25 at 10:15 a.m., Restorative Nursing Aid(RNA), who was supervising Resident 13 and Resident 23 during smoking time at the facility's patio, stated Resident 13 and Resident 23 had been smoking since their admission to the facility. During an interview and record review with facility's MDS Coordinator (MDSC) on 1/24/25 at 11:27 a.m., Resident 13's Significant change in status MDS assessment dated [DATE]; and Resident 23's Admission MDS assessment dated [DATE] were reviewed. The MDS assessments for Resident 13 and Resident 23 indicated both residents were cognitively intact and were not using tobacco at the time of assessments were completed. The MDSC stated he inaccurately coded the MDS on Current Tobacco Use section for both resident s, because both resident s were smokers.

Based on interview and record review the facility failed to have Registered Nurse (RN) coverage for at least eight (8) consecutive hours a day for a total of 11 days. This deficient practice had the potential to cause delayed delivery of necessary assessment and treatment services for resident's day-to-day care. Findings: During a record review of the facilities Payroll Based Journal (1/2024 - 12/2024) was reviewed, which indicated the facility did not use the services of an RN for at least eight consecutive hours a day on the following dates: 1/13/24, 1/27/24, 2/11/24, 2/17/24, 2/25/24, 3/2/24, 3/3/24, 3/30/24, 7/21/24, 7/28/24, and 8/31/24. During a concurrent interview and record review on 1/23/25 at 1:53 p.m. with the Administrator (ADM), the facility payroll document titled NHPPD SNF CNA/RNA HOURS, dated 1/13/24 - 8/31/24 was reviewed. The ADM acknowledged there was not an RN in the facility for eight consecutive hours a day on the following days: 1/13/24, 1/27/24, 2/11/24, 2/17/24, 2/25/24, 3/2/24, 3/3/24, 3/30/24, 7/21/24, 7/28/24, and 8/31/24. The ADM stated this practice put resident health at risk since Licensed Vocational Nurses do not have as the same knowledge level and skills as RN's. During an interview on 1/23/25 at 2:55 p.m., Licensed Vocational Nurse 1 (LVN1) stated RN's are needed in the facility to perform formal nursing assessments, and to provide experienced oversight in emergencies. During a record review of the facility document titled Fall Incidents 2024, (undated), it indicated there were two resident falls when an RN was not onsite to perform a post-fall assessment (7/28/24 and 8/31/24). During a record review of the Facility Assessment Tool, dated 6/2024-1/2025, it indicated Staffing: 1 DON (Director of Nursing) RN full-time days; if has other responsibilities, add RN as assistant DON to equal one FTE (full-time position), and the facility provides sufficient staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services policies and procedures were followed when: 1. Licensed Vocational Nurse (LVN) 1 left the medication cart unlocked and unattended in the hallway. 2. The refrigerator for medication was not maintained within the required temperature range of 36 F to 46 F as outlined in the facility policy and procedure. These failures had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety due to improper storage conditions. Findings: 1. During an observation on 1/21/25, at 2:55 p.m., medication cart II was unlocked, unsupervised and unattended with drawers facing the hallway directly outside the dining and activity room. During a concurrent observation and interview with LVN 1 on 1/21/25 at 2:57 p.m., LVN 1 returned to the medication cart II then proceeded to lock the cart. LVN 1 stated, she did not ensure it fully locked prior to leaving medication cart II unattended. LVN 1 further added, it was important to keep medication cart locked because anyone unauthorized can take medications from the cart. 2. During a concurrent observation and interview on 1/23/25, at 12:45 p.m. inside the medication room, with the Director Of Nursing (DON), there were multiple medications including vaccines, insulin, Tuberculosis skin test, and a refrigerated emergency kit containing various medications, were stored at a temperature of 30 F, as indicated by the thermometer. DON stated, refrigerated medications should be stored at 40 F. DON further added, medications stored outside the parameters may be compromised and become ineffective. During a concurrent interview and a second observation on 1/24/25, at 1:37 p.m. a second observation of storage of refrigerated medications was conducted with the DON. The temperature of the refrigerator storing refrigerated medications was noted to be 35 F. DON stated, the temperature was not acceptable and that refrigerated medications are compromised. DON acknowledged, he did not take corrective actions concerning proper storage of refrigerated medications. During a review of the facility's policy and procedure (P&P), titled Security of Medication Cart, dated, April 2007, the P&P indicated, 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room. 3.the cart should be parked in the hallway against the wall with doors and drawers facing the wall . 4. The medication carts must be securely locked at all times when out of the nurse's view. During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, dated, 4/2008, indicated, Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is only accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized.B. Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During a review of the facility's P&P titled, MEDICATION STORAGE IN THE FACILITY, dated, 4/2008, indicated, Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .K. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring.O. Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.

Based on interview, and record review, the facility failed to comply with Health Insurance Portability and Accountability Act (HIPAA) to protect Resident-identifiable information, including but not limited to full name, date of birth (DOB), and clinical status. Clinical staff including attending physician, nurses, nursing managers; and non-clinical staff including Administration, medical records personnel used their personal cell phones to exchange residents' Protected Health Information (PHI) and confidential biographical details and received text messages for above details even when they were off duty. This failure posed a potential significant risk to protect the privacy and security of facility's residents' information. Findings: During an interview and record review with Licensed Vocational Nurse (LVN) 1 on 1/24/25 at 12:17 p.m., Resident 249's clinical chart for pain management was reviewed. LVN 1 stated she was aware of Resident 249's complaints of pain as she had notified the doctor about it. When asked to show the communication between LVN 1 and Resident 249's doctor, LVN 1 stated she used her personal cell phone to send a text message Resident 249's doctor. During an interview and record review with LVN 1 on 1/24/25 at 12:20 p.m., LVN 1's personal phone was reviewed. LVN 1 stated she used an app called Signal to send a group text thread to clinical team which included doctor, nurses working at the facility, and management team including Director of Nursing (DON), Director of Staff Development (DSD), Administrator (ADM). LVN 1 then showed the group text message dated 1/15/25, which included Resident 249's full name, DOB, and included details for his complaints of pain, episode of fall, request to change his pain medication, details of current narcotic pain medication including name and dosage of the medication. LVN 1 then stated all staff had access to Signal messaging app. LVN 1 stated she was not sure if it was an encrypted app. LVN 1 stated she had been using this messaging app to exchange resident's PHI since she started working at the facility, 09/2024. LVN 1 also stated she took her personal cell phone with her, at her home, at the restaurants, in public areas, when she was off the clock and not working, posing a higher risk of lost/stolen residents' PHI. During an interview with DON on 1/24/25 at 12:43 p.m., DON stated he did not have a facility designated device assigned to him and had Signal app downloaded on his personal cell phone. DON stated he did not know how to ensure if Signal app was an encrypted application. DON stated he needed to enter a passcode to open the Signal app only once a while but not all the time. DON stated he was able to access all text messages and residents' PHI exchanged among staff on the Signal app, even when he was off the clock. The DON stated he carried his personal cell phone around wherever he needed to go, when he was off the clock. The DON stated his staff also continued to get the messages even when they were off. The DON stated it was risky because anyone could break into their personal cell phones, posing an extreme risk for breech to residents' PHI, however they had not discussed this being an issue as an Interdisciplinary Team (IDT) so far. During an interview with ADM on 1/24/25 at 12:56 p.m., ADM stated she did not think exchanging residents' PHI, using Signal app on staff's personal cell phones was concerning as she had verbally reminded the staff not to view and respond to the messages when they were off duty. ADM stated she considered reminding staff. During an interview and record with facility's Clinical Consultant (CC) and ADM on 1/24/25 at 1:43 p.m., facility's California Employee Handbook 2023 was reviewed. ADM stated facility followed the handbook to maintain confidentiality of residents' records. The handbook indicated, ADM and certain staff members were permitted to use their personal mobile devices during work hours to communicate facility related business .If you use devices on which information may be received and/or stored, including but not limited to cell phones .you are required to use these methods in strict compliance with the trade secrets and confidential communication policy established by the facility . CC stated providing access to facility residents' PHI to the staff on their personal cell phone and being able to access this info even when the staff was not on the clock/working, posed risk for medical breach. The CC also stated it was likely not enough to just remind the staff not to use personal device/apps when they are off the clock. During a review of facility's Policy and Procedure (P&P) titled Confidentiality of Information and Personal Privacy dated 10/2017, the P&P indicated, The facility will safeguard the personal privacy and confidentiality of all residents personal and medical records.

Based on observation, interview, and record review, the facility failed to follow infection control prevention practices when: 1. Resident 11's nasal cannula (nc, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was undated and unlabeled. 2. LVN (Licensed Vocational Nurse) 3 did not properly disinfect stethoscope (a device used to amplify internal body sounds) between residents. 3. Housekeeping Manager (HKM) held Resident 14's clean blankets against her clothing during transport to Resident 14's room. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During a review of Resident 11's admission record, dated 1/23/25, indicated Resident 11 was admitted to the facility on [DATE]. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated assessment tool) dated, 12/27/24, indicated Resident had multiple diagnoses that included, Asthma (lung condition that causes inflammation and narrowing of airways), Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause long-term breathing problem). During a review of Resident 11's order summary report, dated 12/22/24, indicated, oxygen: Change oxygen tubing to include NC and/or mask & storage bag every week. Date tubing and bag . During an observation on 1/21/25, at 10:33 a.m., Resident 11 was observed receiving oxygen via nc. The nc tubing was not labeled with date. During a concurrent observation and interview on 1/21/25 at 10:44 a.m. with LVN 3, LVN 3 acknowledged nc tubing was not labeled or dated. LVN 3 stated, there was no way for nursing team to know when the nc tubing was due to be changed when not labeled. LVN 3 added, the importance of labeling the nc tubing was to prevent Resident 11 who received oxygen from developing infection. During a review of the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy) - Prevention of Infection, dated 12/2011, the P&P indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The P&P further indicated, .7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 2. During a concurrent observation and interview on 1/22/25 at 7:48 a.m. LVN 3 was observed using a stethoscope on Resident 22 and 14 without cleaning and disinfecting the stethoscope in between residents. LVN 3 was then observed using same stethoscope on Resident 31 and 1 also without cleaning and disinfecting between residents. LVN 3 stated, there was risk of spread of infection when she did not clean and disinfect stethoscope between residents. During an interview on 1/22/25, at 9:15 a.m., with the Infection Preventionist (IP), IP stated, stethoscope was a shared equipment and must be disinfected between each resident. IP added, there was risk of cross contamination when shared equipment was not disinfected after each use. IP also stated, it was important for nc tubing to be labeled with date, so that nursing team will know when the tubing is due to be changed. IP further stated, there was risk for infection especially for residents with low immune system. During a review of facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, indicated, .5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment. 3. During a concurrent observation and interview on 1/24/25, at 11:35 a.m. in the presence of facility's IP, at the stairwell, HKM was seen carrying four clean blankets with her arms wrapped around holding the blankets against her personal clothing. HKM stated, she was transporting the blankets from laundry to Resident 14's room. IP acknowledged, HKM did not follow infection control practices and stated, HKM should have kept the beddings covered during transport to residents' room. During a follow up interview on 1/24/25, at 11:50 a.m., HKM acknowledged she did not follow policy when she carried residents bedding without cover, and held the beddings against her clothing. HKM also added, she was supposed to keep newly washed bedding clean during transport by securing the items in clean bag. During a review of facility's P&P, titled Departmental (Environmental Services)- Laundry and Linen, dated, 1/2014, indicated, The purpose of this procedure is to provide a process for the safe and septic handling, washing, and storage of linen. P&P also indicated, .7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. During a review of facility's P&P, titled Laundry and Bedding, Soiled, dated 9/2022, indicated under Transport .6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness.

Based on observation, interview, and record review, the facility failed to provide care with dignity for one of three sampled residents (Resident 18) when two facility staff did not provide privacy for Resident 18 during nursing care. This deficient practice resulted in not ensuring resident 18's right to be treated with dignity and respect. Findings: During a review of Resident 18's admission record, dated, 1/23/25, the admission record indicated Resident 18 was admitted to the facility on [DATE] and was readmitted on [DATE]. During a review of Resident 18's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/17/24, indicated Resident 18 had multiple diagnoses which included progressive neurological conditions (type of illness that affects the nervous system like brain, spinal cord, or nerves and gets worse over time) that included cerebral palsy (condition that affects posture and movement), quadriplegia [(condition characterized by the loss of impairment of movement and sensation in all four limbs (arms and legs)], seizure or epilepsy (sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, loss of consciousness), muscle wasting and atrophy (loss of muscle mass and strength). The MDS, revealed, Resident 18 had functional limited in range of motion in the upper and lower extremities on both sides. The MDS also revealed, Resident 18 was dependent on two or more helpers with upper and lower body dressing and with rolling on left and right side. During an observation on 1/22/25, at 9:58 a.m., in Resident 18's room, Licensed Vocational Nurse (LVN) 2, provided wound care treatment to Resident 18's left ischium (lower back part of hip bone) while Certified Nursing Assistant (CNA) 1 helped. Resident 18's buttocks were fully exposed. LVN 2 performed wound care treatment while window blinds were left open, and curtain was not drawn to provide privacy. LVN 2 stated, Resident 18 was not treated with dignity during treatment. CNA, acknowledged Resident 18's rights were violated when not provided privacy during nursing care. During an interview on 1/22/25, at 11:25 a.m., with the Director Of Staff Development (DSD), DSD stated, she was aware LVN 2 and CNA 1 did not provide privacy to Resident 18 during nursing care. DSD further added, the expectation was for the staff to draw curtain to provide privacy during wound care because Resident 18 can be seen exposed by other residents. DSD also stated, LVN 2 and CNA 1 will be given one-on-one in-service training on resident rights. A review of the facility's policy and procedure (P&P) titled, Resident Rights, dated, 2/2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. The P&P also indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; .t. privacy .

Based on observation, interview and record review, the facility failed to ensure an assessment and/or an evaluation for self-administration of medications was completed for one of 46 sampled residents (Resident 11) when the following were observed on Resident 11's bedside table: a. a bottle of Nystatin (antifungal antibiotic topical treatment) powder b. one cup filled with Pepto Bismol (oral medication used for heartburn, indigestion, diarrhea, and nausea) c. Sudafed (allergy) Nasal Spray This facility failure increased the potential for the unsafe self-administration of medications. It also had the potential to result in the use of the medications by other residents, who could come into the room and obtain the treatment from the bedside table where it was stored. Findings: During a review of Resident 11's admission record, dated 6/23/25, the admission record indicated, Resident 11 was admitted to the facility on [DATE], with multiple diagnoses that included, mild cognitive impairment of uncertain or unknown etiology (problems with memory or thinking). During a review of Resident 11's Minimum Data Set (MDS- a federally mandated assessment tool) dated, 12/27/24, the MDS indicated Resident 11 had a progressive neurological condition (continual deterioration of neurological function). During a concurrent observation and interview on 1/21/25 at 10:33 a.m., with Resident 11, stated, the bottle of Nystatin powder, cup of Pepto Bismol, and Sudafed Nasal Spray has been stored on the bedside table. Resident 11 further added, staff were aware she was using these medications on her own. During a concurrent observation and interview on 1/21/25 at 10:44 a.m. with Licensed Vocational Nurse (LVN) 3, in Resident 11's room, LVN 3 acknowledged seeing the medication on Resident 11's bedside table. LVN 3 stated, Resident 11 had been keeping medications on her bedside. LVN 3 further added, she was not aware if Resident 11 had an assessment or evaluation for self-administration of medication. During a concurrent interview, and record review on 1/24/25 at 10:38 a.m. with the Director Of Nursing (DON), in the DON's office, the DON confirmed there was no Interdisciplinary Team (IDT) assessment completed for Resident 11. DON stated, Resident 11 had not been assessed by the IDT to determine whether Resident 11 can self-administer medications/treatments. DON added, the IDT assessment will determine whether the medication stored by the resident can have undesired interaction with her prescribed medication. During a review of the facility's policy and procedure (P&P), titled Self-Administration of Medications, dated, 2/21, indicated 1. As part of the evaluation, comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents . 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS, a resident assessment used to guide resident's care, Quarterly MDS assessment is used to track a resident's status between comprehensive assessment to ensure resident's gradual change in status are monitored) assessment in a timely manner for one of two sampled residents (Resident 28) for over four months. This deficient practice resulted in Resident 28 not receiving the assessment and placed her at risk for not receiving appropriate care and services based on her health status. Findings: During a review of Resident 28's Admission Record printed on 6/22/25 indicated Resident 28 was admitted to the facility on [DATE]. During an interview and record review on 1/23/25 at 10:50 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 28's MDS assessment history was reviewed. MDSC stated he missed to complete Resident 28's Quarterly assessment in 10/2024.The MDSC stated he did not assess Resident 28 after 7/28/24, when quarterly MDS should be completed at least within 92 days. The MDSC stated not completing quarterly MDS assessment for Resident 28 placed Resident 28 at risk for unidentified significant change in health status and hence risk for not receiving care based on her current health condition.

Based on interview and record review, the facility failed to ensure one resident's (Resident 14) Pre-Admission Screening Resident Review (PASARR-Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for serious mental illness was accurately completed and sent to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 14 from receiving appropriate required mental health services. Findings: During a record review of Resident 14's Admission Record, printed 1/23/25, it indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder in which a person has repeated seizures over time. Seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements), major depressive disorder (a mental illness that causes a persistent low mood and loss of interest in activities. It can also affect how a person thinks and functions in their daily life), delusional disorders (a mental health condition that involves having fixed false beliefs that are not based in reality. People with delusional disorder can have delusions about their relationships, their bodies, or the world around them), dementia (a progressive disease that destroys memory and other important mental functions), and congestive heart failure (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs). During a record review of Resident 14's Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 10/4/24, active diagnoses included depression and psychotic disorder (a severe mental illness that causes a person to lose touch with reality). During a record review of correspondence from the Department of Health Care Services (DHS), dated 4/13/23, regarding Negative Level 1 Screening Indicates Level II Mental Health Evaluation Not Required, it indicated, Federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) receive a Level I Screening. The Level I Screening identifies if an individual has a suspected Mental Illness (MI) .if MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. The process is known as the Preadmission Screening and Resident Review (PASRR). Level 1 Screening for: Resident 14 Submitted on: 4/13/2023 Result: Negative Reason: No MI Level II Mental Health Evaluation Referral: Not Required During an interview on 1/24/25 at 11:16 a.m. with the Admission Director (AD), the AD stated it is the facility's responsibility to ensure the Level I PASARR's are done correctly. The AD stated the facility did not notice the error in Resident 14's Level 1 PASARR, and this might have resulted in Resident 14 failing to receive available services from the Department of Developmental Services Regional Center (DDS-Under the [NAME] Developmental Disabilities Services Act, DDS is responsible for overseeing the coordination and delivery of services and supports to more than 400,000 Californians with developmental disabilities including cerebral palsy, intellectual disability, autism, epilepsy and related conditions appropriate treatment and services) . Review of the facility's policy and procedure titled, Preadmission Screening & Resident Review (PASARR), revised 12/11/17, it indicated, the facility will obtain/complete a Preadmission Screening and Resident Review (PASARR) timely, and all errors or if pre-screening is done and resident was not admitted ; DHS suggests responding by email (subject error) or contacting DHS via phone (PASARR Support Number).

Based on interview and record review, the facility failed to ensure/perform a Pre-Admission Screening and Resident Review (PASARR-a screening tool to determine if individuals with serious mental illness or intellectual/developmental disability or related condition require nursing facility services or specialized services) for one (Resident 2) of four sampled residents. This failure had the potential to result in Resident 2 not being provided specialized care and services to address a mental illness. Findings: During a record review of the Resident 2's Admission Record, printed 1/23/25, it indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), paranoid schizophrenia (a mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), epilepsy (a brain disorder in which a person has repeated seizures over time. Seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements), amnestic disorder (a condition that causes memory loss, making it difficult to learn new information or recall past events, and cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes). During a record review of Resident 2's Minimum Data Set, (MDS - an assessment screening tool used to guide care), dated 12/31/24, active diagnoses included depression (a mental disorder that involves a long-lasting low mood and loss of interest in activities) and schizophrenia. Review of clinical records showed Resident 2 did not have a (PASARR) Level I completed. During an interview on 1/24/25 at 11:16 a.m. with the Admission Director (AD), the AD stated it is the facility's responsibility to ensure that the Level I PASARR is done correctly. The AD stated if the Level I PASARR is not completed, residents might not receive the appropriate care and treatment services from the Department of Developmental Services Regional Center (DDS-Under the [NAME] Developmental Disabilities Services Act, DDS is responsible for overseeing the coordination and delivery of services and supports to more than 400,000 Californians with developmental disabilities including cerebral palsy, intellectual disability, autism, epilepsy and related conditions appropriate treatment and services) . During a record review of the facility's policy and procedure titled, Preadmission Screening & Resident Review (PASARR), revised 12/11/17, it indicated the facility will obtain/complete a Preadmission Screening and Resident Review (PASARR) timely, and PASARR must be printed and be within chart upon 5th day (after admission).

Based on interview, and record review, the facility failed to protect residents in the facility from further abuse when: 1. Registered Nurse 1 (RN 1) hit one resident's (Resident 1) knee out of a sample of 20 residents, with a bedside table (A narrow rectangular table on wheels that spans the bed or can be placed over the lap when sitting in a chair. The height of the table can be adjusted up or down with the press of a lever) twice into Resident 1's left knee. In addition, the facility failed to protect 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19) out of a census of 39 residents who were assigned to RN 1, from possible abuse when the Director of Nursing (DON) did not remove RN 1 from direct resident care for five hours after learning of the abuse allegation. 2. The facility failed to report the abuse allegation to the Long-Term Care (LTC) Ombudsman, and the law enforcement agency. These failures resulted in Resident 1 crying and had the potential for Resident 1 to have continued emotional distress, and had the potential to result in RN 1 abusing other residents under her care. The failure to notify the LTC Ombudsman and Law enforcement agency had the potential to result in delayed investigation of the abuse allegation and interference with the ombudsman's ability to act as a resident advocate. An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of the facility to protect residents by allowing RN 1 to continue to provide resident care after the Director of Nursing was made aware of the incident involving Resident 1. The Director of Nursing (DON) was verbally notified of the IJ situation on 9/16/20 at 3:41 p.m. During a visit to the facility on [DATE], the facility initiated a plan of action and the IJ was removed on 9/21/20 at 3:44 p.m. Findings: 1. During an interview with Certified Nursing Assistant 3 (CNA 3) on 9/16/20 at 10:21 a.m., CNA 3 stated on 9/13/20, around 5:59 p.m., while she walked in the hallway towards the main nursing station, she heard a commotion. CNA 3 stated she saw Resident 1 sitting in her wheelchair in the hallway, in front of Room C, which was adjacent to Resident 1's room (Room B). CNA 3 stated Resident 1 was facing the nursing station with her dinner tray, on top of her bedside table, stationed in front of her. CNA 3 stated she heard RN 1 telling Resident 1 to go back to her room to eat dinner and Resident 1 refused. CNA 3 stated she saw RN 1 and Resident 1 both trying to pull the bedside table towards themselves like tug of war. RN 1 then grabbed the bedside table, pushed it twice, and the metallic leg of bedside table hit against Resident 1's left knee really hard, which made Resident 1 cry hysterically. During an interview with CNA 3 on 9/16/20 at 10:21 a.m., CNA 3 checked her cell phone and stated she sent a text message to the Director of Staff Development (DSD) on 9/13/20, at 6:33 p.m., after she had witnessed RN 1 hit Resident 1's left knee with the bedside table. CNA 3 stated the DSD acknowledged the text message on 9/13/20, at 6:36 p.m. CNA 3 stated RN 1 stayed at the facility until the end of the shift on 9/13/20, at 11:30 p.m., and continued to enter resident rooms to provide direct resident care throughout the entire shift. During an interview with the DSD and in the presence of the Director of Nursing (DON) on 9/16/20 at 10:39 a.m., the DSD stated she informed the Administrator (ADM) and the DON about the incident between RN 1 and Resident 1 immediately after receiving a text message from CNA 3 on 9/13/20, at 6:33 p.m. During an interview with the DON on 9/16/20 at 9:55 a.m., the DON stated on 9/13/20, around 9 p.m., after learning of the alleged incident between RN 1 and Resident 1, she had asked RN 1 to stay away from residents and go to the other side of the facility to finish her charting for the shift. The DON stated she asked Registered Nurse (RN 2) to provide direct care to RN 1's assigned residents. During a follow up interview with the DON on 9/16/20 at 10:56 a.m., the DON stated she was not able to speak to CNA 2 and CNA 3 (the two witnesses of the incident) on the evening of 9/13/20. The DON stated separating RN 1 and Resident 1 was enough to do based on her investigation at that time. During an interview on 9/21/20, at 12:20 p.m., with the DON, the DON stated her cell phone records showed she had sent a text message to RN 1 on 9/13/20, at 9:44 p.m., to give RN 1 official notification of her suspension. During a concurrent interview and record review on 9/21/20, at 2:20 p.m., with the DON, RN 1's timecard dated 9/13/20, was reviewed. The DON confirmed the timecard indicated RN 1 stayed at the facility until 9/14/20, at 12:03 a.m., which was six hours after the alleged incident. During a phone interview on 9/17/20, at 9:17 a.m., with RN 1, RN 1 stated the DON only told her not to provide direct care to Resident 1; the DON had not told her to quit providing direct care to her other assigned residents (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19). RN 1 stated she administered 9 o'clock medications to a total of 13 other residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) until 9:30 p.m. that evening. RN 1 stated she continued to provide direct resident care to her other assigned 18 residents (who were all in the same area of the building as Resident 1), including repositioning, helping with feeding, serving water and providing snacks. RN 1 stated she stayed at the facility until the end of her shift on 9/13/20. During a phone interview on 9/23/20, at 4:57 p.m., with Registered Nurse 2 (RN 2), RN 2 stated the DON had not directed her to provide care for RN 1's assigned residents on 9/13/20, and she had not provided care to RN 1's assigned residents. During a review of the facility's PNP titled, Protection of Residents during Abuse Investigations, dated 12/2006, indicated, .Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents . During a phone interview on 9/21/20, at 2:27 p.m., with the LTC Ombudsman, the LTC Ombudsman stated the facility had not notified them via phone or fax about Resident 1's alleged abuse incident. The LTC Ombudsman stated it had been the State licensing agency that first told her about the alleged abuse incident. The LTC Ombudsman also stated she spoke with the DON on the morning of 9/16/20, but the DON did not mention the abuse allegation. During a follow up email communication on 10/2/20, at 4:28 p.m., with the LTC Ombudsman, the LTC Ombudsman confirmed they have not received a written report of Resident 1's alleged abuse incident from the facility. During a review of Resident 1's progress notes dated 9/13/20 through 9/21/20, the progress notes had no documentation the LTC Ombudsman and Law enforcement agency were notified of Resident 1's alleged physical abuse by RN 1 on 9/13/20. During a concurrent interview and record review on 9/16/20, at 12:10 p.m., with Social Services Director (SSD), the facility binder titled, Abuse Report Binder, undated, was reviewed. The SSD confirmed the form in the binder titled, Mandatory Abuse Reporting Guidelines, indicated the facility was required to notify the LTC Ombudsman, law enforcement agency, and the State Licensing Agency via phone and fax within 24 hours of an allegation of physical abuse with no serious bodily injury.

Based on observation, interview, and record review, the facility failed to keep one resident (Resident 1) in a sample of 39 residents free from abuse when a Registered Nurse (RN 1) pushed a bedside table (a narrow rectangular table on wheels that spans the bed or can be placed over the lap when sitting in a chair. The height of the table can be adjusted up or down with the press of a lever) twice into Resident 1's left knee causing her to cry. This abuse caused pain to Resident 1 and had the potential to instill fear in Resident 1 which could result in psychosocial harm. This abuse also had the potential to cause physical harm to Residents at the hands of RN 1 who hit a Resident 1 with a piece of furniture. The Director of Nursing (DON) was verbally notified of Immediate Jeopardy (IJ, a situation in which a facility's actions places one or more in jeopardy of being significantly harmed up to the point of the potential for death to occur if not immediately corrected) situation on 9/16/20 at 3:41 p.m., regarding facility's failure to protect Resident 1 from physical and potential psychosocial abuse, failure to protect 38 other residents from abuse by RN 1. During an on-site visit on 9/21/20, the facility showed a plan of action was initiated, and IJ was lifted and 3:44 p.m. Findings: During a record review of Resident 1's Admission Minimal Data Set (MDS- An assessment tool to guide care) assessment dated [DATE], MDS assessment showed Resident 1 required one staff limited assist for wheeling herself in a wheelchair on and off the unit. The MDS assessment showed Resident 1 had the [DIAGNOSES REDACTED]. During a review of Resident 1's Face Sheet dated 9/16/20, the Face Sheet showed Resident 1's primarily spoke Spanish for communication. During a concurrent observation and interview, with the Activity Director (AD), on 9/16/20, at 12:00 p.m., Resident 1 was sitting in a wheelchair in the dining room. The AD translated in Spanish, Resident 1 stated somebody pushed a table and hit my knee, it hurt me, pointing at left knee. The AD stated Resident 1 referred to a family member who hit her knee, the AD then stated Resident 1 did not have a family member visiting her at the facility, for past couple months. During an interview with the Social Services Director (SSD), on 9/16/20, at 12:10 p.m., the SSD stated Resident likes to stay and eat outside her room and spent most of her time in the hallway. During an interview with the Certified Nursing Assistant (CNA 1), on 9/22/20, at 1:04 p.m., CNA 1 stated on the evening of 9/13/20, Resident 1 was trying to get in her previous assigned room (Room A), which was in the same hallway and not far from her current assigned room (Room B). CNA 1 stated she was providing care to resident in Room A and door was closed. CNA 1 stated she heard someone was banging at the door with bedside table. CNA 1 stated she asked RN 1 to talk to Resident 1 as the resident in Room A was annoyed with the banging sound. CNA 1 stated she observed RN 1 pulling Resident 1's wheelchair, while Resident 1 held onto the bedside table. CNA 1 stated she closed the Room A and did not see what happened next. During a phone interview with Certified Nursing Assistant (CNA 2), on 9/17/20, at 8:58 a.m., CNA 2 stated on the evening of 9/13/20, Resident 1 was in wheelchair in the hallway next to Room B and Room C (two adjacent rooms on the same side). CNA 2 stated she saw RN 1 pushing Resident 1's wheelchair and yelling at her to go back to her room. CNA 2 stated Resident 1 put her feet on the floor so wheelchair wouldn't move. CNA 2 stated RN 1 then grabbed the bedside table and rammed it, shoved it into Resident 1's knee. CNA 2 stated Resident 1 had big tears in her eyes at that time. During an interview with Certified Nursing Assistant (CNA 3), on 9/16/20, at 10:21 a.m., CNA 3 stated on 9/13/20, around 5:59 p.m., while she walked in the hallway towards the main nursing station, she heard a commotion. CNA 3 stated she saw Resident 1 sitting in a wheelchair, in the hallway in front of Room C, adjacent to her room, facing the nursing station. CNA 3 stated Resident 1 had her bedside table, with dinner tray on the top, in front of her. CNA 3 stated she heard RN 1 telling Resident 1 to go back to her room to eat dinner, and Resident 1 refused. CNA 3 stated she saw RN 1 and Resident 1 pulling the bedside table towards themselves (like tug of war). RN 1 then grabbed the bedside table, pushed it twice and the metallic leg of bedside table hit against Resident 1's left knee really hard, which made Resident 1 cry hysterically. CNA 3 stated RN 1 then brought Tylenol medication from the medication cart parked in the same hallway, and told Resident 1, Take it, take it, and Resident 1 refused to take the medication. During a phone interview with Certified Nursing Assistant (CNA 4), on 9/22/20, at 9:53 a.m., CNA 4 stated on 9/13/20 evening, when she was in the hallway on her way to the dining area, she saw Resident 1 was crying while sitting in wheelchair with bedside table in front of her. CNA 4 stated Resident 1 was pointing at the bedside table and her left leg, crying and saying something in her language that she did not understand. During a phone interview with Registered Nurse (RN 2, the 2nd charge nurse on duty on 9/13/20), on 9/23/20, at 4:57 p.m., RN 2 stated on 9/13/20, she saw Resident 1 in a wheelchair, in middle of the hallway outside Room B. RN 2 stated she saw RN 1 with and bedside table in front of Resident 1. RN 2 stated she was passing medications to her residents at a farther end of the same hallway where she saw Resident 1. RN 2 stated after couple minutes she saw Resident 1 was crying. RN 2 stated she did not know what had happened. During a phone interview with RN 1, on 9/17/20, at 9:17 a.m., RN 1 stated on 9/13/20 evening, Resident 1 was trying to go into the dining room, but due to facility's restrictions she asked Resident 1 to go the nursing station. RN 1 stated she pulled Resident 1's wheelchair and on the way to nursing station Resident 1 started to hold her left knee. RN 1 stated she immediately gave 650 milligrams (mg) of Tylenol to Resident 1, and Resident 1 refused to take the medication. During a review of Departmental notes documented by RN 1 at 7:24 p.m., on 9/13/20, Progress notes were reviewed. RN 1 documented Resident 1 did not have episodes of declined mood or sadness ., All evening (PM) medications were given and well tolerated ., Resident 1 was up in wheelchair during entire shift ., No change of condition (COC) noted ., No complain of (c/o) pain during the shift . During a review of Resident 1's follow up Progress notes completed by RN 1 during the same shift, at 10:41 p.m., on 9/13/20, RN 1 documented today at 6:00 p.m., Resident 1 was in wheelchair trying to go in dining room, RN 1 wheeled Resident 1 in hallway ., all of a sudden Resident 1 crying holding her left knee complaining of pain RN 1 stopped wheeling ., left Resident 1 in front of Room C ., offered pain medication ., Resident 1 refused. Resident 1 refused to eat food. During a review of Resident 1's Medication Administration Record [REDACTED]. MAR indicated [REDACTED]. During a review of facility's Policy and Procedures (PNP) titled, Reporting Abuse to Facility Management dated 12/2013, PNP indicated, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. PNP further indicated, Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers .

Based on observation, interview and record review, for 28 of 35 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, and 28), the facility failed to follow their policies and procedures for infection control during the Coronavirus Disease 2019 outbreak (COVID 19, a mild to severe respiratory illness that is airborne and is spread from person to person or by contact with infectious material such as respiratory droplets in the air and to a lesser degree on high touch surfaces in the environment). The facility did not train their staff in preparation for a COVID19 outbreak after receiving the Quality, Safety and Oversight group (QSO) letter QSO-,[DATE]-All letter, dated [DATE] from the Centers of Medicare and Medicaid Services (CMS) and when staff did not implement the necessary infection prevention and control interventions to prevent the spread of COVID-19. The facility failed to screen for symptomatic staff and allowed staff (CNA 1) to work while exhibiting symptoms of COVID 19. The facility failed to separate COVID positive residents from their roommates without COVID 19 for up to three days, (Residents 14, 22, 25, and 27). The facility staff failed to wear a face mask to cover their mouth (AD and CNA 6) and multiple wore ponchos with no sleeves (CNA 3 and housekeepers) instead of disposable personal protective equipment (PPE) coverings with long sleeves when providing care or cleaning high touch areas in the COVID 19 unit. One resident (Resident 5) who had COVID 19 and dementia (a cognitive disease that affects behavior), roamed throughout the facility, both in and amongst the COVID positive and negative rooms. The rooms with COVID 19 resident's doors were not closed to prevent the spread of disease. The facility failed to ensure the cleaning solution used to clean high touch areas was effective to kill the COVID 19 virus. These deficient practices resulted in a widespread outbreak of COVID-19 and Residents ,[DATE] becoming COVID-19 positive. Residents 6, 11, 26, 27 and 28 were transferred to the acute hospital, Resident 24 was transferred to the acute hospital and expired (died ), and Residents 22, 23, and 25 expired of the [MEDICAL CONDITION] 2019 Disease. The Administrator (ADM) was notified verbally of the Immediate Jeopardy (IJ) on [DATE], at 12:30 p.m. The facility failed to implement infection control interventions that would prevent the spread of COVID-19. Through observation, interviews with the staff members and record reviews of the facility's documents, the facility showed they initiated the plan of action through in-services of employees regarding infection control. The IJ was abated on [DATE] at 12:00 p.m. Findings: Upon entering the facility on [DATE] at 9:15 a.m. three staff members were observed standing close to each other and not observing social distancing and talking with each other in the lobby. They were not wearing face shields. During an interview and concurrent observation with the Director of Staff Development (DSD) and the Director of Staff Development Consultant (DSDC) on [DATE] at 9:15 a.m., DSD stated the current facility census was 36. DSD stated that 19 of the 36 residents were COVID-19 positive, and a cumulative total of 27 residents had been confirmed COVID-19 positive. DSD stated that out of the 27 COVID-19 positive residents, six (Residents 6, 11, 24, 26, 27, and 28) had been sent to the acute hospital and two residents (22, 23, and 25) had expired in the facility. DSD stated a total of four staff members (two CNAs and two managers), who were COVID-19 positive with no symptoms, were still working. DSD stated twenty-five staff members were COVID-19 positive and staff who were COVID-19 positive cared for COVID-19 positive residents only, and staff who were COVID-19 negative cared for COVID-19 positive and COVID-19 negative residents. During an observation and concurrent interview with the DSD and DSDC while doing a facility tour on [DATE] at 10:45 a.m., the AD/CNA 6 (Activity Director/Certified Nursing Assistant 6) was observed in the hallway wearing a N95 mask that did not completely cover her mouth, and CNA 3 was in the hallway at the linen cart wearing a poncho covering with no sleeves. DSD stated separate sleeves were available and should be worn with the poncho to prevent contamination of the arms. Resident 5 was observed in the hallway on [DATE] at 10:45 a.m. without a mask. DSD stated this resident had dementia and was COVID-19 positive. DSD stated this resident wandered around the facility, refused to wear a mask and touches everything. Review of Resident 5's care plan, dated [DATE], indicated Resident 5 was COVID-19 positive, and there were no interventions regarding him wandering around the facility addressed in a plan of care. During an observation while doing a facility tour on [DATE] at 10:45 a.m., Housekeeping staff were observed wearing ponchos. The housekeepers were cleaning high touch areas near a resident's room with an unlabeled bottle of solution. The housekeepers stated the solution was a ,[DATE] bleach mixture. The housekeepers were not able to describe the how long the solution should stay on a surface to be effective. During the tour, many rooms in the COVID-19 unit had the doors opened. DSD stated the residents preferred the doors open. Review of the facility's policy and procedure date revised ,[DATE], titled Isolation-Categories of Transmission-Based Precautions, indicated, .1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. Airborne Precautions 1. In addition to Standard Precautions, implement Airborne Precautions for anyone who is documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle residue(5 microns or smaller in size) of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over a long distance). 4. b. Keep the room door closed and the resident in the room. 5. a. All individuals must wear approved respiratory protection when entering the room. 6. a. The resident should only leave an isolation room when absolutely essential. 6. b. Someone who is on Airborne Precautions, should wear a mask when leaving the room or coming into contact with others . During a telephone interview with Certified Nursing Assistant (CNA) 1 on [DATE] at 12:00 p.m., CNA 1 stated she was COVID-19 positive and the last day she worked at facility was [DATE]. CNA 1stated she was not feeling well on [DATE]-had body pain, sore throat and temperature of 99 degrees Fahrenheit. CNA 1 stated she had taken care of Resident 23 and Resident 21 who later tested COVID-19 positive. CNA 1 stated Resident 21 had a cough and a fever the last week of March, and Resident 23 started to decline and was coughing the last two weeks of March. CNA 1 stated the end of March, maybe [DATE], the facility did not have any disposable masks or gowns, and the Director of Nurses (DON) and DSD told her to wear hospital gowns (cloth with short sleeves). CNA 1 had a personal mask from home, but the DON and DSD told her not to wear the mask, because the residents would think she was sick. CNA 1 stated the facility did not tell her that staff members (CNA and RN) had tested positive for COVID-19, and when she left on [DATE], the residents (COVID-19 +) had not been separated from the COVID 19 negative (-) residents, leaving them at risk for exposure to the COVID 19 virus. During an interview with the DSDC on [DATE] at 9:31 a.m., DSDC stated on [DATE], a staff member (a CNA) told the facility via phone that she had a headache and fatigue. DSDC stated that staff member had last worked in the facility on [DATE]. DSDC stated that staff member was tested for COVID-19 on [DATE] and confirmed COVID-19 positive on [DATE]. DSDC stated the facility started mapping and tracking all the residents that staff member had cared for, and the co-worker she had been in contact with. DSDC stated the facility monitored signs and symptoms of the residents and staff members the COVID-19 positive staff member had been in contact with. DSDC stated eight out of fourteen of the residents tested were confirmed COVID-19 positive. DSDC stated on [DATE], a Registered Nurse (RN) had a temperature of 100.4 and fatigue. DSDC stated that RN last worked on [DATE], the RN had been in contact with the first confirmed COVID-19 positive staff member. DSDC stated the RN was tested for COVID-19 on [DATE] and was confirmed positive on [DATE]. DSDC stated on [DATE], Resident 21, who was being monitored for COVID-19 due to exposure, was sent out to the acute hospital for left-side weakness. DSDC stated Resident 21 was confirmed COVID-19 positive at the hospital. DSDC stated on [DATE] Resident 11 was transferred from [MEDICAL TREATMENT] to the hospital and was confirmed COVID-19 positive on [DATE]. Review of a facility undated document titled (Facility) List of COVID Patients, indicated Resident 21 and Resident 11 were sent out to the hospital on [DATE] and were tested and confirmed COVID-19 positive at the hospital. This document indicated Resident 6 was sent out to the hospital on [DATE] and was tested and confirmed COVID-19 positive at the hospital. This document indicated Resident 24 was sent out to the hospital on [DATE] and was tested and confirmed COVID-19 positive on [DATE]. This document indicated Resident 26 was sent to the hospital and was tested and confirmed COVID-19 positive on [DATE]. Further review of this document indicated Residents 1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 25, 27, and 28 were confirmed COVID-19 positive on [DATE]. Review of facility's COVID-19 mapping records (records that tracked the room location and diseases that residents had), indicated mapping for COVID-19 residents started [DATE], and Resident 16 was roomed with a COVID-19 negative resident, Resident 14 was roomed with a COVID-19 negative resident, Resident 22 was roomed with a COVID-19 negative resident, Resident 27 was roomed with a COVID-19 negative resident and Resident 25 was roomed with a COVID-19 negative resident. Further review of the facility mapping records, indicated these residents were not moved and placed in a designated COVID-19 positive unit until [DATE]. During a telephone interview with Licensed Vocational Nurse/Supervisor (LVNS) on [DATE] at 12:44 p.m., LVNS stated the residents were moved to separate units after the first round of COVID-19 testing for residents was done-[DATE]. During a telephone interview with CNA 2 on [DATE] at 12:21 p.m., CNA 2 stated the last day she worked in the facility was [DATE]. CNA 2 stated prior to [DATE], the facility did not have any disposable gowns and the end of March, the facility was short of masks, and she was told only to wear a mask if she had a cough. CNA 2 stated on [DATE] another staff member told her that a resident was COVID-19 positive, but there was no training provided to her regarding COVID-19. Review of the facility's training records did not show any training for COVID-19 on [DATE]. According to the Center for Medicare and Medicaid Services' (CMS) center for Clinical Standards and Quality, Safety and Oversight group (QSO) reference: QSO-,[DATE]-All letter, dated [DATE], indicated .We are disseminating the Infection Control survey developed by CMS and CDC so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of COVID-19 . According to the Center for Disease Control and Prevention (CDC) Guidance, updated [DATE], indicated healthcare personnel who enter the room a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves and eye protection .Ensure that HCP are educated, trained, and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, . During an interview with the DSD on [DATE] at 10:22 a.m., DSD stated she had talked to the county public health department on [DATE] and learned a staff member was COVID-19 positive. DSD stated the residents who were suspected of COVID-19 were monitored every shift (three shifts in 24 hours). During an interview with the DSDC on [DATE] at 12:44 p.m. DSDC stated prior to [DATE], the facility used a line listing for influenza to monitor resident surveillance for COVID-19 signs and symptoms. Review of the facility's document titled Infection Control Surveillance, dated [DATE], did not indicate residents were being tracked for COVID-19 signs and symptoms or influenza signs and symptoms. Further review of facility's COVID-19 surveillance records indicated resident surveillance started [DATE]. Review of facility documents titled Temperature Log Every Shift, dated [DATE], [DATE], [DATE], [DATE] and [DATE], indicated all residents were being monitored for temperature only twice a day and not for signs and symptoms of COVID-19 (e.g. cough, shortness of breath, sore throat). Review of the facility's policy and procedure titled Surveillance for Infections, revised ,[DATE], indicated .1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections . 3. Infections that will be included in the routine surveillance include those with: a. Evidence of transmissibility in healthcare environment . b. Available processes and procedures that prevent or reduce the spread of infections . 9. If transmission-based precautions or other preventative measures are implemented to slow or stop the spread of infection, the Infection Preventionist will collect data to help determine the effectiveness of such measures . Review of facility documents, not titled, indicated the staff at Orinda Care Center were being monitored for temperature only and not for signs and symptoms of COVID-19 from [DATE]-[DATE]. The DON did not provide documentation that staff were being monitored for signs and symptoms of COVID-19. According to the Center for Medicare and Medicaid Services' (CMS) center for Clinical Standards and Quality, Safety and Oversight group (QSO) reference: QSO-,[DATE]-All letter, dated [DATE], indicated .Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility .Monitor the CDC website for information and resources to help prevent the introduction and spread of COVID-19 in nursing homes .We urge providers to review the tools and implement actions to protect the health and safety of individuals to respond to the COVID-19 pandemic . CMS is providing the following expanded guidance to prevent the spread of COVID-19: a) Visitors should receive the same screening as patients, including whether they have had: fever or symptoms of a respiratory infection, such as cough and sore throat . According to the Center for Disease Control and Prevention (CDC) Guidance, updated [DATE], .Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility . Review of the facility's policy and procedure revised date ,[DATE], titled Personal Protective Equipment-Gowns, Aprons, Lab Coats, indicated .9. Employees must receive training relative to the use of gowns, aprons, and lab coats and other protective equipment prior to being assigned tasks that involve potential exposure to blood or body fluids and when new or modified protective equipment or procedures have been introduced into the workplace. Review of the facility's policy and procedure, date revised ,[DATE], titled Infection Control Guidelines for All Nursing Procedures, indicated .1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: a. the facility protocols for isolation (standard and transmission-based) precautions; b. The location of all personal protective gear; c. the location of medical waste disposal containers; . 2. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing infections in residents, including: a. Types of Healthcare-Associated Infections; b. Methods of preventing their spread; c. How to recognize and report signs and symptoms of infection; .5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials . During an interview with the ADM on [DATE] at 10:10 a.m., ADM stated a housekeeping agency was recently hired, because the facility's housekeepers were not coming to work. ADM stated the agency housekeepers only worked day shift. ADM stated the staff handled housekeeping duties the reminder of the day. During an interview with the DSD and AD/CNA 6 on [DATE] at 10:15 a.m., DSD stated the facility staff used a bleach and water solution to clean. DSD stated the facility provided the contracted housekeepers with the cleaning products (bleach solution), and the AD/CNA 6 mixed the bleach and water solution. AD/CNA 6 confirmed that she mixed the bleach and water solution but stated she did not know how long the bleach and water solution should stay on surfaces. DSD stated the facility's housekeeping manager had not returned to work, and he was the one who knew how to operate the disinfectant mixing station. During an observation and concurrent interview with DSDC on [DATE] at 10:45 a.m. in the utility room, a mixing station that contained a hospital grade disinfectant (Maxim 256) was observed but was not being used. DSDC stated the staff did not know how to use the mixing station. During an interview with the DSD on [DATE] at 10:44 a.m., DSD stated the facility's maintenance director's last day in the facility was [DATE]. DSD stated the maintenance director responsible for housekeeping and laundry also. During an interview with the DSDC on [DATE] at 10:49 a.m., DSDC stated the maintenance director responsible for giving his staff an in-service training for cleaning and disinfecting. During an interview with the DSD on [DATE] at 10:55 a.m., DSD stated she did not do in depth education regarding cleaning/housekeeping. During an interview with the DON on [DATE] at 10:56 a.m., DON stated she did not have documentation that showed the maintenance director gave cleaning/disinfecting training to his staff regarding COVID-19. Review of the facility's training records indicated COVID-19 in-service trainings occurred [DATE], [DATE], [DATE] and [DATE]. During an interview with the DSDC on [DATE] at 12:44 p.m., a request was made to review the COVID19 lesson plan and DSDC was unable to produce the COVID-19 lesson plan. Review of the facility's policy and procedure, date revised ,[DATE] titled Policies and Practices-Infection Control, indicated .1. The facility's infection control policies and practices apply equally to all personnel, consultants, contractors .4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter; including where and how to find and use pertinent procedures and equipment related to infection control .

Based on interview and record review, the facility failed to ensure resident received adequate supervision to prevent accidents for one of two residents (Resident 1) when Resident 1 was left in a wheelchair outside a [MEDICAL TREATMENT] (the process of removing excess water, solutes and toxins from the blood) center while unattended. As a result, Resident 1 slid out of the wheelchair, fell on her face. Resident 1 obtained skin injuries and femoral (thigh bone) fracture. Findings: Review of the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. cease functioning on a permanent basis leading to the need for a regular course of long-term [MEDICAL TREATMENT] or a kidney transplant to maintain life). Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care) dated 8/3/18 indicated Resident 1 was cognitively intact and required two person physical assist with transfer. The MDS Section G0400 Functional Limitation in Range of Motion (code for limitation that interfered with daily functions or placed resident at risk for in jury) indicated Resident 1 had impairment on one side of the upper extremity and both sides on the lower extremities. Review of Resident 1's medical documents Fall Risk assessment dated on 7/29/18 indicated Resident 1 had poor judgement and safety awareness, balance problem, decreased muscular coordination, and jerking or unstable when making turns. Review of Resident 1's care plan titled Resident Care Plan-Fall Risk dated 2/1/18 indicated Resident 1 was at risk for fall due to impaired vision, impaired function, decrease strength, endurance, weakness, unsteady balance/gait and poor trunk control/balance deficit. The approaches and plan included frequent visual monitoring and whereabouts of the resident and wheelchair for transport with staff assistance. During an interview with Resident 1 on 8/9/18 at 2:10 p.m., Resident 1 stated on 7/30/18 after the [MEDICAL TREATMENT] treatment, Facility Driver 1 (FD 1) wheeled her outside the center's building and parked the wheelchair without pulling the breaks. FD 1 walked away and left Resident 1 alone to help Resident 2 to the van. The wheelchair started to wheel itself and that she had no safety belt at that time of the incident and she fell out of the wheelchair. Resident 1 further stated that at that time, she had too much pain and was upset that she was left alone because the driver was helping another resident. Resident 1 further stated she was still upset about the way she was handled. During an interview with Resident 2 on 8/9/18 at 2:30 p.m., Resident 2 stated Facility Driver 1 (FD 1) pushed his wheelchair towards the van and left Resident 1 outside in front of the [MEDICAL TREATMENT] center's door, then they heard Resident 1 screaming, FD 1 went back to Resident 1 and saw her on the floor and someone called 911. Resident 2 further stated FD 1 was around ten feet away from Resident 1 when the incident happened. Review of the Hospitalist Discharge Summary dated 8/5/18 indicated Resident 1's principal discharge [DIAGNOSES REDACTED]. Review of the Narrative Course section indicated Patient was mobilizing via wheelchair after [MEDICAL TREATMENT] this afternoon when she fell forward striking her knees first been reported onto the pavement .Underwent radiographic studies given reports of knee pain .findings of age-indeterminate nondisplaced slightly impacted [MEDICAL CONDITION] left femoral metaphysis (narrow portion of a long bone) . During an interview with FD 1 on 8/15/18 at 1:39 p.m., FD 1 stated on 7/30/18 he took Resident 2 outside the [MEDICAL TREATMENT] center and parked Resident 2 outside the center. FD 1 went inside to get Resident 1 and left Resident 2 outside unattended. FD 1 then took Resident 1 from the center and wheeled her outside and parked Resident 1 in front of the [MEDICAL TREATMENT] center. FD 1 proceeded to bring Resident 2 to the van and left Resident 1 by herself outside the [MEDICAL TREATMENT] center, he looked back and saw Resident 1 on the floor and the [MEDICAL TREATMENT] centers' staff called 911. FD 1 stated it would be safer and secured if one resident was transferred at a time. Review of the facility policy Falls and fall Risk, Managing dated (MONTH) 2007, indicated based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to permit one of two residents (Resident 1) to return to the facility after hospitalization . Resident 1 was not offered the first available bed after the facility was informed that Resident 1 was ready for discharge and wanted to go back to the facility. This failure resulted in Resident 1 not being permitted to return to her home of two years. Resident 1 felt anxious and afraid of being discharge to an unknown location. Findings: Review of an undated Face Sheet, indicated Resident 1 was admitted to the facility on [DATE] and was discharged on [DATE] with [DIAGNOSES REDACTED]. The Face Sheet indicated Discharge Status: Return Anticipated During a telephone interview with Resident 1 on 2/1/18 at 12:30 p.m., Resident 1 stated she wanted to go back to the facility as the facility had been her home for few years. Resident 1 stated her Case Manager (CM) had called the facility on 1/26/18 and the facility informed Resident 1's CM that there was no available bed. Resident 1 stated on a subsequent interview on 2/2/18 at 5:40 p.m., that she was anxious to go back to the facility and afraid she will be discharged to another facility. Resident 1 stated she wanted to go back to the facility. During an interview with CM on 2/1/18 at 3:15 p.m., CM stated he called the facility on 1/26/18 to inform the facility that Resident 1 was ready for discharge and she intended to go back to the facility. The facility told CM that there was no available bed for Resident 1. During an interview with the Director of Staff Development (DSD) on 2/2/18 at 3:40 p.m., DSD stated Resident 1 was sent to the hospital on [DATE] for wound surgery and was anticipated to return to the facility after her surgery. During an interview with Admissions Coordinator (AC) on 2/2/18 at 4:30 p.m., AC stated he received a referral from Resident 1's case manager on 1/17/18 and the case manager called on 1/26/18 to inquire for an available bed because Resident 1 was ready for discharge. AC stated they informed the case manager there was no available beds. AC stated after 1/26/18, he did not follow up with the case manager to offer the available bed to Resident 1. Review of a facility letter dated 2/6/18 indicated on 1/26/18 Resident 1 was referred to the facility for readmission and on 1/26/18 there were two female beds vacant at the time. Review of the facility's daily census sheet revealed the following: 1/27/18- two female beds available 1/28/18- two female beds available 1/29/18- two female beds available 1/30/18- one female bed available 1/31/18- one female bed available 2/1/18- one female bed available During an interview with the Social Service Designee on 2/5/18 at 2:22 p.m., SSD stated she was aware that Resident 1 will return to the facility after her surgery and Resident 1's belongings were kept in the facility. Review of the facility's policy and procedure tilted Bed-Hold indicated The facility shall allow a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period (7 days), to be readmitted to the facility immediately upon the first availability of a bed in a semi-private room .

Based on interviews and record review, the facility neglected to treat two of three sampled residents (1, 2) timely for their medical emergencies. 1. On 2/7/15, Resident 1 was admitted at 2:30 p.m., from a hospital after treatment for [REDACTED].%. Normal O2 is 94-100% ). Resident 1 was sent to the hospital via 911 for treatment of [REDACTED]. 2. Resident 2 had increasing confusion and required increasing amounts of anti-anxiety medication over a 2 day period and facility did not inform the physician of the change in behavior, resulting in Resident 2's family calling 911 to send the resident to the hospital where Resident 2 was diagnosed as having a stroke. Findings: 1. On 4/19/15, review of Resident 1's medical record showed the resident was admitted on [DATE], from the hospital after being treated for [REDACTED]. During a phone interview on 2/18/15 at 8:50 a.m., the hospital social worker (SW) stated the hospital faxed the physician's medication orders at 12:00 p.m., on 2/7/15, and transferred Resident 1 to the facility at 2:30 p.m. At 12:20 a.m., the following night, Resident 1 was transferred back to the hospital emergency room because the facility did not have the medications ordered to treat his [MEDICAL CONDITION]. During an interview on 2/19/15 at 10:15 a.m., the Director of Nurses (DON) stated, "He (Resident 1) was admitted stable and began convulsing. The Medical Director (MD 1) and the Co-Medical Director (MD 2) were called but did not respond. The ordered medication to treat Resident 1's [MEDICAL CONDITION] was not in the emergency kit but there were other anti-[MEDICAL CONDITION] meds in the kit. We needed an order from a physician to use them." Review of registered nurse (RN) 1's nurses' notes, dated 2/8/15 at 3:48 a.m., showed, "Unable to take vital signs due to [MEDICAL CONDITION]. Resident (1) started to have [MEDICAL CONDITION] at 2300 (11:00 p.m.) noted by p.m. nurse. Oxygen saturation (measure of oxygen reaching the extremities) at that time was 92% on room air. Called and left message for MD 2, the attending. So I called 911 because resident had a [MEDICAL CONDITION] for 30 minutes and oxygen saturation was 86 to 88% (low). Resident was sent to hospital at 12:20 a.m." During a phone interview on 3/3/15 at 3:50 p.m., RN 1 stated, "I left messages for MD 2 and, after about fifteen minutes, I called the medical director (MD 1). The doctor on call for the medical director would not give his name, said he only took calls for the medical director's patients and hung up. Between 11:30 p.m. and 12:20 a.m., he (Resident 1) continued shaking and his oxygen saturation (the amount of oxygen reaching the extremities) was dropping, so I sent him out." During phone interview on 3/4/15 at 10:30 a.m., DON stated, "MD 2 does not have anyone on-call for him. A physician should be available." Review of the facility's policy and procedure, titled "Emergency Physician Care," revised 2/14, showed, "Emergency physician is available to all residents when the Attending Physicians are unavailable. Should the resident's Attending Physician be unavailable, the Nurse Supervisor/ Charge Nurse must first attempt to contact the physician's designated Referral Physician or Practitioner. Should the designated Referral Physician be unavailable to assist in the emergency, the On-Call Physician or Medical Director shall be contacted." Review of the facility's contract with MD 2, showed "The agreement for Professional Services, dated 8/1/14, is between (MD 2) and the facility. 3.1 During the term of this agreement, the Physician shall perform the professional services normally incident to the position of Co-Medical Director. The scope of duties shall include, but not be limited to: 3.1.3 Coordinating medical care in the facility; 3.1.4 Overseeing that all necessary medical services provided to residents are adequate and appropriate; 3.1.7 Providing 'on-call' availability and responding at all times to medical, regulatory, or other emergencies in the facility." 2. Review of the medical record showed that Resident 2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. During phone interview on 2/18/15 at 9:00 a.m., Resident 2's relative stated that the resident stopped talking and could not get out of bed. The director of nurses (DON) was informed of this change, but nothing was done. The relative stated that the family asked for the physician to visit on 1/28/15 and tried to contact the physician on 1/29/15, 1/30/15 and on 1/31/15 and asked the staff to call 911 due to the family's concern. When the physician could not be contacted, the family called 911 on 1/31/15 and Resident 2 was transferred to the hospital and admitted . The Medication Administration Record [REDACTED]. It was given twice on 1/22/15, 1/23/15, and 1/24/15, once on 1/25/15, twice on 1/26/15, once on 1/27/15, twice on 1/28/15 and 1/29/15 and once on 1/30/15 and 1/31/15. The nurses' notes, dated 1/30/15 showed, "Resident noted with increased confusion. Called, texted, and left voice mail for (MD 2). Family made aware." A nurse's note, dated 1/31/15 at 2:41 p.m., showed, "Patient noted with increased confusion. Texted (MD 2) to report change and possibly get a urinalysis order (to rule out a urinary tract infection as the cause of the increased confusion). Waiting for response." A nurse's note, dated 1/31/15 at 10:41 p.m., showed, "Caregiver arrived at 6:40 p.m. stating the family was going to have patient sent out via ambulance transport because 'there was no way else to get her out of here.' ..At 7:05 p.m., emergency personnel arrived due to 911 being called and they were informed that a patient was having a stroke....Family spoke with paramedics and demanded they take patient to the hospital." During interview on 2/19/15 at 1:00 p.m., LVN 2 stated, " Resident 2 was alert and increasingly confused. She was getting very restless and I gave her [MEDICATION NAME]. I texted MD 2 to report a change and possibly get an order for [REDACTED].' Suddenly paramedics arrived and said she was having a stroke." During interview on 2/19/15 at 2:00 p.m., LVN 1 (licensed vocational nurse) stated, "On 1/31/15, I attempted to contact the doctor (MD 1) and notified the family of increasing confusion. The family was here. Resident 2 was confused but her vital signs were stable. I told her I had left a message for MD 2 because the relative thought Resident 2 was more confused, too. MD 2 didn't call back on my shift." During interview on 2/19/15 at 2:20 p.m., LVN 4 stated, "On 1/30/15, I attempted to contact the doctor (MD 2) and notified the family of the increased confusion. The relative was here and I told her that vital signs were stable. I told her I left a message for the doctor ( MD 2), because she also thought Resident 2 was more confused. MD 2 did not call back on my shift." Review of the hospital emergency department physician's evaluation, dated 1/31/15, showed, "Chief complaint: Worsening confusion. History of present illness: This is a ...female known to have Alzheimer dementia who at baseline is confused, but normally is alert and able to answer questions. However, in the last several days, the patient has been yelling and more confused, speaking gibberish, not following commands. She would usually be given [MEDICATION NAME] and this would result in the patient calming down and being able to sleep through the night...Assessment and Plan: 1. [MEDICAL CONDITION] (a [MEDICAL CONDITION]), likely secondary to a subacute infarct (An area of tissue which undergoes necrosis (death) due to cessation of blood supply, a stroke) involving the left parietal occipital, posterior temporal and lobes. Perhaps cardioembolitic (caused by a blood clot). admitted ...2. Lactic acidosis, unclear etiology (origin). (Lactic acid is formed in muscles due to the breakdown of glycogen, a starch. With muscle contraction glycogen breaks down into lactic acid, causing fatigue.) Urinary tract infection versus colonization. Will await urine culture." During phone interview on 3/4/15 at 10:30 a.m., DON stated, "MD 2 does not have anyone on- call for him. A physician should be available." Review of the facility's contract with MD 2, showed "The agreement for Professional Services, dated 8/1/14 and is entered between (MD 2) ...and ...facility. The term of the agreement shall be 12 months, beginning on the date shown above...3.1 During the term of this agreement, the Physician shall perform the professional services normally incident to the position of Co-Medical Director... The scope of duties shall include, but not be limited to: 3.1.3 Coordinating medical care in the facility; 3.1.4 Overseeing that all necessary medical services provided to residents are adequate and appropriate; 3.1.7 Providing 'on- call' availability and responding at all times to medical, regulatory, or other emergencies in the facility."

Based on observation, interview and record review for one of ten sampled residents (9), the facility did not provide timely pain management. This resulted in severe uncontrolled pain for Resident 9, and limited his mobility. During his recovery from a knee replacement, his physical therapist encouraged him to get out of bed to use the bathroom. Resident 9 used his urinal instead, because of unresolved pain. The facility failed to request a physician's order and instructions to apply Resident 9's personal ice therapy unit. Resident 9 told staff the ice decreased his pain and requested staff to help him apply the ice. Some staff applied the ice, and some staff did not. There was no physician's order for the icing unit. This deficient practice resulted in the ice being applied inconsistently, and may have contributed to Resident 9's unresolved pain. Findings: 1. For Resident 9, record review on 7/14/14, showed that Resident 9 had a left total knee replacement (TKR) surgery on 7/8/14 and a history of a right total knee replacement in 2013. He also had a history of [REDACTED]. (the destruction of joint cartilage and the underlying bone) During observation and concurrent interview on 7/15/14 at 8:49 a.m., Licensed Vocational Nurse 1 (LVN1) was observed placing red colored plastic locks on an Emergency Medication Kit (E-Kit) at the desk of the nurses' station. LVN1 stated that she removed narcotic pain medication for a resident who needed it. LVN1 then placed the unopened pain medication into a plastic medicine cup, and placed that medicine cup into the top drawer of her medicine cart and locked it. LVN1 proceeded to pass routine morning medications to multiple residents. When asked about the medications that were removed from the E-Kit, LVN1 showed the surveyor an unlabeled medication cup that contained 2 narcotic pills commonly used to treat pain ([MEDICATION NAME]). LVN1 confirmed that the medicine cup should have been labeled and then took a black marker out her pocket and labeled the medications. In addition, LVN1 stated that she removed the pain medication from the E-Kit to medicate Resident 9 who had been complaining of pain. LVN1 stated that the pain medication was a new order that the physician prescribed the day before. LVN1 stated that she did not give Resident 9 his new pain medication yesterday when prescribed because she didn't get to it and pharmacy hadn't delivered it. LVN1 agreed that medications removed from an E-Kit should be given immediately after removal. During observation and concurrent interview on 7/15/14 at 9:15 a.m., while lying in bed, Resident 9's ice machine was turned off and at his bedside, and attached to his left knee. He stated, "I am waiting on a new pain medicine ...I'm in pain but dealing with it ...I've been waiting since yesterday for them (nursing staff) to get back to me about the [MEDICATION NAME] ...I doubt they'll give it to me." Resident 9 stated he could not get up out of bed because he was in too much pain. Resident 9 stated the last medication that he had for pain was [MEDICATION NAME]. When asked about the ice machine, he stated no one has refilled it with ice for him. In further interview, Resident 9 stated that his surgeon ordered his ice therapy (machine) so he brought it with him to the facility. He stated the ice reduced the pain and swelling. Resident 9 then stated he couldn't keep it filled and sometimes staff filled it and sometimes they, "Just don't come back". He further stated he used it lot with his previous surgery, and his surgeon ordered it for him but, "No one here knows how to use it" except for the Director of Physical Therapy". In further interview on 7/15/14 at 9:35 a.m., Resident 9 stated, "I can't handle a lot of pain ...that's why I've been using the urinal so much because it hurts too bad to get up and go to the bathroom". Resident 9 had very noticeable swelling around the left knee area. He showed facial grimacing, groaning and guarding of the knee with movement. During observation and concurrent interview on 7/15/14 at 9:40 a.m. LVN 1 entered Resident 9's room to give him medication for pain. LVN 1 confirmed that she gave Resident 9 [MEDICATION NAME] (pain medication) that she removed from the E-Kit earlier. LVN 1 stated to Resident 9 that his new medication just came in and that he could have 1 or 2 tabs as needed for pain. Resident 9 stated that he was relieved to receive the pain meds and asked LVN 1 to refill his ice machine. LVN 1 stated that she, "didn't know anything about the machine." Resident 9 instructed LVN1 step-by-step how to fill the ice machine. During further observation and interview on 7/15/14 at 9:45 a.m. the Director of Physical Therapy (DPT) discussed TED stocking use with Resident 9 while smoothing the wrinkles out his stocking. DPT moved Resident 9's left leg and Resident 9 yelled out "aaahhhh!!!" (with facial grimacing), DPT continued to reposition Resident 9's leg on a pillow while stating that he (Resident 9) needed proper repositioning to reduce swelling. Resident 9 stated that he was in pain. DPT discussed Resident 9's frequent use of the urinal instead of getting up out of bed to go to the bathroom. DPT stated that she was going to remove Resident 9's urinal from his bedside. Resident 9 stated, "No you' re not!" Resident 9 stated he was in too much pain and that he was not going to walk to the bathroom until his knee pain was under control. DPT stated she would return later to assist Resident 9 with ambulation after his pain medication had taken effect. In an interview on 7/15/14 at 9:50 a.m. LVN 1 stated that she didn't know how to use Resident 9's ice machine and had not received any training for it. LVN 1 stated that she didn't know how long or often it should be used. LVN1 stated that it should be on the Resident 9's care plan. In an interview on 7/15/14 at 9:53 a.m. DPT stated there was no order for Resident 9's cold therapy (ice machine use) and it was a nursing responsibility to obtain the physician's order. DPT stated the cold therapy was a good treatment to decrease swelling and pain when properly used. DPT stated she showed two staff Certified Nursing Assistants how to use Resident 9's ice machine and stated that it was not her job to in-service the nursing staff. DPT stated that Resident 9 had a very low tolerance for pain, and stated, "the minute he (Resident 9) hurts he doesn't want to move or do anything ... " DPT stated, "I don't get involved with the nursing side of things ...like his pain medicine, I was told that he would be getting one (new pain med) yesterday but he didn't get it until today ...I'm flexible so I adjust my schedule". During an observation on 7/18/14 at 9:46 a.m. loud screaming was heard from room [ROOM NUMBER]. Surveyor knocked on the door and the DPT opened the door. Resident 9 was seated in a chair at the bedside and stated, "it's okay ...I was in pain and I always yell when I am in pain ... ". DPT stated, "Yeah that's why I closed the door .." DPT also stated, "I came by earlier around 9:20 a.m. but he (Resident 9) had not received his pain med yet, so I'm back now ... " During an interview on 7/18/14 at 10:30 a.m. Director of Nursing (DON) confirmed Resident 9 did not have a physician's order for the use of [REDACTED]. DON agreed that the use of cold therapy needed to be documented on Resident 9's Nursing Care Plan (NCP) and Treatment Administration Record (TAR) after physician's orders were obtained. On 7/15/14 record review for Resident 9 showed the following: 1.) Resident 9's MAR indicated [REDACTED] 2.) [MEDICATION NAME] was discontinued on 7/14/14 at 2:37 p.m. 3.) A new physician order for [REDACTED]. 4.) MAR showed a pain assessment by pain scale as 8 out of 10 during the day shift on 7/14/14. 5.) Nursing note dated 7/14/14 at 3 p.m. showed " [MEDICATION NAME] given at start of shift, but pt. stated, "it didn't touch the pain". Informed Nurse Practitioner (NP) received new order for [MEDICATION NAME] 10/325mg ... " 6.) Nursing note dated 7/15/14 at 4:01 p.m. showed, "[MEDICATION NAME] given for severe left knee pain... Pt also requested [MEDICATION NAME] also... new order received ...ice machine applied to the left knee .." 7.) Resident 9 did not receive new pain medication ([MEDICATION NAME], 2 tablets from E-Kit) until 7/15/14 at 9:40 a.m., 51 hours after the last pain medication(MAR showed documentation for 3:24 p.m. administration time on the same date). 8.) On 7/15/14 Resident 9's pain assessments showed: a.) For the day shift a pain rating of 8 out of 10. b.) For the evening shift a pain rating of 5 out of 10. c.) For the night shift a pain rating of 8 out of 10. 10. ) Resident 9's MAR indicated [REDACTED]. Resident 9's Nursing Care Plans and Treatment Administration Records also showed no documentation of an intervention for cold therapy (ice machine). 11. ) Physical Therapy Notes for Resident 9 dated 7/14/14 at 12:31 p.m. showed, "Pt complained of level 7 pain with movement ...Pt instructed to start using full weight bearing to walk to the bathroom and not using urinal to get him out of bed more often in day " . 12. ) Occupational Therapy Notes for Resident 9 dated 7/14/14 at 8:08 a.m. showed "Requested pain meds from charge nurse before PT". 13. ) Occupational Therapy Notes for Resident 9 dated 7/15/14 at 9:26 a.m. showed "Patient and charge nurse communicated to therapist that new pain med order has not yet arrived". 14. ) Physical Therapy Notes for Resident 9 dated 7/15/14 at 12:37 p.m. showed, "He was given new pain meds and appears to have some relief from [MEDICATION NAME] ... " . 15. ) Physical Therapy Notes for Resident 9 dated 7/16/14 at 2:16 p.m. showed, "Pt has ...less pain with new pain medication allowing increase movement ...He is now getting up to walk to the bathroom throughout the day." According to the Agency for Healthcare Research and Quality (AHRQ), Pain Management means the assessment of pain and, if appropriate, treatment in order to assure the needs of residents of health care facilities who experience problems with pain are met. treatment of [REDACTED].