Every finding on record at Redwood Terrace Health Center

Based on observation, interview, and record review, the facility failed to follow their own policy or guidance regarding Enhanced Barrier Precautions (EBP- an infection control strategy that uses gown and gloves during high contact resident care like medication administration to residents with pressure ulcer [injury to the skin and underlying tissue]), when a licensed nurse entered an EBP room without performing hand hygiene (handwashing or alcohol based handrub) and donning personal protective equipment (PPE-such as the use of gloves, gown, mask). As a result, there was a potential for cross contamination and spread of infection. Findings: Per the facility's admission Record, Resident 66 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer (injury to the skin and underlying tissue) of the sacral region, stage 3 (full thickness skin and tissue loss). On 8/13/25 at 8:36 A.M., an observation of medication administration for Resident 66 was conducted with Licensed Nurse (LN) 11. A signage was posted in Resident 66's room indicating he was on EBP. LN 11 prepared Resident 66's medication and entered Resident 66 room without PPE. LN 11 administered Resident 66's enoxaparin (anticoagulant) and injected subcutaneously (under the skin). LN 11 exited the room without performing hand hygiene before and after medication administration. On 8/13/25 at 8:45 A.M., an interview with LN 11 was conducted. LN 11 stated Resident 66 was on EBP. LN 11 stated she did not wear PPE like gown and gloves while administering medication to Resident 66. LN 11 stated it was important to use PPE to prevent the spread of infection to other residents. On 8/14/25 at 1:13 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was important for facility staff to perform hand hygiene before and after resident care and put on PPE to prevent the spread of infection to all residents. A review of the facility's undated guidance on enhanced barrier precaution indicated, .25. EBP should be followed when performing.close physical contact.Hand hygiene is recommended before and after resident contact.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when a Dietary Aide (DA) 2 was not wearing a hair net while sorting the food utensils in the food cart. This finding had the potential for food contamination and exposed the facility's residents to unsafe and unsanitary food practices that could lead to widespread food borne illnesses.Findings: On 8/11/25 at 8:10 A.M., an observation of the kitchen was conducted with DA 1. In the clean area, DA 2 was noted sorting out food utensils and folding some papers in the food cart without a hair net. DA 1 gestured DA 2 to wear a hair net. DA 1 stated the expectation for the kitchen staff were to wear a hair net when entering the kitchen to prevent hair from contaminating the food. On 8/11/25 at 9:05 A.M., an interview was conducted with DA 2. DA 2 stated she was folding some paper and was putting food utensils in the food cart. DA 2 stated she forgot to wear a hair net. DA 2 stated it was important to wear a hair net all the time in the kitchen because hair could go to the food and contaminate the food. On 8/11/25 at 3:30 P.M., an interview was conducted with the Registered Dietitian (RD). The RD stated the expectation for kitchen staff was to wear a hair net in the kitchen all the time, so the hair was covered to prevent food contamination. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Title 21, Sections 110.10 Personnel .(6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps.or other effective hair restraints . A review of the facility's policy titled, Uniform Dress Code, revised 1/25, indicated, .Associates Working with Food: Wear the approved hair restraint when on duty regardless of length or presence of hair .

Based on observation, interview, and record review, the facility failed to ensure a restraint was re-evaluated for one of one sampled resident (Resident 5) reviewed for physical restraint. This failure had the potential for Resident 5 to be restrained unnecessarily. Cross Reference F 636.Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia (impaired memory and thinking skills) with mood disturbance and a urinary catheter (a device that drains urine from the urinary bladder into a collection bag), per the facility's admission Record. On 8/11/25, a record review of Resident 5's minimum data set (MDS - a federally mandated resident assessment tool) dated, 7/10/25 was conducted. Per the MDS, Resident 5 had limb restraints. On 8/11/25, a record review of Resident 5's care plan initiated on 7/18/25 indicated, hand mittens were present upon admission. On 8/11/25, a record review of Resident 5's physician order was conducted. The physician's order dated 7/7/25 indicated, Pt. (Patient) to wear bilateral mittens at all times except on hygiene to protect self from scratching and unaware wounding of his face every shift. On 8/11/25, a record review of Resident 5's Treatment Administration Record (TAR) for July 2025 was conducted. The TAR indicated, the Licensed Nurses (LNs) signed off the mittens order for Resident 5 as implemented from 7/7/25 to 7/25/25. On 8/11/25 at 9:51 A.M., an observation of Resident 5 was conducted in his room. Resident 5 laid in bed with his eyes closed, with blanket to his torso and did not respond to his name. A urinary catheter was noted attached to the bed rails. On 8/12/25 at 2:13 P.M., a follow-up observation of Resident 5 was conducted in his room. Resident 5 laid in bed with his eyes closed, his upper extremities were exposed and no hand mittens noted. On 8/12/25 at 2:23 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 5 was confused. CNA 1 stated when Resident 5 was admitted , he had the hand mittens because he kept grabbing his urinary catheter while in the hospital. CNA 1 stated Resident 5 did not exhibit the behavior of pulling his urinary catheter during his stay at the facility. On 8/12/25 at 3:15 P.M., a concurrent review of Resident 5's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 5's document, titled TAR, dated July 2025. LN 1 stated the LNs signed off Resident 5's TAR indicating he had hand mittens on every shift. LN 1 stated Resident 5 was completely confused. LN 1 stated Resident 5 came to the facility with hand mittens on per Resident 5's family member's (FM) request. LN 1 stated Resident 5's FM informed the facility that Resident 5 needed the hand mittens to prevent him from pulling his urinary catheter. On 8/12/25 at 4:21 P.M., a concurrent review of Resident 5's clinical record and an interview was conducted with MDS Nurse (MDSN). The MDSN stated Resident 5 came with hand mittens and MDSN coded Resident 5 with limb restraint in the MDS tool. The MDSN stated Resident 5 had a history of scratching his face in the hospital. The MDSN reviewed Resident 5's TAR and stated the LNs signed off the hand mittens were in place and presented as used from 7/7/25 to 7/25/25. The MDSN stated, There was only a statement in the admission notes, and no assessment was done for Resident 5's hand mittens. The MDSN also stated there were no progress notes related to Resident 5's hand mittens in the LNs weekly notes. The MDSN stated there was no evaluation on the use of the hand mittens if Resident 5 still needed them or not because it was a physical restraint. The MDSN stated anything that physically inhibited the resident's movement was considered restraint. On 8/14/25 at 1:07 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 5's hand mittens should have been reevaluated, and education should have been provided to Resident 5's FM to prevent unnecessary use of restraint. Per the facility's policy, titled Use of Restraint, revised 4/17, .Restraints shall only be used for the safety and well-being of the residents and after other alternatives have been tried unsuccessfully.When the use of restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.

Based on observation, interview, and record review, the facility failed to ensure food and nutrition services staff was knowledgeable to safely and effectively carry out the functions of the department, when one [NAME] (CK 1) incorrectly demonstrated how to calibrate a food thermometer. This failure in staff competence could lead to incorrect food temperature, which could increase the risk of foodborne illness in the resident population of 47. Findings: On 8/14/25 at 9:05 A.M., an observation of CK 1 calibrating the food thermometer, with the presence of the Registered Dietitian (RD), the Food Service Director (FSD), and the Executive Chef (EC) and an interview was conducted with CK 1. CK 1 put some ice into a metal bin then put a little bit of sink water into it. CK 1 immersed the food thermometer into the metal bin with the probe touching the bottom of the metal bin. CK 1 stated that was how they were trained to calibrate the food thermometer. On 8/14/25 at 9:40 A.M., an interview was conducted with the FSD. The FSD stated per the facility's policy, CK 1 should have used a small cup or container with ice and put water to the top of the container then submerge the thermometer. The FSD stated it was important to calibrate the food thermometer right to get the right temperature. On 8/14/25 at 9:42 A.M., an interview was conducted with the RD. The RD stated the proper technique to calibrate the food thermometer was to fill a cup with ice and fill up with water to the top. The RD stated the calibration of the food thermometer was important to get the right temperature of the food and the food was safe to consume. A review of the facility's policy, titled Thermometers and Measuring Temperature, dated 10/1/22, indicated, .Verifying thermometer calibration, Fill a cup of or small container with ice, Add cold water to the top of the container, insert thermometer probe into the ice water.

Based on observation, interview, and record review, the facility failed to follow standards of practice when a Licensed Nurse (LN) did not follow physician's order/instructions during medication administration observation. This failure had the potential to cause side effects for Resident 38's health condition. Findings: Per the facility's admission Record, Resident 38 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (a condition wherein stomach contents leak backwards). A review of Resident 38's minimum data set (MDS- a federally mandated assessment tool) dated 8/4/25 indicated, Resident 38's brief interview for mental status (BIMS) was 3 which meant Resident 38's cognition (thought process) was severely impaired. On 8/13/25 at 8:46 A.M., an observation of medication administration to Resident 38 and an interview was conducted with LN 11. Resident 38's medication pack on Amantadine (Parkinson medication) indicated, to be given with food. LN 11 administered Resident 38's Amantadine without offering food to Resident 38. LN 11 stated she should have given Resident 38 some food like applesauce with the medication as ordered by Resident 38's physician. A record review of the physician's order dated 7/31/25 indicated, Amantadine was to be given by mouth with breakfast and lunch. On 8/13/25 at 9 A.M., an interview with Resident 38 was conducted. Resident 38 stated she was not sure if she had eaten her breakfast and that she took her medication from the nurse. On 8/14/25 at 10:30 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated licensed nurses are expected to follow physician's orders and instructions of the medications to prevent possible side effects and or complications like gastric upset with medications that had to be given with meals. A review of the facility's policy titled, Administering Medications, dated April 2019 indicated, .7. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to assess and document the use of hand mittens for one of one sampled resident (Resident 5) reviewed for physical restraint. This failure had the potential for Resident 5 to be restrained unnecessarily. Cross Reference F 604.Findings: Resident 5 was admitted to the facility on [DATE] with diagnoses which included dementia with mood disturbance (impaired memory and thinking skills) and a urinary catheter (a device that drains urine from the urinary bladder into a collection bag), per the facility's Face Sheet. On 8/11/25, a record review of Resident 5's minimum data set (MDS - a federally mandated resident assessment tool) was conducted. Per the MDS dated [DATE], Resident 5's had limb restraint. On 8/11/25, a record review of Resident 5's care plan, initiated on 7/18/25 indicated, hand mittens were present upon admission. On 8/11/25, a record review of Resident 5's physician order. The physician's order dated 7/7/25 indicated, Pt. (Patient) to wear bilateral mittens at all times except on hygiene to protect self from scratching and unaware wounding of his face every shift. On 8/11/25, a record review of Resident 5's Treatment Administration Record (TAR) for July 2025 was conducted. The TAR indicated the Licensed Nurses (LNs) signed off the mittens order for Resident 5 as implemented from 7/7/25 to 7/25/25. On 8/11/25 at 9:51 A.M., an observation was conducted of Resident 5 in his room. Resident 5 laid in bed with his eyes closed, with blanket to his torso and did not respond to his name. A urinary catheter was noted attached to the bed rails. On 8/12/25 at 2:13 P.M., a follow-up observation was conducted of Resident 5 in his room. Resident 5 laid in bed with his eyes closed, his upper extremities were exposed and no hand mittens noted. On 8/12/25 at 2:23 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 5 was confused. CNA 1 stated when Resident 5 was admitted , he had the hand mittens because he kept grabbing his urinary catheter while in the hospital. CNA 1 stated Resident 5 did not exhibit the behavior of pulling his urinary catheter during his stay at the facility. On 8/12/25 at 3:15 P.M., a concurrent review of Resident 5's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 5's document titled TAR, dated July 2025. LN 1 stated the LNs signed off Resident 5 had the hand mittens every shift except on hygiene. LN 1 stated Resident 5 was completely confused. LN 1 stated Resident 5 came to the facility with hand mittens on him per Resident 5's family member (FM) request. LN 1 stated Resident 5's FM informed the facility Resident 5 needed the hand mittens to prevent him from pulling his urinary catheter. LN 1 stated the admitting nurse was responsible for assessing the residents when the residents were admitted to the facility. LN 1 stated there was no assessment done prior to the use of hand mittens for Resident 5. On 8/12/25 at 4:21 P.M., a concurrent review of Resident 5's clinical record and an interview was conducted with MDS Nurse (MDSN). The MDSN stated Resident 5 came with hand mittens and she coded Resident 5 with limb restraint in the MDS tool. The MDSN stated Resident 5 had a history of scratching his face in the hospital. The MDSN reviewed Resident 5's Medication Record and stated the LNs were signing the hand mittens were in placed and indicated as used, from 7/7/25 to 7/25/25. The MDSN stated, There was only a statement in the admission notes, and no assessment was done for Resident 5's hand mittens. The MDSN also stated there was no progress notes related to Resident 5's hand mittens in the LNs weekly notes. The MDSN stated there was no assessment on the use of the hand mittens prior to its use, and there was no assessment if Resident 5 still needed the hand mittens. The MDSN stated the purpose of the assessment was to determine the appropriateness of the use of restraint and if less restrictive interventions or measures could be used if warranted. The MDSN stated the hand mittens used for Resident 5 should have been addressed earlier if he was assessed earlier. The MDSN stated anything that physically inhibited the resident's movement was considered restraint. On 8/14/25 at 1:07 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the LNs to have assessed Resident 5's needs for the use of the hand mittens and to identify less restrictive options to prevent unnecessary use of restraint. Per the facility's policy, titled Comprehensive Assessments, revised 3/22, .Comprehensive Assessments are conducted to assist in developing person-centered care plans.2. admission Assessment - The admission assessment is a comprehensive assessment for a new resident. Per the facility's policy, titled Use of Restraint, revised 4/17, .Restraints shall only be used for the safety and well-being of the residents and after other alternatives have been tried unsuccessfully.When the use of restraint is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented.6. Prior to placing a resident in restraints, there shall be a pre- restraining assessment and review to determine the needs of restraints.

Based on interview and record review, the facility failed to provide a written bed hold notice to the resident and or resident's Responsible Party (RP - an individual authorized by the resident to act as an official representative) upon transfer to the hospital for one of two residents (Resident 4) reviewed for hospitalization. This failure had the potential for Resident 4 and his RP being unaware of the bed hold duration and his right to return to the facility after hospitalization. Findings: A review of resident 4's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (can cause confusion, memory loss and loss of consciousness). The admission Record listed Resident 4's wife as the RP. Resident 4 was transferred to the hospital on 8/4/25 per Resident 4's wife due to difficulty breathing. On 8/12/25, a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool) was conducted. The MDS dated [DATE] indicated, Resident 4 was sent to an acute hospital and was anticipated to return to the facility. On 8/12/25 at 3:23 P.M., an interview was conducted with Licensed Nurse (LN) 2. LN 2 stated Resident 4 was sent out to the acute hospital due to the wife's request and Resident 4 was expected to return to the facility. LN 2 stated bed hold was not discussed to the resident and to the RP. LN 2 also stated a written bed hold notice was not given to Resident 4 and his RP. LN 2 stated there should have been a bed hold notice for Resident 4 to inform him and his RP that there was an available bed for him when the resident returned from the acute hospital. On 8/13/25 at 1:28 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated there was no bed hold provided to Resident 4 and his RP. The DSD stated the LNs should have provided bed hold to Resident 4 as part of the state process and as resident's rights to return to the facility. On 8/14/25 at 1:07 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated there was no bed hold offered to Resident 4. The DON stated the expectation of the facility was for bed hold to be offered to the residents and or their RPs when they were sent out to the acute hospital to assure the residents had options to return to the facility. A review of the facility's policy titled Bed-Holds and Returns, revised 10/22, indicated .Residents and/or representatives are informed (in writing) of the facility and state.bed hold policies.1. All residents/ representatives are provided written information regarding the facility and state bed hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization).

Based on interview and record review, the facility failed to send the results of an alleged staff to resident (Resident 1) abuse investigation to the State agency (California Department of Public Health, CDPH-licensing and certification agency) within five working days. This deficient practice had the potential for residents to not be protected from abuse. Findings: A review of Resident 1 ' s Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses which included dementia (decline in thinking abilities) . On 4/29/25 at 8:55 A.M., an onsite investigation was conducted to investigate an allegation of abuse between Resident 1 and a staff member. The administrator (ADM) was interviewed and stated the facility's abuse investigation between the staff member and Resident 1 was completed on 4/23/25 and the results of the investigation were sent via fax to the CDPH, on 4/23/25. A record review of the facility ' s document titled Confidential Summary of Incident Investigation, fax receipt dated 4/23/25, indicated the facility was made aware of the incident of alleged abuse between Resident 1 and the staff member on 4/15/25 and started their investigation on 4/15/25. On 4/29/25 at 12:35 P.M., an interview was conducted with the ADM. The ADM stated the facility sent the results of their investigation to CDPH seven working days after having knowledge of the incident. The ADM stated the results of their investigation of the incident of alleged abuse should have been sent to CDPH within five working days. A review of the facility ' s policy titled Elder Abuse Prevention, Identification, Response, Reporting revised 10/2023, indicated, .Section E. d. iii. Report the results of all investigations within five working days to the administrator orhis/her designated representative and to the other officials in accordance with State law, including to the State survey and certifications agency

Based on observation, interview, and record review, the facility failed to ensure LN removed an expired medication from the medication cart for one of two medication carts observed. In addition, LN left medications unattended in residents room and allowing residents to self-administer without proper assessment and qualification for two of 13 sampled residents (27 and 88), and five unsampled residents (16, 30, 32, 194 and 200). As a result, there was a potential for staff to administer expired medication. In addition, staff would not have been able to verify the appropriate dose taken by the residents. Findings: 1. On 12/15/22 at 10:21 A.M., an observation of a medication cart was conducted with LN 2. A bottle of calcium citrate tablets was noted to have expired on 8/22. On 12/15/22 at 10:28 A.M., an interview with LN 2 was conducted. LN 2 stated if a resident was given an expired medication, it could have less effectiveness. On 12/15/22 at 10:30 A.M., an interview with LN 6 was conducted. LN 6 stated there should have not been expired medications in the medication cart. On 12/15/22 at 1:45 P.M., an interview with the DON was conducted. The DON stated if there were expired medications in the medication cart, there was a risk it would be given to a resident which could cause potential harm. Per the facility's policy and procedure titled Storage of Medication, dated 9/18, .Procedures .14 .Outdated, .medications .are immediately removed .disposed of . 36471 2a. Resident 30 was admitted to the facility on [DATE] with diagnoses which included glaucoma (vision loss), per the facility's Profile Face Sheet. On 12/12/22 at 8:25 A.M., Resident 30 was observed during the initial tour of the facility. There were two bottles of eye drops on the overbed table. Resident 30 stated she used artificial tears four times a day and the other eye drop at bedtime. A review of Resident 30's medical record was conducted. There was no evidence that Resident 30 could self-administer eye drops. 2b. Resident 16 was admitted to the facility on [DATE] with diagnoses which included hypertension (abnormal blood pressure), per the facility's Profile Face Sheet. On 12/12/22 at 10:16 A.M., during the initial tour of the facility, it was observed that Resident 16's bedside drawer was opened, and there were two large bottles of over-the-counter (OTC) medicine. Resident 16 stated the staff knew about her medications at the bedside and It's fine!. A review of Resident 16's medical record was conducted. There was no evidence Resident 16 had an order from the physician for the OTC or approval for self-administration of medications. 2c. Resident 27 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure (heart problem), per the facility's Profile Face Sheet. On 12/12/22 at 10:33 A.M., during the initial tour of the facility. Resident 27 had a nasal spray bottle on the overbed table. Resident 27 stated he had difficulty squeezing the bottle, so he had to drip the solution into his nose. A review of Resident 27's medical record was conducted. There was no evidence Resident 27 had an order from the physician for the nasal spray or approval for self-administration of medications. 2d. Resident 32 was admitted to the facility on [DATE] with diagnoses which included severe obesity, per the facility's Profile Face Sheet. On 12/12/22 at 10:49 A.M., during the initial tour of the facility, Resident 32's bathroom was observed. On the countertop was a medicine cup with a pink-color cream inside. Resident 32 stated the LN applied the cream last night on her bottom. On 12/13/22 at 3:24 P.M., an interview was conducted with LN 1. LN 1 stated residents who wish to keep their medication at the bedside should have an assessment and an order from the physician. LN 1 further stated the cream on Resident 32's bathroom was a medicated cream. A review of Resident 32's medical record was conducted. There was no evidence Resident 32 had a physician's order for the cream or approval for self-administration of medications. 2e. Resident 88 was admitted to the facility on [DATE] with diagnoses which included a fracture of the left femur (broken thigh bone) per the facility's Profile Face Sheet. On 12/12/22 at 3:20 P.M., during the initial tour of the facility, Resident 88 was observed. Resident 88 had two single-use vials of eye drops inside a medicine cup on the overbed table. Resident 88 stated she used the eye drops four times a day. A review of Resident 88's medical record was conducted. There was no evidence Resident 88 could self-administer eye drops. On 12/13/22 at 3:24 P.M., an interview was conducted with LN 1. LN 1 stated residents who wish to keep their medication at the bedside should have an assessment and an order from the physician. LN 1 further stated no residents in the facility had approval from the physician to self-administer. On 12/14/22 at 3:55 P.M., an interview was conducted with the DON. The DON stated no residents had approval from the physician to self-administer medications. The DON stated the LNs should not leave the medications unattended to ensure residents' safety. 2f. Resident 194 was readmitted to the facility on [DATE] with diagnoses which included mild cognitive (thinking ability) impairment per the facility's Profile Face Sheet. On 12/13/22 at 8:28 A.M., an observation of medication administration to Resident 194 was conducted. LN 1 prepared six medications for Resident 194, placed it in the medicine cup, left the medications on the breakfast tray, and then left the room without observing Resident 194 take the medications. On 12/13/22 at 9 A.M., an interview with LN 1 was conducted. LN 1 stated she knew she should not have left Resident 194's medications without observing her take them. LN 1 stated she should have watched Resident 194 take the medications for patient safety or not take the medications. On 12/13/22 at 10:13 A.M., an interview with the DON was conducted. The DON stated the staff should have taken the medications with her if she had to leave the resident's room prior to the resident taking the medications. The DON stated without observation, the staff would not know what the resident did with the medications. 2g. Resident 200 was admitted to the facility on [DATE] per the facility's Profile Face Sheet. On 12/14/22 at 4:34 P.M., during an observation of medication administration with LN 7 and LN 8, a bottle of vitamin and mineral supplements were found inside Resident 200's drawer inside his room. LN 7 stated Resident 200 may take more than what was prescribed if the medications were kept in his room. On 12/14/22, an interview with LN 2 was conducted. LN 2 stated Resident 7 should not have the medication inside his room. LN 2 stated the medication was in Resident 200's drawer since admission. LN 2 stated Resident 7 may overdose on the medication if it was kept in his room. A record review was conducted. There was no self-administration assessment conducted for Resident 200 prior to 12/14/22. On 12/15/22 at 8:06 A.M., an interview with the DON was conducted. The DON stated if a resident did not pass a self-administration assessment and a medication was kept inside a resident's room, there was always a risk of a resident taking more than what was prescribed which could cause potential harm. Per the facility's policy and procedure, titled Medication Administration Self-Administration by Resident, dated 11/17, .The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment . Per the facility's policy and procedure, titled Medication Storage, dated 9/18, .The medication supply shall be accessible only to licensed nursing personnel .

Based on observation, interview, and record review, the facility failed to follow infection control prevention for one of 13 sampled residents (28) when the LN put on new gloves without performing hand hygiene. As a result, there was a potential for cross-contamination. Findings: Resident 28 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (abnormal blood sugar) per the facility's Profile Face Sheet. On 12/12/22 at 2:26 P.M., LN 2 was observed conducting a wound dressing change to Resident 28. LN 2 cleansed Resident 28's right foot with gloved hands and then, LN 2 removed her gloves. LN 2 put on new gloves without performing hand hygiene, and proceeded to complete the wound dressing change. After Resident 28's dressing change, an interview was conducted with LN 2. LN 2 stated she did not perform hand hygiene after removing the soiled gloves and applying new ones. LN 2 further stated she should have performed hand hygiene between glove changes. On 12/14/22 at 3:55 P.M., an interview was conducted with the DON. The DON stated the staff should perform hand hygiene between glove changes to prevent cross-contamination. Per the facility's policy and procedure, titled Handwashing/Use of Alcohol-Based Hand Rubs, dated 8/20, .Perform hand hygiene before applying non-sterile gloves .When removing gloves .perform hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure food stored and prepared in the kitchen was in accordance with professional standards for food and service safety when: 1. the walk-in refrigerator had open and undated food, and 2. a box of lemon-glycerin swabsticks (lemon-flavored medical swab sticks that were 4-inch plastic swabs with [NAME] or foam tips) was stored in the residents' reach-in freezer. As a result, there was a potential for the staff to serve contaminated or spoiled food, and swabsticks may accidentally be ingested by a confused resident. Findings: 1. On 12/12/22 at 8:20 A.M., a joint observation and interview were conducted with CK 1. Inside the walk-in refrigerator, there was a tray of cube potatoes spread evenly on the tray with no cover, label, or date, and a tray of small plastic cups containing a yellow-colored substance. The tray had no date or label. CK 1 stated prepared items should have been labeled and dated. On 12/12/22 at 8:40 A.M., an interview was conducted with RDS 1. RDS 1 stated the kitchen staff should label and date the prepared foods. RDS 1 further stated it was essential to date items to ensure the items prepared first should have been served first. Per the facility's policy and procedure, titled Production, Purchasing, Storage, dated 1/22, .Cover, label, and date unused portions and open packages .Date and rotate items . 2. On 12/13/22 at 4:38 P.M., the residents' food refrigerator with freezer in the communal area was observed with the DON. A box of lemon-glycerin swabs was found inside the freezer. The DON stated the ST used the items for treatment and should not be inside the resident's refrigerator. A follow-up interview was conducted with ST 1. ST 1 acknowledged she put the lemon-glycerin swabs in the resident's refrigerator and used the swabs during treatment. Furthermore, ST 1 stated she should not place the swabs with the residents' food. On 12/14/22 at 11:25 A.M., an interview was conducted with RDS 2. RDS 2 stated the lemon-glycerin swabs were not food and should not be inside the resident's refrigerator. Per the facility's policy and procedure, titled Production, Purchasing, Storage, dated 1/22, .All food, non-food items and supplies used in food preparation shall be stored in a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .

Based on interview and record review, the facility failed to ensure restorative nursing (care to improve or maintain the functional ability of the resident) was conducted per the physician's order for one of seven sampled residents reviewed for limited mobility (7). As a result, there was a potential for Resident 7 to experience a decrease in mobility. Findings: Resident 7 was readmitted to the facility on [DATE] with diagnoses which included osteoporosis (decrease in bone mass) per the facility's Profile Face Sheet. On 12/14/22 at 2:10 P.M., a concurrent interview and record review was conducted with RNA 1. The physician order dated 10/12/22 indicated RNA ambulation program 5x/wk (times/week), Monday to Friday through 1/12/23 for Resident 7. RNA 1 stated if the order was 5x/wk on Monday to Friday, then it has to be followed. RNA 1 stated the consequence of not conducting the RNA per physician's order would be Resident 7 may lose the ability to walk and that was not good. Resident 7's RNA program's chart indicated in 2022: week of 10/24, Resident 7 had RNA 3x/wk week of 10/31, Resident 7 had RNA 4x/wk week of 11/7, Resident 7 had RNA 4x/wk week of 11/14, Resident 7 had RNA 4x/wk week of 11/21, Resident 7 had RNA 4x/wk week of 11/28, Resident 7 had RNA 4x/wk week of 12/5, Resident 7 had RNA 4x/wk On 12/14/22 at 2:35 P.M., an interview with the DON was conducted. The DON stated if the physician's order for Resident 7's RNA program was not being consistently followed, then there was a potential decline for a resident in activities of daily living [walking]. Per the facility's policy and procedure titled, Restorative Nursing Services, dated 2001, Policy Statement Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on interview and record review, the facility failed to ensure current and accurate records were kept for controlled drugs to prevent diversion (theft or unauthorized use). In addition, the facility did not provide training to registry nurses (employed by an agency or a facility to work on a as needed basis) related to the handling and/or receiving delivered controlled drugs to the facility from the pharmacy. As a result, the facility could not ensure controlled drugs were accounted for to prevent misuse or abuse. Findings: An investigation and record review was initiated on 12/16/20 in response to a facility reported incident to the California Department of Public Health. Sixty tablets of the controlled drug [MEDICATION NAME] (pain medication) were missing and unaccounted for. Per the Drug Enforcement Agency (DEA), [MEDICATION NAME] had been classified as a schedule II drug/medication and had a high potential for abuse or misuse. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 had physician orders [REDACTED]. On 12/16/20 at 11:40 A.M., a joint interview and record review with the interim Director of Nursing (DON) was conducted. The DON stated the incident happened on 12/13/20 when Licensed Registry Nurse (LN) 1 received the medication [MEDICATION NAME] 5 mg/tab, 60 tablets from the pharmacy. The pharmacy delivery manifest (receipt of delivery), dated 12/13/20, was signed by both LN 1 and the pharmacy delivery person, a documentation to show LN 1 received 60 tablets of [MEDICATION NAME] 5mg/tablet. The DON further stated LN 1 then handed over the medication to LN 2. The DON continued on to say that on 12/14/20, the afternoon shift nurse noticed and reported that the [MEDICATION NAME] medication 5 mg/tab, 60 tablets were missing. There was no documented evidence that showed LN 1 handed the [MEDICATION NAME] medication to LN 2. In addition, there was also no documentation that showed LN 2 received the [MEDICATION NAME] medication on her shift. Attempts were made to interview both LN 1 and LN 2 who were both registry nurses but were unsuccessful. The training files of both LN 1 and LN 2 were reviewed. Both files did not show evidence of training from the facility on the handling and/or receiving delivered controlled drugs from the pharmacy. On 1/6/21 at 11:30 A.M., an interview with the interim DON was conducted. The DON stated Resident 1's controlled-substance record (narcotic sheet) that contained all the pertinent information related to [MEDICATION NAME] medication was also missing. On 1/6/21 at 11:35 A.M., an interview was conducted with LN 3. LN 3 stated only licensed nurses were to receive delivered controlled drugs from the pharmacy. LN 3 further stated, the receiving nurse and the delivery person signed the manifest, the nurse in the unit who received the controlled drugs and the controlled-substance record would have signed as well. On 1/6/21 at 11: 45 A.M., an interview with the interim DON was conducted. The DON acknowledged there was a needed improvement recognized by the facility related to the process of handling and/or receiving controlled drugs/medications delivered by the pharmacy. The facility's policy titled, Controlled Substance Policy, dated 05/08, indicated, The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of s II and other controlled substances .

Based on observation, interview, and record review, the facility failed to remove expired medical supplies and specimen tubes (used to collect samples for medical testing) from one of one medication storage room. In addition, the facility failed to assess for the ability to self-medicate and obtain a physician's orders [REDACTED]. This failure had the potential: 1. to affect the test results for the use of expired medical supplies, and; 2. to place Resident 8 at risk not to take their prescribed medication and gave other residents access to the medications left at the bedside. Findings: 1. On [DATE] at 2:54 P.M., an observation of the medication storage room, and interview was conducted with LN 11. On the counter of the medication room, inside a blue bin, there were five (3 cubic centimeter-cc) syringes with needles had an expiration date of ,[DATE]. On one of the bottom shelf, inside the medication room, a bottle of [MEDICATION NAME] packing strip (used for wound care management) had an expiration date of ,[DATE]. In one of the drawers, inside the medication room, there were 20 pieces of aerobic and anaerobic culture swab tubes (used for specimen collection and transport) with the expiration date of [DATE]. LN 11 stated the medical supplies should have been removed from the medication storage room. LN 11 stated expired medical supplies would have decreased its effectiveness and expired culture swab would no longer provide an accurate result. On [DATE] at 11:28 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated expired medical supplies should have been removed from the medication storage room. Expired culture swab could have a false negative result and would affect the resident's treatment. A review of the facility's undated policy, titled, Storage of Medications, indicated The facility shall store drugs and biologicals in a safe, secure and orderly manner . The facility did not have a specific policy addressing the storage of medical supplies. 2. Resident 8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On [DATE] at 8:48 A.M., an observation and interview was conducted of Resident 8 in her room. Resident 8 was sitting in a chair, by herself, and she was holding a medicine cup with numerous medications inside the cup. Resident 8 stated she already took some of her morning medications. On [DATE] at 8:50 A.M., an interview was conducted with LN 12, while in the hallway. LN 12 stated, she had given Resident 8's morning medications that were scheduled for 9 A.M., and thought Resident 8 have taken all her medications. LN 12 went back to Resident 8's room and asked Resident 8 why she had not taken all her medications that she had given her. Resident 8 stated, I waited to take the other half of my medications. On [DATE] at 9 A.M., an observation was conducted with the Director of Nursing (DON) in Resident 8's room. On the floor, was a white round pill, and Resident 8 stated I might have dropped that pill this morning. The DON picked up the pill and stated it was a vitamin. On [DATE], a review of Resident 8's medication record indicated she was scheduled to have received 12 pills at 9 A.M. On [DATE], a review of Resident 8's signed physician orders, dated [DATE], indicated there were no order for Resident 8 to self-administer medications. On [DATE] at 11:24 A.M., an interview was conducted with the DON in her office. The DON stated, the LN should have observed the resident taking all the medications before the LN left the room. The DON further stated, it is our policy for the nurse to observe the resident taking all the pills before leaving the room. Per the facility's policy, undated, titled Self - Administration of Medications, .residents have the right to self - administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .

Based on observation, interview and record review, the facility failed to ensure nurse staffing data was posted in a prominent place accessible to residents and visitors to include: total number of actual hours worked by nursing staff (Registered Nurses, Licensed Vocational Nurses, Certified nurse aides) & resident census. This failure had the potential to result in residents and visitors having to ask the facility for their staffing information. Findings: On 3/5/20 at 3:20 P.M. an observation at the facility's care center nursing station was conducted. The nurse staffing information posted did not include total hours worked by licensed and unlicensed nursing staff for the following categories: Registered Nurses, Licensed Vocational Nurses and Certified Nurse Aides. During an interview with the facility's DSD on 3/5/20 at 3:26 P.M., the DSD stated, the completed nurse staffing information was taken down by the facility's Administrator (Admin) when the facility was remodeled. On 3/5/20 at 3:29 P.M., an interview with the facility's Admin was conducted. The Admin stated, the completed nurse staffing information was in a book at the nurse's station. The Admin stated, going forward it would be posted on the shelf next to our annual survey results for residents and visitors to review.

Based on interview and record review, the facility failed to implement a comprehensive care plan for Resident 22's actual weight loss. This failure had the potential for Resident 22 to not receive person-centered care for their weight loss. Findings: Resident 22 was admitted to the facility on [DATE] as indicated by the Face Sheet. A record review of Resident 22's documented weights was conducted: 12/31/19 120 lbs. 3/2/20 108 lbs. On 3/3/20, a record review of Resident 22's care plans was conducted. A care plan for actual weight loss was not found. On 3/3/20 at 2:41 P.M., an interview with LN 21 was conducted. LN 21 stated, the Registered Dietitian (RD) created Resident 22's nutritional care plan titled, Potential risk for altered nutritional status. During an interview on 3/5/20 at 1:25 P.M. with the Registered Dietitian (RD), the RD stated, Resident 22's nutritional care plan was for potential risk for weight loss. The RD stated, she did not implement a care plan for Resident 22's actual weight loss. A review of the facility's policy and procedure (P&P) titled, Nutrition Alert Committee, dated 1/20, the P&P indicated, During the Nutritional Alert meeting .care plans are updated accordingly.

Based on observation, interview and record review, the facility failed to ensure one of two residents (Res38), low air loss mattress (a medical air mattress used to prevent skin breakdown) was properly set up. This failure had the potential to cause Resident 38's pressure ulcer (skin injury which developed because of pressure over a bony area of the body) to worsen. Findings: Resident 38 was admitted to the facility on [DATE] according to the facility's Face Sheet. During an observation on 3/2/20, at 9:38 A.M., in Resident 38's room, Resident 38 was observed in bed, moaning. A low air loss mattress (LAL) was observed on Resident 38's bed. The LAL mattress was set to static 450 lbs. and was locked. A review of Resident 38's Physician order [REDACTED]. A review of Resident 38's skin assessment dated [DATE] indicated, Resident 38 had a stage 1 pressure ulcer (skin injury to the surface layer of skin) on her coccyx and was at risk for pressure ulcers. During an observation on 3/2/20, at 2:53 P.M., in Resident 38's room, Resident 38 was observed in bed. Resident 38's LAL mattress settings was observed and set to static at 450 lbs. ON 3/2/20 2:55 P.M., CNA 24 stated Resident 38 had pressure ulcers on her buttocks and the wound LN had changed Resident 38's pressure ulcer dressings that morning. On 3/4/20 at 9:14 A.M., an interview with CNA 21 was conducted. CNA 21 stated, the LN's were responsible to monitor Resident 38's LAL mattress to ensure the settings were correct. On 3/4/20 at 2:29 P.M., an interview with RNA 21 was conducted. RNA 21 stated, the LAL mattress settings were based on resident's weight and comfort level. RNA 21 stated, he was responsible for checking Resident 38's weight and then he would adjust the settings of Resident 38's LAL mattress based on Resident 38's current weight. RNA 21 stated, he had adjusted Resident 38 LAL mattress settings recently to 150 lbs. RNA 21 stated, 450 lbs was too hard for Resident 38. RNA 21 stated, if the mattress was too hard it defeated the purpose of preventing pressure on the resident's skin. A review of Resident 38's weight log for February 2020 was conducted. On 2/24/20 Resident 38's weight was documented at 117.8 lbs. On 3/5/20 at 2:22 P.M., an interview with the DON was conducted. The DON stated, LAL mattress settings are based on the resident's weight and comfort. The DON also stated, 450 lbs. was not the correct setting for Residentn 38.

Based on observation, interview, and record review, the facility failed to ensure a resident's personal information was protected, when an empty medication bubble pack for one unsampled resident (25) was left on top of a medication cart. This failure had the potential for the resident's information to be viewed by anyone who passed by the cart. Findings: 1. Resident 25 was admitted to the facility on [DATE], per the facility's Profile Face Sheet. On 3/2/20 at 10:09 A.M., an observation was conducted in the hallway of rooms 201 to 214. A medication cart was observed unattended near room [ROOM NUMBER]. On the top of the cart was an empty medication bubble pack that displayed the name of Resident 25, name and strength of the drug, directions for use, expiration date, and the name of the prescriber. On 3/2/20 at 10:17 A.M., a concurrent observation and interview was conducted with the Assistant Director of Nursing (ADON) in front of the medication cart. The ADON picked up the empty medication bubble pack and stated the Licensed Nurse should not have left the medication pack unattended to protect the resident's information. On 3/5/20 at 11:24 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated resident information must be protected and should not be left in an area where information was accessible for public viewing. A review of the facility's policy and procedure, dated 6/28/18, titled Confidentiality of Protected Health Information, indicated . 3 .family and visitors must be restricted from viewing information and may not be left alone in an area where such information is accessible .

Based on observation, interview and record review, the facility did not ensure that Infection Control Surveillance was developed or implemented. In addition, staff did not implement contact precautions for two of 14 residents (11, 41) consistently. Findings: The following observations and interviews were conducted on 1/22/19 at 9:50 A.M.: 1a. Resident 11 was on contact precautions. Outside Resident 11's door was posted a large sign that indicated, Contact Precautions: see nurse before entering. Also, outside of the room were PPE supplies: gowns, gloves, shoe covers, masks. Resident 11 was observed in her room, sitting in a chair, doing a crossword puzzle with a visitor. The visitor was not wearing a gown, gloves, or mask. The visitor stated, I don't have to wear any gown or gloves because I am not touching the resident; just the puzzle. 1b. Resident 41 was on contact precautions. Outside Resident 41's door was posted a large sign that indicated, Contact Precautions: see nurse before entering.Resident 41 was observed in her bed, sitting up. Resident 41 called out for help. The VPR entered the room without wearing a gown, gloves or mask. The VPR stated, I should have seen the sign and worn the protective equipment that was there. An interview was conducted with the ICN on 1/25/19 at 8:10 A.M. The ICN stated, Not following contact precautions is a problem because it can expose the rest of the community to the pathogen. An interview was conducted with the DON on 1/25/19 at 8:12 A.M. The DON stated, Staff should follow contact precautions; because two staff entered 2 rooms without following contact precautions, our process is not effective. A review of the facility's policy, titled, Infection Control, General Policy Statements, dated 9/08, indicated, .This facility follows Guidelines for the Prevention and Control of Nosocomial Infections and Universal Precautions as provided by the Center for Disease Control . A review of the Center for Disease Control Guidelines, dated 2/17, indicated, .Use personal protective equipment (PPE) appropriately, including gloves and gowns. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. 2. Surveillance of staff implementing contact isolation and hand washing was absent from the infection control record. The ICN and DON confirmed there was no process to track health care provider compliance with hand washing and contact isolation in the facility. Per the facility policy, revised 3/18, titled Infection Control Plan, .It is the policy of this facility to establish an Infection Control Committee which oversees and implements the plan of the Infection Control Program .Maintain accurate records of . infection control measures and surveillance .

Based on observation, interview and record review, the facililty failed to ensure that frozen foods and refrigerated foods had a received-on date and a use-by date. This failure had the potential to expose a vulnerable population to food-borne illness. Findings: During the initial tour of the kitchen with the Registered Dietician (RD), Administrator (Admin) and Cook on [DATE] at 9 A.M. the following observations were made: 1. In the freezer, there were 2 boxes of frozen steaks, 2 boxes of frozen salmon and 2 boxes of frozen shrimp with no received-by dates and no use-by dates; 2. In the refrigerator, there were boxes of fresh tomatoes, fresh mushrooms, fresh apples, fresh oranges, fresh pineapples and fresh asparagus with no received-by dates and no use-by dates; 3. In the refrigerator, there was an opened 32 ounce container of a honey nectar-thick soy beverage with no date to indicate when it was opened. An interview was conducted with the RD on [DATE] at 9:20 A.M. The RD stated, It (food) should be labeled, no one would know if it is ok to use. An interview was conducted with the Cook on [DATE] at 9:25 A.M. The Cook stated, Everything should be labeled, so nothing is used that is expired. An interview was conducted with the Consultant Registered Dietician (CRD) on [DATE] at 9:30 A.M. The CRD stated, The foods should have been labeled; it is important because staff need to know it is still usable. An interview was conducted with the DON on [DATE] at 9 A.M. The DON stated, It is important to label food items with dates because our residents are vulnernable to food-borne illness. Based on the (YEAR) US Food Code Section ,[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: .refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded .

Based on observation, interview and record review the facility failed to provide adequate supervision to 4 of 14 sampled residents (6, 24, 32, 51) and 4 non-sampled residents (13, 20, 21, 34) identified as high fall risks for falls. As a result, 1 of 14 sampled residents (24) sustained a fall in an isolated activity room, without any staff present, and no means for the residents to contact staff. The facility failed to secure harmful chemicals in 1 of 1 laundry room. Findings: 1. During an observation, eight residents (6, 13, 20, 21, 24, 32, 34, 51) were in the pavilion multipurpose (MPR) room, a separate building from the nursing unit, alone and unattended. There was no call light system, no telephone and no other communication device available in the room to summons help from staff in the main building. a. Resident 6, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 6's risk for fall/injury care plan indicated the need for re-orientation with any environmental changes and assistance with transfers. b. Resident 13, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 13's risk for fall/injury care plan indicated the resident was at high risk for falls and required orientation with environment changes, assistance with transfers, and a personal alarm when out of bed. c. Resident 20, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 20's risk for fall/injury care plan indicated the resident was at risk for falls, required orientation with environment changes, assistance with transfers, and a personal alarm. d. Resident 21, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 21's risk for fall/injury care plan indicated the need for re-orientation with any environmental changes and assistance with transfers. e. Resident 24, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 24's risk for fall/injury care plan indicated a history of falls with injuries, personal alarm for safety, and maximum assistance required for activities of daily living (ADL's). f. Resident 32, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 32's risk for fall/injury care plan indicated the resident was at high risk for falls, had a history of [REDACTED]. g. Resident 34, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 34's risk for fall/injury care plan indicated the resident was at high risk for falls, had a history of [REDACTED]. h. Resident 51, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Resident 51's risk for fall/injury care plan indicated the resident was at high risk for falls, history of falls, required orientation with environment changes, assistance with transfers, and a personal alarm when out of bed for safety. At 2:20 P.M., Resident 24 attempted to rise out of her wheelchair and activated her personal alarm. No staff was present, and moments later, Resident 24 fell to the ground. As the other residents in the room yelled for help, CNA 1 (Certified Nursing Assistant), outside the door of the building, pushed a resident in a wheelchair towards the door and seemed unable to hear the alarm or screams from the residents. CNA 1 entered the building, acknowledged the personal alarm and calls for help from other residents. The PTA (physical therapist aide) entered the room behind CNA 1 and ran to the main building for further assistance from the licensed nursing staff. At 2:35 P.M., Resident 51 stated, " Poor thing, she's (24) been trying to get up all morning." Resident 24, transferred by emergency ambulance to the general acute care hospital (GACH), received 10 milligrams of Morphine (narcotic pain reliever) from the paramedics and 1 milligram of Dilaudid (narcotic pain reliever) in the emergency room , per the hospital report. At 3 P.M., during a joint interview, LN 3 (Licensed Nurse), CNA 2, and CNA 3 acknowledged that they would not be able to hear residents' personal alarms outside of the pavilion MPR, or from the nursing unit building. They all stated they never left residents in the pavilion MPR without supervision for safety. CNA 4 and CNA 1 acknowledged they would not be able to hear any alarms or calls for help from residents in the pavilion MPR from outside of the building. CNA 4 and CNA 1 stated they would not leave residents unattended in the pavilion MPR room and thought that the activity aide was present. The DON (Director of Nursing) stated, "They should not have been left alone, a CNA or Activity Aide should have been present at all times." On 5/25/11 at 8 A.M., during an observation and interview, Resident 24 sat in a recliner chair in her room being assisted with breakfast. Resident 24 wore a right arm sling and shoulder immobilizer. Resident 24 stated her arm was very painful and could not move it for fear of additional pain. LN 4 acknowledged that Resident 24 had taken around the clock narcotic pain medication for severe pain related to a fall with injury in the facility on 5/4/11. LN 4 stated Resident 24 had a fractured right proximal humerus (broken right arm bone near the shoulder) from a previous fall and this most recent fall, on her right side, had made the pain worse. At 9:30 A.M., during an interview, Resident 24's daughter acknowledged Resident 24 had fallen in the facility on 5/4/11, and required hospitalization and narcotic pain medication for a right arm fracture. Resident 24's daughter stated Resident 24 ambulated throughout the facility prior to her fall, and now was confined to a wheelchair and unable to maneuver on her own as a result of the pain. Resident 24's daughter stated, "They should have had another staff in the pavilion MPR with the residents, it's not safe to leave them alone." At 10:30 A.M., during an interview, the AD (Activity Director) stated, "I didn't tell the Activity Aide (AA) to stay in the room (Pavilion MPR) while I went for pizza. I assumed the CNA's would stay, they know they should." At 1:30 P.M., Resident 21 stated, "She (24) had tried to get out of her chair before and I try to help her back down. She sees people moving around and she thinks she can too. I don't know of any call light in the room (Pavilion MPR) I just yell for help." At 1:35 P.M., during an interview, Resident 34 stated, "They only leave us alone for a minute while they bring someone back to their room to go to the bathroom. She (24) always tries to get out of her chair and I tell her to sit down but she doesn't listen to me. She had been up and down all morning (5/24/11) and the alarm was always going off." At 1:40 P.M., during an interview, Resident 13 stated, "They've left us alone in the Pavilion MPR before when they're bringing other residents in. I don't think there is a call alarm in there, I just yell for help." At 2:05 P.M., during an interview, the PT (Physical Therapist) stated, "Residents should not be left in the Pavilion MPR alone, it's not safe. She (24) used to walk with a walker but cannot any longer since the fall and broken arm." At 3:10 P.M., during an interview, Resident 32 stated, "The staff go in and out (of the Pavilion MPR), I didn't notice that they were there when she (24) fell . There is no call light that I know of (in the Pavilion MPR)." At 4 P.M., during an interview, LN 5 stated, "Before the fall on 5/4/11, Resident 24 could ambulate with a walker, now she must be placed in a wheelchair and cannot move it on her own. The residents are normally taken to the Pavilion MPR and left with the AA. They should never leave a resident in the Pavilion MPR alone. You cannot hear the personal alarms in that building." On 5/26/11 at 8:10 A.M., LN 1 stated, " (24) is on routine narcotic pain medication for her broken arm, but it's not working. She's in a lot of pain. I'm going to ask the doctor for a narcotic medication patch to help with her pain control. " At 8:30 A.M., during an interview, LN 6 stated, "We would only leave residents in the Pavilion MPR if the activity staff were present." At 9:20 A.M., during an interview, the AA stated, "I was in the nursing unit when the fall happened. There was a miscommunication that day. When it's an activity, then the activity staff are responsible for the residents in the Pavilion MPR. It was my responsibility to be in the MPR with the residents that morning. The AD told me she was leaving that morning. I can't hear the resident's personal alarms in the MPR from the nursing unit. 2. During an environment tour, on 5/25/11 at 8:50 A.M., the laundry room door was unlocked. The unlocked cabinet in the laundry room contained spray bottles of chemicals used to remove chewing gum and candle wax, and insecticide bug spray. The Environmental Services Manager (ESM) acknowledged that the unlocked laundry room door allowed resident access. She said, "Yes, anyone can walk in here. It could be dangerous, and that cabinet should be locked." The Material Safety Data Sheets for the insecticide and gum remover, reviewed on 5/25/11 at 8:50 A.M., indicated that skin and eye contact caused irritation, and inhalation of either product was hazardous, and called for medical attention.