Every finding on record at Santa Clara Post Acute

Based on observation, interview, and record review, the facility failed to ensure staff for the food and nutrition services department competently carried out kitchen duties in a safe, and sanitary manner when a staff member was unable to verbalize and demonstrate correct techniques related to testing the sanitizer buckets. This practice had the potential for 172 residents who received food from the kitchen to be exposed to food borne illness due to lack of staff training and monitoring of their duties. Findings:On 9/10/25 at 8:59 a.m., an observation and interview was conducted with Dietary Aide (DA) F. DA F demonstrated the testing of a sanitizing solution, which was contained inside a red bucket. DA F dipped the test strip in the solution for approximately 1-2 seconds. The test strip turned light green, which indicated the sanitizer solution was not at the appropriate level of 200 ppm (parts per million, the concentration of a solution). When asked what the appropriate level should be, DA F stated, It should be 100. During an interview on 9/10/25 at 9:02 a.m., with the Dietary Supervisor (DS), the DS stated DA F was trained on how to test the sanitizer buckets. The DS stated the correct technique was to hold the test strip in the solution for 10 seconds. The DS stated the test strip should turn green, which indicated 200 ppm, which was the correct concentration for the sanitizing solution in the red bucket. During an interview on 9/10/25 at 9:15 a.m., with the DS, the DS stated kitchen sanitation training, including the testing of the sanitizing solution in the red bucket, was provided to all kitchen staff. Review of the dietary in-service logs indicated an in-service was conducted on 8/4/25 by the DS for red bucket sanitization to the kitchen staff members.Review of the job description for Dining Services Director (DSD) indicated, The job function of the DSD- People Management & Development. Supervises, coordinates and evaluates work of all dining services employees in preparing and serving food, and cleaning facilities and utensils in a production kitchen. Food preparation and Safety- Ensures that established sanitation and safety standards are maintained.Review of the facility's policy, revised June 2025, titled, Environment indicated, All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.2. The Dining Services Director will ensure all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces.

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice when:1. A licensed nurse failed to administer one medication to one of 10 residents observed during medication administration;2. The facility failed to ensure four of 45 residents (Residents 14, 32, 45, and 174) had physician's orders for bed rails. The facility also failed to ensure Resident 32 had a care plan to address the use of bed rails;3. Licensed nurses failed to accurately complete multiple Daily Documentation forms for one of 35 sampled residents (Resident 76); and 4. Licensed nurses failed to document multiple administrations of treatments on the treatment administration record (TAR) for three of 35 sampled residents (Residents 76, 95, and 129).These failures had the potential to compromise the health, safety, and well-being of the residents. Findings: 1. During a medication administration observation, and subsequent interview with Licensed Vocational Nurse (LVN) P, on 9/9/2025 at 4:19 p.m., after administering Resident 89's medications, LVN P stated that was all the medications. The surveyor asked LVN P if he administered Resident 89's eye drops, which had been sitting on top of the medication cart, but were not observed to be there anymore. LVN P acknowledged he did not administer the eye drops. During a review of the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines, dated 10/2017, the P&P indicated medications are administered as prescribed in accordance with good nursing principles and practices. B. Administration: .2) Medications are administered in accordance with written orders of the attending physician.C. Documentation: 1) The individual who administers the medication dose records the administration on the resident's MAR [medication administration record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. 2a. Review of Resident 14's physician's order, dated 4/22/2025, indicated to place quarter bed rails on both sides of the bed. During an observation and interview with the Director of Maintenance Director (DOM) on 9/12/25 at 10:18 a.m., the DOM entered Resident 14's room and confirmed the resident had two half bed rails (not quarter bed rails) elevated at the head of bed. During the same interview as 9/12/25 at 10:18 a.m., the DOM who reviewed the record stated Resident 14's bariatric bed (hospital bed designed to safely accommodate and support people with higher body weight) and two bed rails were ordered by a hospice (end of life care) company on 8/21/25, and were delivered and put to use on 8/22/25. During an observation and interview on 9/12/25 at 1:35 p.m., Registered Nurse (RN) O also went into Resident 14's room and stated the resident had half bed rails in use. RN O reviewed Resident 14's record after leaving the room and did not find a physician's order for the two half bed rails. 2b. Review of Resident 32's admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses including acute and subacute endocarditis (infection or inflammation of the inner lining of the heart and its valves), bacteremia (presence of bacteria in the bloodstream), and methicillin susceptible staphylococcus aureus infection (MSSA, a common type of infection that can be treated with antibiotics). During a concurrent observation and interview with RN L on 9/8/25 at 9:00 a.m., RN L confirmed Resident 32's bed had two upper side rails installed. Review of Resident 32's list of care plans indicated Resident 32 did not have a specific care plan for the use of the side rails. Review of Resident 32's Order Summary Report indicated Resident 32 did not have an order for the use of side rails. Review of Resident 32's Siderail Informed Consent, dated 8/21/25, indicated Resident 32 gave the permission for the use of side rails. During a concurrent interview and record review with the Director of Nursing (DON), on 9/10/25 at 9:19 a.m., the DON confirmed the physician order for the use of side rails was placed on 9/9/25. The DON stated there was no other order for side rails. The DON further confirmed the side rail care plan was initiated on 9/9/25. The DON stated the care plan should have been initiated once the side rails were installed. During a review of the facility's P&P titled Bed Rails, dated 2/21/25, the P&P indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails.Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. During a review of the facility's P&P, titled Care Plan Comprehensive, dated 8/25/21, the P&P indicated, An individualized comprehensive care plan that includes measurable objectives and timetable to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. During a review of the facility's P&P, titled Physician Orders, dated 3/22/22, the P&P indicated, This will ensure that all physician orders are complete and accurate. 2c. During an observation on 9/10/25, at 3:30 p.m. the beds of Residents 45 and 174 were inspected. Both residents had bed rails up bilaterally (on both sides). During an observation and concurrent interview and record review, with LVN Q, on 9/10/25 at 3:38 p.m., LVN Q stated residents with bed rails should have a physician's order. LVN Q visualized the beds of Residents 45 and 174 and confirmed both had bed rails up bilaterally. LVN Q reviewed the medical records of Residents 45 and 174 and confirmed neither resident had a physician's order for bed rails. The facility's policy titled Bed Rails, dated 2/21/25, indicated, Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail . 3. Review of Resident 76's medical record indicated she was admitted on [DATE] and had diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and peripheral vascular disease (PVD, a circulation disorder where blood flow is restricted due to narrowing or blockage of the blood vessels). Review of Resident 76's treatment administration record (TAR) indicated she had a surgical wound from a below-the-knee amputation (BKA, surgical removal of the lower leg). Further review of the TAR indicated Resident 76 received treatment for her BKA surgical wound from 7/9/25 to 7/31/25. Resident 76's Weekly Non-Pressure Reports, dated 7/9/25, 7/15/25, and 7/21/25 were reviewed. These reports indicated Resident 76 had a BKA surgical wound, and the wound had not yet healed. Resident 76's Daily Documentation forms were reviewed. Section P of the form was designated to indicate whether or not the resident had wounds. The individuals who completed Resident 76's Daily Documentation forms on 7/10/25, 7/12/25, 7/13/25, 7/16/25, 7/17/25, and 7/19/25 marked No for section P, which indicated the resident did not have wounds. During an interview and concurrent record review with Treatment Nurse (TN) R and Assistant Director of Nursing (ADON) A on 9/10/25, at 1:33 p.m., TN R and ADON A reviewed Resident 76's medical record and confirmed section P of the Daily Documentation forms for the above dates were not accurate because the resident had a surgical wound during that time frame. TN R and ADON A confirmed the Daily Documentation forms should have indicated Resident 76 had a wound. The facility's policy titled Charting and Documentation, revised 7/2017, indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4a. Review of Resident 76's medical record indicated she was admitted on [DATE] and had diagnoses including diabetes mellitus and PVD. Review of Resident 76's TAR indicated she had a healed stage 2 pressure injury (partial-thickness skin loss as a result of prolonged pressure) to the sacrum (tailbone area). Resident 76 had a physician's order, dated 4/21/25, to cleanse the healed stage 2 pressure injury with normal saline (NS, a solution consisting of sodium chloride and water), pat dry, and apply triad paste (a paste that contains zinc oxide and is used for wound management) for every brief change every day and evening shift. From 7/1/25 to 9/7/25, there were 13 shifts for which the documentation of this treatment was left blank. Review of Resident 76's TAR indicated she had a small open wound on the left plantar area (on the bottom of the left foot). Resident 76 had a physician's order, dated 8/5/25, to cleanse the left plantar wound with NS, pat dry, paint with betadine (a solution that kills microorganisms and helps prevent infection), and cover with dry dressing every day shift. From 8/5/25 to 8/31/25, there were six shifts for which the documentation of this treatment was left blank. During an interview and concurrent record review with TN R and ADON A on 9/10/25, at 1:33 p.m., TN R explained that when a skin treatment is done, the nurse should document this on the TAR. TN R further explained that even if a resident refused to receive a skin treatment, this should still be documented on the TAR, and the TAR should not be left blank. TN R and ADON A reviewed Resident 76's TAR and confirmed there were multiple shifts for which treatment documentation was left blank. 4b. Review of Resident 95's clinical record indicated Resident 95 was admitted to the facility with diagnoses including type 2 diabetes mellitus. Review of Resident 95's physician's orders, on 9/9/25 at 12:19 p.m., indicated Resident 85's had an order, dated 8/7/25, to Apply Zinc oxide (treats or prevents skin irritation) on Sacrococcyx (combined anatomical term for the sacrum [the large, triangular bone at the base of the spine] and the coccyx [the tailbone]) for skin breakdown prevention q [every] shift. Review of Resident 95's TAR for the month of August 2025 indicated for the above order, there was missing documentation of administration for the day shift on the following dates: 8/10/25, 8/13/25, 8/14/25, 8/19/25, 8/21/25, 8/22/25, 8/25/25, 8/26/25, 8/27/25, and 8/31/25. Review of Resident 95's TAR for the month of September 2025 indicated for the above order, there was missing documentation of administration for the day shift on the following dates: 9/1/25, 9/2/25, 9/3/25, 9/6/25, and 9/8/25. During a concurrent interview and record review on 9/12/25 at 10:15 a.m., with the DON, the DON reviewed Resident 95's TAR on the surveyor's state phone and counted the unsigned documentations for August and September 2025. For August 2025, there was a total of 10 unsigned, and for September 2025, there was a total of 5 unsigned. The DON stated she expected the nurses to click the TAR once the treatment was done and if the resident refused, they still have to click the TAR. 4c. Review of Resident 129's clinical record indicated Resident 129 was admitted to the facility with diagnoses includes Parkinson's Disease (PD, a progressive neurological disorder that affects movement, balance, and coordination) and need for assistance with personal care. Review of Resident 129's physician's orders indicated he had an order, dated 6/25/25, for Clotrimazole (antifungal medication) Cream 1% Apply to toenails and feet topically two times a day for trim of dystrophic (any abnormal changes in the color, texture, or shape of the nails, often causing them to become discolored, brittle, thickened, or crumbling) nails and debridement (the removal of damaged tissue or foreign objects from a wound) for 8 months. Review of Resident 129's TAR for month of August 2025 indicated for the above order, there was missing documentation of administration for the day shift on the following dates: 8/1/25, 8/4/25, 8/8/25, 8/10/25, 8/11/25, 8/12/25, 8/13/25, 8/14/25, 8/15/25, 8/19/25, 8/21/25, 8/25/25, 8/26/25, 8/27/25, 8/28/25, and 8/31/25. Review of Resident 129's TAR for the month of September 2025 indicated for the above order, there was missing documentation of administration for the day shift on the following dates: 9/1/25, 9/2/25, 9/3/25, 9/6/25, 9/8/25. During a concurrent interview and record review on 9/12/25 at 10:20 a.m., with the DON, the DON reviewed Resident 129's TAR on the surveyor's state phone for the months of August and September 2025 and confirmed the missing documentation. The DON stated she expected the nurses to click the TAR once the treatment was done and if the resident refused, they still have to click the TAR. The facility's policy titled Charting and Documentation, revised 7/2017, indicated treatments or services performed are to be documented in the resident medical record. The policy indicated documentation of treatments will include the date and time the treatments was provided, the name and title of the individual who provided treatment, how the resident tolerated the treatment, and whether the resident refused the treatment. The policy further indicated documentation in the medical record will be complete and accurate.

Based on observation, interview, and record review, the facility failed to ensure expired medications were taken out of the medication rooms and carts when expired medications were observed in two of four medication rooms and one of eight medication carts. This failure had the potential for residents being administered ineffective medication.Findings:During a medication room observation and subsequent interview on 9/10/25 at 10:38 a.m., with Registered Nurse (RN) E, a stool softener, docusate sodium, was on the shelf, to be used, with an expiration date of 6/2025. RN E had acknowledged the docusate sodium was expired and placed the container in the cabinet for expired medications. During another medication room observation and subsequent interview with RN C, on 9/11/25 at 1:23 p.m., an emergency medication kit (e-kit) had a vial of 0.9% Sodium Chloride injection (a sterile, nonpyrogenic [a substance or device is free from pyrogens, which are compounds known to cause fever in humans and animals] isotonic solution of sodium chloride and water for injection) with an expiration date of 8/1/25. RN C acknowledged the expired 0.9% sodium chloride injection vial in the e-kit.During a medication cart observation and subsequent interview with RN I, on 9/12/25 at 9:46 a.m., a bottle of Geri-Lanta (medication used to treat symptoms of excess stomach acid and gas) with an expiration date of 8/2025 was inside the medication cart. RN I acknowledged the bottle of Geri-Lanta was expired.During a review of the facility's policy and procedure (P&P), titled Medication Labeling and Storage, revised 2/2023, the P&P indicated .3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview and record review, the facility failed to ensure infection prevention and control practices were followed when:1. The door of a Covid-19 (a respiratory illness caused by SARS-CoV-2 virus) isolation room for two residents (Residents 79 and 124) was left open after Certified Nursing Assistant (CNA) K entered and exited the room;2. A CNA was observed improperly handling dirty linen;3. There was no enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) signage posted at the entrance to Resident 202's room; and4. The indwelling catheter (a flexible tube inserted through the urethra (a tube like structure that connects to the bladder] and into the bladder [urine sac] to drain urine) urine drainage bags for Residents 2 and 140 were on the floor.These failures had the potential to result in the transmission of infection in the facility. 1. Review of Resident 79's admission Record indicated Resident 79 was admitted to the facility on [DATE] with diagnoses including influenza (a contagious respiratory illness) due to identified novel influenza A virus with pneumonia (infection of the lungs), and acute respiratory failure with hypoxia (lungs cannot release enough oxygen into the blood). Review of Resident 79's clinical record indicated Resident 79 tested positive for Covid-19 on 9/4/25. Review of Resident 79's physician order, dated 9/4/25, indicated there was an order for Covid-19 infection isolation-contact/droplet (infection control precautions). Review of Resident 124's admission Record indicated Resident 124 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypercapnia (a condition that makes it difficult to breathe), chronic kidney disease (progressive damage and loss of function in the kidneys), and chronic obstructive pulmonary disease (a lung condition that make it hard to breathe). Review of Resident 124's clinical record indicated Resident 124 tested positive for Covid-19. Review of Resident 124's physician orders indicated there was an order, dated 9/4/25, for Covid-19 infection isolation-contact/droplet. During an observation on 9/8/25 at 12:17 p.m., CNA K entered and exited Resident 79 and 124's room without closing the door. During a concurrent observation and interview with CNA J on 9/8/25 at 12:23 p.m., CNA J closed the door of Resident 79 and Resident 124's room. CNA J stated the door should be closed. During an interview with CNA K, on 9/8/25 at 12:24 p.m., CNA K stated she forgot to close the door of Resident 79 and 124's room. CNA K stated the door should be closed. During an interview with the Infection Preventionist (IP) on 9/10/25 at 12:43 p.m., the IP stated the door should be closed at all times. The CDC's (Centers for Disease Control and Prevention) Infection Control Guidance: SARS-CoV2, dated 7/24/24, indicated Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed. 2. During an observation on 9/8/25 at 9:03 a.m., CNA N was observed coming out of Resident 60's room carrying linen and a blue blanket (not in a plastic bag) in her left hand to her left upper arm, touching her jacket. CNA N walked through the hallway to the nurse station and turned left. During an interview with CNA N shortly after the observation, CNA N stated she changed the bedding of Resident 60. She confirmed she walked through the hallway holding the dirty linen and blanket, and they were not in a plastic bag. CNA N stated staff do not put dirty items in a plastic bag, but usually they have to bring the hamper close to the room. During an interview on 9/10/25 at 11:28 a.m., with the IP, the IP was asked what the procedure was when handling dirty linen. The IP stated the instructions were to bring the barrel (hamper) outside the resident's door. The IP further stated the dirty linen should not touch the staff's clothes. During a review of the facility's policy and procedure (P&P) titled Laundry and Bedding, Soiled, revised 9/2022, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control .All used laundry is handled as potentially contaminated using standard precautions.Contaminated linen and laundry bags/container are not held close to the body or squeezed during transport. 3. During an observation on 9/8/26 at 2:49 a.m., in Resident 202's room, Resident 202 was observed lying on her bed with an IV (Intravenous therapy, a medical process that administers fluids, medications and nutrients directly into a person's vein) connected to the left upper arm. There was no EBP signage posted at the entrance to Resident 202's room. Review of Resident 202's clinical record indicated Resident 202 was admitted to the facility with diagnoses including pneumonia due to klebsiella pneumoniae (a species of opportunistic bacteria that typically lives harmlessly in the human gut but can cause serious infections when it moves to other parts of the body, like the lungs, urinary tract, or brain) and muscle weakness. Review of Resident 202's physician's orders indicated an order to Visually Inspect PICC [Peripherally Inserted Central Catheter, a long, flexible tube inserted into a vein in the arm and threaded to a large central vein near the heart, providing long-term IV access for administering medications, fluids, nutrition, or drawing blood) site LUA [left upper arm] q [every] shift and note any redness, swelling, pain or drainage. Report to MD [medical doctor] if noted. During a concurrent interview and record review on 9/10/25 at 11:29 a.m., with the IP, the IP stated EBP was for residents who have indwelling catheters, wounds, and other indwelling devices. The IP confirmed if a resident had a PICC line, the resident should have EBP signage posted outside the room. The IP reviewed three photos of Resident 202's room entrance, taken on 9/8/25 at 2:56 p.m., using a state-issued mobile phone. The IP confirmed there was no EBP signage posted outside Resident 202's room. The IP stated Resident 202 was admitted on [DATE] with a PICC line. She further stated residents on EBP should have signage posted outside the door. According to the CDC's Enhanced Barrier Precautions in Nursing Homes, when implementing contact precautions or EBP, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this, post clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (e.g., gown and gloves). For EBP, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. During a review of the facility's P&P titled Enhanced Standard/Barrier Precautions, revised 2/21/25, the P&P indicated, It is the policy if this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism .The facility will have the discretion on how to communicate to staff which residents require the use of EBP.Provide education to residents and visitors. 4a. Review of Resident 2's clinical record indicated Resident 2 was admitted to the facility with diagnoses including malignant neoplasm of prostate (an abnormal growth of cells that divide uncontrollably in the small gland [organ or group of cells that secrete substances] in the male reproductive system), obstructive and reflux uropathy (a condition where urine flow is blocked, leading to urine backing up into the kidneys), retention of urine (the inability to completely or partially empty the bladder) and history of urinary tract infections. During an observation on 9/9/25 at 9 a.m., Resident 2 was in his bed and his urine drainage bag was on the floor. During an interview on 9/12/25 at 3:35 p.m. with LVN G, LVN G stated the urine drainage bag should not touch the floor. 4b. Review of Resident 140's clinical record indicated Resident 140 was admitted to the facility with diagnoses including parkinsonism (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture), dementia (a progressive state of mental decline), dysphagia (difficulty swallowing), hypertension (high blood pressure) and repeated falls. During observations on 9/8/25 and 9/11/25 Resident 140 was lying in bed with his urine drainage bag positioned on its side on the floor. During a concurrent observation and interview on 9/11/25 at 10:54 a.m., with LVN H, LVN H verified that Resident 140's urine drainage bag was touching the floor and stated, Oh no! It's not supposed to be like that. During an interview on 9/12/25 at 12:58 p.m. with the Director of Nursing (DON), the DON stated the indwelling catheter urine drainage bag should be off the floor. Review of the CDC's Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline Summary of Recommendations, dated 2009, indicated, lll. Proper Techniques for Urinary Catheter Maintenance. ll.B.2.Do not rest the bag on the floor. Review of the facility's policy titled, Infection Prevention and Control Program, dated 9/18/24, indicated, An infection prevention and control program (PCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection . 11. Prevention of Infection: a. Important facets of infection prevention include: . (3) educating staff and ensuring that they adhere to proper techniques and procedures; . (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

Based on observation, interview and record review, the facility failed to provide food according to the scheduled menu for three of 172 residents (Residents 84, 89 and 196). The lunch menu for 9/8/25 indicated strawberry poke cake was to be provided and two residents were not served cake. This failure had the potential to cause disappointment for the residents. Findings: Review of the facility's lunch menu for 9/8/25 indicated strawberry poke cake was to be served. During a meal observation on 9/8/25 at 12:39 p.m., Resident 196 was eating lunch in her room and was served canned fruit and there was no cake on her tray. During an interview at the time of observation, Resident 196 stated, I want cake. During an observation on 9/8/25 at 12:40 p.m., Resident 89 received red jello and there was no cake on his lunch tray. During an observation and interview on 9/8/25 at 12:45 p.m., Resident 84 was eating lunch in her room and received red jello and no cake. Resident 84 then stated, I did not get cake. During an interview on 9/11/25 at 9:46 a.m., Registered Dietitian (RD) B stated dietary staff on 9/8/25 were serving larger pieces of cake and may have run short. RD B reviewed Resident 89 and 196's records and stated there was no reason for the two residents to not receive cake. RD B reviewed Resident 84's record and stated the resident liked jello for dessert but, it did not mean she should have it all the time. RD B stated menus were designed to meet average nutritional needs, and staff needed to communicate to dietitians about any substitutions and changes so they could assess for adequate nutrition (i.e. running out of menu item), and she was not informed. Review of the facility's Menus policy, revised 10/2022, indicated a Registered Dietician/Nutritionist or other qualified nutrition professional reviewed and approved the menus and was to adjust the individual meal plan. Menus were to be followed as written, unless a substitution was provided in response to preferences, unavailability of an item, or a special meal.

Based on observation, interview, and record review, the facility failed to ensure the call light button (button used to activate a visible and audible alarm when a resident needs assistance) was within reach for four of 178 residents (Residents 74, 129, 140, and 182). This deficient practice had the potential to result in a delay in meeting the residents' needs. Findings: 1. During an observation in Resident 74's room, during the initial tour, on 9/8/25 at 11:13 a.m., the call light button was observed on the floor, on the left side of the bed. During an interview with Registered Nurse (RN) C, on 9/8/25 at 11:22 a.m., RN C acknowledged the call light button was not within reach of Resident 74. During an observation in Resident 74's room, on 9/8/2025 at 11:25 a.m., RN C picked up the call light button and handed it to Resident 74. 2. During a concurrent observation and interview, inside Resident 129's room, on 9/9/25 at 8:52 a.m., Resident 129 was lying in bed and his call light button was hanging on the right bedside drawer. Resident 129 was asked where the call light button was. Resident 129 raised his left hand, pointed towards the wall, and stated it was there. Resident 129 could not reach the call light button. During a concurrent observation and interview, inside Resident 129's room, on 9/9/25 at 9:19 a.m., with Licensed Vocational Nurse (LVN) M, LVN M confirmed the call light button was hanging on the right bedside drawer. LVN M stated she did not think Resident 129 could reach the call light button. LVN M reached for the call light button and handed it to Resident 129. During an interview on 9/12/25 at 8:41 a.m., with the Director of Staff Development (DSD), the DSD stated the call light button should always be in reach. The DSD explained staff should make sure to clip the call light button close to the resident and teach the resident how to use it. Review of Resident 129's clinical record indicated Resident 129 was admitted to the facility with diagnoses including Parkinson's Disease (a progressive neurological disorder that affects movement, balance, and coordination) and need for assistance with personal care. Review of Resident 129's brief interview for mental status (BIMS), dated 6/17/25, indicated the resident had a BIMS score of 11 (a score of 8-12 indicates moderate cognitive impairment). Review of Resident 129's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 6/17/25, indicated Resident 129 required substantial to maximal assistance with eating, and was dependent with oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene. Further review of Resident 129's MDS indicated Resident 129 was dependent with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfers. 3. Review of Resident 140's clinical record indicated Resident 140 was admitted to the facility with diagnoses including parkinsonism (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), hypertension (high blood pressure) and repeated falls. Review of Resident 140's MDS, dated [DATE], indicated Resident 140 had a BIMS score of 13 (a score of 13-15 indicates the resident is cognitively intact). During a concurrent observation and interview with Resident 140 on 9/8/25 at 10 a.m., inside Resident 140's room, Resident 140 was sitting up in bed with the call button lying on the floor next to the bed. Resident 140 stated he did not have a call button. During an interview with LVN G on 9/8/25 at 3:20 p.m., LVN G stated all residents should have the call light button within their reach at all times. 4. Review of Resident 182's clinical record indicated Resident 182 was admitted to the facility with diagnoses including pelvic (basin shaped bone) stress fracture (crack in the bone), reduced mobility, obesity (having too much body fat), diabetes mellitus (a condition which affects the way the body processes blood sugar), hypertensive chronic kidney disease (a condition where high pressure in the blood vessels damages the kidneys over time), and dementia. Review of Resident 182's MDS, dated [DATE], indicated Resident 182's BIMS score was 8. During a concurrent observation and interview with Resident 182 on 9/8/25 at 10:54 a.m., inside Resident 182's room, Resident 182 was sitting up in bed with her call light button hanging over the bedside nightstand. Resident 182 stated she could not find her call button. During a concurrent observation and interview with LVN G on 9/8/25 at 3:11 p.m., inside Resident 182's room, LVN G confirmed the call button was hanging over the top of the bedside nightstand. LVN G stated, It's not supposed to be there. The facility's policy and procedure (P&P) titled Answering the Call light, revised 10/24/24, indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs.5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 53) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1a. Resident 53 had an as-needed (PRN) order for lorazepam (medication used to treat anxiety [excessive worry, fear and nervousness]) without a stop date, and there was no side effects monitoring for lorazepam use; and1b. Resident 53 had a PRN order for haloperidol (an antipsychotic medication that helps treat several kinds of mental health conditions) without a stop date.These failures had the potential for increased risks associated with the use of psychotropic medications that could negatively affect the residents' physical, mental, and psychosocial well-being.Findings:1a. Review of Resident 53's clinical record indicated Resident 53 was admitted to the facility with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and dementia (a progressive state of decline in mental abilities).Review of Resident 53's physician's orders indicated she had an order, dated 8/2/25, for lorazepam oral tablet 0.5 milligrams (mg, unit of dose measurement) give 1 tablet sublingually (under the tongue) every 4 hours as needed for agitation and anxiety. There was no stop date for this order.Further review of Resident 53 's clinical record indicated there was no side effects monitoring for the use of lorazepam.During a concurrent interview and record review on 9/10/25 at 2:35 p.m., with the Director of Nursing (DON), the DON reviewed Resident 53's clinical record and confirmed Resident 53 had an active PRN order for lorazepam. The DON stated usually PRN psychotropic orders were for 14 days, depending on the doctor. The DON confirmed PRN psychotropic medication orders were supposed to have a stop date. The DON further confirmed she did not see side effects monitoring for the use of lorazepam. 1b. Review of Resident 53's physician's orders indicated she had an order, dated 8/2/25, for haloperidol lactate oral concentrate 2 mg/ml (milliliter, unit of volume) give 0.5 ml sublingually every 4 hours as needed for anxiety and agitation. This order did not have a stop date. During a concurrent interview and record review on 9/10/25 at 2:41 p.m., with the DON, the DON reviewed Resident 53's clinical record and confirmed Resident 53 had an active PRN order for haloperidol with no stop date. The DON also confirmed the order had been in place for more than 14 days. The DON confirmed PRN antipsychotic medication orders should be for 14 days.During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use, revised 2/2025, the P&P indicated, 3. PRN orders for psychotropic medications are limited to 14 days. a. For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. b. For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication. The P&P further indicated, 4. In addition, residents are monitored for adverse consequences associated with psychotropic medications .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurately completed for two of 35 sampled residents (Residents 16 and 46). This failure had the potential to compromise the facility's ability to develop and implement an individualized plan of care for the residents. This failure also had the potential to compromise the accuracy of the facility's quality measures (reports that reflect the facility's performance in certain care areas), which could negatively affect the facility's ability to identify areas for improvement and implement interventions accordingly. Findings: 1. Review of Resident 16's medical record indicated he was admitted on [DATE] and had diagnoses including dysphagia (difficulty swallowing), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (high blood pressure). Resident 16's MDS, dated [DATE], was reviewed. Section K0300 was coded with a number 2, which indicated Resident 16 had significant weight loss (loss of 5% or more in the last month or loss of 10% or more in the last 6 months). Further review of Resident 16's medical record indicated there was no documentation indicating he had significant weight loss. During an interview and concurrent record review with Registered Dietitian (RD) B on 9/11/25, at 1:42 p.m., RD B reviewed Resident 16's medical record and confirmed the resident had not had significant weight loss. RD B reviewed Resident 16's MDS, dated [DATE], and confirmed section K0300 was coded incorrectly, as it should have indicated Resident 16 did not have significant weight loss. The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS instructions), dated 10/2024, indicated for section K0300, Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. 2. Review of Resident 46's medical record indicated he was admitted on [DATE] and had diagnoses including difficulty in walking. Review of Resident 46's Change in Condition Evaluation, dated 2/19/25, indicated Resident 46 had a fall and was observed to be sitting on the floor next to his walker. Resident 46's MDS, dated [DATE], was reviewed. Section J1800 was coded with a number 0, which indicated the resident had not had any falls during the specified time frame. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 9/10/25, at 11:14 a.m., the MDSC reviewed Resident 46's medical record and confirmed the resident had a fall on 2/19/25. The MDSC stated this fall should have been coded on Resident 46's MDS, dated [DATE]. The MDSC reviewed the MDS, dated [DATE], and confirmed Resident 46's fall on 2/19/25 was not coded. The MDSC confirmed section J1800 should have been coded with a number 1 to indicate Resident 46 had a fall during the specified time frame. The CMS RAI Manual, dated 10/2024, indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame.

Based on interview and record review, the facility failed to ensure a Serious Mental Illness (SMI) Level II Health Evaluation (an assessment that determines if an individual with mental illness requires special services) was completed for one of seven sampled residents (Resident 7). This failure had the potential to result in Resident 7's needs not being met while residing in the facility.Findings: Review of Resident 7's medical record indicated he was admitted on [DATE] and had diagnoses including bipolar disorder (a mental health condition that causes extreme mood swings) and depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest). Resident 7's Preadmission Screening and Resident Review (PASRR) Level I Screening (an assessment that helps to ensure individuals with mental disorders are placed in facilities that can provide appropriate care), dated 8/5/25, was reviewed. The individual who completed the PASRR Level I Screening marked Yes for item number 9, which indicated Resident 7 had a diagnosed serious mental illness. Review of Resident 7's document titled Notice of PASRR Level I Screening Results, dated 8/5/25, indicated Resident 7 required a Level II Mental Health Evaluation. The document further indicated the facility would be contacted within two to four days to set up an appointment for an evaluator to conduct a Level II Mental Health Evaluation. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 9/11/25, at 9:46 a.m., the MDSC was asked to verify if Resident 7 received a Level II Mental Health Evaluation. The MDSC reviewed the PASRR website and confirmed Resident 7 did not receive a Level II Mental Health Evaluation. The MDSC presented Resident 7's document titled Notice of Attempted Evaluation, dated 8/8/25. This documented indicated a Level II Mental Health Evaluation could not be completed for Resident 7 because, Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of Level I Screening. During a follow-up interview and record review with the MDSC on 9/12/25, at 11:19 a.m., the MDSC reviewed Resident 7's medical record and confirmed there was no documentation indicating the facility followed up with the entity that performs Level II Mental Health Evaluations after receiving the Notice of Attempted Evaluation on 8/8/25. The Department of Health Care Services website (dhcs.ca.gov) indicated, The PASRR process consists of a Level I Screening, Level II Evaluation, and final Determination. The facility's PASRR Completion Policy, revised 9/30/24, indicated, The Center will make sure that all admissions have the appropriate Patient Assessment and Resident Review (PASRR) completed.

Based on observation, interview and record review, the facility failed to ensure three of 11 sampled residents (Residents 6, 88 and 206) received necessary respiratory care and services in accordance with professional standards of practice when:1. Licensed staff failed to ensure oxygen (O2, a colorless, odorless gas) was administered as specified in the physician's order for Resident 6;2. Resident 6's door or entrance did not have a posted Oxygen in use/No smoking sign; 3. Resident 88's door or entrance did not have a posted Oxygen in use/No smoking sign; and4. Resident 206's door or entrance did not have a posted Oxygen in use/No smoking sign.These failures had the potential to compromise the residents' health and safety. Findings:1. Review of Resident 6's clinical record indicated he had diagnoses including acute respiratory failure (a condition that affects the lungs and airways making it difficult for air exchange in the lungs), pleural effusion (a build-up of fluid between the tissues that line the lungs and the chest), and atelectasis (a collapse of the whole lung or an area of the lung).Review of Resident 6's physician's order, dated 7/11/25, indicated he was to receive oxygen at 2 L/min (liters per minute [LPM] rate of oxygen administration) continuously every shift for SOB (shortness of breath).Review of Resident 6's oxygen therapy care plan, initiated on 7/12/25 indicated, Provide respiratory treatment as ordered and monitor .During an observation on 9/8/25 at 10:15 a.m., Resident 6's oxygen concentrator (machine used to deliver oxygen) was set at 1.5 LPM.During an observation and concurrent interview with Licensed Vocational Nurse (LVN) H on 9/9/25 at 2:41 p.m., LVN H looked at Resident 6's oxygen concentrator gauge, slightly turned the adjustment knob (used to increase or decrease the oxygen flow rate), and verified it was set at 1.5 LPM. LVN H stated the oxygen concentrator gauge should have been set at 2 LPM. Review of the facility's policy, dated 1/31/23, titled, Oxygen Administration, indicated, .Review the physician's orders or facility protocol for oxygen administration. 2. During an observation on 9/8/25 at 10:15 a.m., Resident 6 was sitting up in bed with oxygen in place at 1.5 LPM through a nasal cannula (NC, a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration). There was no oxygen signage posted on Resident 6's door.During a concurrent observation and interview on 9/9/25 at 3:35 p.m., with LVN G outside the room of Resident 6, LVN G stated there used to be an oxygen/no smoking sign on the door and there should be signs on the doors of all residents receiving oxygen for safety. 3. During an observation on 9/8/25 at 10:59 a.m., Resident 88 was sitting up in bed with oxygen in use at 1.5 LPM via nasal cannula. There was no oxygen signage posted on Resident 88's door.Review of Resident 88's physician's order, dated 4/11/25, indicated Oxygen at 4-6 L/min via NC as needed for chest pain, SOB as needed. 4. During an observation on 9/8/25 at 10:15 a.m., Resident 206 was sitting up in bed with oxygen concentrator and equipment set up at the bedside. There was no oxygen signage posted on Resident 206's door.Review of Resident 206's physician's order, dated 8/29/25, indicated Oxygen at 2 L/min via nasal cannula at bedtime every evening and night shift for history of sleep apnea [a sleep disorder in which breathing repeatedly stops and starts].During an interview on 9/12/25 at 12:58 p.m., with the Director of Nursing (DON), the DON stated there should be signs outside the door if the resident is receiving oxygen. Review of Cal/OSHA (State of California Department of Industrial Relations- California's state agency responsible for establishing and enforcing safety and health regulations) guidelines indicated, To comply with Cal/OSHA and related safety guidelines, a California Skilled Nursing Facility must: Post No Smoking-Oxygen in Use signs in all areas where oxygen is being administered or stored.

Based on interview and record review, the facility failed to complete multiple Facility-Dialysis Unit Communication Report forms for one of seven residents (Resident 76). This failure had the potential to compromise the facility's ability to identify potential complications and implement interventions accordingly. Findings: Review of Resident 76's medical record indicated she was admitted on [DATE] and had diagnoses including end stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificiallythrough a machine when the kidneys have failed). Further review of the medical record indicated Resident 76 received dialysis every Monday, Wednesday, and Friday. Resident 76's Facility-Dialysis Unit Communication Report forms were reviewed. There was a section on the bottom of these forms designated to fill out assessment information after the resident returned from dialysis. This information included the resident's vital signs (blood pressure, heart rate, respiration rate, temperature), assessment of the dialysis access site (the part of the body to which the dialysis machine is attached), information regarding the resident's weight, and the resident's skin condition. This section was left blank on Resident 76's Facility-Dialysis Unit Communication Report forms dated 8/25/25, 8/27/25, 8/29/25, 9/3/25, 9/5/25, and 9/8/25. During an interview and concurrent record review with Assistant Director of Nursing (ADON) A on 9/12/25, at 10:51 a.m., ADON A confirmed that when residents return to the facility from dialysis, the nurses must complete the bottom portion of the Facility-Dialysis Unit Communication Report forms. ADON A reviewed Resident 76's forms for the above dates and confirmed the nurses did not complete the bottom portion of these forms. The facility's policy titled Dialysis Care, dated 8/25/21, indicated, All documentation concerning dialysis services and care of the dialysis resident will be maintained in the resident's medical record. The facility' policy titled Charting and Documentation, revised 7/2017, indicated documentation in the medical record will be complete.

Based on observation, interview and record review, the facility failed to ensure bed rails were assessed for the risk of entrapment (person's head, neck or body becoming trapped or entangled in the spaces of a bed's side rails, frame or mattress) for one of 45 residents (Resident 14). Resident 14 was observed to be in bed with two half bed rails elevated at the head of bed. There was no assessment supporting the bed rails were evaluated to be safe from entrapment. This failure created a potential for health and safety risk for the resident.Findings: Review of Resident 14's record indicated his most recent bed entrapment measurement device test results were dated 8/5/25. During an observation and interview with the Director of Maintenance (DOM) on 9/12/25 at 10:18 a.m., the DOM entered Resident 14's room and confirmed the resident had two half bed rails elevated at the head of bed. During the same interview on 9/12/25 at 10:18 a.m., the DOM who reviewed the record stated Resident 14's bariatric bed (hospital bed designed to safely accommodate and support people with higher body weight) and two bed rails were ordered by a hospice (end of life care) company on 8/21/25. The DOM explained these were delivered to the facility and put to use on 8/22/25. The DOM then stated he did not have any information about bed entrapment assessment for the bariatric bed and two half bed rails that were delivered and put to use on 8/22/25 Review of the facility's Bed Rails policy, dated 2/21/25, indicated there was to be an assessment to assess the resident's risk of entrapment between the mattress and bed rail and the facility was to assure the correct installation and maintenance/instructions regarding bed rail use.

Based on interview and record review, the facility failed to ensure two of five residents (Residents 85 and 95) were free from unnecessary medication when.1. Resident 95 had no side effects monitoring for rivaroxaban (an anticoagulant medication used to treat and prevent blood clots); and2. Resident 85 received furosemide (used to treat edema [fluid retention; excess fluid held in body tissues]) without monitoring for edema.These failures resulted in unmonitored side effects of anticoagulant medication and unmonitored medical condition. Findings:1. Review of Resident 95's clinical record indicated Resident 95 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) and acute embolism and thrombosis of unspecified deep veins of the left lower extremity (blood clot in the left leg).Review of Resident 95's physician's orders indicated she had an order, dated 12/26/23, for rivaroxaban oral tablet 10 milligrams (mg, unit of dose measurement) give one tablet by mouth one time a day for DVT (Deep vein thrombosis, a condition where a blood clot forms in a deep vein, usually in the lower leg) prophylaxis (prevention).Review of Resident 95's physician's orders and September 2025 medication administration record (MAR) indicated the nursing staff did not monitor for the anticoagulant side effect of bleeding.During a concurrent interview and record review on 9/10/25 at 2:43 p.m., with the Director of Nursing (DON), the DON reviewed Resident 95's physician's orders and confirmed Resident 95 was on rivaroxaban. The DON stated she could not find the side effect monitoring for bleeding. The DON stated residents on anticoagulants should have monitoring for bleeding. 2. Review of Resident 85's clinical record indicated Resident 85 was admitted to the facility with diagnoses including unspecified atrial fibrillation (A Fib, a type of irregular heartbeat where the exact cause is unknown).During a record review on 9/9/25 at 1:21 p.m., Resident 85 had a physician's order for furosemide Tablet 20 mg Give 1 tablet by mouth one time a day for Right foot +2 pitting edema [condition characterized by swelling that leaves an indentation (pit) when pressure is applied to the affected area].Review of Resident 85's physician's orders and September 2025 MAR indicated the nursing staff did not monitor for right foot +2 pitting edema.During a concurrent interview and record review on 9/10/25 at 2:49 p.m., with the DON, the DON reviewed Resident 85's physician's orders and confirmed Resident 85 was on furosemide 20 mg for right foot +2 edema. The DON stated she could not find the monitoring for right foot edema. The DON further stated residents on furosemide, if the indication is for edema, should be monitored for edema.During a review of the facility's policy and procedure (P&P) titled Medication Therapy, revised 4/2007, the P&P indicated, 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2.Medication use shall be consistent with an individual's condition, prognosis, values, wishes and response to such treatments. 3. All medication orders will be supported by appropriate care and practices . 2. All decisions related to medications shall include appropriate elements of the care process, such as: a. Adequate detailed assessment.

Based on observation, interview and record review, the interdisciplinary team (IDT, group of healthcare members that meet to discuss and plan residents' care) failed to identify and determine if one of 35 sampled residents (Resident 116) could safely self-administer and store medications that were kept at bedside. This failure placed Resident 116 at risk for unsafe medication self-administration, and had the potential to result in medications being accessed by unauthorized individuals such as other residents. Findings: During an observation on 9/9/25 at 11:03 a.m., Resident 116 had the following medications on his bedside table: 1. A tube of hydrocortisone cream 1% (a medication applied to the skin to relieve itching); 2. One bottle of nasal spray (medication administered into the nasal passages to treat various conditions); and 3. One bottle of eye drops. Review of Resident 116's Minimum Data Set (MDS, an assessment tool), dated 6/23/25, indicated the resident did not have any problems with memory and daily decision-making skills. Review of Resident 116's record on 9/11/25 indicated there was no assessment indicating the resident was capable of safely self-administering medications. There was also no documentation that addressed whether storing medications at bedside was safe from unauthorized use (i.e. by other residents and/or visitors). During an observation with Registered Nurse (RN) C on 9/12/25 at 8:58 a.m., Resident 116's bedside table contained a tube of 1% hydrocortisone cream, a plastic bottle of nasal spray, and two plastic bottles of eye drops. There were also four unopened boxes of Mucus Relief (medication used to treat congestion) 1200 milligrams (mg, a metric unit of measurement) containing 14 extended release pills in the resident's top bedside drawer. During an interview on 9/12/25 at 11:01 a.m., the Minimum Data Set Coordinator (MDSC) stated the facility just found out today that the resident had medications at his bedside. During an interview on 9/12/25 at 11:24 a.m., RN C stated right after seeing Resident 116's medication in his room, she assessed the resident, notified the physician, and determined the resident could safely self-administer medications. RN C stated Resident 116 used hand sanitizer before showing how he instilled eye drops. Further review of Resident 116's IDT Care Conference form, dated 9/12/25 at 9:41 a.m., indicated the resident was assessed and determined to safely self-administer medications. It indicated the resident demonstrated correct technique for administration of each medication and the resident was permitted to keep medications at bedside. The IDT assessment did not address all factors as outlined in the facility's self-administration of medication policy, such as whether storing the medications at the bedside was safe from unauthorized access, who was responsible for monitoring and documenting medications used, and if the resident had the physical ability to open and remove medications from a container and had the ability to ingest and swallow. During an observation and concurrent interview with Resident 116 and RN C on 9/12/25 at 11:39 a.m., the bottle of eye drops was still at Resident 116's bedside and there was no hand sanitizer. Resident 116 then stated he had been using the hydrocortisone cream since March 23, 2025, had instilled eye drops for years, and he twice stated he did not show a nurse this morning how he instilled eye drops to himself. RN C stated she will provide hand sanitizer to the resident. Review of the facility's Self-Administration of Medications policy, revised February 2021, indicated the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy further indicated the IDT needed to consider factors such as whether the resident was able to ingest and swallow medications, had the physical capacity to remove medications from a container, to determine who was responsible (resident or nursing staff) for documenting medications were taken, and to store in a safe and secure place which was not accessible by other residents.

Based on interview and record review, the facility failed to implement their antibiotic stewardship program (program intended to prevent overuse of antibiotics) for one of five residents (Resident 168) on antibiotics (medications used to treat bacterial infections) when the McGeer Criteria (a tool used to track infection) and/or Loeb's Criteria (a tool used to determine when to initiate antibiotic treatment for suspected infections) were not done. This failure had the potential to increase the prevalence of multi-drug-resistant organisms in the facility.Findings:Review of Resident 168's admission record indicated Resident 168 was admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis (infection or inflammation of the inner lining of the heart and its valves), bacteremia (presence of bacteria in the bloodstream), methicillin susceptible staphylococcus aureus infection (a common type of infection that can be treated with standard antibiotics).Review of a physician's order, dated 8/16/25, indicated Resident 168 was on Cefazolin Sodium (used to treat infection caused by bacteria) intravenous (administering medications into a vein) solution.During an interview with the Infection Preventionist (IP), on 9/11/25 at 3:14 pm, the IP stated the McGeer Criteria would be used to determine whether or not the antibiotic prescribed met the criteria for the presence of an infection. The IP stated the physician would be notified if the McGeer Criteria was not met.During a concurrent interview and record review with the IP, on 9/12/25 at 10:52 a.m., the IP could not provide an answer when asked if Resident 168 met the McGeer Criteria or not.During an interview with Assistant Director of Nursing (ADON) D, on 9/12/25 at 10:52 a.m., ADON D stated the McGeer Criteria was not used for community-acquired infections (an infection contracted outside of a healthcare setting).During a concurrent interview and record review with ADON D, on 9/12/25 at 12:20 p.m., ADON D stated there was no need to do the McGeer Criteria on Resident 168 because the antibiotic was started in the acute care facility and it was a community-acquired infection. ADON D stated that the McGeer Criteria was not done because she did not know when the antibiotic was started, the reason for the antibiotic and no laboratory results. ADON D further stated that the McGeer Criteria was not done because the physician reviewed the antibiotic order on admission and continued in the facility.During a concurrent interview and record review with the Administrative Services Registered Nurse (ASRN), on 9/12/25 at 12:24 p.m., the ASRN stated antibiotic surveillance, including the McGeer Criteria or Loeb's Criteria, must be done for residents admitted with antibiotics. The ASRN stated information must be requested from the acute care facility and notify the physician. The ASRN further stated to re-evaluate the resident after 72 hours.During an interview with the Director of Nursing (DON), on 9/12/25 at 3:03 p.m., the DON stated antibiotic surveillance using the McGeer Criteria and Loeb's Criteria must be used for community-acquired infection and facility-acquired infection. The DON further stated that McGeer Criteria and Loeb's Criteria must be done for residents admitted to the facility with antibiotics.Review of the facility's policy and procedure (P&P), titled Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes, revised date 12/2016, indicated, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. 1. A part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.3. At the conclusion of the review, the provider will be notified of the review findings.4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form.Review of the facility's P&P, titled Antibiotic Stewardship, dated 9/18/23, indicated Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.Review of the facility's P&P, titled Infection Prevention and Control Program, dated 9/18/23, indicated .8. Antibiotic Stewardship.c. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews.

Based on interview and record review, the facility failed to ensure a medication was administered as prescribed by the physician for one of three sampled residents (Resident 1) when Resident 1 received 12 doses of Tacrolimus (a medication used to suppress [preventing something] the immune system) 5 milligrams (mg, unit of measurement), which was 10 times the ordered dose of 0.5 mg. This failure had the potential to result in Tacrolimus toxicity (the quality of being poisonous or harmful) for Resident 1 and could potentially contribute to Resident 1's hospitalization on 4/19/25. Findings: A review of the manufacturer's Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions [a change in a drug's effect on the body when the drug is taken together with a second drug], and contraindications that is available to clinicians) for Tacrolimus, issued in December 2018, indicated it is an immunosuppressant (a medication that weakens or reduces the activity of the immune system) indicated for the prophylaxis (measures taken to prevent disease rather than treat an existing one) of organ (a group of tissue that work together to perform a specific function within a living organism) rejection (the act of refusing) in adult and pediatric patients receiving allogenic (transported to its present position from elsewhere) liver, kidney or heart transplant (an operation in which an organ or tissue are moved or transferred to another place). A review of Resident 1's face sheet (a concise document summarizing a resident's key information) indicated he was admitted on [DATE] and had diagnoses including chronic myeloid leukemia (a slowly progressing and uncommon type of blood cell cancer that begins in the bone marrow [the soft tissue found in the bones]), graft versus host disease (a complication that might occur after a transplant, and bone marrow transplant (a procedure where healthy bone marrow stem cells are infused into a person to replace damaged or diseased bone marrow) status, Pneumonia (a type of lung infection), sepsis (a life-threatening complication of an infection). A review of Resident 1's SNF (Skilled Nursing Facility) orders from the hospital, dated 3/30/25, indicated, for Vancomycin (antibiotic medication) 125 mg capsule, Take 1 capsule by mouth every 6 hours for 8 days, then 1 capsule 2 times a day for 7 days, then 1 capsule daily for 7 days, then 1 capsule every other day for 7 days, then 1 capsule every 3 days for 14 days for diagnoses: clostridium difficile colitis (C-diff, inflammation of colon caused by the bacteria clostridium difficile) infection. A review of Resident 1's SNF orders from the hospital, dated 3/30/25, indicated, for Tacrolimus 0.5 mg capsule, Take 1 capsule (0.5 mg total) by mouth every day. A review of Resident 1's SNF physician order, dated 3/30/25, indicated, for Tacrolimus 5 mg, Give 1 capsule by mouth one time a day for graft versus host disease. A review of Resident 1's SNF March and April 2025 Medication Administration Records (MAR) indicated that Tacrolimus 5 mg was administered at 9:00 a.m. from 3/31/25 to 4/11/25, total of 12 dosage in 12 days. During an interview with Resident 1 on 5/5/25 at 12:03 p.m., he stated he was very sick, was sent to the hospital, and returned to the facility not too long ago. He also stated he had been taking Tacrolimus 0.5 mg since his transplant in 2022. A review of the complaint information received by the California Department of Public Health dated 4/21/25, indicated the facility license nurses were administering wrong dosage of Resident 1's Tacrolimus medication. During an interview and record review with the Director of Nursing (DON) on 5/5/25, at 1 p.m., she confirmed that the SNF order from the hospital for Resident1's Tacrolimus was 0.5 mg daily, but Registered Nurse (RN) A transcribed Tacrolimus 5 mg daily. The DON verified Resident 1 had taken Tacrolimus 5 mg from 3/31/25 to 4/11/25. The DON stated the facility's pharmacy consultant discovered that the dosage of Tacrolimus given to Resident 1 from 3/31/25 to 4/11/25 did not match the SNF order from the hospital during monthly medication regimen review (MRR) on 4/11/25. The DON acknowledged the nurse should have transcribed the dosage of Tacrolimus accurately. During an interview and record review with RN A on 5/5/25 at 2:45 p.m., she confirmed that the SNF order from the hospital for Resident 1's Tacrolimus was 0.5 mg daily, but she transcribed as 5 mg. RN A stated she misread the dosage of Tacrolimus. RN A acknowledged she should have transcribed the dosage of Tacrolimus accurately. A review of Resident 1's Consultant Pharmacist's MRR, recommendations created between 4/1/25 and 4/25/25, indicated, For Tacrolimus: Discharge order is for Tacrolimus 0.5 mg NOT 5 mg. Please clarify immediately. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a tool use to communicate information to the resident's doctor) on 4/11/25 indicated, Upon admission resident with order of Tacrolimus 0.5 mg & it was misread or transcribed as 5 mg, and Recommendations of Primary clinicians: Monitor for s/s (signs and symptoms) of tacrolimus toxicity: Hives (skin rash), sleepiness, N/V (nausea/vomiting), diarrhea, uncontrollable shaking of part of the body, headache, confusion, imbalance & extreme tiredness, swelling of arms & legs, fever or other signs of infection. A review of Resident 1's Tacrolimus level, laboratory sample collected on 4/7/25, the lab result dated 4/11/25 indicated Tacrolimus by HPLC-MS/MS 25.7 nanograms per milliliter (ng/ml, a unit of measurement). Resident 1 laboratory results report of Tacrolimus level further indicated, Therapeutic Range, Kidney transplant: 3 months and older: 5.0-15.0 ng/ml; Liver transplant: 1-12 months post-transplant: 5.0-20 ng/ml; Heart transplant: 3 months and older: 5.0-20 ng/ml. Toxic value: Greater than 25 ng/ml. Therapeutic range is based on a whole blood specimen drawn 12 hours post-dose or prior to next dose (the trough). The optimal therapeutic range for a given patient may differ from this suggested range based on the indication for therapy. A review of Resident 1's Tacrolimus level, laboratory sample collected on 4/17/25, the lab result dated 4/21/25 indicated 4.2 ng/ml. During a telephone interview with Physician B on 6/10/25 at 12:50 p.m., she stated that she was aware of Resident 1's Tacrolimus level which was not therapeutic level but not toxic level for Resident 1. Physician B stated she consulted with an oncologist, and the oncologist stated the level was not toxic level for resident 1. A review of Resident 1's SBAR on 4/19/25 indicated, Resident had episode of diarrhea with complain of fatigue (extreme tiredness), headache, SOB (shortness of breath) and was transferred to the hospital. A review of Resident 1's hospital Discharge Summary on 4/29/25 indicated, Admitting diagnosis: HCAP [healthcare associated pneumonia (a pneumonia that develops in person who have recently received healthcare in nursing home, long term care facilities, and home health care)], C diff colitis and Final diagnoses included severe sepsis with acute organ dysfunction (sudden impairment or failure of one or more organs) and pneumonia. A review of the facility's policy and procedures (P&P) titled Medication Administration with effective date: October 2017 indicated, Medications are administered as prescribed .

Based on observation, interview, and record review, the facility failed to follow guidelines for masking during respiratory illness season when four staff members were observed not wearing face mask. This failure had the potential to spread infection throughout the facility. Findings: During an observation on 2/25/25 at 10:20 a.m., licensed nurse A (LN A) was observed in nursing station BB with his mask down below his mouth, at chin level, which he pulled up when he saw the surveyor. During an observation on 2/25/25 at 10:23 a.m., certified nursing assistant B (CNA B) was observed by the nursing station CC with her mask down below the mouth, at chin level, which she pulled up when she saw the surveyor. During an observation and subsequent interview on 2/25/25 at 10:30 a.m., in the hallway near the director of nursing's office, the administrator in training (AIT) was observed with his face mask down below his mouth, at chin level, which he pulled up upon seeing the surveyor. The AIT stated he was in a patient care area and his face mask should have been pulled up. During an interview with LN A, on 2/25/25 at 10:47 a.m., at nurses station CC, he stated the mask should always be pulled up when at nurses stations. During an observation and subsequent interview on 2/25/25 at 10:52 a.m., CNA C was in room AA with her face mask down below her mouth, at chin level. CNA C then pulled up her mask after being approached by the surveyor. During an interview with CNA B on 2/25/25 at 11:39 a.m., CNA B stated she remembered her mask was pulled down and should have been pulled up. Review of the County guidelines, titled, Health Order requiring use of face masks in patient care areas of health care delivery facilities during designated winter respiratory virus period; rescission of prior health orders, effective 4/4/2023, the County guidelines indicated: .3. Mandatory Requirement to Wear Face Masks in Patient Care Areas of Health Care Delivery Facilities During the Designated Winter Respiratory Virus Period. 1.Regardless of vaccination status, all persons in Patient Care Areas of Health Care Delivery Facilities must wear a Face Mask during the period deemed the Designated Winter Respiratory Virus Period by the Health Officer . e. Designated Winter Respiratory Virus Period means the period from November 1 to March 31 of each year. In any given year, the Health Officer may adjust the dates of the Designated Winter Respiratory Virus Period based on respiratory virus surveillance data. If the Health Officer changes the dates of the Designated Winter Respiratory Virus Period, the Health Officer will notify Health Care Delivery Facilities through a Health Advisory and a notice posted on the County Public Health Department's website (https://publichealth.santaclaracounty.gov).

Based on interview and record review the facility failed to ensure appropriate treatment and services were provided to one of two residents (Resident 1) when the restorative nursing assistant (RNA, program that helps residents to gain and improve quality of life by increasing their level of strength and mobility) services were not implemented per the physician's order. The deficient practice had the potential to result in residents' decline in range of motion. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Spondylosis without myelopathy or radiculopathy, lumbar region (general wear and tear of the lower back without any pressure on the spinal cord or nerves); post laminectomy lumbar region (a condition of the lower back after surgery to remove part of the vertebra (bone) to relieve pressure on the spinal cord or nerves); and difficulty in walking. Review of Resident 1's Order Summary Report, order date of 2/1/24, indicated, RNA services order: Sit to stand exercises inside the parallel bars for 2 reps x2 person assistance for 3 times per week x 90 days. Every day shift every Tue, Thu, Sat for 90 days. End date 5/1/24. Review of Resident 1's Order Summary Report, order date 3/27/24, indicated, RNA services order: Sit to stand exercises inside the parallel bars for 2 reps x2 person assistance for 3 times per week x 90 days. Every day shift every Tue, Thu, Sat for 90 days. End date 6/26/24. Review of the facility document, titled, Documentation Survey Report v2, for March 2024, indicated, RNA program for 3x/wk x 90 days for AROM using APT performer x 15 mins at level 2-3. The document indicated RNA services were done on 3/1, 3/15, and 3/31. The document indicated NA (not applicable) on 3/6, 3/22, 3/24, and 3/27, and RR (resident refused) on 3/3, 3/13/, 3/17. Review of the facility document, titled, Documentation Survey Report v2, for April 2024, indicated, RNA program for 3x/wk x 90 days for AROM using APT performer x 15 mins at level 2-3. The document indicated RNA services were done on 4/3, 4/5, 4/7,4/12, 4/17, 4/22, and 4/26. The document indicated NA (not applicable) on 4/15, 4/16, 4/18, 4/19, 4/23, 4/29, and RR (resident refused) on 4/24 and 4/25. Review of Resident 1's Care Plan, indicated Restorative Range of Motion (ROM): Resident at risk for decrease ROM. RNA services order: Sit to stand exercises inside the parallel bars for 2 reps x2 person assistance for three times per week x 90 days. - start: 2/1/2024. RNA program for 3x/wk x 90 days for AROM using APT performer x 15 mins at level 2-3. Start 4/8/24. The care plan indicated interventions the RNA will assist with AROM to bilateral lower extremities 3 times a week as tolerated. During a concurrent interview and record review with the Case Manager (CM) on 4/25/24, at 3:30 p.m., the CM stated that she monitors and supervises the RNAs. During the interview, the CM spoke with restorative nursing assistant A (RNA A) via phone call. The CM stated that according to RNA A, Resident 1 refused RNA services, but RNA A admitted that there were not enough RNAs to provide the services to Resident 1, who requires two-person assistance. At times, one of the RNAs would be pulled out to work on the floor. Additionally, the CM was not informed by the RNAs that Resident 1 refused RNA services. There was also no plan of care in the record regarding any RNA refusal from Resident 1. During an interview with Resident 1 on 4/25/24, at 4 p.m., Resident 1 stated she did not receive RNA services at the facility as ordered by the physician. Resident 1 stated that she never refused RNA services. Resident 1 stated that she should receive sit to stand exercises but often only one staff member would come to assist. Resident 1 stated she requires the assistance of two persons to get out of bed, staff did not get her up due to not enough RNA staff. Resident 1 stated the facility did not have enough RNAs because they were also assigned to other duties on the floor. During a phone interview with RNA A on 5/3/24, at 4:04 p.m., the surveyor inquired about the above dates in the Documentation Survey Report indicating NA or RR. RNA A stated that on those days, RNA services were not provided to Resident 1. RNA A stated that sometimes only one staff member was available to provide RNA services to Resident 1, who requires assistance from 2 persons. Additionally, RNA A stated that most of the time RNAs were asked to work on the floor as a CNA, which left fewer staff available to provide RNA services. During a follow-up phone interview and concurrent record review with the CM on 6/18/24, at 3:40 p.m., the CM confirmed that the RNA services order: Sit to stand exercises were ordered for Resident 1 since 2/1/24. The CM confirmed that the RNA services order for sit to stand exercises were not recorded on the Documentation Survey Report previously provided to the surveyor. The CM stated it should have been included in that report. The CM also noted that the sit to stand exercises were documented as done in the RNA weekly summary for 3/1/24, 3/7/24, and 3/14/24. However, there was no further documentation for April and May indicating that the sit to stand exercises were provided to Resident 1. Review of facility's policy, titled, Restorative Nursing Services, revised 7/2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, interview and record review, the facility failed to ensure, staff performed their job functions competently according to standards of practice when one cook did not properly verbalize the cool down process for cooking any hot foods such as meat dishes. This failure had the potential to expose 175 residents to food borne illnesses. Findings: During an observation on 5/7/24 at 9:39 a.m., Cook J was seen attending to pots and pans on the stove. During an interview on 5/7/24 at 9:39 a.m., Cook J was asked about the proper coo ldown process for cooked foods such as meat dishes. Cook J stated, the food was cooked to 165 degrees Fahrenheit (F, scale for measuring temperature), then cooled down to 145 degrees F in one hour. Cook J said, he did not know, what should be the temperature in two hours or after. During an interview with the Dietary Services Supervisor (DSS) on 5/8/24 at 1:55 p.m., the DSS stated, any hot foods should be cooled down to 140 degrees F in one hour, then cooled down to 70 degrees F in two hours, and then cooled down to 41 degrees F in four hours. The DSS also stated these were the correct temperatures and she expected Cook J to know that. Review of the 2022 Federal FDA Food Code, section 3-501.14, titled Cooling, indicated, Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 135 degrees F to 70 degrees F; and (2) Within a total of 6 hours from 135 degrees F to 41 degrees F or less.

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive, resident-centered and specific care plans for three out of 39 sampled residents (Residents 162, 55 and 26), when: 1. There were no care plans developed for Resident 162's diagnoses; 2. For Resident 55, there was no care plan to address Resident 55's diabetes, use of insulin, depression and use of antidepressant medication; and 3. For Resident 26, the interventions in her activity care plan did not mention about the room visits and the activities provided during room visits. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 162's medical record indicated Resident 162 was admitted on [DATE] and had diagnoses including Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Post-Traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock) Further review of Resident 162's medical record indicated there were no care plans developed to address Resident 162's Bipolar disorder or PTSD. During an interview with Minimum Data Set Coordinator A (MDSC A) on 5/9/24 at 9:13 a.m., MDSC A stated resident care plans should be completed within 14 days from the date of admission. MDSC A confirmed that all the resident's diagnoses and interventions should be included in the care plan. MDSC A stated Resident 162 should have a comprehensive care plan to address interventions in placed, for the diagnoses of PTSD and Bipolar disorder, to ensure Resident 162's mental health was addressed. 37686 2. Review of Resident 55's medical record indicated Resident 55 was admitted on [DATE] and had diagnoses including diabetes (a disease that impairs the body's ability to control blood sugar) and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 55's Order Summary Report indicated Resident 55 had the following physician's orders, dated 1/24/24, for diabetes: 1. Insulin aspart (medication used to lower blood sugar) 100 units per milliliter (unit/ml, dose measurement) inject 14 units subcutaneously (SQ, under all layers of the skin) before meals; and 2. Insulin NPH (medication used to lower blood sugar) 100 unit/ml inject 7 units SQ two times a day. The Order Summary Report indicated Resident 55 also had a physician's order, dated 1/24/24, for venlafaxine (medication used to treat depression) 37.5 milligrams (mg, dose measurement) give 1 capsule by mouth one time a day for depression manifested by verbalization of sadness. Further review of Resident 55's medical record indicated, there was no care plan to address Resident 55's diabetes and use of insulin. There was also no care plan to address Resident 55's depression and use of antidepressant medication. During concurrent record review and interview with MDSC A on 5/8/24 at 12:43 p.m., MDSC A stated resident care plans should be completed within 14 days from the date of admission. MDSC A confirmed that all the resident's diagnoses and interventions should be included in the care plan. During an interview and concurrent record review with MDSC B on 5/10/24 at 7:39 a.m., MDSC B reviewed Resident 55's medical record and confirmed there was no care plan to address Resident 55's diabetes and use of insulin. MDSC B also confirmed there was no care plan to address Resident 55's depression and use of antidepressant medication. 44185 3. During an observation of Resident 26 on 5/6/24 at 12:43 p.m., Resident 26 was in her room, laying in her bed, alert and verbally responsive. She appeared calm and comfortable. Review of Resident 26's admission record indicated, Resident 26 was admitted to the facility on [DATE] with diagnoses including unspecified fracture (a partial or complete break of the bone) of left pubis (pubic bone or pelvic girdle, one of the three main bones that make up the pelvis), subsequent encounter for fracture with routine healing, history of falling and other reduced mobility (decreased or limited movement). During an interview with Registered Nurse M (RN M), on 5/9/24 at 10:30 a.m., RN M verified that Resident 26 was non-ambulatory (unable to walk) and she was wheelchair bound (person is restricted, bound and completely defined by their wheelchair). RN M further verified that Resident 26 would participate in group activities sometimes, but most of the time, she usually would stay in her room. During an interview with the Activity Director (AD), on 5/9/24 at 1:40 p.m., the AD verified that Resident 26 does not participate in group activities. The AD then stated that activity staffs visit Resident 26 in her room twice per week, providing hand massage, exercises and playing music in the tablet (portable touch-screen device that can play music, videos and games). Review of the active physician orders of Resident 26 as of 5/8/24 indicated, Resident 26 may participate in activity and general conditioning program as desired, ordered on 2/20/24. Review of the activity care plan of Resident 26 indicated that the interventions in the activity care plan of Resident 26 did not mention about the room visits twice per week and the activities that were provided during room visits. The activity care plan of Resident 26 was not comprehensive and was not specific about the room visits. During a concurrent review of Resident 26's activity care plan and further interview with the AD, on 5/9/24 at 1:52 p.m., the AD verified that Resident 26 activity care plan did not mention room visits and the activities provided during room visits. The AD further verified that the activity care plan of Resident 26 was not comprehensive and was not specific about the room visits and will update her activity care plan. During an interview with the Director of Nursing (DON) on 5/9/24 at 4:30 p.m., the DON verified that Resident 26 activity care plan should have interventions about the room visits and the activities done during room visits. The DON further verified that the activity care plan of Resident 26 was not comprehensive and was not specific about the room visits and should be updated. The facility's policy titled Care Plan Comprehensive, effective date 8/25/21, indicated, an individualized comprehensive care plan shall be developed for each resident. The policy further indicated, each resident's comprehensive care plan is designed to incorporate identified problem areas, reflect treatment goals, timetables, objectives in measurable outcomes and includes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based an interview and record review the facility failed to provide required assistance while eating for one out of four sampled residents (Resident 1). Resident 1's minimum data assessment (MDS: Clinical and functional assessment tool) dated [DATE] indicated, Resident 1 required extensive assist (extensive assistance: resident involved in part of the activity and staff provided full assistance with no participation by resident three or more times over the 7 days period) with 1 staff physical assist with his eating. This failure resulted in Resident 1 to aspirate (happens when food, liquid, or other material enters a person's airway and eventually the lungs by accident) the food, became unresponsive, with no blood pressure, no pulse, stopped breathing, and physician pronounced Resident 1's death in the facility. Findings: Review of Resident 1's undated face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was initially admitted to facility on [DATE]. Resident 1's admission diagnoses included dysphagia (difficulty swallowing foods or liquids), aneurysm (a bulge and weakness in the wall of the artery) of the iliac artery (a set of two major blood vessels that provide blood to the lower part of the body), chronic respiratory failure (a serious condition that makes it difficult to breathe), diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting to mouth and stomach), morbid obesity (a disorder involving excessive body fat that increases the risk of health problems), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident 1's ADL self-care performance deficit care plan (a form summarizes resident's health conditions, specific care needs, and current treatments), dated on [DATE] indicated, the intervention includes, Eating: Resident requires limited assistance (limited assistance: resident highly involved in activity and received staff's physical help in guided maneuvering of hands for eating assistance). Review of Resident 1's physician orders for life-sustaining treatment (POLST) form dated on [DATE] indicated, Do Not Attempt Resuscitation/Do Not Resuscitate (DNR: allow natural death when person's heart or breathing stops). Review of Resident 1's care plan for swallowing problem related to dysphagia, dated on [DATE] indicated, the intervention includes Instruct resident to eat in an upright position, eat slowly, and to chew each bite thoroughly. Review of Resident 1's speech therapist (ST: a highly qualified health care professional who diagnoses and treats swallowing problems) 's discharge summary dated [DATE] indicated, short-term goals: safe swallow precautions given min (minimal number) cues. Long -term goals: safe swallow precautions: sitting up for meals. Alternating solids/liquids, small bites given min cues. ST discharge summary document further indicated, discharge status and recommendations for strategies: Swallow strategies: To facilitate safety and efficiency, it was recommended the patient use the following strategies to increase safety during oral intake: upright position at least 30 minutes after meals, slow rate and alternate liquids and solids. ST discharge status and recommendations also indicated, Intake Protocol: Supervision for oral intake=Occasional supervision Review of Resident 1's physician's order for diet dated on [DATE] indicated, Consistent Carbohydrate (CCD) diet (eating same amount of carbohydrates [sugar molecules] every day) Regular Texture, Thin (regular liquids) consistency, Therapeutic Lifestyle changes (TLC: diet plan combines diet, physical activity, and weight management to adopt a heart-healthy eating regimen), No Salt on Tray. Review of Resident 1's MDS assessment dated [DATE] indicated, Resident 1's brief interview for mental status (BIMS) a score of 14 of 15 (13 -15: intact cognition [mental process involved in knowing, learning, and understanding things]). Resident 1's MDS also indicated Resident 1's ADL assistance for eating required extensive assistance with one-person physical assist. Review of Resident 1's health status note dated [DATE] indicated, at around 7:50 a.m., Resident 2 who was the roommate of Resident 1 alerted the facility staff to their room. The Resident 1's health status also indicated staff observed Resident 1 was pale, aspirating on food when arrived at his bedside. License vocational nurse A (LVN A) suctioned and was able to remove pieces of food and saliva from resident's mouth, Resident 1 continues to desaturate (decreased oxygen level), and oxygen applied via nasal cannula (a device used to deliver oxygen to person in need of a respiratory help). The document further indicated Resident 1 was noted with no blood pressure, no pulse, or not breathing, no heart sounds auscultated (listening sounds), and his eyes remained fixed (eyes unresponsive). Physician pronounced Resident 1's death over the phone when nursing supervisor notified above. Review of facility's menu on [DATE] for breakfast indicated, baked cheese omelet, oatmeal cereal, toast, milk, coffee or hot tea, and orange juice. During an interview with Resident 2 (Resident 1's roommate) on [DATE] at 10:45 a.m., Resident 2 confirmed there was no staff in the room when Resident 1 was eating breakfast on [DATE]. Resident 2 stated he saw Resident 1 was holding his throat with his both hands, unable to cough or talk, pale face, making wheezing (breathing with a whistling or rattling sound in the chest) sounds, and dropped Resident 1's silverware in his plate. Resident 2 stated he shouted for help for Resident 1. Resident 2 also stated staff came to help Resident 1. Resident 2 further stated it was too late, and Resident 1 died within few minutes. Review of Resident 2's (Resident 1's roommate) MDS assessment dated [DATE] indicated, his (Resident 2) BIMS score of 14 of 15, intact cognition. During an interview with licensed vocational nurse A (LVN A) on [DATE] at 12:15 p.m., LVN A confirmed there was no staff in Resident 1's room when he was eating breakfast on [DATE]. LVN A stated she went to Resident 1's room, observed Resident 1's mouth was opened, mouth was full of food appeared like scrambled egg and his face was looking pale. LVN A also stated she observed Resident 1 was aspirated on food. LVN A stated she (LVN A) suctioned, removed pieces of scrambled eggs and saliva from his mouth and started oxygen (a treatment that provides with extra oxygen to breathe in). LVN A stated Resident 1 became unresponsive, stopped breathing, and no signs of life after few minutes. LVN A also stated Resident 1's physician pronounced Resident 1's death over the telephone when called to notify Resident 1's condition. LVN A confirmed of Resident 1's diagnoses of dysphagia, and care plan for eating required staff assistance. LVN A further stated staff should have implemented Resident 1's care plan for eating assistance. LVN A also stated staff should have stayed in room, provided supervision and assistance for Resident 1 with eating breakfast on [DATE]. During an interview with director of nursing (DON) on [DATE] at 1:57 p.m., DON stated staff should have supervised and assisted Resident 1 while he was eating breakfast on [DATE]. During a telephone interview with certified nursing assistant B (CNA B) on [DATE] at 3:30 p.m., CNA B stated she was assigned to Resident 1 on [DATE] and CNA B confirmed there was no staff in the room to supervise Resident 1 while he was eating breakfast on [DATE]. CNA B stated Resident 2 (Resident 1's roommate) alerted the staff to the room. CNA B stated she went to Resident 1's room and found Resident 1 with mouthful of scrambled eggs, holding his throat with his both hands, coughing with squeaking sounds from his throat. CNA B stated she alerted LVN A. CNA B stated Resident 1 became unresponsive and stopped breathing few minutes after. CNA B also stated Resident 1 needed staff's supervision and assistance while eating. CNA B further stated staff should have stayed and assisted Resident 1 while he was eating. During a telephone interview with CNA C on [DATE] at 5:20 p.m., CNA C stated Resident 1 needed staff's supervision and assistance while eating. CNA C stated staff should have stayed and assisted Resident 1 during his mealtime on [DATE]. During a telephone interview with Resident 1's primary care physician (PCP) on [DATE] at 1:03 p.m., PCP stated Resident 1 definitely required staff's supervision and assistance while he was eating due to his frail medical condition. During a telephone interview and record review with Minimum Data Set Assistant (MDSA) on [DATE] at 12:45 p.m., the MDSA confirmed Resident 1's MDS assessment dated [DATE] indicated, Resident 1 required extensive assist with 1 staff physical assist with his (Resident 1) eating. The MDSA stated, extensive assistance means, Resident 1 would not be able to perform or complete the activity of eating without nursing staff's physical help. The MDSA also stated staff should have stayed with Resident 1 and assisted with eating as required for Resident 1. During a concurrent interview and record review of Resident 1's ST discharge summary recommendations for oral intake, and care plan interventions for eating assistance with LVN D on [DATE] at 10:40 a.m., LVN D stated Resident 1 required staff supervision while eating with each meal based on Resident 1's ST's discharge summary recommendations and care plan interventions for eating assistance. LVN D also stated staff should not have allowed Resident 1 to eat on his own. During a telephone interview and record review of ST's discharge summary notes with facility's ST on [DATE] at 3:46 p.m., the ST stated Resident 1 was not 100 % safe to eat on his own without staff's supervision during mealtime. The ST further stated staff should have provided supervision and assisted Resident 1 as needed while he was eating. During a concurrent interview and record review of Resident 1's diet order and facility's breakfast menu for [DATE] with the dietary supervisor (DS) on [DATE] at 1:22 p.m., the DS stated Resident 1 was served regular textured scrambled eggs ,d+[DATE] cup, oatmeal, toast, 2 % milk, hot tea, and orange juice on [DATE] for breakfast. Review of Resident 1's undated discharge summary indicated, Resident 1's discharge date was [DATE] with diagnoses including dysphagia, chronic respiratory failure, aneurysm of iliac artery, diabetes type 2, and congestive heart failure. Discharge summary also indicated, Resident 1's condition upon discharge was death in the facility. Review of Resident 1's undated certificate of death from State of California, indicated, sudden cardiac death as the immediate cause final disease or condition resulting in death. During a telephone interview with Resident 1's PCP on [DATE] at 11:45 a.m., PCP stated lack of oxygen supply to Resident 1's heart and brain after Resident 1 aspirated on food could have caused sudden cardiac death. During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, revised [DATE], the P&P indicated, Residents should receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays and will help residents who require assistance with eating. During a review of facility's P&P titled, Care Plan Comprehensive, dated [DATE], the P&P indicated, the facility's Interdisciplinary Team, in coordination with the resident and /or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of Centers for Medicare &Medicaid Services (CMS) 's resident assessment instrument (RAI: helps facility staff to gather definitive information on a resident's strengths and needs which must be addressed in an individualized care plan) manual 3.0 revised [DATE], the RAI manual indicated, extensive assistance with one-person physical assist: if resident performed part of the activity over the last 7 days and help of the following types (s) was provided three or more times.

Based on interview and record review the facility failed to: 1. Ensure safety for Resident 1 when Resident 1's physician ordered diet was not followed; 2. Ensure that Resident 1's dietary profile was followed, which required staff supervision while eating; 3. Follow the facility's policy and procedure on Nutrition Management of Dysphagia Mechanical, dated 2020, when CNA C provided a peanut butter and jelly sandwich to Resident 1 which resulted in Resident 1 choking and being transferred to the general acute care hospital (GACH) for urgent treatment. As a result of these failures, Resident 1 was sent to the GACH on [DATE] to have a large food bolus removed via laryngoscopy (a procedure where a tube placed in the throat and allows doctors to remove foreign objects). Resident 1 suffered hypoxia (lack of enough oxygen) which induced a cardiac arrest (sudden unexpected loss of heart function), and neurological damage (brain damage). Resident 1 expired [DATE] due to complications of choking on food bolus. Findings: Review of Resident 1's face sheet, dated admitted [DATE], indicated Resident 1 had a history of Parkinson's Disease (a disorder of the central nervous system that affects movement and can cause difficulty swallowing), dysphagia (difficulty in swallowing), oropharyngeal phase (swallowing problems that occur in the mouth and/or throat), and diabetes (a chronic condition that affects the way the body processes sugar). During an interview with licensed vocational nurse A (LVN A), on [DATE] at 10:27 a.m., LVN A confirmed Resident 1's face sheet indicated Resident 1 had a history of Parkinson's Disease, dysphagia, and diabetes. Record review of Resident 1's Speech Language Pathology (SLP) Evaluation and Plan of Treatment, dated [DATE], indicated Resident 1 had poor self-monitoring skills, decreased safety awareness and at risk for aspiration (when food or liquid enter the airway) and choking. During an interview with LVN A, on [DATE] at 10:27 a.m., LVN A confirmed Resident 1's speech therapy SLP Evaluation and Plan of Treatment, dated [DATE], indicated Resident 1 had poor self-monitoring skills, decreased safety awareness and at risk for aspiration, and choking. Review of Resident 1's dietary profile, dated [DATE], indicated Resident 1 required supervision under eating assistance. During an interview with LVN A, on [DATE] at 10:27 a.m., LVN A confirmed Resident 1's dietary profile, dated [DATE], required supervision under eating assistance. Review of Resident 1's nutritional risk assessment, dated [DATE], indicated Resident 1 required supervision while eating, had chewing and swallowing problems, and fed self with verbal cues. During an interview with LVN A, on [DATE] at 10:27 a.m., LVN A confirmed Resident 1's nutritional risk assessment, dated [DATE], indicated Resident 1 required supervision while eating, had chewing and swallowing problems, and fed self with verbal cues. During an interview with the Director of Rehabilitation Services (DRS), on [DATE] at 3:37 p.m., DRS confirmed Resident 1 had Parkinson's Disease and muscle weakness and stated he required reminders to swallow and chew and to check for pocketed food (storing food inside the mouth and not swallowing) at times. The DRS stated these all put him at risk for choking. Review of Resident 1's Minimum Data Set (MDS; tool used to assess residents), dated [DATE], indicated Resident 1 required staff supervision or touching assistance with verbal cues, touching, and steadying while eating. During an interview with the Minimum Data Set Coordinator (MDSC), on [DATE] at 4:11 p.m., the MDSC confirmed Resident 1's MDS indicated Resident 1 required staff supervision or touching assistance with verbal cues, touching and steadying while eating. Review of Resident 1's physician orders, dated [DATE], indicated Resident 1 was on a fortified (nutrients are added to food to improve nutrition) diet that was mechanical altered level two texture (moist, mechanically altered or easily mashed and must not be sticky or bulky). During an interview LVN A, on [DATE] at 10:27 a.m., LVN A confirmed Resident 1's physician orders, dated [DATE], indicated Resident 1 was on a fortified diet that was mechanical altered level two texture. During an interview with the Dietary Supervisor (DS), on [DATE] at 2:38 p.m., the DS indicated for the mechanical altered level two texture diets that the food must be easily mashed and that, for this diet, the diet excludes difficult to chew foods, sticky foods, and bulky foods. Review of the facility's diet manual section Nutrition Management of Dysphagia Mechanical, dated 2020, indicated for the dysphagia mechanical diet, foods must not be sticky or bulky and that they would increase the risk of airway obstruction if sticky or bulky. The manual further indicated bread and peanut butter were on the avoid list and not on the allowed list for this diet and indicated that should be followed. During an interview with the Dietary Supervisor (DS), on [DATE] at 2:38 p.m., she confirmed the facility's diet manual section for the dysphagia mechanical diet indicated foods must not be sticky or bulky and that they would increase the risk of airway obstruction if sticky or bulky. She confirmed the manual further indicated the bread and peanut butter were on the avoid list for Resident 1 and the avoid list should have been followed. Record review of Resident 1's Change of Condition, dated [DATE] at 4:45 a.m., indicated Resident 1 was in a wheelchair in front of the nurse's station. The note indicated he was given a sandwich and an ensure milk (nutritional drink that provides protein). During a phone interview with the Certified Nursing Assistant C (CNA C), on [DATE] at 9:28 a.m., CNA C stated Resident 1 woke up early that morning on [DATE]. CNA C stated she assisted Resident 1 into a wheelchair and brought Resident 1 in front of the nurse's station. CNA C stated she then gave Resident 1 a peanut butter and jelly sandwich. CNA C stated she did not know Resident 1's diet order or if Resident 1 could have peanut butter and jelly sandwiches. CNA C stated she usually asks the nurse if she could give a sandwich to a resident, but this time she did not ask the nurse. CNA C stated she did not ask the nurse because she has given Resident 1 sandwiches in the past and she stated she knows him. CNA C stated she did not observe or supervise while Resident 1 ate the sandwich. CNA C stated shortly after giving the sandwich she was walking by and saw Resident 1's .head was down, so we assumed he choked. CNA C stated Resident 1's nurse did the Heimlich maneuver (a first aid procedure for dislodging an obstruction from person's windpipe) with no results. CNA C stated emergency services were called and they told the nurse to initiate Cardio-Pulmonary Resuscitation (CPR, a medical procedure involving repeated of resident's chest compression to restore the blood circulation and breathing). During a phone interview with Registered Nurse B (RN B) on [DATE] at 7:46 a.m., RN B stated she remembered Resident 1 and the incident on [DATE]. RN B confirmed CNA C brought Resident 1 to the nurse's station and gave him a sandwich. RN B stated .I was passing my meds and he looked okay when I passed by. During a phone interview with RN B on [DATE] at 7:46 a.m., RN B stated Resident 1 ate more than half of the sandwich and stated she did not know if Resident 1 could have sandwiches or not. RN B confirmed nursing should follow the diet orders. RN B stated the CNA C was supposed to check with the nurse prior to giving any food. She stated CNA C did not ask her prior to giving Resident 1 a sandwich. She stated she told CNA C to check with her before giving food to any resident. RN B stated she was administering medications to other residents during this time and was not directly supervising Resident 1 as he was eating. Record review of Resident 1's Change of Condition, dated [DATE], for shortness of breath and unresponsiveness, indicated at 5:15 a.m. CNA C found the resident head facing down and unresponsive with labored breathing. The note indicated emergency services were notified and the Heimlich maneuver (first aid procedure for when someone is choking and done to dislodge food from throat or windpipe) was performed on Resident 1 with no results. Resident 1 was placed on the floor and at 5:30 a.m. Cardio-Pulmonary Resuscitation (CPR; emergency procedure with chest compressions and artificial breathing to preserve intact brain function) was initiated. At 5:40 a.m. Resident 1 was transferred to a nearby hospital via ambulance. During a phone interview with RN B on [DATE] at 7:46 a.m., RN B stated CNA C saw Resident 1's head down and .he was not responding, so I immediately did the Heimlich maneuver. RN B stated she did so because Resident 1 was eating, and she believed Resident 1 had choked. RN B stated she then moved Resident 1 to the floor and emergency services indicated she start CPR, so she did. During a phone interview with the Registered Dietician (RD), on [DATE] at 3:04 p.m., she indicated a peanut butter and jelly sandwich would be excluded from Resident 1's diet because of the peanut butter and bread and stated it would increase his risk of choking. She confirmed the facility manual has further information on the allowable food items for the mechanical altered level two diet. During a phone interview with the Medical Doctor (MD), on [DATE] at 12:39 p.m., the MD stated Resident 1 had weakness and was not able to communicate his needs very well. The MD confirmed Resident 1 had difficulties eating and was evaluated for the appropriate diet and based off the evaluation needed a mechanical level two diet. MD stated he was not aware Resident 1 was given a peanut butter and jelly sandwich and stated they should not have given this. MD also stated he expected the facility should have followed the physician diet order and the physician diet order was a part of the plan of care for Resident 1. Record review of the acute hospital's admission note, dated [DATE], indicated Resident 1 was brought into the hospital with a hypoxia (lack of oxygen) induced cardiac arrest in the setting of an aspiration event. Record review of the local hospital's emergency department note, dated [DATE], indicated Resident 1 required a foreign body removal from orifice (an opening in the body) and indicated a .large food bolus that was a concretion (a hard solid mass) removed from the oropharynx (part of the throat at the back of the mouth) that was occluding (blocking) the airway as well as the esophagus (canal that connects throat to stomach). The note indicated the large food bolus was removed by laryngoscopy (a procedure where a tube is in the throat and allows doctors to remove foreign objects) into the pharynx (the throat). Record review of the local hospital's discharge note, dated [DATE], indicated Resident 1 had pulseless electrical activity (when there is no pulse, and the heart has stopped due to cardiac arrest) due to choking on food. The note indicated Resident 1 had poor neurological status due to this anoxic (lack of oxygen) brain injury. Review of Resident 1's death certificate, which listed [DATE] as the date of death , listed the immediate cause of death as .complications of choking on food bolus. The death certificate further indicated the date of injury was [DATE], that the injury occurred in the skilled nursing facility, and that the injury was the result of choking on food. Review of facility policy Diet Orders, dated [DATE], indicated the diet order was based on resident assessment and any health diseases or conditions. Policy further indicated that consistency altered diets may not be waived or changed without assessment and order change. Record review of facility policy Physician Orders, dated [DATE], indicated the licensed nurse was responsible for implementing the orders for the resident. As a result of these failures, Resident 1 was transferred to the GACH to have a large food bolus removed from the back of the throat because it was blocking the airway and the resident suffered hypoxia which induced a cardiac arrest and neurological damage. Resident 1 expired [DATE] due to complications of choking on the wrong texture of food provided.

Based on interview and record review the facility failed to implement written facility abuse policy and procedures to prevent abuse for three of three sampled residents (Resident 32, Resident 100, and Resident 119) when the facility failed to: 1. Report Resident 32's and Resident 100's allegation of abuse regarding humiliation. The facility failed to suspend the accused admissions coordinator (AC) when the facility became aware of the allegation of abuse, did not investigate the allegation of abuse and complete a written report of the investigation's findings within five working days of the occurrence, or complete a background check on the AC prior to employment with the facility; 2. Suspend the accused licensed vocational nurse D (LVN D) when the facility became aware of the allegation of verbal abuse, did not thoroughly investigate the allegation of verbal abuse, and failed to follow-up on a background check on LVN D who had a court record regarding misdemeanor (offense and punishable by law). These failures resulted in psychosocial distress to Resident 119, and for Resident 32 and Resident 100 the reasonable person (hypothetical person response to a situation that most people would have in a situation) would feel privacy violation, shame, and humiliation. These failures had the potential for all 136 residents to be at risk for further mistreatment and abuse. Findings: Review of the facility census on 4/26/22 confirmed 136 residents in the facility. 1. Review of Resident 32's face sheet, dated 4/13/2021, indicated Resident 32 was not self-responsible or able to make his own medical and financial decisions and instead had a responsible party (RP) to do so. Resident 32's face sheet indicated the resident had a medical history including dementia (a condition of impairment of memory and judgment). Review of Resident 32's Minimum Data Set (MDS, an assessment tool), dated 2/4/ , indicated Resident 32 had memory problems, inattention, and disorganized thinking. Review of Resident 100's face sheet, dated 5/3/2022, indicated Resident 100 was not self-responsible or able to make his own medical and financial decisions and instead had a responsible party to do so. Resident 100's face sheet indicated the resident had a medical history including dementia (a condition of impairment of memory and judgment), stroke (damage to the brain from interruption of its blood supply), and heart failure (condition when heart does not pump blood as well as it should). During telephone interview with certified nursing assistant R (CNA R), on 4/26/2022 at 4:23 p.m., CNA R stated on 12/4/2021 she reported to the facility's former administrator (ADM O) that the AC posted pictures of Resident 32 and Resident 100 to a social media platform that allows users to post pictures or images with text and share. She stated the AC posted pictures of both Residents 32 and 100 and stated that with Resident 32's picture the AC posted vulgar (explicit and offensive sexual remarks) text about Resident 32. She stated she did not know what to do and felt posting the pictures and the vulgar writing on the images was wrong. CNA R stated she followed the AC name on the social media platform and regularly saw AC's posts on the social media platform. She stated the name associated with the account was the AC's name and the picture she provided of the social media post listed the AC's name. CNA R stated she took a picture of the post so she could report it. She stated the AC posted pictures of both Resident 32 and Resident 100 but was only able to get a picture of one of the posts. The social media platform used had a time frame when posts would be available to users. CNA R stated that sometime at the end of November 2021 or early December 2021 she showed the images to licensed vocational nurse J (LVN J) and asked her what she should do. She stated LVN J advised her to report to adminstrator O (ADM O). During interview with LVN J, on 4/27/2022 at 9:22 a.m., LVN J stated CNA R showed her social media posts by the AC some time in December 2021, but was unsure of the exact date. She stated CNA R showed her the picture of Resident 32 with the text at the bottom of the image .I want to f___ you and want to suck my c___ . and, .Come get your daily dose of with the resident's first name. LVN J said it made her feel sick to her stomach and upset her. She stated she did not know what to do. She stated she knew it was illegal and unethical, and told CNA R to go to ADM O. She did not report it herself. She stated she did not know she should. She confirmed she was a mandated reporter (one who is required by law to report reasonable suspicions of abuse), but stated she was unsure if she needed to do anything. She stated it all occurred in December 2021, and she recognized the picture to be Resident 32 and she saw it was the AC who posted the image. During a subsequent interview with LVN J on 4/27/2022 at 10:16 a.m., she stated she followed-up with CNA R sometime in December 2021. She stated CNA R complained of a slow response from ADM O and that she did not think anything was being done about it. LVN J stated the AC confronted her over having the allegations reported to ADM O. LVN J stated she felt uncomfortable, and the AC said it was okay to take the pictures because Resident 32 liked having the pictures taken. LVN J stated she wanted out of the conversation and stated she told the AC it was never right to take pictures of residents and have crude text like that on the photos. She stated she informed the AC that CNA R did the right thing by reporting it to ADM O. During interview with ADM O, on 4/26/2022 at 9:18 a.m., ADM O initially stated CNA R never reported to him any social media posting in December of 2021 regarding residents at the facility. ADM O confirmed he was the administrator during the time of the allegation of abuse and was the acting Abuse Coordinator of the facility. ADM O stated he no longer works in the administrator role and is now in another role in the facility. ADM O stated the facility was in the process of trying to establish a responsible party (RP, a person empowered to make decisions for the resident/person legally responsible and liable for decision or action), for Resident 32 as his current RP was difficult for the facility to reach. He stated there was some difficulty in reaching Resident 100's RP as well. He confirmed the facility did not obtain consent for the pictures to be taken for social media for either Resident 32 or Resident 100. During subsequent interview with ADM O on 04/26/2022 at 1:22 p.m., ADM O stated he was aware of the allegations of abuse for Resident 32 and Resident 100. He stated he had email and cell phone correspondence with CNA R on 12/4/2021 in which she reported to him the allegations and provided him with pictures of some of the allegations. In the series of emails, ADM O stated CNA R reported allegations of abuse of Resident 32 and Resident 100 by the AC. ADM O stated CNA R reported AC posted pictures of Resident 32 and Resident 100 to a social media platform. ADM O stated CNA R stated the AC posted a picture of Resident 32 along with crude and sexual comments such as .I want to f___ you and want to suck my c___ . and, .Come get your daily dose of with the resident's first name. ADM O stated he asked CNA R to provide any of the pictures of this via text to him. He stated CNA R provided photos and screenshots. During a subsequent interview with ADM O on 4/27/2022 at 9:37 a.m., ADM O confirmed he received images of Resident 32 from CNA R and stated vulgar language such as .I want to f___ you and want to suck my c___ . and, .Come get your daily dose of with the resident's first name. ADM O confirmed he asked when the picture was time stamped and stated CNA R informed ADM O it was on 11/21/2021. ADM O stated he then told CNA R he would . take care of it from here. ADM O also confirmed it looked like the picture AC posted was taken inside the facility. Record review of the permission to photograph, dated 4/15/2021, indicated the resident may be photographed for medical documentation and for various activities on bulletin boards in areas of the facility. The form was signed by Resident 32's RP. During interview with the director of nursing (DON), on 4/27/2022 12:18 p.m., the DON stated she was unaware of any pictures of Resident 32 or Resident 100 posted to any social media platform. She stated ADM O never informed her of the allegations of abuse of Resident 32 and Resident 100. DON stated she was sorry and embarrassed to have someone like this working in the facility. DON stated it was unacceptable to take pictures and she would have reported the allegations to the state agency as a mandated reporter. DON confirmed Resident 32 and Resident 100 images would be humiliating and demeaning to any person. DON stated the facility does not have the consent to use a photo like this and stated even if the facility had permission to take pictures that this picture and text would not fall under that. During interview with AC, on 4/26/2022 at 4:31 p.m., AC denied ever posting any images of residents or any information about a resident on a social media platform. The AC denied she posted the picture of Resident 32 with the text .I want to f___ you and want to suck my c___ . and, .Come get your daily dose of with the resident's first name to social media. The AC stated she used a cell phone she owned, but the monthly bill for the phone service was paid for by the facility. The AC did not answer further questions regarding the social media account and instead offered to show her personal photographs. During interview with ADM O, on 4/27/2022 at 9:37 a.m., ADM O stated the image looked like Resident 32 and he confirmed there was a Health Insurance Portability and Accountability Act (HIPAA, federal law to protect residents' private information from being disclosed without consent or knowledge) concern with the sharing of the image. ADM O stated the writing or text on the image was crude and always inappropriate, but in his opinion it did not rise to abuse level and stated he concluded this without a formal investigation. ADM O stated he did not alert any state agency or any providers because he did not think it was necessary. He stated he thought it may have just been from AC to another phone and that would be okay because he felt cell phone to cell phone was secure. He stated he did not know who shared the photographs and stated he did not investigate any further. ADM O also stated he did not think Residents 32 or 100 were even aware. About Resident 32, ADM O stated .the resident was not alert or aware in relation to the circumstances, so I am not sure it caused him harm. ADM O added [Residents 32 and 100] were not even aware and the images should not have been taken. The ADM O stated both residents were confused and it is unlikely they recalled the pictures being taken. During this interview, on 4/27/2022 at 9:37 a.m., ADM O confirmed once he was informed of the alleged abuse, on 12/4/2021, he did not suspend AC, he did not investigate, did not document the investigation, and did not report the result of the findings of the investigation to any state agency. During interview with ADM O, on 4/27/2022 at 9:37 a.m., ADM O stated he thought he followed-up with AC regarding the alleged abuse via text message, but stated he was not sure. He stated he asked AC if she took any resident pictures and he said she stated no. He stated he told her .we cannot take pictures of residents with no consent and it is best to avoid this. During interview with AC, on 4/27/22 at 10:53 a.m., AC stated taking pictures of the residents was never okay and stated ADM O did a .light in-service with me about a HIPAA violation. It was verbal and I did not know why. I did not ask. AC stated her phone was her personal phone and for the facility use. She stated the department heads discuss residents by room numbers via text message. She stated she did not see an issue with confidentiality in doing this. During interview with the facility's current administrator (ADM P), on 4/27/2022 at 1:13 p.m., ADM P stated AC and ADM O were suspended on administrative leave until the investigation was completed. During interview with ADM P on 4/28/2022, at 11:15 a.m., ADM P provided a final investigation from 12/4/21 to 4/28/22 and it was more than four months after ADM O was notified of the allegation of abuse. ADM P confirmed ADM O was notified on 12/4/2021 of the alleged abuse. ADM P became aware of the allegations because of this investigation and completed a formal investigation himself and final report on 4/28/2022 which was more than four months after ADM O was notified of the social media posts of Resident 32 and Resident 100. ADM P stated he concluded AC did take a picture of a resident, that it contained a .rude message, and she distributed it to another facility staff member who he could not identify because AC would not provide that information. He stated AC expressed remorse but also denied taking the images or writing vulgar text messages on the social media platform. He stated AC was vague and not forthcoming in his interviews with her. ADM O stated AC violated facility policy protecting residents. ADM P stated AC was terminated by the facility because of the investigation findings. During interview with the DON, on 4/27/2022 at 2:01 p.m., the DON confirmed a criminal background check on AC was not completedwhen she started her employment at the facility in March of 2020. The DON confirmed the facility uses an external agency to perform criminal background checks. That agency stated the search was not performed which means a criminal background check was not completed. Review of the Abuse Prevention Program policy, dated 1/1/2020, indicated residents had the right to be free from abuse. As part of the resident abuse prevention, the administration was to conduct employee background checks. This policy indicated the facility administration will identify and assess all possible incidents of abuse. Review of the Abuse Investigation and Reporting policy, dated 1/31/2022, indicated the administrator was to suspend immediately any employee who was accused of resident abuse. Policy indicated the administrator would assign the investigation to an appropriate individual to do the investigation, and would ensure any further potential abuse, neglect, exploitation, or mistreatment would be reported immediately, but not later than two hours if the alleged violation involved abuse and would ensure witness report statements be obtained in writing. The policy further indicated the facility would report to the appropriate agencies with a written report of the investigation's findings within five working days of the occurrence of the investigation. Review of the Resident's Rights policy, dated 1/1/2020, indicated that residents at the facility are to be treated with dignity and respect and have the right to a dignified existence and be free from exploitation. Review of the Videotaping, Photographing, and other imaging of Residents, dated 1/1/2020, indicated staff may not take or release images or recordings of any resident without explicit written consent and transmitting unauthorized images of any resident through email, internet, or social media is a violation of resident rights and any image that may be construed is humiliating or demeaning to a resident is considered resident abuse and will be reported and investigated as such. 2. Review of Resident 119's Minimum Data Set (MDS, an assessment tool), dated 3/16/2022, indicated he did not have any problems with memory and daily decision-making skills. Review of the Change of Condition (COC) form, dated 4/11/2022, indicated on 4/10/2022 at 10:30 p.m., the resident complained a licensed nurse (LN) had poor bedside manners when the resident asked for water to drink with his medications. During an interview on 4/19/2022 at 10:00 a.m., the director of nurses (DON) stated there was a recent incident when Resident 119 stated licensed vocational nurse D (LVN D) would not give him water and LVN D and the resident had cussed (saying offensive words in anger or annoyance) at each other. During an interview on 4/19/2022 at 2:15 p.m., Resident 119 stated when he asked LVN D for water to take his medication, LVN D got irate and stated I am not your maid and we started 'barking' at each other. Four female staff came into his room to calm LVN D and he was escorted out. Resident 119 stated he felt afraid, LVN D .wanted to fight me, and he could not sleep and was worried as he still saw the staff member working in his unit. Review of Resident 77's MDS, dated [DATE], indicated he was mostly intact with memory and daily decision-making skills. During an interview on 4/19/2022 at 12:20 p.m., Resident 77 who was Resident 119's roommate recalled he could not remember when it happened but when LVN D was injecting Resident 77 with insulin, Resident 77 stated the injection hurt him. LVN D told Resident 77 to be still and called him an[OBSCENITY] . During a follow-up interview on 4/19/2022 at 4:20 p.m., Resident 77 stated on 4/10/2022, he heard Resident 119 ask for water to take his medication and LVN D stated he was not his waiter. Resident 119 and LVN D were arguing loudly, and he kept quiet. During an interview on 4/21/2022 at 4:45 p.m., LVN N stated last Sunday (4/10/2022) when she heard loud screaming and yelling between two people in Resident 119's room, she had certified nurse assistant CC (CNA CC) page a nurse supervisor, and saw CNA DD ask LVN D to leave. LVN N stated she asked LVN D who was at a nurse's station to calm down then asked what happened. LVN D stated when Resident 119 asked for water he said to Resident 119 .why don't you drink your juice, I'm not your f___ing waiter. LVN N soon after checked on Resident 1 and the resident stated LVN D told him .why you don't drink your juice on the table, I am not your f___ing maid. LVN N also stated Resident 77 was in the room at the time of the incident. She was instructed by the charge nurse to provide a note of what happened, and she was not interviewed by the administrator about the incident. During an interview on 4/19/2022 at 12:35 p.m., LVN D described Resident 119 as rude and manipulative and stated an incident with the resident occurred during medication administration around 8:30 to 9 p.m. on 4/10/22. LVN D denied arguing with Resident 119 and LVN D was not suspended. Review of the undated facility's investigation conducted by ADM O indicated LVN D was immediately reassigned and there was bickering (arguing) between the LVN D and Resident 119. It did not indicate LVN D had cursed Resident 77 and the investigation did not include interviews with Resident 119 and Resident 77. It was indicated LVN N was interviewed. The conclusion indicated the facility was unable to substantiate the abuse claim as it was not independently witnessed by a third party. Review of the HireRight (background check) form, dated 2/14/2022, indicated LVN D had a misdemeanor related to violation of a court order dated 8/9/2021, with jail time imposed for 65 days, of which 57 days were credited for time served. It also indicated probation time was imposed for three years. There was no documentation indicating the background check was reviewed and if any follow-up inquiry or action with LVN D or Superior Court was taken. During an interview on 4/19/2022 at 1:50 p.m., administrator (ADM) O stated he had spoken to LVN D about his misdemeanor and learned a restraining order was placed by a family member and ADM O confirmed these events occurred prior to LVN D being hired at the facility. ADM O stated he hired LVN D because he determined his past record would not affect his job performance and he did not document this. During a follow-up interview on 4/19/2022 at 3:55 p.m., ADM O stated he learned about the incident by a text message the next morning on 4/11/2022, and he stated he did not suspend the staff member because the staff member had to complete medication administration. Review of the Superior Court of California, County of Santa [NAME], case information site indicated LVN D had six cases on file. LVN D was hired on 2/12/22 at the nursing facility. There was an active case dated 8/9/2021 related to family violence complaint and indicated LVN D was sentenced. The 6/11/2021 case indicated complaint, family violence in active status. The 4/3/2019 case indicated elder or dependent abuse restraining order in active status. During an interview on 5/3/2022 at 9:00 a.m., ADM P stated the administrator was the facility's abuse coordinator, verbal altercations (disagreement and argument) with residents was considered abuse, and the alleged staff should be suspended right away pending investigation. ADM P stated if a staff member had a misdemeanor charge in their record, he would interview that person and would not hire anyone with a record of elderly abuse regardless of being formally charged and that he was not informed about LVN D's situation. Review of the Abuse Prevention Program policy, dated 1/1/2020, indicated residents had the right to be free from abuse. As part of the resident abuse prevention, the administration was to conduct employee background checks and would not knowingly employ any individual who had been found guilty of abuse or mistreatment by a court of law. Review of the Abuse Investigation and Reporting policy, dated 1/31/2022, indicated the administrator was to suspend immediately any employee who was accused of resident abuse, pending outcome of the investigation and all alleged violations involving abuse or mistreatment was to be reported immediately, but not later than two hours if the alleged violation involved abuse.

Based on observation and interview, the facility failed to follow the recommendations set for by the Centers for Disease Control (CDC) to conduct employee health screenings, which included an assessment of their current body temperature and evaluation of any signs or symptoms related to COVID-19, prior to having contact and providing nursing care to residents, in accordance with the facility's policy titled Precautions for COVID-19, dated 3/11/20. This non-compliance placed all 171 residents in the facility at risk for COVID-19. A determination was made that the facility's non-compliance with one or more requirements of participation at F880 had caused or was likely to cause serious injury or death to any of the 171 residents residing in the facility. On 4/1/20 at 2pm, the Administrator and the Director of Nursing were informed of the identified immediate jeopardy. Findings include: Review of the Centers for Disease Control (CDC), Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19) states all healthcare professionals should be screened at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document the absence of shortness of breath, new or change in cough, and sore throat. Review of the facility's policy titled Precautions for COVID-19, dated 3/11/20, and identified all department supervisors were to screen their department staff prior to start of shift for temperature and signs and symptoms. Review of a map of the layout of the facility, showed the employee entrance was located at the back of the building and upon entrance, staff ambulated to the time clock at the end of a long hallway which had been identified as the service hallway. The facility map revealed the layout of the facility had four separate nursing stations located throughout the building. Upon clocking in for their assigned shift, staff would have to travel to their assigned area in the facility. This allowed staff to be in resident care area's and have contact with any resident in the hallways of the facility prior to having their body temperature assessed and being screened for signs and symptoms of COVID-19. Observation on 4/1/20 at 1:00pm, showed an exit door in the back of the facility identified by staff as the employee entrance, which connected to a long hallway identified as the service hallway with a time clock at the end of the hallway on a wall. Four nursing stations were observed in separate areas of the facility, with hallways containing resident rooms leading to each one. Observations on 4/1/20 at various times throughout the day showed residents in hallways and positioned close to the nurses stations throughout the building. During an interview on 4/1/20 at 1:05pm, the Registered Nurse (RN) 1, House Supervisor stated she was responsible for conducting screenings on nursing staff. She stated at the start of the 7am shift, she would make a copy of the daily nursing schedule and would then go to each nurse's station area to locate the nursing staff who were scheduled to work the day shift and obtain a body temperature on them and to see if they had any respiratory symptoms. She stated she typically was finished screening all nursing staff whose shift started at 7am, by 7:30am each day. She stated she typically screened all nursing staff on the day shift but at approximately 7:20-7:30am this morning, she still needed to screen approximately 10 staff members whose shift began at 7am. She stated that she had asked another staff member to complete the remainder of the employee screenings. During an interview on 4/1/20 at 12:51pm, Licensed Vocational Nurse (LVN) 1, stated she entered the facility through the employee entrance, clocked in and then reported to her assigned area in the facility. She stated she screened herself by taking her temperature at the nurse's station this morning. During an interview on 4/1/20 at 12:55pm, Nurse Aide (NA) 2 stated she worked the day shift (7:00am-3:00pm), and usually clocked in and then reported to her assigned area to begin her work assignment. She stated staff would come and look for her in the hallways of her assigned area and check her temperature. During an interview on 4/1/20 at 1:20pm, NA1 stated she enters the facility through the employee entrance, clocks in for her shift and then goes to her assigned area to begin her care assignments. She stated that staff do check her body temperature. She stated that sometimes she is at the nurse's station when it is checked and sometimes the staff person is waiting in the hallway to check it once she completes the care she is providing the resident and exits the resident room. During an interview on 4/1/20 at 2:00pm, the Director of Nursing (DON) stated staff are screened at the beginning of each shift. She stated it was the responsibility of the nursing supervisor to screen the nursing staff. She stated the nursing supervisor assesses the employee's body temperature and observes and questions them about any respiratory or flu like symptoms. She stated that the nursing supervisor conducts the employee screenings at the nursing station in the area the employee is assigned to work. The IJ was removed on 4/3/20 after surveyor's verified implementation of an acceptable remove plan. The implemented plan required all employees to be screened upon entrance though a back door of the facility prior to beginning their shift or entering any resident care areas.

Based on observation, interview, and record review, the facility failed to carry out the treatment plan and to implement physician orders [REDACTED]. 1. Resident 1 had an order to transfer Resident 1 to the emergency room after an X-ray confirmed a fracture was present was not carried out after a fall on [DATE] and; 2. The order to administer oxygen and to notify the physician if Resident 1's oxygen saturation (level of oxygen in the blood) was less than 90% was not done. These failures resulted in a delay for Resident 1 in receiving a higher level of care at the hospital. Findings: Review of Resident 1's clinical record indicated Resident 1 was initially admitted to the facility on [DATE] from home. Review of the physician's progress notes on [DATE] indicated Resident 1 had the [DIAGNOSES REDACTED]. able to work at a level needed for day-to-day life), [MEDICAL CONDITION] (reduced production of red blood cells) due to [MEDICAL CONDITIONS] (inflammation or loss of cartilage in the joint) of the left knee. Review of Resident 1's Physician order [REDACTED]. Cardiopulmonary Resuscitation (CPR) if patient has no pulse and is not breathing. It also indicated Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do no intubate. (MONTH) use non-invasive positive airway pressure. Generally avoid intensive care. under B. Medical Interventions - if patient is found with pulse and/or is breathing. Review of Resident 1's Order Summary Report indicated an order dated [DATE] to Check Oxygen Saturation every shift Start O2 (oxygen) at 2 L/min (liters per minute, a unit of measurement of volume over time) if O2 < (less than) 90% and notify physician. During an observation of the video surveillance on [DATE] and interview with the director of nursing (DON) on [DATE] at 2:38 p.m., CNA I and Resident 1 were observed going in the shower room around 10:00 a.m. CNA I was observed leaving the shower room at 10:10 a.m. without Resident 1 and walked towards the nursing station. At 10:11 a.m., CNA I went back in the shower room followed by CNA J. At 10:15 a.m., CNA I was observed wheeling Resident 1 out of the shower room. At 10:15 a.m., Resident 1 and CNA I were observed entering Resident 1's room followed by licensed vocational nurse C (LVN C) and physician (MD A). The DON confirmed the observations. The DON stated Resident 1 had a witnessed fall in the shower with CNA I on [DATE] and was assessed by MD A and LVN C in Resident 1's room after the fall. Review of physician A's (MD A) Physician's Progress Notes, dated [DATE], indicated Resident 1 had a fall in the bathroom while standing, hit her right buttocks and was complaining of pain in the right hip and low back/tailbone area. It indicated Resident 1 was seen and examined by physician A (MD A) on [DATE]. It indicated Resident 1 was in pain with movement of the right hip joint and tender to palpation (touch) on the sacrum (lower backbone) area. It also indicated to give Tylenol ([MEDICATION NAME], an over-the-counter pain medication) as needed for pain control, stat X-ray of bilateral (both sides) of the hip and lumbosacral (LS, lower part of the back bone) spine to rule out fracture. It also indicated to give Tylenol as needed for pain control, bed rest, stat X-ray of the hip and spine to rule out fracture, and to transfer Resident 1 to the emergency department if there was a fracture. It indicated the Physician's Progress Notes were noted by licensed vocational nurse C (LVN C) on [DATE]. Review of licensed vocation nurse C's (LVN C) Nursing - Fall Incident Report: Change of Condition, dated [DATE] at 3:30 p.m., indicated Resident 1 had a fall on [DATE] at 10:30 a.m. It indicated the new order of stat X-ray for the hip and spine was carried out. During an interview with radiology representative H (RR H) on [DATE] at 10:09 a.m., RR H stated the X-ray report for Resident 1 was faxed to the facility on [DATE] at 1:14 p.m. Review of the Radiology Report, dated [DATE] at 1:14 p.m., indicated There is a fracture involving left pubic ring with healing. The age of the fracture is non acute. Review of LVN F's Nursing - Change of Condition (Initial only), a late entry on [DATE] at 2:32 a.m., indicated vital signs were taken at 5:38 p.m. and Resident 1 had an oxygen saturation of 88% while on room air. It indicated the oxygen saturation was rechecked 30 minutes later and Resident 1 was breathing room air. It also indicated the X-ray results for Resident 1 was received around 6:00 p.m. and the results were reported to the after-hours physician with an order from MD B to transfer Resident 1 to the emergency room in the acute hospital. On [DATE] at 8:00 p.m., Resident 1 was noted yelling for help and was complaining of SOB (shortness of breath). It also indicated Resident 1 had an oxygen saturation of 88% while on room air. Review of Resident 1's physician order, a late entry on [DATE] at 2:27 a.m., indicated an order to send Resident 1 to acute hospital emergency room from after-hours physician (MD B). During an interview with the registered nurse supervisor (RNS) on [DATE] at 3:44 p.m., the RNS stated LVN F told RNS about the X-ray results around 6:00 p.m. The RNS stated Resident 1 had a fracture and instructed LVN F to call the after-hours physician's office about the X-ray results. The RNS stated the after-hours physician's office called back with an order from MD B around 7:00 p.m. to send Resident 1 to the emergency room . The RNS stated she was not aware there was already an order to send Resident 1 to the emergency room from MD A. During an interview with LVN F on [DATE] at 10:20 a.m., LVN F stated she was the nurse in the afternoon shift for Resident 1 on [DATE]. LVN F stated she did not call the X-ray services to follow-up on the Stat X-ray results for Resident 1. LVN F stated she saw the X-ray results around 5:30 p.m. and called the after-hours physician's office between 5:,[DATE]:00 p.m. LVN F stated the after-hours physician's office called back around 7:00 p.m. with an order to send Resident 1 to the emergency room . LVN F stated she was not aware there was already an order to send Resident 1 to the emergency room if there was a fracture from MD A in the morning. LVN F stated she heard Resident 1 calling for help around 8:00 p.m. LVN F stated Resident 1 was complaining of pain and was having a hard time breathing. LVN F stated Resident 1 became unresponsive while LVN F and another staff member were repositioning Resident 1 in bed. LVN F stated Resident 1 was pronounced dead by paramedics (a specialist healthcare professional who studied emergency medicine and responds to calls for medical help outside of a hospital) on [DATE] around 8:30 p.m. During an interview with the LVN C on [DATE] at 12:55 p.m., LVN C stated she did not know about the physician's orders [REDACTED]. LVN C stated she signed that she noted the physician's progress notes on [DATE] but did not read the part about the transfer if there was a fracture. During a concurrent record review of the [DATE] progress notes for Resident 1 and interview with registered nurse M (RN M) on [DATE] at 1:50 p.m., the RN M stated the nurse should have carried out the plan of treatment in the progress notes as physician's orders [REDACTED]. RN M also stated Resident 1's progress notes was noted by a nurse which meant the treatment plan was carried out. During an interview with the MD A on [DATE] at 12:55 p.m., the MD A stated the treatment plan in the progress notes on [DATE] indicating to perform a Stat X-ray and to transfer Resident 1 if there was a fracture were physician's orders [REDACTED]. MD A stated he was not informed regarding Resident 1's low oxygen level in the afternoon after the fall on [DATE]. During an interview with the LVN F on [DATE] at 12:59 PM, the LVN F stated Resident 1 had an order for [REDACTED]. During an interview with certified nursing assistant K (CNA K) on [DATE] at 1:44 p.m., CNA K stated Resident 1 did not use oxygen when she worked with Resident 1 on [DATE] in the afternoon. CNA K stated Resident 1 died when she was on break and Resident 1 did not have oxygen on before she went to take her break. During an interview with RNS on [DATE] at 3:07 p.m., RNS stated LVN F did not inform her regarding Resident 1's low oxygen level at 5:30 p.m. RNS stated if a resident was having a low oxygen saturation level then the staff has to immediately administer oxygen and inform the doctor. During an interview with the assistant director of nursing (ADON) on [DATE] at 11:33 a.m., the ADON stated the licensed nurse would wait at least four hours for the Stat X-ray results. The ADON also stated the licensed nurse would need to follow-up with the X-ray company if the results have not come in by four hours. During another interview with the ADON on [DATE] at 1:44 p.m., the ADON stated there was no documentation the licensed nurses followed-up Resident 1's Stat X-ray results with the X-ray company. The ADON also stated there was no documentation LVN F administered oxygen to Resident 1 when Resident 1's oxygen saturation was 88% and confirmed LVN F documented reporting only the results of the Stat X-ray to the after-hours physician office. Review of the facility's policy and procedure, FALL PREVENTION PROGRAM dated [DATE], indicated the Licensed nurses will carry out doctor's orders and will implement any new orders immediately. Review of the facility's CONTRACT FOR SERVICES, with the radiology company under Responsibilities of Facility dated [DATE] indicated It is the Facility's sole responsibility to ascertain that the printer is checked often enough for the presence of printed reports, and that the printer is in working order, with sufficient paper, ink, toner, etc., and that the Facility has suitable personnel available to accept telephonic reports. It also indicated Similarly, Provider may not know and therefore could not be responsible for faxed or printed reports not being properly received, printed, or retrieved at the Facility, or telephonic reports that are not properly transcribed into the medical record of the resident or communicated to the attending physician. Review of the California Board of Registered Nursing (RN) website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated licensed nurse would implement necessary treatment ordered by and within the scope of the licensure of a physician. (http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=6.&article=2.) Review of Resident 1's Report of Autopsy dated [DATE], indicated Resident 1's cause of death was Hypertensive and [MEDICAL CONDITION] Cardiovascular Disease complicated by [MEDICATION NAME] Force Pelvic Injury due to Ground-Level Fall(s).

Based on interview and record review, the facility failed to consult and notify the physician regarding Resident 1's pain issues when Resident 1 had complained of moderate to severe pain after sustaining a fall on [DATE] at 10:30 a.m. and was administered only [MEDICATION NAME] (Tylenol, an over-the-counter pain medication) used for mild pain. This failure resulted in facility not resolving the moderate to severe pain of Resident 1. Findings: During an observation of the video surveillance on [DATE] and interview with the director of nursing (DON) on [DATE] at 2:38 p.m., certified nursing assistant I (CNA I) and Resident 1 was observed going in the shower room around 10:00 a.m. CNA I was observed leaving the shower room at 10:10 a.m. without Resident 1 and walked towards the nursing station. At 10:11 a.m., CNA I went back in the shower room followed by CNA J. At 10:15 a.m., CNA I was observed wheeling Resident 1 out of the shower room. At 10:15 a.m., Resident 1 and CNA I was observed entering Resident 1's room followed by licensed vocational nurse C (LVN C) and physician (MD A). The DON confirmed the observations. The DON stated Resident 1 had a witnessed fall in the shower with CNA I on [DATE] and was assessed by MD A and LVN C in Resident 1's room after the fall. A review of Resident 1's Order Summary Report indicated an order on [DATE] for [MEDICATION NAME] (Tylenol, an over-the-counter medication used for pain) tablet 650 milligrams (mg, a unit of measurement for weight) every four hours as needed for mild pain. (numeric pain scale: 0 = no pain, ,[DATE] = mild pain, ,[DATE] = moderate pain, and ,[DATE] = severe pain) Review of LVN C's Nursing - Fall Incident Report: Change of Condition, dated [DATE] at 3:30 p.m., indicated Resident 1 had a fall on [DATE] at 10:30 a.m. It also indicated Resident 1 had five out 10 pain level with facial grimacing and wincing. It indicated the new order of stat X-ray for the hip and spine was carried out. It did not indicate a new order for pain medication. Review of MD A's Physician's Progress Notes, dated [DATE], indicated Resident 1 had a fall in the bathroom while standing, hit her right buttocks and was complaining of pain in the right hip and low back/tailbone area. It indicated Resident 1 was seen and examined by the physician (MD A). It indicated Resident 1 was in pain with movement of the right hip joint and tender to palpation (touch) on the sacrum (lower backbone) area. It also indicated to give Tylenol as needed for pain control, bed rest, stat (emergency) X-ray (an image of the internal composition of something, especially a part of the body) of the hip and spine to rule out fracture, and to transfer Resident 1 to the emergency department if there was a fracture. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of LVN C's nursing progress notes, dated [DATE] at 4:05 p.m., indicated Resident 1 complained of pain to her right hip and buttocks and lower back area. It indicated Resident 1 was medicated as needed for pain management with minimal relief noted. Review of LVN F's Nursing - Change of Condition (Initial only), dated [DATE] at 2:32 a.m., indicated Resident 1 was received in the afternoon lying in bed with complaints of pain. It indicated Resident 1's complains of pain in pelvic (hip area) area persisted. It indicated Resident 1 was administered Tylenol 650 mg at 6:00 p.m. on [DATE] but did not indicate Resident 1's pain level. During an interview with LVN C on [DATE] at 2:59 p.m., LVN C stated MD A was in the facility at the time of the fall and was there to assess Resident 1 immediately after the fall on [DATE]. LVN C stated Resident 1's pain was about a level 8 out of 10 on the pain scale but the pain went down to level 6 out of 10 after administering medication at the end of morning shift on [DATE]. LVN C stated she did not call the physician regarding Resident 1's pain. During an interview with CNA K on [DATE] at 3:12 p.m., CNA K stated she was assigned to Resident 1 on [DATE] on the afternoon shift. CNA K stated she saw Resident 1 around 3:00 - 3:10 p.m. during her initial rounds. CNA K stated Resident 1's face was very pale and was in a lot of pain. CNA K stated Resident 1 had asked for a pain pill and stated she fell down in the shower. CNA K stated she called LVN F because Resident 1 was in a lot of pain. CNA K stated she checked Resident 1 every 30 minutes and Resident 1 was in pain the whole time and even refused dinner. During an interview with the registered nurse supervisor (RNS) on [DATE] at 3:44 p.m., the RNS stated that if Resident 1 had a level 8 out of 10 pain and there was only Tylenol for mild pain then the licensed nurse needed to call the physician for a stronger medication. RNS stated on [DATE] at 8:15 p.m., LVN F called her that Resident 1 became unresponsive. RNS stated Resident 1 did not have a pulse and was not breathing when she arrived in Resident 1's room to assess Resident 1. During an interview with LVN F on [DATE] at 10:20 a.m., LVN F stated she was the nurse in the afternoon shift for Resident 1 on [DATE]. LVN F stated Resident 1 was complaining of a lot of pain in the pelvic area at the beginning of the afternoon shift and wanted to be repositioned in bed. LVN F stated she did not reposition Resident 1 because she did not want to aggravate the area if there was a fracture. LVN F stated the LVN C gave Resident 1 pain medications at 2:00 p.m. LVN F stated she did not call the physician that the Tylenol was not relieving Resident 1's pain. LVN F stated she heard Resident 1 calling for help around 8:00 p.m. LVN F stated Resident 1 was complaining of pain and was having a hard time breathing. LVN F stated Resident 1 became unresponsive while LVN F and another staff member were repositioning her in bed. LVN F stated Resident 1 was pronounced dead by paramedics (a specialist healthcare professional who studied emergency medicine and responds to calls for medical help outside of a hospital) on [DATE] around 8:30 p.m. Review of the facility's policy and procedure, PAIN MANAGEMENT dated ,[DATE], indicated to notify the physician for a review of medications if pain is not relieved with current medications.

Based on interview, and record review, the facility failed to provide appropriate care and treatment for one of three sampled residents (Resident 1) when an identified pressure ulcer (skin injury caused by unrelieved pressure resulting in damage to the underlying tissues) of the right foot (1) had no treatment order obtained from the attending physician; (2) was not assessed by a nurse; (3) was not care planned; and (4) was left untreated for over a week. These failures resulted in Resident 1's right foot pressure ulcer evolving into a deep tissue injury (DTI, a localized area of pressure damaged underlying soft tissue.) Findings: Review of Resident 1's closed clinical record indicated he was admitted on [DATE] with the following Diagnoses: [REDACTED]. His Minimum Data Set (MDS, an assessment tool) dated 12/21/17, indicated he was at risk for developing pressure ulcers, had moderately impaired cognition (memory loss), and required extensive assistance for bed mobility and transfers. Resident 1's closed clinical record indicated he was conserved. Review of Resident 1's closed medical record indicated a stage 1 pressure ulcer to both buttocks and a stage 2 pressure ulcer in the coccyx area were healed on 1/3/18. Review of Resident 1's closed medical record indicated on 1/21/18, an identified open area on the right foot measuring 12 centimeters long, six centimeters wide and no depth. Review of Resident 1's care plan dated 1/21/18 indicated there was no evidence a care plan was initiated regarding Resident 1's right foot open area. Review of Resident 1's treatment administration record for 1/1/18 to 1/29/18 indicated no documentation for treatment of the right foot open area. Review of Resident 1's nursing notes dated 1/29/18 indicated Resident 1 was transferred to the hospital via ambulance due to shortness of breath and decreased response. During review of Resident 1's hospital record dated 1/29/18, Resident 1's physical examination indicated pressure ulcer to the right foot with surrounding [DIAGNOSES REDACTED] and central eschar and multiple chronic pressure ulcers both in the coccyx area. During an interview with licensed vocational nurse 2 (LVN 2) on 2/7/18 at 2:20 p.m., she stated a stage 2 right foot pressure ulcer identified on 1/21/18 was entered in the care plan as a skin tear. LVN 2 stated there was no treatment order obtained from the attending physician, no documentation of treatment administered and no care plan initiated regarding Resident 1's right foot open area. During an interview with registered nurse 1 (RN 1) on 2/8/18 at 2:25 p.m., she stated Resident 1 was admitted on [DATE] with a stage 1 pressure ulcer on both buttocks and a stage 2 in the coccyx. RN 1 stated these pressure ulcers were healed on 1/3/18. RN 1 stated there was no weekly skin assessment done. During an interview with the complainant (CMP) on 2/9/18 at 8:05 a.m., she stated Resident 1 came to the emergency roiagnom on [DATE], with pressure ulcers to the coccyx and on the right foot. In another interview with LVN 2 on 1/14/18 at 2:15 p.m., regarding the stage 2 pressure ulcer on the right foot, she confirmed there was no treatment order obtained from the attending physician, no documentation of treatment administered and no plan of care developed. LVN 2 stated there was no wound care referral done for Resident 1. During an interview and record review with the director of nursing (DON) on 2/14/18 at 2:40 p.m., she stated Resident 1's stage 2 pressure ulcer to the coccyx area was healed on 1/3/18. The DON stated she was unaware of pressure ulcers in Resident 1's coccyx area and right foot at the time of the hospital transfer on 1/29/18. Review of the facility's policy, Wound And Skin Management, dated 4/2013, indicated any resident who had a pressure sore will receive the necessary treatment and services to promote healing, prevent infections, and prevent new ulcers or sores from development. A licensed nurse will refer newly identified pressure ulcers to the interdisciplinary team (IDT, a group of healthcare professionals from different disciplines organized to do task together) for further assessment and care planning. The IDT and licensed nurse will assure care plans and progress notes reflect a resident's status and that appropriate interventions are implemented, documented and evaluated.

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of two residents (1) when the facility failed to provide a foot rest while transporting Resident 1. This resulted in a fall with injury. Resident 1 sustained a mildly displaced fracture of the cervical 1 vertebra (C1, neck). Findings: Resident 1 was admitted with [DIAGNOSES REDACTED]. The MDS (Minimum data set, an assessment tool) dated 5/14/17, indicated he had a BIMS (Brief interview of mental status) score of 4 (ranging from 0 to 15, 15 being alert and oriented). During an observation on 5/30/17 at 8:35 a.m., Resident 1 was seen in the hallway across from Nursing Station A sitting in his wheelchair with his feet on the floor wearing a pair of non-skid socks. During an interview with the activities aide (AA) on 5/30/17 at 9:05 a.m., he stated on 5/14/17 sometime after lunch, he assisted certified nursing assistant A (CNA A) in transporting Resident 1 to the bathroom for a brief (a protective adult undergarment used for incontinence) change. The AA was in the front of Resident 1 and saw Resident 1 had his feet on the ground. CNA A pushed the wheelchair forward and Resident 1 fell with his arms folded across his chest and hit his forehead on the floor. He stated Resident 1 was not using the foot rest at that time. During an interview with CNA A on 5/30/17 at 9:20 a.m., she stated she saw Resident 1 in front of Nursing Station 3 in a wheelchair requesting a brief change. CNA A requested the AA to assist with the transport. At the time of the transport, Resident 1 was seen leaning forward and his feet were on the ground. CNA A heard the AA yell, hey, hey, hey and saw Resident 1 fell from the wheelchair with his face landing on the floor first. Resident 1 ended up with a little bump on his forehead above his eyebrow. During an interview with the director of staff development (DSD) on 5/30/17 at 11:37 a.m., he stated he had given staff inservice on how to transport and/or assist residents in wheelchairs. Instructions included use of foot rests for all residents with mobility issues including muscle weakness. Foot rests are not required for residents who are able to lift their feet. During an observation on 5/30/17 at 11:45 a.m., Resident 1 was in the physical therapy (PT) room sitting in a wheelchair with a foot rest attached to the wheelchair. The physical therapist was doing passive foot lift exercises with Resident 1. Resident 1 was barely able to lift one foot at a time and with much difficulty. During a telephone interview on 6/2/17 at 9:00 a.m., the Rehabilitation Director (RD) stated Resident 1 was initially on physical therapy 8/16/13 and was discontinued from therapy on 9/28/13 with recommended 24 hour assist upon discharge from the facility. The RD also stated Resident 1 was again referred to PT on 5/18/17 after the fall. During a telephone interview on 6/2/17 at 1:08 p.m., the physical therapist stated Resident 1 had the tendency to lean forward and his leg position was always on knee flexion (bending the lower leg toward the back of the thigh). She stated with Resident 1's posture, use of a foot rest is highly recommended for safety purposes and to prevent falls. Record review of PT evaluation and plan of treatment dated 5/18/17, indicated Resident 1 was referred to PT due to a new onset of decrease in strength, reduced balance, reduced functional activity tolerance, and decreased postural alignment indicating the need for PT to promote safety awareness, enhance rehabilitation potential, increase functional activity tolerance, increase lower extremity range of motion and strength, and facilitate with all functional mobility. Initial assessments including prior level of function indicated maximum assist for wheelchair mobility and fixed position of muscle tone on both upper and lower extremities. Plan of care included passive range of motion (ROM) and gentle stretching of tight muscle on bilateral lower extremities (BLE). A review of the Nursing Fall Incident Report dated 5/14/17, indicated CNA A attempted to push Resident 1 to his room for a brief change. The moment CNA A pushed the wheelchair forward, Resident 1 fell forward hitting his head on the floor. Head to toe assessment was performed and a small bump was found on the left side of his head. Acetaminophen (analgesic used for pain relief) was given for pain scale (level of pain severity ranging from 0-10, 10 being the worst) of 3/10. The attending physician was notified and ordered to send Resident 1 to the hospital for a computerized axial tomography scan (CT scan - a form of diagnostic imaging) of the head. A review of the CT of the cervical spine diagnostic imaging report dated 5/14/17, indicated a mildly displaced fracture was present through the right posterior ring of C1 and a mildly displaced fracture was also noted through the left anterior ring of C1. During record review, the care plan for Resident 1 dated 5/30/17 indicated Resident 1 was a high risk for falls related to history of falls, depression, anxiety, incontinence, cardiovascular medication, diuretic use, poor safety awareness, impaired vision, decreased ROM, and [DIAGNOSES REDACTED]. According to Physical Medicine and Rehabilitation: Principles & Practice Volume 1 Fourth Edition, Lippincott Williams & Wilkins, The foot rest must provide sufficient support for the lower legs and feet and must hold the feet in proper position to prevent foot drop or other deformities. The feet must remain on the foot rest at all times during propulsion. Review of the facility's policy and procedure titled Fall Prevention Program dated 9/1/10, indicated that all residents' environment shall remain as free of accident hazards as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents.

Based on observation, interview, and record review, the facility failed to recognize and address hearing deficit issues for one of 26 sampled residents (21) when licensed nurses did not carry out the physician order [REDACTED]. This practice resulted in Resident 21's becoming emotionally upset and had loss interest in group activities. Findings: During the initial tour on 5/8/17 at 8:45 a.m., Resident 21 was lying in bed. During a concurrent interview, Resident 21 stated in a loud voice that he can't hear, while pointing to both of his ears. He stated the nurses keep his hearing aids and had requested staff to bring his hearing aids. During a follow-up observation on 5/8/17 at 1:40 p.m., Resident 21 was still not wearing hearing aids. He stated he likes watching television (TV) and live music and talking with other residents when he had his hearing aids on. During another observation on 5/9/17 at 8:20 a.m., Resident 21 was seen watching TV without his hearing aids. The TV sound could be heard in the hallway and at the nurses station. The TV volume was set at the maximum level of 100/100. Resident 21 stated he likes to watch the news in the morning and had asked staff to get his hearing aids. A review of Resident 21's clinical record indicated he was admitted with hypertension (high blood pressure), [MEDICAL CONDITION] (low red blood cell count), and cataract (eye disorder). His minimum data set (MDS, an assessment tool), dated 4/2/17 indicated he had no cognitive impairment but had severe hearing difficulty. There was a physician order, dated 7/13/15, to apply hearing aid in both ears in the morning and remove at bedtime. An inventory belongings form, dated 7/13/15, indicated he had bilateral hearing aids. A review of Resident 21's care plan entitled The resident has a communication problem related to poor hearing and indicated nurses were to make sure he wore bilateral hearing aids at daytime and removed at night. During an interview with the Minimum Data Set Coordinator (MDSC) on 5/10/17 at 3:09 p.m. she confirmed there was an inaccurate MDS assessment. The MDSC stated it did not reflect Resident 21's need of bilateral hearing aids. During an interview with Certified Nursing Assistant L (CNA L) on 5/9/17 at 8:20 a.m., she stated Resident 21 had hearing difficulty but she was not aware he had hearing aids. CNA L stated she would inform the nurse. During an interview with Licensed Vocational Nurse B (LVN B) 5/9/17 at 12:56 p.m., she stated Resident 21 had hearing aids. LVN B checked the medication cart and found few hearing aids that belonged to other residents but could not locate Resident 21's. During another observation on 5/10/17 at 7:32 a.m., Resident 21 was watching TV at a very loud volume. He was not wearing hearing aids. He stated he was very upset staff could not find his hearing aids. During an interview with LVN M on 5/10/17 at 8:15 a.m., she stated she had never seen the hearing aids since September of last year. LVN M went to look for Resident 21's hearing aids and found them in the treatment cart. During an interview with the Assistant Director of Nursing (ADON) on 5/10/17 at 8 a.m., she confirmed Resident 21 had a communication problem due to his hearing difficulty. The ADON stated she revised the care plan to include wearing bilateral hearing aids in the daytime and removed at bedtime. She was surprised licensed nurses were not implementing the care plan, as well as, carrying out physician order. The ADON stated no licensed nurses reported any hearing aids issue during their daily meeting or if the hearing aids were missing or broken. On 5/10/17 at 8:30 a.m., the ADON visited Resident 21 and tried to talk to him. Resident 21 stated, I can't hear you! while nodding his head sideways. Resident 21 looked very upset and frustrated. The ADON acknowledged Resident 21's frustrated and that he was not wearing his hearing aid. She walked towards the nurses station and spoke to LVN C. During an interview with LVN C on 5/10/17 at 1:50 p.m., Resident 21 had difficulty hearing. LVN C stated hearing aids should be place daily in the morning and remove at bedtime as care planned. LVN C stated he tried to apply bilateral hearing aids but neither were working. During an interview with the Social Services Assistant (SSA) 5/9/17 at 3:10 p.m., she stated that the social services department was responsible for following up with appointments on issues with hearing aids. The SSA stated they never received reports from licensed nurses that Resident 21's hearing aids were missing or broken. During an interview with the Social Services Director (SSD) on 5/11/17 at 8:40 a.m. she stated nurses should notify them if hearing aids were missing or broken so they can contact the audiologist (a hearing doctor) as soon as possible. During an interview with the Activities Assistant N (AA N) on 5/10/17 at 1:35 p.m., she stated Resident 21 used to attend special events like live music. She stated he was not attending group activities lately. AA N stated Resident 21 seemed to be withdrawn from group interaction. During an interview with AA O on 5/10/17 at 1:47 p.m., she stated Resident 21 had difficulty hearing. AA O stated she was not aware that he had hearing aids. During an interview with the Activities Director (AD) on 5/11/17 at 9:30 a.m., she stated Resident 21 used to attend special events like concerts. The AD reviewed the Activities Assessment, dated 4/3/17, it indicated Resident 21's activities plan was not modified to accommodate his hearing deficit and did not address Resident 21's use of hearing aids. During an interview with Director of Nursing (DON) on 5/11/17 at 1:55 p.m., she stated to ensure quality of life and quality of care, staff should address the needs of any hearing impaired residents including Resident 21. The DON stated licensed nurses should have communicated if Resident 21's hearing aids were missing or broken so they could address the issue. The DON stated licensed nurses should communicate the issue through their daily 24 hour report. Review of the facility's undated Twenty Four Hour Report policy indicated the form would, provide a communication system that will alert facility staff of changes in resident's condition and other important aspects of care and treatment. Review of the facility's undated Hearing Services policy indicated to ensure all residents have access to hearing services. All resident's hearing will be assessed upon admission and quarterly and will be referred as needed for a hearing evaluation.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and treatment for one of 26 sampled residents (Resident 5) when an identified pressure ulcer (skin injury caused by unrelieved pressure resulting in damage to the underlying tissues) of the left buttock was (1) unreported to Physician 1 (P1); (2) not fully assessed by a nurse; (3) not care planned in a timely manner; and (4) left untreated for over a week. Resident 5 also had Stage I and II pressure sores (a localized skin area of non-blanchable redness - usually over a bony prominence) on the left buttock. These failures resulted in Resident 5's left buttock pressure ulcer evolving into a deep tissue injury (DTI, a localized area of pressure damaged underlying soft tissue often viewable from the skin's surface as a purple or maroon discoloration). Findings: Review of Resident 5's clinical record indicated he was admitted on [DATE] with the following Diagnoses: [REDACTED]. His Minimum Data Set (MDS, an assessment tool) dated 5/31/17, indicated he was at risk for developing pressure ulcers, was cognitively impaired (memory loss), and required assistance for bed mobility and transfers. Review of Resident 5's Admission Data Collection tool, dated 1/30/17, indicated he had wounds on his scalp, right ear, and redness of the skin over his sacrum (a large triangular bone at the base of the spine). There was no documentation of pressure ulcers to the left buttock. Review of Resident 5's Braden scale (a tool that can be used to identify residents at-risk for pressure ulcer), dated 2/13/17, indicated he had a score of 11 (a score of 10-12 represents a high risk for developing pressure ulcers). Review of Resident 5's skin integrity care plan, dated 10/19/16, indicated he had the potential for impaired skin integrity related to fragile skin and a history of [MEDICAL CONDITION]. The interventions to prevent pressure ulcers included keeping his skin clean and dry. During an interview with certified nurse assistant D (CNA D) on 5/9/17 at 8:10 a.m., he stated he reported to the charge nurse before the week that Resident 5 had an open area on his buttock. During a wound care observation and interview with Treatment Nurse A (TN A) on 5/9/17 at 10:25 a.m., she stated Resident 5's left buttock had a facility acquired (developed during the resident's stay at the facility) DTI, a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed), and a Stage I pressure sore. TN A stated she was not previously aware of Resident 5's Stage II pressure ulcer to the left buttock and that it should have been treated to promote healing. TN A confirmed there was no daily treatment listed on the treatment administration record (TAR). During an interview with Licensed Vocational Nurse B (LVN B) on 5/9/17 at 1:45 p.m., she stated CNA D informed a treatment nurse about an open area on Resident 5's left buttock on 4/30/17. Review of Resident 5's treatment administration record (TAR), dated 5/2017, indicated no evidence of treatment for Resident 5's left buttock open area. Review of Resident 5's progress note, dated 4/30/17, indicated no evidence that Resident 5's left buttock open area was assessed by a licensed nurse or that the physician was informed of it. Review of Resident 5's pressure ulcer care plan, dated 4/30/17, indicated there was no evidence a care plan was initiated regarding Resident 5's left buttocks open area. During an observation and interview with licensed vocational nurse C (LVN C) on 5/10/17 at 8:10 a.m., Resident 5 wore a disposable brief soaked with dark yellow urine while he laid on his back. LVN C stated Resident 5's dispoable brief should not be soaked wit dark yellow urine since this would contibute to worsening skin issues. During an interview and record review with the Assistant Director of Nursing (ADON) on 5/10/17 at 10:35 a.m., she stated she was unaware of Resident 5's left buttock open area. The ADON confirmed, in regards to Resident 5's left buttock open area, there was: (1) no involvement by the interdisciplinary team (IDT, team composed of members from different departments involved in a resident's care); (2) no registered dietician (RD) referral; (3) no care plan; (4) no initiation of daily treatment; and (5) the physician was not informed. The ADON stated, in regards to Resident 5's left buttock, the licensed nurse should have assessed the wound, initiated a care plan, and informed the physician. The ADON stated that daily treatment to Resident 5's left buttock open area should have been started to prevent the wound from worsening. During an interview with P1 on 5/11/17 at 10:50 a.m., he stated he should have been informed of any changes to Resident 5's skin. He stated that when the left buttocks open area was identified, the licensed nurse should have addressed and treated it to prevent it from worsening. Review of the facility's policy, Wound And Skin Management, dated 11/2015, indicated any resident who had a pressure sore will receive the necessary treatment and services to promote healing, prevent infections, and prevent new ulcers or sores from development. A licensed nurse will refer newly identified pressure ulcers to the IDT for further assessment and care planning. The licensed nurse shall report any changes in a resident's condition to the attending physician. The IDT and licensed nurse will assure care plans and progress notes reflect a resident's current status and that appropriate interventions are carried out.

Based on observation, interview and record review, the facility failed to assess pain and offer a pain medication for one of 26 sampled residents (Resident 3) prior to the treatment of [REDACTED]. It can range from mild reddening of the skin to severe tissue damage and sometimes infection that extends into muscles and bones. The PU at stage 4, is a very deep injury, reaching into the muscle and bone, and causes extensive damage). This failure caused the resident to experience unnecessary pain and discomfort during the treatment. Findings: During an observation on 6/26/16, at 12 p.m., Resident 3 was in her bed and positioned on her right side with assistance by a staff member waiting for the dressing change. Resident 3 had a dressing at the sacral (base of the spine on the back) area. Licensed vocational nurse K (LVN K) started removing the dressing releasing a foul smelling odor and gauze from inside the wound. Resident 3 started making sounds. LVN K did not assess if Resident 3 was in pain or discomfort. She continued her treatment by cleaning the deep wound and packing it with gauze. During the procedures, Resident 3 said ouch several times. Resident 3's clinical record was reviewed. A review of the resident's Minimum Data Set (MDS, an assessment tool) dated 6/2/16, indicated the resident was cognitively intact. Review of Resident 3's care plan for the PU, initiated 2/26/16, indicated the resident had a PU at stage 4 and the goal was the resident to be free from complications, i.e., pain and discomfort. The intervention included to administer pain medication as needed. Review of Resident 3's physician orders [REDACTED]. It indicated to administer [MEDICATION NAME] (a pain medication) one tablet 50 mg for mild pain as needed. Review of Resident 3's Medication Administration Record [REDACTED]. During an interview on 6/26/16, at 1:05 p.m., LVN K stated she usually asked the charge nurse to administer a pain medication 30 minutes prior to Resident 3's treatment. LVN K stated she forgot to ask the charge nurse to administer Resident 3's pain medication on that day. LVN K admitted she did not assess Resident 3 for pain prior to or during the treatment. During an interview on 6/26/16, at 1:30 p.m., LVN X stated she was not always asked by the treatment nurse to administer Resident 3 a pain medication prior to the treatment. During an interview on 6/29/16 at 7 a.m., Resident 3 stated she was always in pain when she had a treatment on her wound, and it was very painful when she had the dressing change on 6/26/16. Review of Resident 3's pain assessment on the MAR indicated [REDACTED]. During an interview on 6/30/16 at 3:15 p.m. with the assistant director of nursing (ADON), the ADON confirmed Resident 3 should be assessed for pain and a pain medication should be administered 30 minutes before the resident had a treatment. Review of the facility's 4/13 policy Wound and Skin Management, indicated the licensed nurse will assess residents for pain related to pressure ulcer or the treatment.

Based on observation, interview, and record review, the facility failed to ensure nursing staff medically justified the continuing use of an indwelling catheter (a tube inserted into the bladder for urinary drainage), removed the catheter as ordered, and prevent a catheter related infection for one of 26 residents (Resident 10). These failures resulted in Resident 10 having an unnecessary indwelling catheter and catheter related urinary tract infection [MEDICAL CONDITION]. In addition, the facility failed to provide bladder training (a behavior therapy that can be effective in treating urinary incontinence (the involuntary loss or leakage of urine)) for one of 26 residents (Resident 4) to improve or maintain as much of his normal urinary function. This failure had a potential to miss opportunities to improve the resident's urinary continence. Findings: 1. During an observation on 6/26/16 at 12:10 p.m., Resident 10 had an indwelling catheter which was connected to a urinary bag with yellow urine drained in it. Resident 10's clinical record was reviewed. The resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident 10's physician orders, dated 5/6/16, indicated the resident had an indwelling catheter for urinary incontinence and it should be removed on 5/19/16. It further indicated bladder training should be done every two hours for 24 hours, prior to removal of the indwelling catheter on 5/18/16. Review of Resident 10's Treatment Administration Record (TAR), dated 5/2016, indicated the bladder training, prior to removal of the indwelling catheter, was performed for 2 hours, instead of 24 hours, and the indwelling catheter care was continued after 5/19/16 when the indwelling catheter was supposed to be removed. It further indicated registered nurse DD (RN DD) signed on the TAR indicating she removed the indwelling catheter. Review of Resident 10's Nursing-Daily Skilled Documentation, dated from 5/18/16 to 5/21/16, indicated the resident's indwelling catheter was intact and drained yellowish colored urine every shift although RN DD documented she removed the catheter on 5/19/16. Review of Resident 10's Nursing-Daily Skilled Documentation, dated 5/22/16, indicated the resident's indwelling catheter was clogged, licensed vocational nurse G (LVN G) removed it, and inserted a new indwelling catheter. Review of Resident 10's physician order [REDACTED]. Review of Resident 10's Nursing-Daily Skilled Documentation, dated from 5/23/16 to 6/5/16, indicated the re-inserted indwelling catheter remained. Review of Resident 10's Change of Condition, dated 6/5/16, indicated Resident 10 had hematuria (blood in urine). Review of Resident 10's care plans dated 6/5/16, indicated the resident had hematuria related to indwelling urinary catheter use. Review of Resident 10's urine culture (a urine test to find and identify germs that may be causing a UTI) result, dated 6/7/16, indicated the resident had a UTI with extended spectrum beta lactamase (ESBL, a type of bacteria). During an interview on 6/30/16 at 3:35 p.m., LVN G, who worked on 5/18/16, validated Resident 10's bladder training prior to removal of the indwelling catheter, was not complete as ordered. LVN G stated she was unaware Resident 10's indwelling catheter was supposed to be removed on 5/19/16 and she reinserted Resident 10's indwelling catheter on 5/22/16 because of the clog, not because of the [MEDICAL CONDITION]. LVN G stated the resident did not have the [MEDICAL CONDITION]. During an interview with LVN E on 6/30/16 at 4:30 p.m., she stated she was assigned to Resident 10 from 5/19/16 to 5/21/16 and Resident 10's indwelling catheter was not removed on 5/19/16 as ordered. During an interview with Resident 10's primary physician (PP) on 6/28/16 at 9:25 a.m., he stated the resident's urinary incontinence could not be an indication to use an indwelling catheter. The PP stated he ordered the bladder training for Resident 10 prior to the removal of an indwelling catheter to check whether the resident had [MEDICAL CONDITION] (the inability to completely empty the urinary bladder). The PP stated Resident 10 had a risk for UTI when the indwelling catheter was not removed. During an interview with the assistant director of nursing (ADON) on 6/29/16 at 12:30 p.m., she confirmed Resident 10's bladder training program was not provided as ordered by the physician. Review of the facility's 4/2010 policy, Catheter Care, Urinary, revised 4/2013 indicated a goal was to prevent unnecessary use of indwelling urinary catheter and prevent urinary tract infection. The clinical decision to use an indwelling urinary catheter should have a valid clinical indication, which includes [MEDICAL CONDITION] that cannot be treated or corrected medically and surgically and which alternative therapy was not feasible, pressure ulcer with urine impeded healing, and terminal illness or severe impairment. 2. Review of Resident 4's Bowel and Bladder Program Screener (a nursing form to assess a resident's bowel and bladder status) dated 2/29/16, indicated the resident was continent of bladder. Review of Resident 4's Bowel and Bladder Program Screener dated 5/16/16, indicated the resident was incontinent and to proceed to a bladder training program. Review of Resident 4's Bowel and Bladder Assessment Summary, dated 6/7/16, indicated the resident was totally incontinent of bladder and could not communicate the need for his voiding. It indicated the resident would not proceed for the bladder retraining. The evaluation was done by the director of staff development (DSD). During an interview with the ADON on 6/27/16 at 4 p.m., she reviewed Resident 4's Bladder Elimination (a documentation of certified nurse assistants in activities of daily living (ADL)) between 5/29/16 and 6/26/16. The ADON stated the resident had a pattern. The resident was continent during day times and incontinent at night. The ADON stated the resident needed bladder training at night for urinary incontinence. During an interview with the DSD on 6/27/16 at 4:25 p.m., he stated he did not review Resident 4's Bladder Elimination (ADL) and the resident needed bladder training for the night time. Review of the facility's policy Bowel and Bladder Management Program dated 5/13, indicated to ensure that residents entering the facility will remain continent unless the resident's clinical condition demonstrates that it is unavoidable. The licensed nurse is responsible for summarizing the outcomes of the data collected and for determining the type and causal factors of incontinence. The licensed nurse and the interdisciplinary care team (IDT, facility staff members from different departments who coordinate care provided to residents) will determine the best approach for interventions to meet the individual needs of the resident.

Based on observation, interview, and record review, the facility failed to adequately supervise and prevent accidents and injuries for two of 26 sampled residents (Residents 20 and 22). For Resident 20, she had a history of [REDACTED]. Resident 20 did not have needed assistance during ambulation and there were no new interventions implemented for two of her six falls. For Resident 22, there were no new interventions implemented for six of his 12 falls and the fall care plan was not revised to reflect the current interventions. These failures resulted in falls and a pelvic fracture for Resident 20 and had a potential for injury for Resident 22. Findings: 1. During an observation on 6/29/16, at 12:15 p.m., Resident 20 sat upright on her bed. Her legs were hanging out of the bed to the right side, wrapped in her blanket. Resident 20 was balanced at the edge of the mattress with her buttocks. The alarm unit for a bed pad alarm was hanging on the right upper half side rail. The unit was on, but no alarm sounded as Resident 20 tried to get up from her bed. Certified nurse assistant Y (CNA Y) was present and confirmed the alarm unit was on. CNA Y asked Resident 20 to stand up with her help. Resident 20 agreed and when she was lifted up, no alarm went off. During further investigation, the alarm pad was found under the bed sheet completely to the left outer side of the mattress. Resident 20 was not sitting on the pad. The unit manager who was present during this observation, confirmed the bed alarm pad was placed incorrectly and Resident 20 could have gotten up without the system's sound alarm. Resident 20's clinical record was reviewed. The resident had [DIAGNOSES REDACTED]. Review of Resident 20's Minimum Data Set (MDS, an assessment tool), dated 2/26/16, indicated the resident was cognitively impaired, had impaired balance, and required the assistance of one person for walking. A review of Resident 20's fall risk assessment, dated 3/15/16, indicated Resident 20 had a fall risk score of 65 (scores 45 and higher indicate high risk for falls). Review of the interdisciplinary team (IDT, team members from different departments involved in a resident's care) Post Fall Assessment, dated 7/7/15, indicated Resident 20 fell on [DATE] in the dining room and had a bump on the left side of her head. It indicated to place the resident closer to the activity staff to her prevent from getting up unassisted, continue with current fall interventions, and perform a neurological check (neuro check, assessment to determine nervous system function or brain injury) for 72 hours. There was no documented evidence the neuro check was performed and no new interventions were developed to prevent recurrent falls. Review of the IDT Post Fall Assessment, dated 7/20/15, indicated Resident 20 had a witnessed fall on 7/17/15 inside her room and hit her head. Resident 20 had a bump on her head. There was no nursing staff in the room with Resident 20 at the time of the fall. Review of the IDT Post Fall Assessment, dated 9/8/15, indicated Resident 20 had a witnessed fall on 9/6/15 while walking inside her room. Review of the IDT Post Fall Assessment, dated 9/14/15, indicated Resident 20 fell on [DATE] in the hallway while pushing a laundry hamper. She had a bump on her head. The IDT recommended a urinalysis and urine culture and sensitivity (UA/CNS, a urine test to determine if an infection is present) and a private caregiver at bedside. There was no result of the UA/CNS and no documentation of a neuro check available. There was no documented evidence the social service (SS) followed-up to provide a private caregiver. Review of the IDT Post Fall Assessment, dated 3/15/16, indicated Resident 20 fell on [DATE]. The resident spit at staff and lost her balance. She was transferred to an acute care hospital and returned to the facility with a [DIAGNOSES REDACTED]. A physician order, dated 3/15/16, indicated a medication order to start Cefidinir (an antibiotic) for UTI. The IDT note indicated the resident was unable to ambulate. A neuro check, dated 3/14/16 to 3/16/16, was not completed as scheduled. Review of the IDT Post Fall Assessment, dated 4/11/16, indicated Resident 20 was in the hallway sitting in a wheelchair and fell when she tried to get up unassisted on 4/10/16. A neuro check, dated from 4/10/16 to 4/12/16, was not completed as scheduled. Review of Resident 20's MDS, dated [DATE], indicated Resident 20 had not been walking in the hallway or in her room. During an interview with the assistant director of nursing (ADON) and the director of social services (DSS) on 6/30/16 at 2 p.m., The ADON reviewed Resident 20's fall incidents and stated IDT did not develop new interventions after the 7/7/16 fall incident to prevent another fall. The ADON stated Resident 20's UA/CNS were not done and the DSS stated she did not follow-up to have a private caregiver for Resident 20 as the IDT recommended after the 9/14/15 fall incident. During an interview on 6/30/16, at 2:05 p.m., licensed vocational nurse E (LVN E) stated Resident 20 was unable to walk the way she used to. LVN E stated Resident 20 used to walk around on her own before the pelvic fracture. LVN E stated she has not seen Resident 20 walking after the pelvic fracture. During an interview on 6/30/16, at 2:20 p.m., certified nurse assistant L (CNA L) stated Resident 20 used to walk alone before she broke her pelvis. After she broke her pelvis, she stayed in bed for a week and was unable to walk. CNA L stated the resident mostly sat in her wheelchair and could take up to five steps when walking. During an interview, on 6/30/16, at 2:55 p.m., the ADON stated Resident 20 should have had one person to physically assist her when she walked in her room or in the hallway. The ADON stated when Resident 20 fell on [DATE], there was no staff with her while she was walking. The ADON stated Resident 20 should be supervised while she was sitting in her wheelchair on 4/10/16. During a telephone interview, on 6/30/16, at 4:20 p.m., licensed vocational nurse M (LVN M) stated Resident 20 walked around with her wheelchair by herself. LVN M stated when Resident 20 fell on [DATE], she walked away from the station as staff followed behind her, but did not physically assist her. LVN M stated when Resident 20 turned around and spit at staff, she lost her balance and fell . During an interview, on 6/30/16 at 4:30 p.m., the DON and nurse supervisor D (NS D) confirmed the neurological checks on 3/14/16 and 4/10/16 were not done according to the neuro check schedule. NS D stated neuro checks should have been done every 15 minutes four times, every 30 minutes four times, every hour four times, every 4 hours four times, and every shift two times. Neuro checks were not done after the fall incidents on 7/6/15 and 9/12/15. During an interview, on 6/30/16 at 4:50 p.m., the DON stated when Resident 20 walked, staff walked with her, but did not physically assist her when walking on 3/14/16. 2. Resident 22's clinical record was reviewed. The resident had fall incidents 12 times on 10/24/15, 10/30/15, 10/31/15, 12/6/15, 12/10/15, 12/19/15, 2/1/16, 2/4/16, 3/24/16, 4/17/16, 6/2/16, and 6/3/16. During an interview with the assistant director of nursing (ADON) on 6/29/16 at 11:10 a.m., she reviewed Resident 22's fall incidents. The ADON stated when the resident fell , the IDT reviewed the current interventions and should revise or adjust them to prevent recurrences. The ADON stated the IDT did not adjust or add new interventions after six of 12 fall incidents which occurred on 10/30/15, 12/10/15, 12/19/15, 2/1/16, 2/4/16, and 3/24/16. The ADON stated the resident was not referred to a psychologist after the 12/19/15 fall incident and a urine test was not done after the 2/1/16 fall incident as the IDT recommended. The ADON reviewed Resident 22's fall care plan. She stated since 5/16, Resident 22 had a private caregiver, and it was not included in current fall interventions. The facility's policy Fall Prevention Program dated 9/1/10 and revised 3/21/14, indicated all residents will receive adequate supervision and assistive devices to prevent accidents. It indicated to complete neuro checks for a all unwitnessed falls or known head injuries. The IDT will complete a post fall assessment and will summarize findings and recommendation in the IDT progress notes. The IDT will review and revise care plans.

Based on observation,interview, and record review, the facility failed to provide adequate supervision to prevent 2 fall incidents from occurring for 1 of 26 residents (Resident 23). Resident 23 was identified as a high risk for falls after a fall on 02/16/12 and subsequently fell a second time on 11/25/12. Resident 23 sustained a left ulnar and radius (wrist) fracture from the second fall on 11/25/12. Findings: Resident 23 was admitted to the facility on [DATE] with current active [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had cognitive impairment with long term and short term memory problems and was rarely or never understood. The MDS also showed the resident required extensive and total dependence from facility staff with ADL's (Activities of Daily Living)including toileting needs for both bowel and bladder incontinence. Additionally, the resident was assessed to have impairment to both her lower extremities and therefore, was unsteady with gait and balance and required staff to assist with transfers and ambulation. The resident's mobility device was a wheelchair. The resident's "Fall Risk Evaluation" was scored between 10 to 18 from 02/17/12 to 11/25/12. The score is determined by nursing by evaluating the resident in eight clinical condition parameters (level of consciousness/mental status, history of fall past 3 months, ambulation/elimination status, vision status, gait/balance, systolic blood pressure, medications, and predisposing diseases) and if the total score is 10 or greater, the resident should be considered at high risk for falls and a prevention protocol should be initiated immediately and documented on the care plan. The resident's fall risk score after the fall on 02/16/12 was 10. On 11/15/12, one week before the second fall on 11/25/12, the score was 14, and then increased to 16 after the second fall incident on 11/25/12. The facility developed a fall risk care plan after the fall on 02/16/12 when the resident slid down her wheelchair and ended up on the wheelchair's footrest. The resident did not sustain an injury from this incident. The facility instituted the following interventions in their plan of care as a result from this fall: " Notify MD and RP (responsible party), observe resident for pain and/or complications from fall every 2 hours, pharmacy regimen med. review, review and revise LT (long term)care plan, refer to Physical Therapy as needed, Refer to Occupational Therapy as needed, fall assessment, bed pad alarm, wheelchair pad alarm, perimeter mattress, keep in supervised area when up in wheelchair or gerichair, resident unable to use call light anticipate needs". On the "Post Fall Assessment" dated 02/17/12, the IDT (Interdisciplinary Team) documented the following under "Review Safety Devices in Use or those Potentially in Need related to this occurrence": "Resident with pad alarm on bed and wheelchair to alert staff when getting up unattended. Will apply star sticker by name and door for falling star program". And under "IDT Notes/ Recommendations/ Targeted Plan to Prevent recurrence": " Resident alert, confused and disoriented. Unable to recall event prior to episode. IDT recommends Rehab.(Rehabilitation) to screen and eval. for use of pommel cushion on wheelchair to prevent sliding off chair...". On a second fall incident that occurred 11/25/12 at 2:57 PM, Resident 23 fell in the hallway outside her room and the events were captured on a recording from the facility's CCTV (close captioned television) installed on the ceiling near the resident's room in the hallway and the following was documented by the IDT team on 11/26/12 at 9:40 AM: "...Resident had an episode of fall on 11/25/12 3:05 PM. Resident was observed on the floor with her face down by house keeper. She immediately reported to LN (Licensed Nurse)... She has a laceration on the left forehead with bleeding. First aid applied and 911 called... Resident can't explain what happened... IDT checked camera on 11/26/12 noted at 11/25/12 2:57 PM. Resident opened her room's door and tried to walk towards nurse station with her pants is half down. Her right foot stopped on her pants and she fell forward face down...". On another IDT note dated 11/28/12 at 9:50 AM, the following was documented: "...Res. has history with falls with most current fall on 02/26/12. Interventions since then includes falling star, perimeter mattress, bed and W/C alarm. On the day of the event, it was observed, post event via CCTV, that resident had her room closed. Resident was observed to have opened her room and closed it behind her. As resident was standing on front of the room holding to the hand rails. Resident started to step forward and started to lose balance and fell to her left side... On observation with CCTV appeared that res. had sweat pants that was lose and may have contributed her fall. New intervention for this resident is to check size and fit of clothing to ensure proper fit and that it does not interfere with resident's ability to ambulate. Will also refer resident to therapy to screen for RNA (Restorative Nursing Assisitance) ambulation program". During an interview on 5/23/13 at 2:13 PM, Environmental Services staff (EVS)-1 stated that she remembered the fall event from 11/25/12. She was cleaning the shower room just a few doors down from the resident's room when she heard a "boom", like "someone or something falling", and she came out into the hallway and found Resident 23 face down on the floor next to the railing and wall near the resident's room. Then, EVS-1 called for help right away. EVS-1 cannot remember if she heard any alarms sounding off or not from the resident's room. During an interview on 5/23/13 at 12:30 PM, Licensed Vocational Nurse (LVN) -2 stated she was the charge nurse who took care of Resident 23 during the day shift on 11/25/12 and that she was very familiar with her. She had only heard of the fall via report because she had already gone home for the day when the incident occurred. LVN-2 stated Resident 23 did not have a history of attempts to get up on her own. LVN-2 stated the resident had an alert, oriented, and ambulatory roommate who liked their bedroom door closed and who also "kind of looked after (Resident 23". LVN-2 could not remember if she heard the resident's alarms sound toward the shift change from day shift to evening. She stated that the staff frequently checked on the resident during the shift. The care plan for falls dated 11/15/12 stated for "frequent checks" but did not specify how often. During another interview on 5/24/13 at 9:25 AM, the Assistant Director of Nursing (ADON),who took part in the main investigation of the 11/25/12 fall, stated the Resident 23's roommate was alert and oriented and was able to ambulate. The ADON confirmed that the roommate liked their bedroom door closed and was able to close the door on her own. The ADON did not interview Resident 23's roommate (Resident 24) for additional information about the fall. Of note, Resident 23's roommate was also identified as a high risk for falls with being on the falling star program and having a bed pad alarm as well. On a physician's note dated 02/17/12 during a hospitalization , it was noted that the roommate had a history of [REDACTED]. Asked why the issue of the residents' closed door was not part of the plan of care for either residents who were both at risk for falls nor why wasn't it considered as a possible environmental factor in the post fall assessment of the 11/25/12 accident, the ADON did not have an answer. Additionally, the ADON confirmed that the "Change of Condition" form was not marked to whether the resident's alarms were activated or sounded off or whether there was an alarm failure or device removal. The ADON could not remember if the alarm was evaluated and there was no evidence from the IDT documentation that showed that they considered this in their their post fall assessment. On a subsequent interview on 5/24/13 at 10:20 AM, the Rehabilitation Director stated that rehab screening is initiated by the nursing staff and does not require a physician's orders [REDACTED]. The screenings would be discussed during the daily stand-up meetings between the IDT team and then rehab would know when to initiate the assessments. Record review of Res. 23's 02/16/12 and 11/25/12 fall care plans showed screening was marked by nursing for rehab to evaluate Resident 23's post falls. Screening was also indicated and documented on the IDT notes dated 02/17/12 and 11/28/12. But there was no subsequent documentation from rehab to any follow up screening for either falls. The Director of Rehab stated that the rehab staff would document their screening after they are done with their assessments. The Rehab Director confirmed that there was no documentation to confirm that the assessments were done and she also confirmed that she did not have a signature to any of the IDT notes on 02/17/12 and 11/28/12 that would have indicated that she was involved in the IDT decision and discussion meetings. During an observation on 5/24/13 starting at 11:40 AM, Resident 23 was sitting in her wheelchair in the dining room area near her room. She was alert and pleasant and she was difficult to understand when this surveyor attempted to engage a conversation with her. Her wheelchair alarm was attached to her wheelchair and her shirt. This surveyor asked one of the staff to disarm the alarm so as to simulate how the alarm would sound if the resident attempted to stand up on her own. The staff detached the alarm cord from the resident and the alarm sounded off effectively and was very loud. Next, this surveyor evaluated the resident's pad alarm on her bed which was located in the "A-bed" closest to the door and asked another staff to demonstrate and simulate what would occur if the resident were to get up on her own. The staff sat on the bed and when she got up, the pad alarm sounded off effectively and was also very loud. The resident's bedroom door was open and a couple of nursing assistants were coming down the hallway to asses the alarm sounding off. The facility's undated policy and procedure titled, "Supervision of Resident Care", documented the following: " Purpose: To assure that the resident's safety and well being are maintained. Policy: All residents shall receive adequate supervision. Procedure: 1)Nursing staff shall check resident at least every 2 hours unless otherwise defined in the care plan. 2)Resident rounds shall include review of the environment for safety... and assessing needs...". The facility's policy and procedure, Policy #R600, titled, "Screening of Residents", effective date 5/2013, documented the following: " Policy: Resident will be screened by the rehabilitation department upon referral from nursing for possible therapeutic intervention. Procedure: 1)The rehabilitation department will be notified of all residents that have been determined to have had functional decline, be at risk for fall or who have had a recent fall. 2)The rehabilitation department will assess the extent of the decline, fall risk and/or fall from a comprehensive approach addressing such areas as: a. Balance control (including sensory input, cognition and medication), b. Musculoskeletal function, c. Gait deviations, d. Equipment needs, e. Environmental factors, (and) f. extent of functional limitations, 3)The rehabilitation department will request a physician order [REDACTED]. The facility's policy and procedure, "Fall Prevention Program", revised 3/29/13, documented the following: "Purpose: To Prevent Accidents by providing an environment that is free from hazards over which the facility has control. Policy: All residents' environment shall remain as free of accident hazard as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents... All residents shall be assessed for being at risk for falls. Any residents identified as "at risk" for falls shall have an individual plan of care that includes interventions to prevent falls from occurring, and a method for identifying residents at high risk (e.g. Falling Star Program). Procedure: ... 2. POST FALLS - d. Licensed Nurse will document all falls on the 24-hour report and document pertinent information related to the fall and condition of the resident on the Change of Condition-Falls Form... g. Following a resident's fall, the IDT (including Rehab if appropriate)will complete a post fall assessment within 24 hours or as soon as practicable. The assessment will include review of possible causal factors... j. The Licensed Nurse who is most familiar with the incident will initiate an investigation, interview staff, residents and/or visitors who may know some information related to the incident. The facility's undated, policy and procedure, "Care Planning/Interdisciplinary Team Care Planning Conference", documented the following: " To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions. Policy: All residents will have a comprehensive care plan to meet their individual needs that is prepared by an Interdisciplinary Team 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. Procedure: 4. The IDT members include but not necessarily limited to: g. Therapists as applicable, 8. Care planning shall include review of clinical issues,... coordination of care and management of resources".