Every finding on record at Sherwood Oaks Post Acute

Based on interview and record review, the facility failed to ensure residents were free and protected from abuse on one of one resident (Resident 6) per facility's policy and procedure, when an allegation of abuse was reported against a Certified Nurse Aid (CNA4). CNA 4 was not sent home but instead transferred to another area of the facility to continue working with care of other residents. This failure placed residents at risk for potential acts of abuse from the CNA. During an interview, on 6/9/26, at 2 p.m., with the Director of Staff Development (DSD), in the Director of Nursing (DON) office, the DSD stated that an allegation of abuse was reported CNA 2 on 6/8/26, at 12 p.m., involving CNA 4. The allegation was CNA 4 was brushing the hair of Resident 6 aggressively, roughly and hurriedly during care, at the same uttering profanities in Spanish in front of the resident and a fellow CNA. The DSD further stated, after the report from CNA 2 on 6/8/26, CNA4 was moved to another area of the facility away from Resident 6 and took care of other residents, until the end of the shift (7 a.m. - 3 p.m.). When DSD was asked why CNA 4 was not sent home instead, while the facility was initiating their investigation, the DSD had no response.During a review of the facility and policy (P&P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revision date September 2022, indicated, 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.During a telephone interview, on 6/10/26, at 8 a.m., with the facility Administrator (ADM), regarding the allegation of abuse against CNA 4 on 6/8/26, and of the CNA remaining in the facility while the investigation was ongoing. The ADM stated, facility staff did not follow/observe the facility P&P on abuse and abuse reporting. The ADM also concurred that any staff with allegations of abuse should be sent home/suspended pending investigation.

Based on interview and record review, the facility failed to ensure allegations of abuse was reported and investigated by staff on three of three residents (Residents 2,3, and1).This failure placed residents in harm's way, unmonitored abusive action by staff and non-implementation of abuse policy by facility. During a telephone interview conducted on 6/9/26, at 11:15 a.m., with Certified Nurse Aid (CNA 2), CNA 2 stated, while assisting CNA3, who had provided care to Residents 2,3,1, on three occasions, CNA3 was rough.For Resident 2 (CNA 2 could not remember the date of the incident) while CNA 3 was changing the shirt of Resident 2, the resident who was nonverbal cried out in pain. CNA 2 stated, witnessing CNA3 grabbing Resident 2's nape (back of neck) roughly and forcibly thrusted the neck and head forward, while changing the resident's shirt. CNA 2 reprimanded CNA 3 of the resident's rough handling but did not report the incident witnessed.For Resident 3 who is non-verbal and is cognitively impaired (CNA 2 does not remember the time of the incident), CNA 3 roughly turned Resident 3, from side to side during care. The resident who was nonverbal making grunting sounds. CNA 2, stated, the said incident was reported to Registered Nurse (RN2).CNA2 further stated on 6/7/26, at 5:30 a.m. to 6 a.m., CNA 3 was rendering peri care (private area) to Resident 1, and CNA 3 forcibly, aggressively, and roughly separated /spread Resident 1's legs and the resident cried out. CNA 2 reported the witnessed incident to RN 1.During an interview, on 6/9/26, at 7:30 a.m., RN 1 at the nursing station, RN 1 stated on 6/7/26, at approximately 5:30 a.m. to 6 a.m. CNA 2, reported witnessing CNA 3 aggressively, forcibly and roughly, separated/spread Resident 1's legs apart during care. when providing care. RN1 did not indicate starting an investigation of the reported incident. During a telephone interview, on 6/10/26, at 11:30 p.m., with RN 2, RN 2 confirmed on 6/5/26, CNA 2 reported, witnessing CNA 3 roughly turning Resident 3 from side to side during care and the resident who was nonverbal was making grunting sounds. RN 2 stated not reporting the incident to the facility's abuse coordinator (Administrator/designee). RN 2 further stated, the incident reported by CNA 2 was considered abuse and not being familiar with the facility abuse policy and procedure (P&P) and protocol on abuse reporting when there was an allegation of abuse.During a review of the facility and policy (P&P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revision date September 2022, indicated, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled resident's (Resident 100) medications were secure and inaccessible to unauthorized staff and residents.This failure had the potential to cause medication errors, including residents ingesting incorrect medications.Findings:During an initial tour observation on 5/18/26, at 6 a.m., in room [ROOM NUMBER] A, a 3-ounce Antifungal Powder, a 59 ml. (milliliter) Body Lotion, and an unlabeled plastic cup in a kidney basin with an unidentified substance was observed on Resident 100's bedside table.During a concurrent interview and record review on 5/18/26, at 11 a.m., with the Assistant Director of Nursing (ADON), ADON reviewed Resident 100's electronic Medical Record (eMR) for Resident 100's Self-Administration Assessment (an evaluation by an interdisciplinary care team to determine if a resident can safely and accurately manage and take or apply their own medications). The ADON confirmed Resident 100 did not have a Self -Administration Assessment on file in her eMR and should not have any kind of medication(s) with her or in her room.During an interview, on 5/21/26, at 12:45 p.m., with licensed nurse (LN 1), LN 1 said medications should not be left at resident's bedside and all medications should be kept in the medication cart.During an interview, on 5/21/26, at 2:05 p.m., with the Director of Nursing (DON), DON stated, Medications are not allowed to be left in the resident's rooms.During a review of the facility policies and procedures (P&P) titled, Self-Administration of Medications, revision date February 2021, indicated, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident and 9. All medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.

Based on observation, interview, and record review, the facility failed to ensure safe food handling practices by not labeling resident food items stored in the resident refrigerator with the resident's name and the date of opening.This deficient practice created a potential risk for foodborne illness due to the inability to determine food ownership and product freshness.Findings:During an observation conducted on 5/19/26 at 10:30 a.m. of the resident refrigerator located in the clean linen room, three food items were found without resident identification or labeling. The unlabeled items included:One 64 oz bottle of [NAME] French Vanilla Coffee CreamerOne 32 oz bottle of International Delight Coffee CreamerOne 52 oz carton of Plant Oat OatmilkDuring an interview on 5/19/26 at 10:35 a.m., with Infection Preventionist (IP), IP confirmed resident information was not placed on the 3 items and verbalized, the items were brought in by residents' families and should have been labeled with the resident's name.During an interview on 5/19/26 at 11:20 a.m., with Administrator (ADM), ADM verbalized, all items stored in the refrigerator are required to include resident information.During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, dated March 2022, P&P indicated that perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator, and that containers must be labeled with the resident's name, the item, and the use by date.

Based on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice when:Facility staff were unaware a Bilevel Positive Airway Pressure (BiPAP or BPAP - a non-invasive ventilator used to assist breathing by delivering pressurized air through a mask using a higher pressure level for inhalation and a lower pressure level for exhalation, to improve oxygen levels and reduce carbon dioxide) was beeping/alarming (alarm was not audible) and not delivering the prescribed therapeutic effect in one of two residents (Resident 1).Facility did not have an operator manual onsite or readily accessible to refer for troubleshooting guidance for an alarming BiPAP.Oxygen flow rate was not accurately set to administer oxygen as ordered by the physician (MD) in two of three residents (Resident 2 and Resident 3).MD orders for oxygen administration were unclear and inaccurate in one of three residents (Resident 1).Facility failed to follow its own policy documentation requirements for General Assessment. These failures have the potential to place residents at risk for unattended breathing difficulty which can result in further compromised conditions and adverse health outcomes.1.During review of Resident 1's admission Record (AR), dated 4/2/26, the AR indicated Resident 1 was admitted to the facility with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation (worsening of respiratory symptoms such as difficulty breathing, chronic cough, and/or an increase in the volume and/or thickness of milky or foul-smelling sputum that results in needing additional therapy), acute and chronic respiratory failure with hypoxia (a failure of the lungs to adequately oxygenate the blood), and facioscapulohumeral muscular dystrophy (a genetic muscle disorder that causes progressive wasting or thinning of muscles in the face, shoulder blades, and upper arms). Resident 1's brief interview of mental status score (BIMS - a measurement of cognitive abilities that ranges from 0 to 15 with scores of 13-15 classified as having no significant cognitive impairment) was 15. During a concurrent observation and interview on 4/6/26 at 2:54 p.m. with Resident 1, the front of the BiPAP machine was facing the wall with the back of the machine facing the resident's right side. The BiPAP was displaying a message that indicated Attention: Leak detected, check your system setup and all connections. There was no audible beeping sound. Resident 1 stated the BiPAP beeps when there is an air leak. Resident 1 stated being unaware the BiPAP was displaying a leak detection message at that time. Resident 1 acknowledged not being able to hear the beeping sound. The attention message displayed non-stop for approximately 15-20 minutes with no staff awareness or intervention. During a concurrent observation and interview on 4/6/26 at 3:25 p.m. with Licensed Nurse (LN 1) inside Resident 1's room, LN 1 was asked to verify the BiPAP monitor. LN 1 said the BiPAP was leaking a little. LN 1 stepped out of the resident's room to get Registered Nurse (LN 2) to troubleshoot the BiPAP alarm. During a concurrent observation and interview on 4/6/26 at 3:36 p.m. with LN 2, LN 2 re-adjusted Resident 1's BiPAP face mask. The face mask was removed and reapplied, and the face mask straps were adjusted, however, the BiPAP continued displaying a leak warning with no audible beeping sound. LN 2 acknowledged the BiPAP was displaying a leak warning with no audible beep to alert the resident or staff. During an interview on 4/7/26 at 12:30 p.m. with Respiratory Therapist (RT), RT stated the alarms are intended to inform staff when there are issues with the BiPAP's function. RT stated that a resident may not be receiving the prescribed therapeutic dose if frequent leak detection alarms go unattended by staff. During a concurrent observation and interview on 4/7/26 at 2:02 p.m. with Director of Nursing (DON) and Respiratory Therapist (RT), inside Resident 1's room, the BiPAP settings were verified. RT indicated the audible alarms (beep/beeping) were enabled and functioning. DON acknowledged the BiPAP alarms were hard to hear with the facility background noise. 2. During a concurrent observation and review on 4/6/26 at 4 p.m., Resident 1 was observed on oxygen via nasal cannula and no longer using the BiPAP. Review of Resident 1's Order Summary (OS), dated 4/2/26, indicates in part, BiPAP via face mask with oxygen at 2 liters per minute (LPM) on every 1 p.m. and off every 5 p.m. total of 5 hours of treatment. During an interview on 4/6/26 at 4:06 p.m. with LN 2, LN 2 was asked why Resident 1 was not on the BiPAP as ordered by the physician. LN 2 stated the BiPAP kept displaying an air leak was detected that could not be resolved after readjusting the face mask multiple times. LN 2 stated the BiPAP supplier was contacted for troubleshooting guidance and was waiting for a return call. LN 2 was asked for the BiPAP operator's manual but instead LN 2 provided the manual for the BiPAP face mask. LN 2 stated the operator manual was not inside Resident 1's room. During an interview on 4/7/26 at 9:45 a.m. with Director of Nursing (DON), DON stated the facility should have an operator manual available so staff can refer to for use and troubleshooting. DON acknowledged the facility did not have an operator manual for Resident 1's BiPAP. Review of facility policy and procedure (P&P) titled, CPAP/BiPAP Support, dated March 2015, indicates in part, Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery. 3. During an observation inside Resident 3's room on 4/7/26 at 11:20 a.m., Resident 3's oxygen concentrator was set at 1.5 LPM. During a concurrent observation and record review on 4/7/26 at 11:30 a.m. with Registered Nurse (RNS) inside Resident 3's room, RNS acknowledged Resident 3's oxygen concentrator setting was set at 1.5 LPM. Subsequently, RNS verified Resident 3's oxygen order in the electronic medical system and said, it should be set at 2 LPM. Review of Resident 3's oxygen order, dated 3/1/26, indicates in part Routine oxygen inhalation at 2 LPM via nasal cannula every shift. During an observation inside Resident 2's room on 4/7/26 at 12:14 p.m., Resident 2's oxygen concentrator was set at 3.5 LPM. During a concurrent observation and record review on 4/7/26 at 12:14 p.m. inside Resident 2's room with Licensed Nurse (LN 3), LN 3 was asked to verify Resident 2's oxygen concentrator setting. LN 3 slightly bent over to look at the oxygen concentrator and said it was set at 4 LPM. LN 3 was asked to get at eye level and read the setting again. LN 3 acknowledged it was at 3.5 LPM. During review of Resident 2's oxygen order, dated 10/9/25, LN 3 acknowledged the order is for 4 LPM. Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe the orders are in error or would harm clients. 4. During a concurrent interview and review on 4/7/26 at 12:21 P.M., with Licensed Nurse (LN 5). LN 5 stated being assigned Resident 1 on 4/6/26 but did not recall the resident being on the BiPAP in the afternoon. LN 5 stated that Resident 1 did not need to be on BiPAP during the hours of 1 p.m. to 5 p.m. LN 5 reviewed Resident 1's OS and indicated the physician orders for the BiPAP and oxygen were unclear. During a concurrent interview and record review on 4/7/26 at 2:02 p.m. with Director of Nursing (DON), Resident 1's oxygen and BiPAP orders, dated 4/2/26 were reviewed. The orders indicated the following: Routine oxygen at 2 LPM via nasal cannula when not on BiPAP. BiPAP via face mask with oxygen at (2 LPM) on every 1 p.m. and off every 5 p.m. total of 5 hours of treatment.remove per schedule. BiPAP via face mask with oxygen at (2 LPM) on every 8 p.m. and off every 8 a.m. total of 12 hours of treatment.and remove per schedule.DON stated the orders were clear and that Resident 1 should be without oxygen or BiPAP during 5 p.m. - 6 p.m. DON was asked why the oxygen order indicated routine oxygen.when not on BiPAP , DON re-stated the resident should be without oxygen or BiPAP between 5 p.m. to 6 p.m. during dinner time. DON contacted the ordering physician via telephone on 4/7/26 at 2:31 p.m. to clarify the order. The physician stated that Resident 1 should be on the BiPAP everyday 1 p.m. - 5 p.m. and again 8 p.m. - 8 a.m. AND be on 2 LPM of continuous oxygen for 24 hours. During a concurrent interview and review on 4/7/26 at 2:35 p.m. with Licensed Nurse (LN 6), Resident 1's oxygen and BiPAP orders, dated 4/2/26 were reviewed. LN 6 acknowledged entering the oxygen order at 2 LPM for 1 p.m. to 5 p.m. instead of 1 p.m. to 6 p.m. Review of [NAME] and [NAME], seventh Edition, Mosby's Fundamentals of Nursing, page 336 in the section titled, Physician's Orders indicates, Nurses follow physician orders unless they believe the orders are in error or harm clients. Therefore, you need to assess all orders, and if you find one to be erroneous or harmful, clarification from the physician is necessary. 5. During an interview on 4/7/26 at 2:40 p.m. with DON, the DON was asked for documentation on general assessments prior to BiPAP procedures. The DON could not provide the requested documentation. During a review of the facility's policy and procedure (P&P) titled, CPAP (a continuous positive airway pressure device that uses mild air pressure, delivered through a mask, to keep the airways open)/BiPAP Support, dated March 2015, the P&P indicates in part, Document the following in the resident's medical record:1. General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure;2. Time CPAP was started and duration of the therapy;3. Mode and settings for the CPAP/IPAP (inspiratory positive airway pressure - a setting in the BiPAP that provides higher air pressure during inhalation to assist breathing, help open airways, increase oxygenation, and reduce breathing effort)/EPAP (expiratory positive airway pressure - a small nasal devices that creates resistance when breathing out);4. Oxygen concentration and flow, if used;5. How the resident tolerated the procedure; and6. Oxygen saturation during therapy.

Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when a nebulizer mask (a medical device worn over the nose and mouth to deliver liquid medication directly into the airways as a fine mist) used for breathing treatments was not stored in a manner to maintain hygiene and prevent contamination in one of three residents (Resident 1). This facility failure had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact a resident's health and safety and cause preventable HAIs (Healthcare Associated Infections) for a resident in an already compromised condition During review of Resident 1's admission Record (AR), dated 4/2/26, the AR indicated Resident 1 was admitted to the facility with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation (worsening of respiratory symptoms such as difficulty breathing, chronic cough, and/or an increase in the volume and/or thickness of milky or foul-smelling sputum that results in needing additional therapy), acute and chronic respiratory failure with hypoxia (a failure of the lungs to adequately oxygenate the blood), and facioscapulohumeral muscular dystrophy (a genetic muscle disorder that causes progressive wasting or thinning of muscles in the face, shoulder blades, and upper arms). Resident 1's brief interview of mental status score (BIMS - a measurement of cognitive abilities that ranges from 0 to 15 with scores of 13-15 classified as having no significant cognitive impairment) was 15. During an observation on 4/6/26 at 2:54 p.m., Resident 1's nebulizer mask and tubing were observed on a shelf, uncovered. During a review of Resident 1's Medication Review Report (MRR) dated 4/6/26, the MRR indicated ipratropium-albuterol inhalation solution (inhaled medication used to relaxing muscles in the airways to improve breathing) orally via nebulizer (machine that converts liquid medication into a fine mist (aerosol) for direct inhalation into the lungs and respiratory tract using a machine called a nebulizer) 3 mg (milligrams - a unit of mass or weight)/3 mL (milliliters - a measure of volume) every two hours as needed for chest congestion. During a concurrent observation and interview on 4/6/26 at 3:25 p.m. inside Resident 1's room with Licensed Vocational Nurse (LN 1), LN 1 acknowledged the nebulizer equipment (tubing and nasal mask) were on the shelf, uncovered, and not properly stored per the facility's policy. During a review of the facility's policy and procedure (P&P) titled Departmental (Respiratory Therapy) - Prevention of Infection, dated February 2026, the P&P indicates in part, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, among residents and staff. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use.

Based on observation, interview and record review, the facility failed to ensure a shower room was sanitary and in good repair.This failure had the potential to violate Residents rights to receive care in a safe, clean and homelike environment. During a concurrent observation and interview, on 7/31/25, beginning at 12:55 p.m., with the Maintenance Director (MTD 1), a shower room located in hallway four was inspected. In the shower room, the shower doorframe was in a state of disrepair, the wall had broken tiles, the call light cord was broken and had been replaced with plastic bags in lieu of replacing the cord, a bottle of lotion was stored atop a dirty sharps container and a used razer was stored in a plastic cup atop a box of clean gloves. The MTD 1 confirmed and verbalized the doorframe was in a state of disrepair, there were broken tiles, the call light cord needed to be replaced, staff had stored a lotion bottle atop a dirty sharps container and a dirty razer was stored atop a box of clean gloves. During a review of the facility's policy and procedures titled Homelike Environment dated 2/21, indicated in part Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary and orderly environment.

Based on observation, interview and record review the facility failed to adhere to its policy and procedure for foods brought in by family and visitors. This failure had the potential for Residents to consume spoiled food and to experience negative outcomes.During a concurrent observation and interview, on 7/31/25, at 1:21 p.m., with the Infection Preventionist (IP 1), the resident refrigerator was inspected. Inside the resident refrigerator was a unlabeled and undated plastic bag containing a head of lettuce which had partially turned brown and two unlabeled and undated half eaten sandwiches in plastic containers. The IP 1 confirmed the observations and verbalized the resident food items should have been labeled with a resident's name and date. When asked how long these items had been in the resident refrigerator the IP 1 could not give a definitive answer but did verbalize facility practice was to clean out the refrigerator once a week on Friday's.During a review of the facility's policy and procedure titled Foods Brought by Family/Visitors dated 3/22, indicated in part Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date.The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger.

Based on observation, interview, and facility policy review, the facility failed to post the State Survey Agency contact information and a statement regarding a resident's right to file a complaint with the State Survey Agency. This failure had the potential to affect all 94 residents who resided at the facility. Findings included: A facility policy titled, Federal Posting Policy, version 05/2024, revealed, This policy ensures compliance with federal posting requirements for skilled nursing facilities. The facility will prominently display all federally mandated notices to inform employees, residents, and visitors of their rights and protections under federal law. This policy applies to all required postings in publicly accessible areas of the facility. The policy revealed that 1. Required Postings: included, A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with advance directive requirements. An observation on 02/05/2025 at 12:36 PM of the facility's bulletin board, located on the wall beside the nurses' station, revealed no evidence of a posting or statement that outlined the resident's right to file a complaint with the state survey agency. During interview on 02/05/2025 at 12:40 PM, Resident #32 (who had a Brief Interview for Mental Status [BIMS] score of 12, which indicated the resident had moderate cognitive impairment, per an admission Minimum Data Set [MDS] assessment, with an Assessment Reference Date [ARD] of 01/21/2025), stated they did not know whether they could file a complaint with the state agency about care at the facility. The resident stated they had not seen a posting or information with the state survey agency's contact information. During an interview on 02/05/2025 at 12:51 PM, Certified Nursing Assistant (CNA) #1 stated she was not aware of a posting in the facility with information on how a resident could file a complaint with the state survey agency. During an interview on 02/05/2025 at 1:08 PM, the Director of Nursing (DON) stated if a resident had a complaint, they should complete a grievance form. The DON revealed there was no posting or information in the facility with the state survey agency's contact information or the residents' right to file a complaint. During a follow-up interview on 02/05/2025 at 2:46 PM, the DON stated she expected the facility to post all required information. During an interview on 02/06/2025 at 1:51 PM, the Administrator stated the facility reviewed to ensure everything was posted, monthly. He stated, Obviously we haven't done a good job with that. The Administrator said it was his expectation that all required data was posted.

Based on interview, record review, and facility document and policy review, the facility failed to report a resident-to-resident abuse allegation to the State Agency within two hours of an incident for 2 (Resident #7 and Resident #39) of 3 residents reviewed for abuse. Specifically, on 01/27/2025, the police responded to the facility after Resident #39 reported that Resident #7 bumped into their wheelchair, then bumped the resident's knee. The facility Social Services Director (SSD) documented that she and the Administrator had a conversation with Resident #7 on 01/30/2025 about harassment of Resident #39; however, there was no documented evidence the facility notified the State Agency of a resident-to-resident abuse allegation until 02/05/2025. Findings included: A facility policy titled, Abuse Prevention, dated 12/31/2015, indicated, 1. All health practitioners and all employees in a long-term healthcare facility are mandated reports [sic] (Welfare and Institutions Code, Section 15630, Appendix IV). 2. Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, isolation, financial abuse, or neglect, or is told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, isolation, financial abuse or neglect, or reasonably suspects abuse shall report known or suspected abuse. The policy revealed, 5. First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. 6. Any employee who suspects an alleged violation shall immediately notify the Administrator or designee. 7. The Administrator shall report all alleged or suspected violations to the appropriate state agencies immediately or within 24 hours (California H&S [Health and Safety] Code 1418.91a) and Vice-President of Operations. Resident #39's Admission Record indicated the facility admitted the resident on 06/05/2019. According to the Admission Record, the resident had a medical history that included diagnoses of depression, other abnormalities of gait and mobility, and diffuse traumatic brain injury with loss of consciousness of unspecified duration. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #39 had utilized a walker and a wheelchair during the assessment look-back period. The MDS revealed the resident had no behavioral symptoms during the assessment look-back period. Resident #39's Care Plan included a problem statement initiated 02/04/2025, that indicated the resident was at risk for emotional distress due to an alleged disagreement with another resident. Interventions (initiated 02/04/2025) directed staff to divert the resident's attention to pleasant thoughts, encourage the resident to participate in activities of choice, encourage the resident to verbalize feelings, notify the medical doctor of any significant changes, and obtain a psychiatric consultation as ordered by the physician. Resident #7's Admission Record indicated the facility admitted the resident on 11/06/2021. According to the Admission Record, the resident had a medical history that included diagnoses of chronic pain syndrome, bipolar disorder, anxiety disorder, unsteadiness, and muscle weakness. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #7 had utilized a walker and a wheelchair during the assessment look-back period. The MDS revealed the resident had no behavioral symptoms during the assessment look-back period Resident #7's Care Plan included a problem statement initiated 02/04/2025, that indicated the resident was at risk for emotional distress due to an alleged disagreement with another resident. Interventions (initiated 02/04/2025) directed staff to monitor interactions between the resident and the other party involved observe the resident for signs and symptoms of emotional distress, obtain a psychiatric consultation for further assessment and intervention, offer emotional support and reassurance, report to the medical doctor and document any signs of distress or further incidents, and separate the residents if necessary to prevent escalation. Resident #7's Social Service Note, dated 01/29/2025 at 1:22 PM, indicated the Social Services Director (SSD), Administrator, and Administrator in Training spoke with Resident #7 regarding claims that Resident #39 accused the resident of harassment. Per the note, Resident #7 stated that they had not harassed Resident #39 or any other resident of the facility and stated that Resident #39 was harassing them (Resident #7). The note revealed the SSD told Resident #7 that moving forward, they should not look at, have a conversation with, or interact with Resident #39 and that the SSD would contact the Ombudsman regarding the matter. A facility Report of Suspected Dependent Adult/Elder Abuse, dated 02/04/2025, revealed the facility reported to the State Agency that there was an alleged verbal disagreement between Resident #7 and Resident #39 and there was no physical injury. An addendum letter sent to the State Agency on 02/05/2025 revealed the incident occurred on 01/27/2025 at 4:40 PM. During an interview on 02/03/2025 at 1:56 PM, Resident #39 stated that the week prior, they were speaking with the Social Services Assistant (SSA), and they did not want to talk in the open because there were too many nosy people. Resident #39 stated that afterward, Resident #7 bumped into their wheelchair, then bumped their knee and said, You're not God. There's only one God. Resident #39 stated they were not hurt. According to Resident #39, they called 911 on 01/27/2025 at 7:55 PM about the incident. During a follow-up interview on 02/04/2025 at 10:31 AM, Resident #39 stated Resident #7 had never hurt them, but they still felt unsafe because they (Resident #7) want to start something with me and I never know what [Resident #7's] going to do next. During an interview on 02/05/2025 at 11:38 AM, Resident #69 stated Resident #7 bumped into Resident #39's chair. According to Resident #69, it was intentional, because Resident #7 changed their trajectory to do it. Resident #69 stated that staff were around, and they separated the residents. During an interview on 02/05/2025 at 12:37 PM, Resident #7 stated they did not bump into Resident #39's chair and stated, Check the cameras. Resident #7 also insisted that Resident #39 was bullying them. On 02/06/2025 at 11:05 AM, an attempt was made to contact Deputy #21, and the deputy was not on duty. During a telephone interview on 02/09/2025 at 11:55 PM, conducted after the survey exit date, Deputy #21 stated she responded to a call from the facility on 01/27/2025. Per the deputy, Resident #39 stated they were talking with a social worker, which halted the games residents were playing. Per the deputy, Resident #39 stated this made Resident #7 mad, and Resident #7 began staring down at Resident #39. Deputy #21 stated Resident #39 reported that several hours later, Resident #7 bumped into Resident #39's walker while Resident #39 was eating and said something like, Only God can judge you. Per Deputy #21, the incident did not meet the legal criteria for any type of elder abuse, crime, or threat, which was what she told the facility when she exited. She stated she completed an internal document, not a police report. She stated a week later, the facility requested a report, and she wrote a courtesy report. During an interview on 02/06/2025 at 12:10 PM, the SSA stated she first became aware of an incident on Wednesday (01/29/2025). Per the SSA, the sheriff's office came in on Monday night (01/27/2025). She stated she was notified that the residents had a disagreement and were not on good terms. She stated she knew that they did not like each other but nothing had ever happened between them. The SSA also stated that the incident occurred at night when most department heads were not in the facility. She stated anyone who witnessed it should have reported it to the Administrator. She stated per policy, abuse had to be reported to the abuse coordinator and a report had to be filed with the State Agency. The SSA stated they were monitoring Resident #39 because the resident initially stated that they felt unsafe. During an interview on 02/05/2025 at 2:40 PM, the SSD stated that to her knowledge, the residents' mutual dislike had never escalated to physical contact. During an interview on 02/06/2025 at 1:35 PM, the Director of Nursing (DON) stated she was notified of an incident on 01/27/2025. She stated she only knew that Resident #39 called the sheriff and that the police had given a report to a nurse that there was no crime or altercation. Per the DON, she was not notified that Resident #39 alleged there was a physical altercation. She stated she notified the Administrator. Per the DON, the facility did not report an abuse allegation based on the police's conclusion that there had been no altercation. During an interview on 02/06/2025 at 2:04 PM, the Operations Manager stated he learned of an incident on 01/27/2025, when the DON contacted him. He stated he knew there had been a verbal disagreement between the two residents, and that the police did not find grounds for any further action. He stated he was never told of a collision in the dining room. The Operations Manager stated he reported what he learned to the Administrator. Per the Operations Manager, the expectation was to report abuse allegations; however, the Administrator probably did not find that it rose to the level of abuse based on what the police said. During an interview on 02/06/2025 at 1:51 PM, the Administrator stated he was first made aware of an incident on 01/27/2025. He stated the Operations Manager informed him that the police were at the facility. According to the Administrator, the police spoke with Licensed Vocational Nuse (LVN) #14, who was on shift when the incident occurred. The Administrator stated that according to the police, there was a disagreement/dispute between the two residents; however, no altercation took place. The Administrator stated that LVN #14 also stated there was a disagreement/dispute and Resident #69 stated there was no altercation. According to the Administrator, he was not notified that Resident #7 collided with Resident #39's wheelchair. On 02/05/2025 at 3:30 PM, 02/06/2025 at 8:37 AM, and 02/06/2025 at 9:41 AM, attempts were made to reach LVN #14, who was working the evening shift of 01/27/2025. All attempts were unsuccessful. During a follow-up interview on 02/05/2025 at 8:46 AM, the Administrator stated he did not report the allegation from the previous week until 02/04/2025.

Based on interview, record review, and facility policy review, the facility failed to refer 1 (Resident #49) of 2 residents reviewed for Pre-Admission Screening and Resident Review (PASRR) for a Level II screening when Resident #49 was admitted with a diagnosis of psychosis and depression. Findings included: A facility policy titled, PASARR [Pre-Admission Screening and Resident Review, PASRR], dated 03/2024, indicated, a. The facility verifies with [sic] acute hospital if a Level I PASARR screen for potential admissions and readmissions, regardless of payer source, to determine if the individual meets the criteria for a MD [mental disorder], ID [intellectual disability] or RD [related disorders]. b. Before a patient can be transferred from a hospital, they must undergo a PASARR Level I screening. This initial screening is designed to identify individuals who may have mental illness (MI), intellectual disability (ID) or related conditions. The goal is to determine whether they require further evaluation (Level II) to assess the need for specialized services. c. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. Resident #49's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 10/16/2024, revealed the resident had no diagnosed serious mental illness, such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. The Level I PASRR revealed after observing the resident and reviewing the resident's records, there was no suspected mental illness. The PASRR also revealed the resident had not been prescribed any psychotic medications for a serious mental illness. An Admission Record revealed the facility admitted Resident #49 on 10/19/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of unspecified psychosis not due to a substance or known physiological condition and unspecified depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/25/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) of 5, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had active diagnoses of depression and psychotic disorder. The MDS revealed the resident had taken antipsychotic and antidepressant medications during the assessment's seven-day look-back period. Resident #49's Care Plan included a problem area initiated 10/19/2024, that indicated [Resident #49] has Psychosis. The Care Plan included a problem area initiated 10/21/2024, that indicated the resident required antidepressant medication related to depression. Resident #49's physician orders revealed an order for quetiapine fumarate oral tablet 100 milligrams (mg) with instructions to give one tablet by mouth at bedtime for psychosis, that started on 10/19/2024 and ended on 01/06/2025. Resident #49's Medication Review Report, revealed an order dated 01/13/2025 for quetiapine fumarate 50 mg with instructions to give one tablet by mouth at bedtime for psychosis. During an interview on 02/06/2025 at 9:51 AM, the Admission Director stated the hospital completed PASRRs and usually sent them to the facility via the PASRR portal. She stated the diagnosis was likely added on admission. The Admission Director revealed she did not know who was responsible for referring a resident for a PASRR when the resident had a new diagnosis of an SMI. During a follow-up interview on 02/06/2025 at 10:42 AM, the Admission Director revealed Resident #49 had a diagnosis of psychosis from the hospital. She revealed she probably missed the diagnosis since the resident was admitted to the facility on a weekend. During an interview on 02/06/2025 at 2:19 PM, the MDS Coordinator stated the facility received PASRRs from the hospital where they were completed. He stated his process for reviewing PASRRs included reviewing the resident's diagnosis list and resubmitting a PASRR if it did not match the diagnosis list. The MDS Coordinator stated Resident #49 was admitted on a weekend and the diagnosis got passed them. During an interview on 02/06/2025 at 1:35 PM, the Director of Nursing (DON) stated that on admission from the hospital, the Admission Director reviewed the resident's PASRR and the resident's diagnoses and medications. She stated the MDS Coordinator completed a second review. She stated that the admission PASRR did not capture Resident #49's diagnosis of psychosis. During an interview on 02/06/2025 at 1:51 PM, the Administrator stated that admissions staff reviewed new resident admissions to see if a Level II screening was required. He stated the facility missed Resident #49's psychosis diagnosis.

Based on observation, interview and record review, the facility failed to promote dignity and respect when Resident 1's custom-built hearing aids was lost and was not replaced timely. This failure increased the potential for Resident 1 to not effectively communicate his needs and overall well-being. Findings: During the review of medical records, Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a progressive disease affecting memory and other mental functions). A record titled Inventory of Personal Effects dated 6/24/24 indicated, Resident 1 had hearing aids. During an interview on 1/28/24 at 11:36 a.m., with Resident 1's responsible party (RP), RP stated when Resident 1's custom-built hearing aids got lost sometime in July last year, the facility did not replace them and provided generic type hearing aids that kept on falling off from his ears and getting lost again. During a concurrent observation and interview on 1/28/25 at 2:15 p.m., with a certified nurse assistant (CNA1), Resident 1 was observed in bed, awake, no hearing aids; Resident 1 was unable to hear and understand questions asked. CNA1 stated Resident 1 had lost the hearing aids sometime in July last year; and further confirmed Resident 1 was not wearing hearing aids. During a concurrent interview and record review on 1/28/25 at 2:30 p.m., with the admitting clerk (AC), AC stated she did the inventory of Resident 1's personal belongings during admission on 6/21/24, and confirmed there was a pair of hearing aids worn by Resident 1. During the interview on 1/28/25 at 3:30 p.m., with the operations manager (OM), OM confirmed being aware of the request to replace the custom-built hearing aids for Resident 1 which was still pending approval by the upper management. OM further agreed the quality of life can be affected when someone cannot hear and not promote good communication between residents and staff.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), was free from misappropriation of resident property. This failure had the potential for Resident 1 to be subject to financial abuse. Findings: During an interview on 12/30/24, at 5:09 p.m., with Resident 1, the Resident 1 verbalized a Certified Nursing Assistant (CNA 1) told Resident 1 that the CNA 1 was having car troubles and bill troubles and needed $1,000. Resident 1 verbalized upon hearing about CNA 1's financial hardship, provided the CNA 1 with a total of $740 dollars to help CNA 1 with the cost of the car repairs and bills. Resident 1 verbalized the two made an agreement that Resident 1 would be paid back by CNA 1 sometime during 1/25. During a review of Resident 1's Progress Notes dated 12/23/24, indicated in part Resident 1 stopped by the activities office and informed the activities staff that [Resident 1] had let a staff member (CNA 1) borrow some money. During a review of Resident 1's Progress Notes dated 12/27/24, indicated in part C.N.A. (CNA 1) came to the facility to bring the money to pay [Resident 1] the total of $740.00. D.S.D (Director of Staff Development, DSD 1) and Concierge were present in the resident's (Resident 1) room when C.N.A. (CNA 1) handed the money to the resident (Resident 1). During an interview on 12/30/24, at 3:02 p.m., with the Director of Nursing (DON 1), the DON 1 confirmed that CNA 1 took $740 dollars from Resident 1, when Resident 1 offered to help CNA 1 out due financial hardship. The DON 1 verbalized the CNA 1 paid Resident 1 back in full on 12/27/24. During a review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 4/21, indicated in part Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. During a review of the facility's policy titled Gifts, Gratuities, and Payments, undated, indicated in part Our facility prohibits employees from .engaging in any activity, practice, or act which conflicts with the interest of the facility or its residents.

Based on interview and record review, the facility failed to implement a comprehensive care plan and follow physician orders, for one of two sampled residents (Resident 1). These failures had the potential to negatively impact Resident 1. Findings: During a review of Resident 1's Care Plan, dated 11/4/24, indicated in part, Resident 1 Requires Antidepressant medication related to diagnosis of depression. Resident 1's care plan further indicated in part, an intervention to Administer antidepressant medication as ordered by the physician. During a concurrent record review and interview, on 12/17/24, starting at 10:34 a.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's medication administration record (MAR) was reviewed. Resident 1's MAR indicated in part, two physician orders pertaining to the monitoring of Resident 1, due to Resident 1 taking the medication Trazadone (an antidepressant). One physician order was to monitor Resident 1 for episodes of depression manifested by difficulty in falling asleep every shift and a separate physician order for staff to monitor Resident 1 for adverse side effects of Trazadone every shift. Resident 1's MAR had a missing/blank entry once on 11/7/24, and once on 11/25/24, for both orders. The DON 1 and MRD 1 acknowledged the missing entries and could not provide additional documentation indicating both physician orders were carried out by staff on those dates. Resident 1's MAR further indicated Resident 1 had a physician order to receive one 100 mg tablet of Trazadone HCL by mouth two times a day for depression, manifested by a difficulty in falling asleep. Resident 1's MAR indicated Resident 1 only received one of the two ordered doses on 11/26/24. The DON 1 and MRD 1 acknowledged Resident 1's MAR indicated Resident 1 received only one of the two ordered doses on 11/26/24, and could not provide documentation indicating nursing staff administered both doses of the Trazadone, as ordered by the physician on 11/26/24. During a review of the facility policy titled Care Plans, Comprehensive Person-Centered dated 2001, indicated in part A comprehensive, person-centered care plan .is developed and implemented for each resident .The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide requested medical records in a timely manner, to a resident representative, for one of two sampled residents (Resident 1). This failure had violated Resident 1's rights. Findings: During an interview on 11/4/24, at 3:17 p.m., with the Social Services Director (SSD 1), the SSD 1 was asked to confirm when Resident 1's representative first made the request to obtain Resident 1's medical records. The SSD 1 stated Resident 1's representative verbally and in writing, requested Resident 1's medical records on 10/3/24. During an interview and concurrent record review, on 11/4/24, stating at 2:48 p.m., with the Director Of Nursing (DON 1) and Medical Records Director (MRD 1), the MRD 1 and DON 1 stated the facility required residents and/or their representatives to sign a facility authorization form titled Authorization Form For The Release of Health Information in order to obtain medical records. Both the DON 1 and the MRD 1 stated if a resident or resident representative made a verbal or written request for medical records, the facility would not produce the medical records, unless the facility's authorization form was also signed. The MRD 1 confirmed that as of 11/4/24, the facility had not provided Resident 1's representative with the requested medical records. During a review of the facility policy and procedure titled Resident Rights dated 12/16, indicated in part Federal and State Laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .access personal information and medical records pertaining to him or herself. During a review of the facility policy and procedure titled Release of Information dated 2001, indicated in part A resident may have access to his or her records within 48 hours (excluding weekends or holidays) of the resident's written or oral request.

Based on record review and interview, the facility failed to follow a care planned intervention to monitor the intake and output of one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experince negative outcomes. Findings: During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 had a urinary tract infection on 6/22/24, with an intervention for staff to Monitor intake and output. During a concurrent record review and interview, on 10/9/24, at 4:21 p.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's Care Plan was reviewed. The DON 1 and the MRD 1 verbalized they were unable to provide documentation indicating Resident 1's care planned intervention to monitor intake and output was carried out by staff. During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001, indicated in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated in part The comprehensive, person-centered care plan .describes the services that are to be furnished.

Based on record review and interview, the facility failed to follow physician orders for catheter care, for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to experience negative outcomes including an increased risk for developing urinary tract infection(s). Findings: During a concurrent interview and record review, on 10/9/24, starting at 4:30 p.m., with the Director of Nursing (DON 1) and the Medical Records Director (MRD 1), Resident 1's Treatment Administration Record (TAR), was reviewed. Resident 1's TAR indicated in part Resident 1 had a physician order of Indwelling catheter: Monitor for change in urine character .every shift for f/c (foley catheter) management. The physician order was active from 5/30/24 to 8/23/24. Resident 1's TAR indicated missing/blank entries on 6/8/24, 6/17/24, 7/2/24, 7/5/24, 7/7/24, 7/19/24, 7/21/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/8/24, 8/12/24, 8/13/24. The DON 1 and MRD 1 confirmed the missing entries. During a concurrent interview and record review, on 10/9/24, starting at 4:30 p.m., with the DON 1 and the MRD 1, Resident 1's TAR was reviewed. Resident 1's TAR indicated in part Resident 1 had a physician order to Monitor proper placement, no kinking or compression that could obstruct urine flow to a gravity bag during catheter care Q (every) shift every shift for f/c management. The physician order was active from 5/30/24 to 8/23/24. Resident 1's TAR indicated missing/blank entries on 6/8/24, 6/17/24, 7/2/24, 7/5/24, 7/7/24, 7/19/24, 7/21/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/8/24, 8/12/24, 8/13/24. The DON 1 and MRD 1 confirmed the missing entries.

Based on record review and interview, the facility failed to administer Metoprolol (a medication used to treat high blood pressure) per physician orders, for one of two sampled residents (Resident 1). This failure had the potential to result in a medication being withheld, when it should have been administered. Findings: During a concurrent record review and interview, on 8/8/24, starting at 11:28 a.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's medical record was reviewed. Resident 1's Medication Administration Record (MAR) indicated in part, Resident 1 had a physician order of Metoprolol .Give 12.5mg (milligrams) by mouth two times a day for HTN (hypertension [high blood pressure]) hold for SBP (systolic Blood Pressure) < (less than) 110 or HR (heart rate) < 60 (60 beats per minute). Resident 1's MAR indicated on 8/1/24, at 9:00 p.m., Resident 1 did not receive the scheduled dose of the medication due to Resident 1's vital signs being outside the parameters of the order. Review of Resident 1's Weights and Vitals Summary indicated in part, Resident 1's recorded blood pressure was 118/78, and heart rate was 72 beats per minute, at 9:06 p.m. on 8/1/24. The DON 1 and MRD 1 acknowledged according to the facility's documented blood pressure reading and heart rate reading for Resident 1 on 8/1/24, at 9:06 p.m., Resident 1 should have received the scheduled dose of Metoprolol instead of it being withheld. During a review of Resident 1's Care Plan, undated, the Care Plan indicated in part Resident (Resident 1) requires antihypertensive (medication used to lower blood pressure) medication related to hypertension. Resident 1's care plan further indicated in part Resident 1 had an intervention of Medication as ordered. Adhere to parameters for holding medication as ordered. During a review of the facility's policy and procedure (P&P) titled Documentation of Medication Administration, dated 11/22, the P&P indicated in part, Documentation of medication administration includes .reason(s) why a medication was withheld, not administered, or refused.

Based on record review and interview, the facility failed to provide documentation indicating a care planned intervention for falls was carried out for one of two sampled residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1. Findings: During a review of Resident 1's Progress Notes dated 7/8/24, indicated in part on 7/6/24, at 3:20 a.m., CNA (certified nursing assistant) (CNA1) was walking by resident's room and observed the resident (Resident 1) sitting on the landing mat .Resident (Resident 1) was alert and stated that (Resident 1) got up to use the commode and lost (Resident 1) balance and fell , hitting the back of (Resident 1) head on the armrest of the commode .small laceration on the back of the head with bleeding .Resident (Resident 1) c/o (complaints of) pain on the back of the head 4/10 and right rib area 7/10. The progress note entry further indicated in part Resident (Resident 1) is at risk for further falls and injury due to non-compliance with safety precautions, transferring and ambulating without assistance. Resident (Resident 1) has a hx (history of) falling with displaced fracture .of left clavicle . (Resident 1) is incontinent (having no voluntary control) of bowel and bladder. With lack of coordination, muscle weakness and unsteady gait (walking). During a concurrent record review and interview, on 8/1/24, starting at 3:45 p.m., with the Director of Nursing (DON 1) and Medical Records Director (MRD 1), Resident 1's medical record was reviewed. Resident 1 had a fall care plan which indicated in part Resident (Resident 1) is at risk for falls with or without injury related to history of falls .7/6/24 - Evaluated at [Hospital Name] with Dx (diagnoses) of Acute Fracture Right 8th and 9th Ribs, Head Injury, Scalp Laceration (cut) with staples. Resident 1's care plan for falls indicated in part an intervention created on 7/6/24, to Check resident (Resident 1) at least every 2 hours and as needed and ask if (Resident 1) needs assistance with toileting. The DON 1 and MRD 1 were asked to provide documentation indicating this facility chosen care planned intervention was carried out. The DON 1 verbalized the facility could not provide documentation indicating this care planned intervention was carried out by staff, post Resident 1's return from the hospital. During a review of the facility's policy and procedure titled Care Plans, Comprehensive Person-Centered dated 2001, indicated in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of the facility's policy and procedure titled Falls and Fall Risk, Managing dated 2001, indicated in part The staff .will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with history of falls .the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, interview and record review, the facility failed to ensure there was timely monitoring and skin evaluation on a resident's skin in one of three sampled residents (Resident 1). This failure had the potential for miscommunication in skin care that may result in further decline in Resident 1's skin condition after cast removal on the right lower limb . Findings: During a review of the undated admission record, Resident 1 was admitted to the facility on [DATE] following a right knee surgery and had conditions listed as encounter for orthopedic (the treatment of bones that have been damaged) aftercare. A review of the history and physical dated 3/23/24, Resident 1 has the capacity to understand and make decisions. During a review of Resident 1 s Physician's orders dated 3/22/24, it indicated right knee immobilizer on at all times, check for circulation, skin integrity, and signs and symptoms of infection and skin breakdown. During a concurrent observation and interview on 5/1/24 at 3:15 p.m., Resident 1 was observed in her room awake, alert, right leg slightly elevated with brace (immobilizer) from thigh to below knee and above right heel. Right ankle was noted to be swollen, right foot with heel protector, protective padded brown dressing noted covering the entire right heel. Resident 1 stated she did not have any wound other than her surgical wound on her right knee when she went in the facility. During an interview on 5/14/24 at 2:00 p.m., Certified Nurse Assistant (CNA) stated that she helped Resident 1 with bed bath and confirmed the right leg had a cast from thigh to foot, so she was unable to see the right foot including the heel. During an interview on 5/14/24 at 2:15 p.m., the treatment nurse (TN 1) stated Resident 1 was admitted with a cast on right leg from thigh down to the right foot exposing only the right toes and was unable to see the right heel. TN 1 stated that Resident 1's cast was removed at the Orthopedic surgeon s office on 4/15/24 and came back to the facility with a right knee immobilizer making the right heel visible to for monitoring and assessments. TN 1 confirmed there was no communication from the orthopedic doctor's office and nursing did not follow-up to check for new additional order. During an interview on 5/14/24 at 2:30 p.m., treatment nurse (TN 2) stated there was a chance to check for the skin on Resident 1's right foot area when the cast was removed on 4/15/24 but confirmed there was no monitoring documented in the medical records until the discovery of a deep tissue injury (soft tissue loss) on Resident 1's right heel on 4/17/24. During an interview on 5/17/24 at 04:15 p.m., wound consultant (WC) from Omni Wound Physicians stated Resident 1 was referred to him on 4/23/24 and was assessed with unstageable injury (thick dead tissues under the skin) on Resident 1's right heel. WC stated he did right heel wound debridement (process of removing dead skin or tissue from a wound) thus changing the wound status to stage IV (a wound that has full thickness tissue loss with exposed bone, tendon, or muscle). WC stated that an unstageable wound can develop within few hours from pressure to a bony structure like the heel area given the high-risk factors and limited mobility of Resident 1. WC confirmed that the injury can be invisible up to 48 hours following a friction to an immobilizer or device. WC stated he ordered offloading/floating (raising the affected foot to a pillow to prevent friction and shearing to any surface) on the right heel instead of using a heel protector to promote air flow to the area for faster healing. During a review of undated facility policy and procedure (P&P), titled Charting and Documentation, the P&P indicated, Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record. The medical record is a format that facilitates communication between the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to ensure staff accordingly by professional standard followed and implemented the facility's policy and procedure on elopement by notifying the police when one of two residents (Resident 1) was found missing from the facility on 1/4/22 for more than an hour (7:15 AM to 8:40 AM) and remained missing after search of the facility by staff. This failure contributed to the delay in the search of Resident 1, and when found by a good samaritan (GS) almost a mile away from the facility, the resident already sustained body injuries from a fall by the side of a busy street and was transported to a local hospital. Findings: According to the California Nursing Practice Act, Board Approved: 11-28-2012;Enacted:1-1-2013, Section 2725 Legistative intent:Practice of Nursing Defined (c) Standardized procedures,as used in this section, means either of the following:(1) Policies and protocols developed by a health facility licensed pursuant to Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code through collaboration among administrators and health professionals including physicians and nurses. Review of the facility's policy and procedure titled, Elopements dated revised 12/2007 indicated in part, 4. If the employee discovers that a resident is missing from the facility he/she shall: a. Determine if the resident is out on authorized leave or pass; b.If the resident was not authorized to leave, initate a search of the building and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services,the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e.,Emergency management, Rescue Squads,etc,); d. Provide search teams with resident identification information; and e. Initiate an extensive search surrounding the area. During a review of the clinical record for Resident 1,the face sheet (form containing resident information) indicated multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The document Fall risk assessment (FA) dated 12/28/21, for Resident 1, indicated history of 1-2 falls in the last 90 days, the resident was non ambulatory (unable to walk) and uses a wheelchair for locomotion (moving around). Further review of the clinical record, the document Nursing Progress Notes (NPN) dated 1/4/22 at 12:35 PM (late entry), authored by a licensed nurse (LN 1) had documentations of : At around 6:30 AM, Resident 1 was walking on unit hallway, around nursing station, with a four wheeled walker (FWW). Resident was last seen walking around the nursing desk area at about 7:15AM. At around 8:30 AM another RN (registered nurse) reported the daughter of Resident 1 was on the phone and inquiring if the resident had fallen and wanted to the speak to the resident. Another daughter of the resident with a male companion was at the facility's front door requesting to see the resident. The NPN did not indicate the whereabouts of the resident after 7:15 AM, no documentation of the facility search for the resident was noted and if the police was informed about a missing person. During a review of the NPN dated 1/4/22 at 4:44 PM (late entry), the NPN had documentations authored by LN 3 of: Arrived for the morning shift around 7:50 AM , noticed that the resident was not in the room. Staff were searching for the resident and nowhere to be found in the facility. Around 8:40 AM, AM supervisor received a call from daughter stating someone ( GS) found the resident at (name of the street) at around 7:45 AM, walking with a walker. 911 was called and the resident was sent to a local hospital. No documentation in the NPN was located about the staff and facility calling law enforcement for a missing person and informing family on 1/4/22 after 7:50 AM when LN3 found the resident was not located in the facility. During an interview with the GS on 1/11/22 at 12:29 PM, the GS indicated on 1/4/22 at 7:38 AM, Resident 1 was noted on the side of a busy street about a mile from the facility dressed in pajamas, walking with a walker and then falling by the side of the street. The GS called 911 as the resident had injuries on the left forehead, was bleeding down to the cheek area and was transported by EMT (emergency medical technicians) to a local hospital. The GS further indicated calling the facility at 8:07 AM to notify them of Resident 1's whereabouts. GS stated, The nurse said, I believe he is in his room.The facility staff didn't even know the resident was gone. They didn't even know he was missing. Review of the emergency medical transport Electronic Patient Care Report_v2 dated 1/4/22 at 8:08 a.m., indicated Resident 1 was transported by ambulance to a local hospital .The Emergency Provider Report (EPR) dated 1/4/22 indicated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The EPR had documentations of resident undergoing several blood tests and a Computerized Tomography Scan (CT -radiographic imaging-scanning via a machine) of the neck. During an interview on 2/2/22 at 7:16 AM , LN1 confirmed working on 1/3/22 at 11 PM to 7 AM of 1/4/22. LN1 stated, the Certified Nursing Assistant (CNA 1), came in to work between 7:15 AM to 7:30 AM, proceeded to do his rounds and told me he can't find Resident 1. LN1 stated, At around 8 AM or 8:30 AM, I called the code elopement. During an interview on 2/23/22 at 8:15 AM, LN2 confirmed working on 1/4/22 for 7AM to 3 PM shift. LN2 also confirmed starting late in shift with CNA 1 and another staff. CNA 1 did his rounds and found Resident 1 was missing and reported to LN1. LN 2 stated, I received a call from the resident's daughter around 8:35 AM stating the resident fell , I transferred the phone call to the resident's room but I could not find him. LN2 confirmed receiving the call from the GS on 1/4/22 about 8:45 AM indicating Resident 1 was found injured by the side of the road about a mile away from the facility. During an interview on 6/1/22 at 2:11 PM about elopement policy and procedure, LN1 indicated, a sweep of the building should have been done and in 15 minutes of not locating the resident the police should have called, the Director of Nursing (DON),the Administrator, the Social Services, and family. LN1 further indicated this was not done. During another interview on 6/22/22 at 1:30 PM about the facility's elopement policy and procedure, LN1 indicated not calling law enforcement/ family when resident was reported missing on 1/4/22 between 7:15AM to 7:30 AM by CNA1 . LN1 stated, Yes I was ultimately responsible for notifying law enforcement, the emergency rescue team and filling out the SBAR /Change of Condition/Incident Report and it was not done.

Based on observation, interview, and record review the facility failed to ensure isolation precautions per policy and procedures were followed and implemented in the care of residents with [REDACTED] (an infectious disease -thick crusts of skin that contain large numbers of scabies mites and eggs, a parasitic disease infestation of the skin resulting to itching ) and suspicious rashes originally identified in the Sub-Acute Unit ((nursing unit for residents with [MEDICAL CONDITION]- opening in throat for breathing ) and later outside of the unit when : 1. Wearing of personal protective equipments (PPE- disposable gown, mask, gloves, hair covering, shoe covering) and strict handwashing were not observed by staff during care of residents on isolation precautions (strict contact with need to use PPE). 2. Care equipments used on isolation residents were not labeled, stored, and sanitized properly. 3. Trash bins overflowing with used PPEs were left unattended, isolation cabinets containing PPEs were not set up properly, unlabeled care equipments were stored inside the PPE cabinet, and staff rendering care were with no appropriate PPE's. 4. Eating wares and food trays used by residents on isolation were not bagged when sent back to the facility's kitchen for cleaning and sanitizing per facility protocol. 5. Facility's policy and procedure on scabies was not followed on skin scraping and maintaining of the contact list and monitoring log. These failures had the potential to spread the norwegian scabies to residents, staff , and visitors. Findings: 1. During an observation on 12/12/19 at 11:30 a.m.,with licensed nurse (LN 2) in the Sub Acute Unit, Rooms 36, 37, 38, 40, 43, 44, and 45 were under isolation precautions . LN1 with PPEs on entered room [ROOM NUMBER] after exiting two other rooms (rooms [ROOM NUMBERS]) without changing PPEs and washing hands. LN2 confirmed LN1 did not wash hands, change PPEs and did not follow the facility's infection control guidelines. The facility's policy and procedure titled, Enhanced Standard Precautions, dated revised 1/10/19, stated in part . Hand hygiene should be performed before donning and after removal of gloves each time gloves are used. Before leaving the room remove gloves, gown and other PPEs and wash hands immediately in part 2. During an observation and concurrent interview with a Respiratory Therapist (RT1) and LN 3 on 12/12/19 at 12:15 p.m., an unlabeled stethoscope and blood pressure cuff was found stored inside the PPE cabinet outside room [ROOM NUMBER]. In addition an unlabeled pulse oximeter (small gadget to measure oxygen level by fingertip) used by RT1 on Resident 3 (on isolation) was left on top of the PPE cabinet outside the resident's room. RT 1 acknowledged the pulse oximeter was not sanitized after use. RT1 indicated not knowing the sanitizing agent to use and was not aware the pulse oximeter, blood pressure cuff, and stethoscope was only dedicate for the use of Resident 3. LN3 confirmed the care equipments were unlabeled and should only be use on Resident 3. The facility's policy and procedure titled, Enhanced Standard Precautions, dated revised 1/10/19, stated in part . When possible dedicate non critical care equipment such as stethoscope, sphygmomanometer (blood pressure machine, cuff) to a single resident, if equipment will be removed the room it must be adequately clean and disinfected 3. During an observation and concurrent interview with LN3 on 12/12/19 at 12:30 p.m., PPE cabinets were set up inside rooms [ROOM NUMBERS]. Trash bins with overflowing used /soiled PPEs were directly by the doorways of rooms [ROOM NUMBER]. A certified nursing assistant (CNA 1) was inside room [ROOM NUMBER] (isolation room) with unprotected lower garment touching the resident's privacy curtain. LN3 acknowledged the trash bins were overflowing with soiled PPEs and should have been emptied by now and not be directly positioned by the doorways of the isolation rooms. The PPE cabinets should be set up outside the isolation rooms and not inside. LN3 indicated staff rendering care to residents on isolation are expected to wear PPEs appropriately to protect personal clothing's and not touching anything that might be infected such as the privacy curtains. The facility's policy and procedure titled, Enhanced Standard Precautions, dated revised 1/10/19, stated in part .Personal protective equipment should be stocked on or in a covered cart to avoid contamination before use outside the isolated resident's room. The cart for PPE should not block egress of the resident's room. The facility's policy and procedure titled, Enhanced Standard Precautions, dated revised 1/10/19, stated in part . All personal protective equipment should be discarded in either the trash or linen receptacles before leaving the room . The facility's policy and procedure titled, Enhanced Standard Precautions, dated revised 1/10/19, stated in part . Don the appropriate personal protective equipment if planning to be within three feet of the resident or the resident's environment. Contact with environmental surfaces such as siderails, cubicle curtains etc . require doning of personal protective equipment as does contact with any of the resident's care equipment . 4. During an observation on 12/12/19 at 1:00 p.m., lunch was served at the Sub Acute Unit in non disposable lunch trays by certified nursing assistants. The used lunch trays and eating wares were returned to the meal carts, unbagged and wheeled back to the facility's kitchen. During an interview on 12/12/19 at 1:15 p.m., the infection preventionist (IP)indicated, used meal trays are double bagged for isolation identification and sent back to the kitchen via meal carts for washing and disnfection. During an interview on 12/12/19 at 6:30 p.m., dietary staff (DS1) indicated there is no special procedure on washing dishes and wares used by residents on isolation. No policy was presented on washing isolation eating wares upon request. 5. During an interview on 12/12/19 at 1:46 p.m., the administrator and DON indicated the suspicious rashes cases are all confined in the facility's Sub Acute Unit. During an observation outside the Sub Acute Unit on 12/12/19 at 3:20 p.m., Rooms rooms [ROOM NUMBERS] located in Hallway 1, room [ROOM NUMBER] in Hallway 2, and room [ROOM NUMBER] in Hallway 3 were noted with isolation precautions set up (disposable gowns, masks,footwear covers and gloves). During an interview on 12/12/19 at 3:30 p.m., the DON indicated the rooms were with residents recently identified with suspicious rashes and currently on isolation precautions. The DON verbally confirmed the case of suspicious rashes are not only contained in the Sub Acute Unit but are now in the other resident rooms outside the Sub AcuteUnit. Review of the facility's policy and procedure titled, Scabies Prevention Program dated , revised 1/10/19, stated in part . Pruritis, rashes, and [MEDICAL CONDITION] should be documented and brought to the attention of the nursing supervisor and attending physician. Develop a contact identification list. The list should identify every resident, health care workers, visitor and volunteer who may have had direct ,physical contact with the case within previous month . include the nursing unit, room number, name and onset of symptoms results of skin scrapings, date of initial scraping, date of initial treatment, results of treatments . in part. Review of the facility's Rashes Monitoring Log dated 12/3/19 to 12/8/19, indicated no skin scrapings were done, as stated in the facility's policy and procedure. No contact identification list was located in the monitoring log and none was presented during request. During an interview on 12/12/19 at 4:00 p.m., the facility Infection Preventionist (IP) confirmed no skin scrapings were done and no contact list had been generated only facility staff were offered [MEDICATION NAME] treatment and not visitors. On 12/12/19 at 4:55 p.m. Immediate Jeopardy was called. On 12/12/19 at 10:50 p.m. the facility provided a plan of correction including the following : 1. In service of all staff on infection control program, scabies prevention program, handwashing, PPE use (gloves, gowns, mask, shoe protector and hair covering) and contact precautions during care, serving of meals, laundry, and room sanitization. 2. Non admittance of new residents to the Sub-Acute Unit until clearance by the County Department of Public Health is issued. 3. Systematic deep cleaning of rooms in the Sub -Acute Unit then to the other residents rooms outside the Sub-Acute Unit. 4. Current room placement for all identified residents in the SNF (skilled nursing facility) with rashes were reviewed .The plan was to cohort residents with suspicious rashes in one room and on one designated hallway. 5. Infectious control referral and evaluation of affected residents by the end of the week 12/16/19. 6. Skin scrapings on suspicious rashes per policy and procedure. 7. Line listing to be submitted to the County Department of Public Health and to the licensing Department. On 12/12/19 at 11:00 p.m. the Department accepted the plan of correction and the Immediate Jeopardy was removed in the presence of the DON.

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) assessed by the facility as a fall risk and requiring toileting assistance was provided supervision and assistance when the resident verbalized the need to go to the toilet. This failure resulted in Resident 1, standing up with no supervision then falling and sustaining a left [MEDICAL CONDITION] requiring surgical repair. Findings: During a review of the clinical record for Resident 1 the Admission Record dated 1/11/19 indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment and care screening tool), dated 1/17/19 indicated Resident 1 had memory problems but can communicate needs. Resident 1 required extensive assistance of two persons physical assist for transfers and extensive assistance with one person physical assist with toilet use. Resident 1 was unable to walk by self, not steady, able to stabilize self with staff assistance from moving on and off toilet and with moving from seated to standing position. Review of Initial Fall Risk assessment dated [DATE] identified Resident 1 as a Moderate Risk for falls due to history of falls within the last six months, memory problems, and was unable to independently come to a standing position. Review of Fall Care Plan initiated on 1/11/19 indicated The resident is (High) risk for falls related to [MEDICAL CONDITION], repeated falls and unsteady gait . Interventions to prevent falls included, anticipating and meeting Resident 1's needs, prompt response to all requests for assistance and toileting program. Review of the progress notes authored by the Director of Nursing (DON) dated 2/16/19 at 15:07 (3:07 P.M.) indicated, Resident 1 was sitting in the hallway outside the room when noted by licensed vocational nurse (LN 1) who was passing medications trying to get up from the wheelchair (WC). Resident 1 stated to LN 1, he wanted to use the toilet. LN 1 went to look for a Certified Nursing Assistant (CNA) to transfer the resident to the toilet. When LN 1 returned to the hallway, Resident 1 was found on the floor. Resident 1 stated, I was trying to go to the bathroom and fell . Review of the Progress Notes dated 2/18/19 at 12:05 P.M. (two days after the fall) indicated Resident 1 was noted with a small bruise (skin discoloration) on the left eyelid under the left eyebrow. At 15:31 (3:31 P.M.) bruising was noted on the resident's left arm, at 16:10 (4:10 P.M.), pain medication ([MEDICATION NAME]- controlled pain medication) was administered for a pain level of 4-6 (moderate). Review of the physical therapy notes dated 2/18/19 at 4:21 P.M., indicated Resident communicated pain using face pain scale with all movement and range of motion (ROM) of the upper extremities (UE) and lower extremities (LE). Review of the Progress Notes dated 2/18/19 at 19:16 (7:16 P.M.) indicated Resident 1 was transferred out to the hospital due to confusion. During an interview with the DON on 2/22/19 at 11:21 A.M., the DON confirmed LN 1 left Resident 1 who was actively trying to get up and out of the wheelchair. The DON stated I think the fall was preventable. Review of the hospital Emergency Department (ED) document dated 2/18/19 indicated Resident 1 was admitted to the ED. The ED physician notes indicated the Resident 1's chief complaint was left hip pain, and the computerized tomography (CT- X-ray visualization thru a tube like machine) results demonstrated a left femoral neck fracture (broken bone in the neck of the femur -left largest longest bone from hip to knee). The CT results dated 2/18/19 further indicated severe compression [MEDICAL CONDITION] 1 vertebrae body (collapse of the bone of the lower spine). Review of the hospital's pre and post operative document dated 2/21/19 indicated Resident 1 underwent a left hip arthoplasty (left hip repair) on 2/21/19 (three days after admission 2/18/19). Review of the hospital Diagnosis, Assessment and Plan document dated 3/11/19 pages 1 to 3 of 6, indicated Resident 1 was hospitalized from [DATE] to 3/11/19 and was discharged to another nursing facility. During a phone interview with LN 1 on 3/20/19 at 11:47 A.M., LN 1 stated, Looking back the fall could have been prevented. I could have taken him (Resident 1) with me to find the CNA or taken him (Resident 1) to the restroom myself. During an interview with the DON on 4/2/19 at 2:43 P.M. the DON stated,Yes, the fall was preventable. LN 1 could have taken the resident (Resident 1) to the bathroom himself (LN 1)or took the resident with him to find the CNA. The facility's policy and procedure titled,Falls Management, dated revised 11/2012, indicated, Residents will be assessed for fall risk and interventions will be implemented to reduce the risk for falls.

Based on observation, interview, and record review the facility failed to implement interventions related to fall risk precautions for one of 10 sampled residents (Resident 8) as ordered by the physician. As a result, Resident 8 was at an increased risk for injury related to a fall. Findings: During the initial tour of the facility on 1/9/12 beginning at 9:30 a.m., Resident 8 was described, by a licensed nurse (LN 2), as having fallen the previous day while attempting an unassisted transfer from bed (1/8/12). A tab alarm box was observed attached to the bed siderail. The clip, designed to connect the tab alarm box to Resident 8's clothing was observed hanging between the bed mattress and the side rail and not attached to Resident 8. LN 2 stated a certified nursing assistant (CNA 1) admitted for getting to "attach clip of tab alarm to resident (Resident 8)" after rendering morning care. Record review on 1/9/12, revealed Resident 8 was admitted with [DIAGNOSES REDACTED]. Review of the most recent comprehensive assessment dated [DATE] indicated Resident 8 was able to make herself understood and understood others. Resident 8 was assessed as requiring extensive assistance of one staff member for bed mobility, transfers and toilet use. Review of Resident 8's fall risk assessment dated [DATE] identified Resident 8 was at high risk for falls. Review of the change of condition assessment dated [DATE] at 1:30 a.m. indicated Resident 8 was observed getting up unassisted from bed, lost her balance, and fell to the floor. Review of the physician orders [REDACTED]." Review of the interdisciplinary team conference note dated 1/9/12, indicated when Resident 8 fell ,on 1/8/12 at 1:30 a.m. Resident 8 sustained a skin tear to her right check, right eyebrow and right knee. The interdisciplinary team documented a tab alarm was to be used while Resident 8 is in bed in an effort to prevent the reoccurance of unassisted transfers from bed. Review of a facility log titled "Residents Information Log"dated 1/9/12 listed each resident in the facility and the type of alarm used. This list failed to identify Resident 8 as a resident with a tab alarm even though the tab alarm had been ordered by the physician on the previous day. This list was described in the facility's previous survey plan of correction as updated "daily" and used by staff as a reference in assisting residents with fall prevention.