Every finding on record at Sierra Valley Rehab Center

Based on interview and record review, the facility failed to ensure physician orders were followed for one of three sampled residents (Resident 1). This failure resulted in a delay of care.Findings:During a review of Resident 1's Physician Progress Note (PN)'s dated 7/17/25 at 5 p.m., the PN indicated, Assessment/Plan.Recommend checking UA (urinalysis-analyzes a sample of urine to detect and measure various substances and conditions) given chronic indwelling catheter and history of UTIs (urinary tract infections) with presence of spasms - discussed with nursing on date of service.During a review of the Order Summary Report (OSR) dated 7/23/25, the OSR indicated there was no order for a UA on 7/17/25.During a concurrent interview and record review on 8/4/25 at 1:01 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes were reviewed. LVN 1 stated she was assigned to Resident 1 on 7/17/25 when the physician ordered the UA and she did not enter the physician order.During an interview on 8/4/25 at 2:10 p.m. with Director of Nursing (DON), DON stated when the physician ordered the UA on 7/17/25 the order should have been put in physician orders and collected on the next lab day.During a review of the facility's policy and procedure (P&P) titled, Implementation and Management of Physician Orders dated 9/13/13, the P&P indicated, Order entry and MAR (Medication Administration Record)/eMar (electronic Medication Administration Record) updates.Nurses are responsible for ensuring that new and changed medication orders are transcribed or entered the MAR/eMAR accurately and promptly.

Based on interview and record review, the facility failed to ensure the binding Arbitration Agreement (a contract that requires parties to resolve disputes outside of court) was written in a form and manner resident could understand for three of three sampled residents (Resident 44, Resident 70, and Resident 329). This failure had the potential for Resident 44, Resident 70, and Resident 329 to sign the Arbitration Agreement without understanding the implications. Findings: During a review of the facility's ARBITRATION AGREEMENT (AA), 1/20/22, the AA indicated, The Resident and/or Resident's agent certifies that he/she has read this Agreement and has been given a copy of this Agreement, and affirmatively represents that he/she is duly authorized by virtue of the Resident's consent, instruction, and/or durable power of attorney, to execute this Agreement and accept its terms. During a review of Resident 44's ADMISSION RECORD (AR), dated 2/26/25, the AR indicated, Primary [NAME]. [language] Spanish. During a review of Resident 44's AA, dated 5/31/24, the AA (printed in English) indicated the AA was signed by Resident 44 on 5/31/24. During an interview on 2/26/25 at 2:58 p.m. with Resident 44, Resident 44 stated she does not read, speak, or understand English. Resident 44 stated she did not know what an arbitration agreement was and did not remember signing the AA printed in English. Resident 44 stated she would have preferred to have the AA written in Spanish. During a review of Resident 70's AR, dated 2/26/25, the AR indicated, Primary [NAME]. Spanish. During a review of Resident 70's AA, dated 11/24/23, the AA (printed in English) indicated the AA was signed by Resident 70 on 11/24/23. During an interview on 2/26/25 at 2:51 p.m. with Resident 70, Resident 70 stated he did not read English and understood very little spoken English. Resident 70 stated he did not know what an AA was and did not remember signing an AA. During a review of Resident 329's AR, dated 2/26/25, the AR indicated, Primary [NAME]. Spanish. During a review of Resident 329's signed AA, dated 2/6/25, the AA (printed in English) indicated the AA was signed by Resident 329 on 2/6/25. During an interview on 2/26/25 at 2:41 p.m. with Resident 329, Resident 329 stated she did not understand, speak or read English. Resident 329 stated she spoke only Spanish and she did not understand the AA she signed. During an interview on 2/26/25 at 3:22 p.m. with Admission Coordinator (AC), AC stated she tells residents that the AA can be rescinded/canceled within 30 days after signing the legal document. AC stated the AA was written in English which would prevent the Spanish speaking residents from reviewing the AA to see if they would like to rescind the AA. During an interview on 2/27/25 at 2:19 p.m. with Administrator, Administrator stated the facility has a Spanish speaking population which is greater than 5% and stated the importance of having vital information like the AA written in the residents' preferred language. During a review of the facility's policy and procedures (P&P) titled, Translation and/or Interpretation of Facility Services, dated November 2020, the P&P indicated, Policy Statement. This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Policy Interpretation and Implementation. 6. This facility shall provide written translation of vital information pertaining to health services, resident rights and facility policy if the limited English proficiency (LEP) population represents at least five (5) percent of the population of 1000 people eligible to be served by the facility (whichever is fewer). During a review of the facility's P&P titled, Binding Arbitration Agreements, dated November 2023, the P&P indicated, Policy Statement. Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Policy Interpretation and Implementation. 1. Residents (or representatives) have the right to make informed decisions about important aspects of their health, welfare and safety. 6. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manner that he or she understands, taking in to consideration the resident's (or representation) language, literacy and stated preference for learning.8. Residents (or representatives) are provided 30 days after signing to fully review and rescind any agreement not understood at the time of admission.

Based on observation, interview, and record review, the facility failed to follow standards of practice for infection control when: 1. One of one sampled resident (Resident 42) presented with signs and symptoms of a cough and treated with Influenza (flu-a contagious respiratory virus) medication was not put in Droplet Isolation Precautions (Isolation for residents with contagious respiratory symptoms requiring resident to be isolated and staff/visitors to wear a gown, gloves, and a mask. 2. Two of two sample residents (Resident 4 and Resident 42) requiring oxygen, did not have the tubing on their oxygen and nebulizer machine dated and timed and oxygen tubing found on the floor uncovered. 3. One of one resident (Resident 229) requiring portable suction machine [used to clear secretions from resident mouth and throat], did not having the tubing and canister dated or timed and the suction tip of the machine was left at bedside uncovered. 4. One of one sampled resident (Resident 86) was provided hand hygiene before being served lunch. These failures had the potential to result in infections or viruses for Resident 4, Resident 42, Resident 229, Resident 86 and staff/visitors. Findings: 1. During a concurrent observation and interview on 2/24/25 at 10:38 a.m. with Resident 42, in Resident 42's room, Resident 42 had a wet cough and stated it started last Friday and his roommate and family was concerned about him being contagious. During a concurrent interview and record review on 2/27/25 at 11:08 a.m. with Director of Nursing (DON), Resident 42's, Clinical Record (CR), multiple dates, were reviewed. The CR indicated, on 2/15/25 Resident 42's physician was notified Resident 42 was not feeling well and had a cough. On 2/15/25 Nursing Note indicated, MD [Medical Doctor] made aware received new order to start Xofluza [medication used to treat the flu] 80 mg [milligram] 1 tab[tablet] for one time, Tamiflu [medication used to treat the flu] 75 mg bid [twice a day] for 5 days and prednisone [medication used to treat inflammation] 10mg daily for 10 days r/t [related to] flu. Interdisciplinary team (a group of department leaders that meet to discuss resident needs) note dated 2/17/25 at 9:22 a.m. indicated, Change of condition- Flu like symptoms with Interventions: Medications as ordered. Respiratory assessments - ongoing, O2 as ordered. Physician and Responsible Party notified. DON stated there is no documentation supporting or showing that Resident 42 was put on Droplet Isolation Precautions and stated if a resident is on Tamiflu and Xofluza they should be on isolation precautions to protect staff and visitors. During an interview on 2/27/25 at 11:14 a.m. with Infection Preventionist (IP). IP stated, The medications were given because [Resident 42] had a cough and was refusing to go to the ER, so MD put him on Tamiflu just in case it was the flu. During an interview on 2/27/25 at 11:32 a.m. with Registered Nurse Consultant (RNC) 2, RNC 2 stated if a resident is being treated with virus medication and symptomatic with respiratory sign and symptoms, the resident should be placed in Droplet Precautions. RNC 2 stated there is no evidence that Resident 42 was placed in Droplet Precautions. During a review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precautions, dated September 2022, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptom of a transmissible infection, arrives for admission with symptoms of an infection.and is at risk of transmitting the infection to other residents. 2. Transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person.Droplet Precautions 1. Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets . that can be generated by the individual coughing, sneezing, talking.2. Residents on droplet precautions are placed in a private room if possible. 3. Masks are worn when entering the room. 4. Gloves, gown, and goggles are worn if there is risk of spraying respiratory secretions. 2. During a concurrent observation and interview on 2/24/25 at 10:33 a.m. with Licensed Vocational Nurse (LVN) 4, in Resident 42's Room, Resident 42 was wearing oxygen tubing that was connected to a oxygen machine next to his bed. There was no date or time on the tubing. There was also a Nebulizer Machine at the bedside with tubing and a mask without date or time. LVN 4 stated the tubing on both machines were supposed to be changed every Sunday and should have had a label on them and stated neither of them were labeled. During a record review of Resident 42's, Order Summary (OS), dated February 2025, the OS indicated, CHANGE O2 [Oxygen] TUBING EVERY WEEK every Sat [Saturday]. O2 AT 2 LITERS/MINUTE VIA NASAL CANULA [oxygen tubing] PRN [as needed] FOR SOB [Shortness of Breath]. During a concurrent observation and interview on 2/24/25 at 10:50 a.m. with LVN 4, in Resident 4's room, there was an oxygen machine by the bed with oxygen tubing that connects to the resident on the ground. No date on the oxygen tubing. There was a nebulizer machine also at bedside. Facemask and tubing not dated. The pouch holding the mask was dated 1/9/25. LVN 4 stated the oxygen tubing should not be on the floor and should have a date on it. LVN 4 stated the nebulizer mask and tubing should have a date on it. During a review of Resident 4's, OS, dated February 2025, the OS indicated, Oxygen at 2 liters per minute via nasal cannula as needed. CHANGE O2 TUBING every night shift every Sat. [Saturday] 3. During an observation on 2/24/25 at 11:45 a.m. in Resident 229's room, there was a suction canister noted at bedside. The suction tip was sitting on bedside table, not covered or in a package. The suction canister contained liquid that was not labeled or dated. During a concurrent observation and interview on 2/25/25 at 10:20 a.m. with LVN 3, in Resident 229's room, the suction canister was still at the bedside with the suction tip on the bedside table uncovered. The suction canister still had the same liquid as the day before without a date or label. LVN 3 stated the suction canister should have a date and time on it and the suction tip should not be uncovered. During an interview on 2/27/25 at 11:43 a.m. with DON, DON stated the suction machine canister should have a date and time and the suction tip should be covered in a package or a bag. During a review of Resident 229's, OS, dated February 2025, the OS indicated, CHANGE SUCTION CANISTERS 2X/WEEK [two times a week] ON WEDNESDAY & SATURDAY & PRN [as needed] every night shift every Wed [Wednesday], Sat [Saturday] AND as needed. During a review of the facility's P&P titled, Suctioning, dated August 2014, the P&P indicated, The purpose of this procedure is to help prevent infections associated with suctioning and to prevent transmission of such infections to residents and staff. General guidelines: 12. The suction collection canister should be emptied and cleaned daily and changed or decontaminated as necessary. 4. During a concurrent observation and interview on 2/24/25 at 1:07 p.m. with Licensed Vocational Nurse (LVN) 10 in Resident 86's room, LVN 10 delivered Resident 86's lunch tray. LVN 10 was asked if she had provided hand hygiene to Resident 86 prior to her giving him his lunch tray. LVN 10 stated she had not provided hand hygiene to Resident 86 and stated she should have. During a review of the facility P&P titled, Hand Hygiene Policy for Patients before and after Meals, [undated]. The P&P indicated, Hand Hygiene Before Meals.Nursing staff must assist resident who are unable to wash their hands by: providing hand wipes or sanitizer or assisting with handwashing at a sink if needed. 41035

Based on observation and interview, the facility failed to ensure the dining room was accessible and had space to accommodate the 132 Residents who reside at the facility. This failure had the potential to negatively affect the resident's social interaction, physical, mental, and psychosocial well-being. Findings: During a concurrent observation and interview on 2/24/25 at 12:13 p.m. with Assistant Director of Nursing (ADON) in the dining room, the dining room door was closed and had a coded lock. There were seven round tables. There was a seating chart on the wall that listed where 15 residents would sit. Eight residents were waiting for lunch to be served. ADON stated they usually have around eight residents in the dining room at one time. ADON stated the facility does not have the space for more than eight reisents at one time in the dining room. ADON stated the residents wait in the hallway until the other residents finish their meal and leave the dining room before they enter the dining room for their meal. ADON stated the coded lock on the door is to ensure only staff can open the dining room door. During a concurrent observation and interview at 2/26/25 at 11:27 a.m. with ADON in the dining room, there were six residents sitting at the tables waiting for lunch to be served. DON stated there were 10 residents in the hallway waiting to enter the dining room. Door was closed. ADON stated the10 residents in the hallway were waiting for the other six residents to finish eating before they entered the dining room. During a concurrent observation and interview on 2/26/25 at 11:50 a.m. with Certified Dietary Manager (CDM) outside the locked and closed dining room door. Ten residents were waiting for lunch outside of dining room. CDM stated the dining room door was always closed and locked as not to be accessible to residents. CDM stated I am not sure why that is. CDM stated the dining room is not big enough to accommodate the 10 residents waiting in the hall in addition to the six residents that were already in the dining room. During an interview on 2/27/25 at 11:31 a.m. with Administrator, Administrator stated the dining room will accommodate no more than 15 residents. The dining room should not have a closed locked door. Administrator stated the dining room should be a common space area allowing Residents to come and go. A Policy and Procedure addressing dining room space was requested and not provided.

Based on interview and record review, the facility failed to accurately complete MDS (Minimum Data Set- A tool used to collect data to establish person-centered care needs) for one of 55 sampled residents (Resident 47). This failure had the potential for Resident 47 to not receive care based on his specific needs. Findings: During a concurrent interview and record review on 2/25/25 at 2:50 p.m. with MDS consultant (MDSC) and MDS nurse (MDSN), Resident 47's, MDS-Section N-Medications (MDS-N), dated 1/6/25, and Medication Administration Record (MAR), dated 2/2025 were reviewed. MDSN was unable to provide documentation Resident 47 was on anticoagulant medications (delay blood clot formation). MDSC stated Resident 47 was prescribed Aspirin (helps prevent blood clots) which should not have been coded as an anticoagulant on the MDS. MDSN stated, It [coding Aspirin as an anticoagulant medication] was a mistake on my part. During a review of Center for Medicare and Medi-Cal (CMS) Resident Assessment Instructions (RAI) Manual Version 3.0 for MDS (CMS RAI), [undated], the CMS RAI indicated, Planning of care: Medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes, such as curing an illness, diagnosing a disease or condition, arresting or slowing a disease's progress, reducing or eliminating symptoms, or preventing a disease or symptom.Steps for assessment: 1. Review the resident's medical record for documentation that any of these medications were received by the resident and for the indication of their use. Coding Instructions: .Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release. as N0415E, Anticoagulant.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of 55 sampled residents (Resident 329) when communication interventions were not developed and implemented. This failure had the potential for Resident 329's communication and care needs to not be met. Findings: During a review of Resident 329's Care Plan Report (CPR), dated [DATE], the CPR indicated, Communication: [Resident 329] is at risk for impaired communication related to primary language is Spanish. Goal.Will be able to make needs known. Will have needs met. Will have no declines in communication.Interventions [none]. During an interview on [DATE] at 2:30 p.m. with Resident 329, Resident 329 stated she was Spanish speaking only. Resident 329 stated at times English speaking staff did not understand her and she does not understand English. Resident 329 stated staff use an interpreter when they communicated with her. Resident 329 stated the staff would only check her brief and change it when she called for assistance. Resident 329 stated she would have preferred someone who could communicate with her in her language. During an interview on [DATE] at 9:40 a.m. with Registered Nurse Consultant (RNC) 1, RNC 1 stated Resident care plans are required to have interventions listed. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated [DATE], the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation.4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to. g. receive the services and/or items included in the plan of care. 7. The comprehensive, personal-centered care plan.10. When possible, interventions address the underlying source(s) of the problem area(s).

Based on observation, interview, and record review the facility failed to follow medication orders for one of 13 residents (Resident 76). These failures had the potential for Resident 76 to not receive the full effect of the medication. Findings: During an observation on 2/26/25 at 2:20 p.m. in the doorway of Resident 76's room, Licensed Vocational Nurse (LVN) 9 was preparing to administer medication to Resident 76. LVN 9 removed a package of Potassium Chloride tablets (medicine to treat or prevent low blood levels of potassium) ER (extended release) 20 MEQ [milliequivalent- unit of measure] from her medication cart and compared the medication package with Resident 76's Medication Administration Record (MAR). LVN 9 removed two Potassium Chloride ER 20 MEQ tablets from the medication package. LVN 9 crushed the two tablets of Potassium Chloride ER 20 MEQ. LVN 9 placed the crushed Potassium Chloride tablets in a small cup of apple sauce. LVN 9 fed Resident 76 the apple sauce with the crushed Potassium Chloride ER 20 MEQ tablets. During a concurrent interview and record review on 2/26/25 at 3:42 p.m. with Director or Nursing (DON), Resident 76's Order Listing Report (OLR), dated 2/27/25 was reviewed. The OLR indicated, Potassium oral tablet (Potassium) give 40 mEq by mouth three times a day for Hypokalemia [low potassium]. Resident 76's MAR, dated 2/2025 was reviewed. The MAR indicated, Potassium oral tablet (Potassium) give 40 mEq by mouth three times a day for Hypokalemia. DON stated the LVN should have clarified why the Potassium oral tablet ER medication package did not match with the MAR and OLR which did not indicate Potassium Chloride ER. Resident 76's Potassium Chloride ER tablet package label was reviewed. The package label indicated Potassium CHL (chloride) ER 20 MEQ. DON stated the pill package label indicated Potassium Chloride ER. DON stated LVN 9 should not have crushed the ER medication. During an interview on 2/26/25 at 3:48 p.m. with Pharmacist, Pharmacist was asked if Potassium ER tablets could be crushed. Pharmacist stated Potassium ER should not be crushed. During a review of a Cleveland Clinic Medication Article (CCMC), [undated], the CCMC indicated, Potassium Chloride Extended-Release Tablet.Take it as directed on the prescription label at the same time every day. Take it with food. Do not cut, crush, chew, or suck this medication. Swallow the capsules whole. During a review of the facility's policy and procedure (P&P) titled, Appendix 6: Medication Crushing Guidelines, dated 2019, the P&P indicated, Medications that should not be crushed or chewed. When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc.) the nurse administering the medication should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance to obtaining the medication in liquid form, if possible. The rationale for not crushing some medication includes.Time released tablets are designed to release medication over a sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action. During a review of the facility's P&P titled, Administering Medications, revision date 2019, the P&P indicated, The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Physician Orders, Accepting, Transcribing, Carrying Out and Implementing (Noting), for one of two sampled residents (Resident 126) when Resident 126's wound treatment orders were not implemented. This failure resulted wound care not being provided for Resident 126's right heel blister which had the potential for development of infection and delayed wound healing. Findings: During a concurrent interview and record review on 2/27/25 at 11:26 a.m. with Registered Nurse Consultant (RNC) 1, Resident 126's SBAR [Situation, Background, Assessment, Recommendation] Communication Form and Progress Note for RNs [Registered Nurse]/LPN [Licensed Practice Nurse]/LVNs [Licensed Vocational Nurse] (SBAR), dated 2/19/25 was reviewed. The SBAR indicated, Resident 126 developed a right heel blister, the primary care clinician was notified and a wound treatment was ordered on 2/19/25. The SBAR indicated, Cleanse [right heel blister] with NS [Normal Saline - irrigating fluid], pat dry, paint with Betadine [antiseptic] BID [twice a day]. RNC 1 stated based on Resident 126's SBAR, the physician ordered a wound treatment for the right heel blister and the physician's order was not recorded in Resident 126's medical record. RNC 1 was unable to provide a physician's order for treatment of Resident 126's right heel blister. RNC 1 stated the Resident 126's physician's treatment order for the right heel blister was not implemented. During a review of the facility's P&P titled, Physician Orders, Accepting, Transcribing, Carrying Out and Implementing (Noting), [undated], the P&P indicated, Licensed nursing personnel will ensure that telephone and verbal orders will be recorded and implemented. All physician orders are to be complete and clearly defined to ensure accurate implementation. Procedure 1. Telephone and Verbal Orders. b) Record the actual order received from the physician with the date and time that the order was received. c) The nurse taking the order will sign with a full signature. Telephone and verbal orders shall be immediately recorded on the resident's Clinical Record. 2. Implementation of Orders. a) Licensed nursing shall verify each order for completeness, clarify and appropriateness of doses and allergies.

Based on interview and record review, the facility failed to provide hearing aids for one of one sampled resident (Resident 22). This failure had the potential to affect Resident 22's quality of life. Findings: During a review of Resident 22's Initial ENT (Ears, Nose, Throat) Consultant (IENTC), dated 6/11/24, the IENTC indicated, REASON FOR VISIT.#2 Difficulty Hearing. #6 Stuffy Ears. REFERRALS. Audiogram [test for hearing loss] Recommended: Yes - Hearing abnormal by observation and patient also c/o [complain of] hearing problems. During a review of Resident 22's Audiogram, dated 7/10/24, the Audiogram indicated, Qualified Hearing Loss for Hearing Aids: Y [yes]. Eligibility: Y. Recommendation: Hearing Aids. Notes: The patient [Resident 22] has hearing loss significant enough to qualify for hearing aids. The patient has a greater hearing loss at higher frequencies in the right ear, meaning the patient has greater difficulty discriminating between different sounds during conversation and hearing higher-pitched voices and sounds. During an interview on 2/24/25 at 12 p.m. with Resident 22, Resident 22 stated she does not have hearing aids and was not seen by a hearing doctor recently. During an interview on 2/26/25 at 11:52 a.m. with Social Service Director Case Manager (SSDCM), SSDCM stated she was not aware Resident 22's audiogram on 7/10/24 had recommended hearing aids. During an interview on 2/26/25 at 3:09 p.m. with Social Services (SS), SS stated she was unaware Resident 22 needed hearing aids and stated it was her mistake for not following up after Resident 22's audiogram was completed. During a review of the facility's policy and procedure (P&P) titled, Hearing and Vision Services, [undated], the P&P indicated, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Policy Explanation and Compliance Guidelines. 3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources. for the provision of the vision and hearing services the resident needs. 6. Assistive devices to maintain hearing include, but are not limited to, hearing aids and amplifiers.

Based on observation, interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Administration Set/Tubing Changes for one of one sampled resident (Resident 329). This failure had the potential to place Resident 329 at risk for infection. Findings: During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 in Resident 329's room, Resident 329's Intravenous (IV-flexible tube is inserted into a vein to administer fluids, medications, or blood products directly into the bloodstream) tubing was not labeled. LVN 1 stated the IV tubing should have been labeled with date and time of when the IV tubing was hung and the initials of who hung the IV tubing. During a review of the facility's P&P titled, Administration Set/Tubing Changes, dated February 2023, the P&P indicated, The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment. General Guidelines. 4. Label tubing with date, time and initials. If facility requires, label may include the date and time that tubing was initiated and when tubing should be discontinued or changed. 5. Any tubing that is found not labeled must be changed and then labeled accordingly.

Based on interview and record review, the facility failed to ensure annual competencies were completed for one of five sampled Certified Nursing Assistants (CNA) 1. This failure had the potential for CNA 1 to not be competent when providing care to residents. Findings: During a concurrent interview and record review on 2/26/25 at 3:47 p.m. with Director of Staff Development (DSD), CNA 1's Employee Orientation Checklist (EOC), undated was reviewed. The EOC indicated, CNA 1 date of hire was 12/26/23. CNA 1's new employee orientation began on 12/26/23 and was completed on 12/27/23. CNA 1's Nurse Assistant Competency Checklist (NACC), [undated] was reviewed. The NACC indicated, CNA 1 had completed the competency checklist on 12/27/23. DSD was unable to provide a 2024 annual competency for CNA 1. DSD stated CNA 1 did not have a current annual competency completed as required. Policy requested from facility and was not provided.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Food Preparation, for one of one cooks (Cook 1) when [NAME] 1 did not measure recipe ingredients. This failure had the potential for residents' nutritional needs to not be met. Findings: During a review of the facility's RECIPE: ZESTY SPINACH, (RZS) dated 2/24/25, the RZS indicated, add 1 tsp to 1 1/2 tsp of garlic powder, add 1/4 tsp to 3/4 tsp of salt, and add 1/2 tsp to 1 tsp of red pepper flakes. During a concurrent observation and interview on 2/25/25 at 9:14 a.m. with [NAME] 1, Certified Dietary Manager (CDM), and Registered Dietician (RD), in the kitchen, [NAME] 1 was preparing spinach to be pureed. [NAME] 1 poured all the pureed spinach into a larger dish then added unmeasured amounts of garlic powder, iodized salt, chili powder, and melted butter into the spinach. [NAME] 1 stated she does not use the recipe, she went by taste. [NAME] 1 stated she should have measured the seasoning as listed in the RZS. During an interview on 2/25/25 at 3:17 p.m. with CDM, CDM stated [NAME] 1 should have followed the RZA and measured the spices prior to adding to the spinach dish. During a review of the P&P titled, Food Preparation, dated 2023, the P&P indicated, food shall be prepared by methods that conserve nutritive value, flavor, and appearance. 1. The facility will use approved recipes, standardized to meet the resident census. 2. Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines.

Based on observation, interview, and record review, the facility failed to ensure assistive feeding devices were available for one of one sampled resident (Resident 72). This failure had the potential to prevent Resident 72 from maintaining or improving his independence in self-feeding skills when consuming meals and snacks. Findings: During a review of Resident 72's Admission Record (AR), dated 2/27/25, the AR indicated, Resident 72 was readmitted on [DATE] with a diagnosis hemiplegia (inability to move one side of the body) following cerebral infarction (stroke resulting in blockage in the blood vessels supplying blood to the brain) affecting right dominate side. During a concurrent observation and interview on 2/24/25 at 1:34 p.m. with Resident 72 in Resident 72's room, Resident 72's lunch tray had a cup of tea with one handle, four small bowls containing pureed food, and two regular eating spoons. Resident 72's meal ticket was reviewed. The meal ticket indicated ADAP [adaptive] Equip [equipment] 2 Handle sip cup, coated spoon, [NAME] grip spoon. Resident 72 stated she had not received or used a cup with 2-handles or special spoons in a while. During a concurrent interview and record review on 2/26/25 at 3:56 p.m. with Registered Dietician (RD) in the conference room, RD was shown a picture of Resident 72's lunch tray and meal ticket. RD stated the adaptive eating or drinking devices listed on Resident 72's meal ticket was not on Resident 72's lunch tray. RD stated the kitchen staff are responsible to follow the meal ticket and place the appropriate adaptive equipment on the Resident's meal tray. During a concurrent interview and record review on 2/26/25 at 4:15 p.m. with Certified Dietary Manager (CDM), Resident 72's Adaptive Equipment Tally Report (AETR), dated 2/24/25 was reviewed. The AETR indicted, Resident 72 should have had adaptive Equipment which included 2-Handle sip cup, coated Spoon, and [NAME] grip spoon. CDM stated the kitchen staff should have provided Resident 72 with the appropriate adaptive devices for meals. During a review of Resident 72's Occupational Therapy Treatment Encounter Notes ([NAME]), dated 10/23/24, the [NAME] indicated, Date of service 10/23/24: skilled interventions to facilitate Independence with Self Feeding abilities included compensatory training to increase independence in self-feeding, adaptive equipment instruction to facilitate safety, analysis of performance with adaptive equipment and self-feeding techniques. Pt [Patient-Resident 72] attempted use of built-up handle and ucuff [universal cuff - a leather cuff that fits around the palm of the user's hand and is secured with an elastic strap for better control with utensils] for self-feeding. Pt was able to use both successfully with dycem [a non-slip surface] required to keep plate from sliding. Spoke with OT [occupational therapist] and did right (sic) orders for kitchen to have Pt with built up utensil, maroon spoon, dycem and plate guard as needed for each meal. During a review of Resident 72's Order Listing Report (OLR), dated 2/27/25, the OLR indicted, Resident 72 will use Universal Cuff, built up utensil (plastic, maroon spoon), dycem, and plate guard during all mealtimes as needed to facilitate independence during feeding. During a review of the facility's policy and procedure (P&P) titled, Assistive Devices and Equipment, [undated], the P&P indicated, Policy Statement. Our facility maintains and supervises the use of assistive devices and equipment for residents. Policy Interpretation and Implementation 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include (but are not limited to): a. specialized eating utensils and equipment.

Based on observation, interview, and record review, the facility failed implement its Policy and Procedure (P&P) titled, Smoking, for one of 21 Residents (Resident 4) when tobacco was at the bedside, a smoking care plan and smoking assessment were not completed. These failures had the potential to place residents, visitors, and staff at risk for injury/harm due to potential unsafe smoking practices and access to tobacco. Findings: During a concurrent observation and interview on 2/25/25 at 11:31 a.m. with Licensed Vocational Nurse (LVN) 4 in Resident 4's room, Resident 4 had a can of tobacco at the bedside. LVN 4 stated the tobacco should be locked up and not left at the bedside. During an interview on 2/26/25 at 11:18 a.m. with Activities Assistant (AA), AA stated, If [Resident 4] had full access to his chewing tobacco he will use too much .It is supposed to be locked up. During a concurrent interview and record review on 2/27/25 at 11:52 a.m. with Director of Nursing (DON), Resident 4's, clinical record was reviewed. DON was stated there was no tobacco use care plan or safe smoking evaluation for Resident 4. DON stated Resident 4 should not have tobacco products at the bedside and there should be a tobacco use evaluation and tobacco care plan in place before he is able to use the tobacco. During an interview on 2/27/25 at 2:34 p.m. with Family Member (FM) 1, FM 1 stated, His [Resident 4] tobacco pouches have always been at the bedside but I noticed today they aren't, he needs that, he has been using tobacco for over [AGE] years. During a review of the facility's P&P titled, Smoking, dated 2001, the P&P indicated, This facility has established and maintains safe resident smoking practices. 6. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes a. current level of tobacco consumption; b. method of tobacco consumption (traditional cigarettes, electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed safe smoking evaluation). 7. The staff consults with the attending physician and the director of nursing services (DNS) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. 8. A resident's ability to smoke safely is reevaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 13. Residents with smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision.

Based on observation and interview, the facility failed to provide the minimum square footage as required by regulation in 20 of 48 facility bedrooms. This failure had the potential to affect the care and safety of residents. Findings: During a concurrent observation and interview on 2/27/25 at 10:13 a.m. with Environmental Services Director (ESD), in the facility's multiple occupancy rooms, the multiple occupancy rooms were measured. ESD stated the following rooms did not provide the minimum square footage (sq. ft.) as required by regulation (80 sq. ft. per resident for multi-occupation rooms): room [ROOM NUMBER] measured 239 inches (in.) x (by) 132 in. (219 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 239 in. x 132 in. (219 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 130 in. (215 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 129 in. (213 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 130 in. (215 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 128 in. (211 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 130 in. (215 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 132 in. (218 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 240 in. x 126 in. (210 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 240 in. x 130 in. (217 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 239 in. x 129 in. (214 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 239 in. x 130 in. (216 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 240 in. x 130 in. (217 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 297 in. x 128 in. (264 sq. ft.) and had four resident beds; room [ROOM NUMBER] measured 238 in. x 129 in. (213 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 129 in. (213 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 126 in. (208 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 132 in. (218 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 130 in. (215 sq. ft.) and had three resident beds; room [ROOM NUMBER] measured 238 in. x 130 in. (215 sq. ft.) and had three resident beds. ESD stated there had not been any adjustments to room sizes or the facility floor plan since the previous survey. During an interview on 2/27/25 at 11:17 a.m. with Administrator, Administrator stated there had been no changes to resident room sizes. Administrator stated although 20 of the resident rooms did not provide the minimum sq. ft. as required by regulation, residents had reasonable amount of privacy, closets, adequate storage, bedside tables, and there was sufficient space to ambulate and/or use their wheelchair. Requested a copy of previous room waiver, unable to provide.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse inflicted by his roommate (Resident 2). This failure resulted in Resident 1 being agitated, noisy, restless and the inability to sleep with the potential for psychosocial harm. Findings: During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated, Brief Interview for Mental Status (BIMS).05 (severe cognitive impairment). During a review of Resident 2's MDS dated [DATE], the MDS indicated, BIMS.13 (cognition is intact). During a review of Resident 1's Admission Record (AR), dated 3/3/25, the AR indicated, Resident 1 was admitted [DATE] and had the following diagnoses.quadriplegia c-1-c-4 complete (spinal cord injury resulting in total paralysis of both arms and legs), dysphasia (condition that affects the ability to understand, use, or produce language) following cerebral infarction (lack of oxygen causing an area of dead tissue in the brain). During a review of the facility's Report of Suspected Dependent Adult/Elder Abuse (SOC341), dated 1/23/25, the SOC 341 indicated, It was reported today to Abuse Coordinator/Administrator and designee (Social Services Director) that the alleged aggressor, (Resident 2), displayed angry outbursts toward his roommate, (Resident 1). During a review of Resident 1's and Resident 2's Census List (CL), dated 2/7/25, the CL indicated, Resident 1 and Resident 2 had been roommates since 6/7/23 (approximately one year and 7 months). During an interview on 2/3/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated when Resident 1 and Resident 2 shared a room, Resident 2 would call Resident 1 a pedophile (person sexually attracted to children) and cuss at him. CNA 1 stated Resident 1 was unable to talk but would make grunting noises. CNA 1 stated after Resident 1 and Resident 2 were separated (1/23/25), Resident 1 yelled out less, slept more and seemed more comfortable. During an interview on 2/3/25 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 would yell at Resident 1 when he was moaning and groaning. LVN 1 stated Resident 2 was verbally aggressive towards Resident 1. LVN 1 stated after Resident 1 was moved to a different room, Resident 1 was resting more. During an interview on 2/3/25 at 12:54 p.m. with Social Service Director (SSD), SSD stated Resident 2 would have angry outburst towards others no matter how much he was redirected. During an interview on 2/3/25 at 1:37 p.m. with Director of Staff Development (DSD), DSD stated on 1/23/24, Resident 2 was telling Resident 1 to shut up you f****** baby. DSD stated it was unfair for Resident 1 to hear those words on a day-to-day basis. DSD stated Resident 2 would say shut the f*** up all the time to Resident 1. DSD stated Resident 2 has always said (bad) words to Resident 1. DSD stated she reported it on 1/23/24 because when she went to ask Resident 2 to stop, Resident 2 told her to get the f*** out and if he was verbally abusive to her, she could only imagine what he said to Resident 1. DSD stated after Resident 1 was moved to a different room, Resident 1 was happier, sleeping more and he could moan without being called names. DSD stated Resident 2's verbally abusive behaviors should have been reported to the Administrator when it was happening in the past to protect Resident 1. During an interview on 2/6/25 at 3:55 p.m. with CNA 1, CNA 1 stated Resident 1 could not talk but was able to moan and yell out. CNA 1 stated Resident 2 would get mad at Resident 1 and tell him to shut up. CNA 1 stated when Resident 1 and Resident 2 shared a room together it was stressful to go in the room to provide care to Resident 1 because Resident 2 would call Resident 1 a dirty Mexican, say racial slurs and tell Resident 1 he was gay. CNA 1 stated Resident 1 and Resident 2 had shared a room together for a year. CNA 1 stated when she would report the verbal altercations to the nurses, they would say they were going to make a note of the behavior and care plan it. CNA 1 stated several CNAs said Resident 2 was verbally abusive to Resident 1. During an interview on 2/20/25 at 3:49 p.m. with Administrator, Administrator stated staff had never reported Resident 1 being verbally abusive to Resident 2. Administrator stated the staff should have reported the verbal abuse to him or the Director of Nursing (DON). During a review of the lesson plan titled Abuse: Reporting Requirement & Procedures.What constitutes Abuse? (ARRPWCA), dated 11/19/24 at 2 p.m., the ARRPWCA indicated, Abuse Reporting & Investigations.What are the 7 types of abuse.verbal abuse.five things to do if you witness an abuse: Protect the victim.call for help.report.Resident Rights.Be free from abuse and neglect. During a review of the facility policy and procedure titled, Behavioral Assessment, Intervention and Monitoring dated 3/19, the P&P indicated, The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. During a review of the facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 9/22, the P&P indicated If resident abuse, neglect, exploitation, misappropriation of resident property or injury or unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as within two hours of an allegation involving abuse resulting in serious bodily injury.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when verbal abuse was not reported to the Administrator. This failure resulted in Resident 1 experiencing persistent verbal abuse from his roommate (Resident 2). Findings: During a review of Resident 1's Minimum Data Set (MDS), dated [DATE], the MDS indicated, Brief Interview for Mental Status (BIMS).05 (severe cognitive impairment). During a review of Resident 2's MDS dated [DATE], the MDS indicated, BIMS.13 (cognition is intact). During a review of Resident 1's Admission Record (AR), dated 3/3/25, the AR indicated, Resident 1 was admitted [DATE] and had the following diagnoses.quadriplegia c-1-c-4 complete (spinal cord injury resulting in total paralysis of both arms and legs), dysphasia (condition that affects the ability to understand, use, or produce language) following cerebral infarction (lack of oxygen causing an area of necrotic tissue in the brain). During a review of Resident 1's and Resident 2's Census List (CL), dated 2/7/25, the CL indicated, Resident 1 and Resident 2 had been roommates since 6/7/23 (approximately one year and 7 months). During a review of Resident 1's Psychiatric Consultation (PC), dated 12/9/24, the PC indicated, Patient.seen in room.shows an inability to relax, as evidenced by calling out and episodes of crying. During a review of Resident 2's PC dated 12/9/24, the PC indicated, Patient.seen in room.exhibiting irrational outbursts of anger.Behavior.aggressive.angry.agitated. During an interview on 2/3/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated when Resident 1 and Resident 2 shared a room, Resident 2 would call Resident 1 a pedophile (person sexually attracted to children) and cuss at him. CNA 1 stated Resident 1 was unable to talk but would make grunting noises. CNA 1 stated after Resident 1 and Resident 2 were separated (1/23/25), Resident 1 yelled out less, slept more and seemed more comfortable. During an interview on 2/3/25 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 2 would yell at Resident 1 when he was moaning and groaning. LVN 1 stated Resident 2 was verbally aggressive towards Resident 1. LVN 1 stated after Resident 1 was moved to a different room, Resident 1 was resting more. During an interview on 2/3/25 at 12:54 p.m. with Social Service Director (SSD), SSD stated Resident 2 has angry outburst towards others no matter how much he is redirected. SSD stated when Resident 2 was calling Resident 1 names the staff should have reported it. During an interview on 2/3/25 at 1:37 p.m. with Director of Staff Development (DSD), DSD stated on 1/23/24, Resident 2 was telling Resident 1 to shut up you f****** baby. DSD stated it was unfair for Resident 1 to hear those words on a day-to-day basis. DSD stated Resident 2 says shut the f*** up all the time to Resident 1. DSD stated Resident 2 has always said (bad) words to Resident 1. DSD stated she reported it on 1/23/24 because when she went to ask Resident 2 to stop, Resident 2 told her to get the f*** out and if he was verbally abusive to her, she could only imagine what he says to the roommate. DSD stated after Resident 1 was moved to a different room, Resident 1 was happier, sleeping and he could moan without being called names. DSD stated, Resident 2's verbally abusive behaviors should have been reported to the Administrator when it was happening in the past to protect Resident 1. During an interview on 2/3/25 at 1:55 p.m. with Director of Nursing (DON), DON stated when staff were aware of an abuse allegation it was their responsibility to report it to the administrator. DON stated no allegations of verbal abuse to Resident 1 were reported by staff. During an interview on 2/6/25 at 3:55 p.m. with CNA 1, CNA 1 stated Resident 1 could not talk but was able to moan and yell out. CNA 1 stated, Resident 2 would get mad at Resident 1 and tell him to shut up. CNA 1 stated when Resident 1 and Resident 2 shared a room together it was stressful to go in the room to provide care to Resident 1 because Resident 2 would call Resident 1 a dirty Mexican, say racial slurs and tell Resident 1 he was gay. CNA 1 stated Resident 1 and Resident 2 had shared a room together for a year. CNA 1 stated when she would report the verbal altercations to the nurses, they would say they were going to make a note of the behavior and care plan it. CNA 1 stated several CNAs said Resident 2 was verbally abusive to Resident 1. During an interview on 2/6/25 at 3:54 p.m. with LVN 2, LVN 2 stated Resident 1 would make sounds and wake up Resident 2 at night and Resident 2 would tell Resident 1 to shut the f*** up, you retard. LVN 2 stated Resident 2 was mean, vulgar and verbally abusive to Resident 1 and staff. LVN 2 was unaware if the verbal abuse was reported. LVN 2 stated when Resident 1 was sharing a room with Resident 2 he was up more at night and since the room change, he was resting more. During an interview on 2/6/25 at 4:39 p.m. with CNA 3, CNA 3 stated Resident 2 was verbally abusive to Resident 1 and would tell Resident 1 he was a child predator, baby [NAME] and make fun of his disabilities. CNA 3 stated it had been going on for years and it made Resident 1 feel helpless and upset. CNA 3 stated he had reported the verbal abuse to the nurses and the Director of Staff Development (DSD) in the past. CNA 3 stated since Resident 1 was moved to a different room he had calmed down. During an interview on 2/20/25 at 3:49 p.m. with Administrator, Administrator stated staff had never reported Resident 1 being verbally abusive to Resident 2. Administrator stated the staff should have reported the verbal abuse to him or the Director of Nursing (DON). During a review of the lesson plan titled Abuse: Reporting Requirement & Procedures.What constitutes Abuse? (ARRPWCA), dated 11/19/24 at 2 p.m., the ARRPWCA indicated, Abuse Reporting & Investigations.What are the 7 types of abuse.verbal abuse.five things to do if you witness an abuse: Protect the victim.call for help.report.Resident Rights.Be free from abuse and neglect. During a review of the facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 9/22, the P&P indicated If resident abuse, neglect, exploitation, misappropriation of resident property or injury or unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as within two hours of an allegation involving abuse resulting in serious bodily injury.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to follow their policy and procedure when a resident-to-resident allegation of abuse was not reported to California Department of Public Health (CDPH-state agency) per facility policy and procedure for two of two sampled residents (Resident 4 and Resident 5). This failure resulted in the allegation of abuse not being reported to CDPH timely. Findings: During a review of the Initial Facility Reported Event (IFRE), (undated), the IFRE indicated, Date/Time Reported: 12/16/24 approx. (approximately) 5 p.m. CDPH.Obtained knowledge 12/16/24 of incident on 12/14/24 at approx. 5:44 p.m. (approximately 48 hours prior to the abuse being reported) .Type of Incident. resident-to-resident physical contact.An incident of resident-to-resident mistreatment occurred between (Resident 5) and (Resident 4). Per staff witness, both residents were initially arguing when (Resident 4) kicked (Resident 5). During a review of Resident 4's Minimum Data Set (MDS-resident assessment tool) dated 12/8/24, the MDS indicated, Brief Interview for Mental Status (BIMS).12 (moderately impaired cognitively). During a review of Resident 5's Minimum Data Set (MDS-resident assessment tool) dated 12/7/24, the MDS indicated, Brief Interview for Mental Status (BIMS). 03 (severe cognitive impairment). During an interview on 12/16/24 at 4:22 p.m. with Administrator (prior to the facility reporting the incident), Administrator stated he was not aware of the resident-to-resident (Resident 4 and Resident 5) altercation on 12/14/24, but it should have been reported to CDPH. During an interview on 12/30/24 at 2:28 p.m. with Social Services Director (SSD), SSD stated when the resident-to-resident (Resident 4 and Resident 5) altercation occurred, the staff should have notified the abuse coordinator right away and it should have been reported to CDPH per facility policy. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the P&P indicated 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.Immediately is defined as. within two hours of an allegation involving abuse or result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to ensure the care plan was followed for one of three sampled residents (Resident 3) when the mesh stop sign on Resident 3's door was not in use. This failure had the potential for residents to wander into Resident 3's room. Findings: During a review of Resident 3's Care Plan (CP), (undated), the CP indicated, 12/3/24 Alleged receiver of inappropriate touching from another resident.Interventions/Tasks.Place a bright colored stop sign at the entrance to deter wandering residents. During a concurrent observation and interview on 12/30/24 at 3:29 p.m. with Certified Nursing Assistant (CNA) 1 in the hallway, the mesh stop sign on Resident 3's door was not in use. CNA 1 confirmed the findings and stated the mesh stop sign was used to keep wandering resident's out of Resident 3's room and it should have been in use. During an interview on 12/30/24 at 3:45 p.m. with Social Service Director (SSD), SSD stated Resident 3's stop sign should always be used to deter the wandering residents from entering the room. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 3/22, the P&P indicated, 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 psychological well-being.

Based on interview and record review, the facility failed to ensure the physician orders were implemented for one of three sampled residents (Resident 3). This failure resulted in Resident 3 not receiving the medication as ordered by the physician and had the potential for adverse health outcomes. Findings: During a review of Resident 3's Physician's Orders (PO), dated 12/11/24, the PO indicated, 12/11/24 Increase Xanax (medication used to treat anxiety) 1mg (milligram-a unit of measurement) TID (three times a day). During a review of Resident 3's Order Summary Report (OSR), dated 12/30/24, the OSR indicated, Resident 3 had a physician order for Alprazolam (also known as Xanax) oral tablet 1 mg give 1 tablet by mouth two times a day.start date 10/24/24. During a review of Resident 3's Medication Administration Record (MAR), dated 12/24, the MAR indicated, Alprazolam.1 mg. two times a day was being administered daily. During an interview on 12/30/24 at 2:34 p.m. with Social Service Director (SSD), SSD stated she was the one who received Resident 3's PO from the psychologist. SSD stated she did not provide nursing with the PO and she should have. SSD stated Resident 3 should have been receiving Xanax 1 mg TID and not the Xanax two times daily. During a review of the facility's policy and procedure (P&P) titled Administering Medications dated 4/19, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to implement comprehensive person-centered care plan for activities of a daily living (ADL) when Hoyer (mechanical, device used to safely lift and transfer patients who have limited mobility) lift was not used to transfer one of three sampled residents (Resident 1) from wheelchair to bed. This failure resulted in Resident 1 falling multiple times and sustaining two broken bones in each lower leg, requiring an open reduction and internal fixation (ORIF, surgical procedure to repair broken bones that may include use of screws, rods, or plates) of the left upper tibia and lateral tibial plateau plate (shin bone). Findings: During a review of Resident 1's Admission Record (AR), dated 10/08/22, the AR indicated, Resident 1 was a readmission on 2/23/23 with diagnoses of difficulty in walking, and muscle wasting in right and left lower legs, difficulty in walking, generalized muscle weakness, other- lack of coordination, abnormality of gait (walking) and mobility, hypertensive (the heart has to work hard to pump blood against high blood pressure) heart disease with heart failure. During a review of Resident 1's MDS dated [DATE], the MDS, the MDS indicated Section GG - Functional Abilities and Goals GG indicated A. Roll left and Right, Resident 1's score was 01 (score of 01 means dependent, indicating Helper does ALL of the effort). The MDS indicated E. chair/bed-to chair transfer: Resident 1's score was 01. During a review of Resident 1's Fall Risk Observation/Assessment (FROA), dated 8/14/24, the FROA indicated Resident 1 score was 20 (score of 16-42 means high risk for falls). During a review of Resident 1's Care Plan (CP), dated 8/19/24, the CP indicated Resident 1 requires a Hoyer lift for transfer. During an interview on 10/2/24 at 9:00 a.m. with Director of Nursing (DON), DON stated Resident 1 required a Hoyer lift for transfers. DON stated therapy (OT) uses the sliding board (a flat board used to move individuals from one place to another) and standing pivot (assisting with guided transfer movement). During an interview on 10/22/24 at 11:50 a.m. with Occupational Therapist (OT), OT stated on 9/12/24 Resident 1 was a stand and pivot with therapy and a maximum (Hoyer lift) for staff. During an interview on 10/22/24 at 11:52 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, During report, I was told that therapy had given CNAs the okay to transfer the resident from walker to bed. I was helping Resident [1] go from the chair to the bed on 9/12/24 when Resident [1] was already standing, and she [Resident 1] stated she was tired, and she started to go down. CNA 2 stated, I assisted her [Resident 1] to the floor. During a review of Resident 1's Interdisciplinary Team Progress Notes (ITPN), dated 9/13/24 at 2:56 p.m., the ITPN indicated interventions for Resident 1: ADL: dependent assist with ADLs and transfers. Anticipate resident needs, provide verbal cue, and safety education. During an interview on 10/22/24 at 1:27 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, She [Resident 1] was assisted by three staff, they used a gait belt [a device that helps with mobility issues to move safely, a thick, woven strap that's placed around a resident's waist and fastened with a buckle] that is why I found a bruise on the left upper arm bicep [a large muscle in the upper arm] area on 9/13/24. During a concurrent observation and interview on 11/4/24 at 10:10 a.m. with Resident 1, in Resident 1 ' s room, Resident 1 was lying in bed with casts (holds a broken bone/fracture in place and prevents the area from moving as it heals) on both lower legs. Resident 1 stated she had two recent falls this month. Resident 1 stated her first fall was on 9/12/24. Resident 1 stated, CNA [2] asked me to stand and use the board. Resident 1 stated she tried to turn her body and fell . Resident 1 stated she had a second fall on 9/20/24. Resident 1 stated every morning the staff has her stand and use the walker from the wheelchair, and the Hoyer lift is never used. Resident 1 stated, CNA [1] asked me to stand. Resident 1 stated she felt weak, and CNA 1 stated, You can do it and next thing I remember is I am on the floor. Resident 1 stated when she was on the floor her knees were bent and she was sitting on her legs. Resident 1 stated a therapist picked her up by her waist and tossed her on the bed. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/14/24, the MDS indicated Resident 1 had a Brief for Mental Status (BIMS) score of 14 (score of 13-15 means cognitively intact). During a review of the Resident 1's Progress Notes (PN), dated 9/21/24 at 8:30 a.m., the PN indicated, [Resident 1] had bruising to bilateral lower extremities painful/hot to touch. Pain was 8/10 [using pain scale 0-10, with 0 representing no pain and 10 representing the worst pain possible] and physician was notified, and [Resident 1] was transferred to a local hospital. During a review of the hospital's Image Report (IR), dated 9/23/24, the IR indicated Resident 1 had comminuted displacement fracture (where the bones are broken in several places) to both right and left tibia (inner larger bones between the knee and the ankle on the inside) and fibula (the outer smaller bones between the knee and the ankle). During a review of the hospital's Emergency Department Note (EDN), dated 9/21/24, the EDN indicated, Recommends admission in the hospital and will perform surgery on Monday. During a review of the hospital's Operative Report (OR), dated 9/23/24, the OR indicated, Pre-op diagnosis: Displaced fracture (broken bone not in alignment) right upper tibia (shinbone) and displaced fracture left upper tibia. The OR report indicated (Resident 1) had a surgical procedure for open reduction and internal fixation of the left upper tibia and lateral tibial plateau plate of each leg. During a review of the facility's policy and procedure (P&P), titled, Falls - Clinical Protocol, dated 2001, the P&P indicated, Treatment/Management: 1. Will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. During a review of the facility's P&P, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to provide the necessary assistance for one of one sampled resident (Resident 1) when Certifed Nursing Assistant (CNA) 1 attempted to transfer the resident with no assistance from another staff resulting in the resident falling to the ground. The facility also failed to complete the Fall Risk Evaluation (FRE - an assessment containing a series of questions which are used to determine if a resident is at risk of falling. A score of under 10 is low risk for falls and a score of 10 or greater is a high risk for falls) to accurately reflect Resident 1's risk of falling and failed to update the Communication Document (CD - document located at the nursing station which documents the required level of assistance for each resident) for Resident 1 to accurately reflect the level of assistance required when transferring the resident from the chair to the bed. These failures resulted in the Resident 1 falling to the floor and sustaining a fracture of the right femur (thigh bone). Findings: During a review of Resident 1's ADMISSION RECORD (AR) dated 11/2/22, the AR indicated Resident 1 had diagnoses of muscle weakness, abnormality of mobility and gait (manner of walking), need for assistance with personal care, reduced mobility, repeated falls, and cerebral infarction (disruption of blood flow resulting in lack of oxygen to the brain). During an interview on 11/2/22, at 11:41 AM, with Certified Nursing Assistant (CNA 1), CNA 1 stated on 10/21/22 she assisted the resident with a shower. CNA 1 stated after assisting the resident with the shower she rolled the resident back to her room via the shower chair (specially designed rollable, waterproof chair used to shower a resident) to place the resident back to bed. CNA 1 stated she was by herself when she tried to transfer Resident 1 back to her bed from the shower chair. CNA 1 stated she was holding Resident 1's left arm when Resident 1 stood up. CNA 1 stated when Resident 1 stood up to transfer from the shower chair to the bed, the resident started to slide down to the floor. CNA 1 stated she shouted for help as Resident 1 fell to the floor. Resident 1 landed on the floor with her legs in a spread open position. CNA 1 stated after the fall to the floor Resident 1's right leg looked, swollen. CNA 1 stated the CD form located at the nurse's station indicated Resident 1 required one person to assist the resident with transferring from a chair to the bed and from the bed to the chair. CNA 1 stated she was not aware Resident 1 required two persons to assist the resident with transferring until after the resident fell on [DATE]. During a concurrent interview and record review on 11/2/22, at 12:56 PM, with Minimum Data Set Nurse (MDSN 1), Resident 1's Fall Risk Evaluation (FRE), was reviewed. The FRE indicated the following: A. 3/3/22 - Resident 1 had a fall risk score of 15 (high fall risk) B. 6/3/22 - Resident 1 had a fall risk score of 11 (high fall risk) C. 9/2/22 - Resident 1 had a fall risk score of 5 (low fall risk). MDSN 1 stated she did not accurately complete the 9/2/22, FRE when she marked Resident 1's cognitive status as cognitively alert and oriented x4 (the resident can state their name, place, time and date) and that was the reason Resident 1's fall risk score changed from a high risk for falling on 6/3/22 to a low risk for falling on 9/2/22. MDSN 1 stated if a resident is a high fall risk for fall versus a low fall risk, the facility would implement more actions to prevent a fall (for example increased monitoring of the resident's whereabouts, placing the bed in the lowest position, fall mats on the floor on both sides of the bed). MDSN 1 stated the facility had an IDT (Interdisciplinary Team - a meeting of various professionals that meet to discuss resident concerns and issues) meeting on 9/2/22 that consisted of the Director of Nursing (DON), Activities Director (AD), Physical Therapist (PT), Dietary Director (DD), MDSN 1 and MDSN 2 to discuss Resident 1's fall risk assessment. MDSN 1 stated the IDT did not identify the inaccuracies in Resident 1's FRE which resulted in the low fall risk score of 5. During a concurrent interview and record review on 11/2/22, at 12:56 PM, with MDSN 2, Resident 1's MDS section titled Functional Status (FS), dated 9/3/22 was reviewed. The FS indicated Resident 1 required extensive two-person assistance for transfers (the residents' ability to transfer in and out of bed), bed mobility, dressing, and toilet use. Resident 1's Care Plan (CP) dated 4/14/21 was reviewed. The CP indicated Resident 1 required extensive two-person assistance for bed mobility and transfers from bed to chair and chair to bed. MDSN 2 stated this information is relayed to nursing staff via the CD located at each nursing station. MDSN 2 reviewed the CD for Resident 1 located at the nursing station and stated the document inaccurately documented Resident 1's required level of assistance. MDSN 2 stated the CD indicated Resident 1 only required one-person assistance to transfer Resident 1 from the chair to the bed and the bed to the chair. MDSN 2 stated the nursing staff used the CD information to determine Resident 1's level of assistance required by staff. MDSN 1 stated the CD did not accurately reflect what Resident 1's need were as indicated by the FS assessment and the CP. During a review of Resident 1's facility Radiology Results Report (RRR), dated 10/23/22, at 1:31 PM, the RRR indicated, Resident 1 had an acute (new) fracture (break in the bone) of her femur (large thigh bone). During a review of Resident 1's emergency room Note (ERN), dated 10/23/22, at 3:09 PM, the ERN indicated Resident 1 presented to the Emergency Department with leg pain. Resident 1 had a pain level of six to eight out of 0 to10 pain scale when motionless (a numerical pain scale is used to assess a patient's pain level with a score of zero - no pain, one to three is considered mild pain, four to six is considered to be moderate pain, and seven to nine is considered to be severe pain, and a score of 10 is very severe pain). During a review of Resident 1's Acute Hospital History and Physical Report (HPR), dated 10/23/22, at 9:51 PM, the HPR indicated, [Resident 1] is a [AGE] year-old [sic] female . who presented to the ED [Emergency Department] after sustaining a fall at her [facility] on Thursday of this week, approximately 3 days ago. On reevaluation, the patient [Resident 1] was fairly somnolent [drowsy] after receiving fentanyl [a narcotic pain medication] for severe pain. Per the patient's [Resident 1] son, they were unaware of the fall at [facility] until earlier today [10/23/22] . Femur CT [Computed Tomography - a form of Xray] demonstrated distal fracture at the [right] femur. Plan . Orthopedic [specialized medical field regarding bones] surgery [consult] . low-dose morphine [narcotic pain medication] for pain control . During a review of the facility's policy and procedure (P&P) titled, MDS ASSESSMENT, undated, the P&P indicated, It is the policy of this facility to conduct and document a comprehensive assessment on all residents.for patient care planning in order to coordinate all data collected, assess all resident's level of function and develop a plan of care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was transferred by two staff. This failure resulted in Resident 1 experiencing an assisted fall resulting in a fracture. Findings: During a review of Resident 1's Progress Notes (PN), dated 2/2/22, at 9:43 AM, the PN indicated, Alerted by staff member, while attempting to transfer resident from bed to wheelchair, she was uanble [sic] to transfer her and slid her down to her bottom onto the floor. Upon entering residents room, resident noted to be by her bed sitting on her bottom with assistance from staff member. Resident unable to to [sic] answer due to being non-verbal, but slightly groans of discomfort, and some facial grimacing, discomfort treated with PRN [as needed] pain medication. During a review of Resident 1's PN, dated 2/3/22 at 9:54 AM, the PN indicated, IDT [Interdisciplinary Team] note.Fall non-injury 2/2/22.educated staff on safe resident transfers and resident being total dependence/two-person assist for transfers.Interventions.Educate staff on proper transfer technique. During a review of Resident 1's PN, dated 2/8/22, at 2:14 PM, the PN indicated, Communication- with Physician. Situation: Resident noted to have +2 (leaves a 3-4-millimeter depression or slight indentation when pressed) swelling to right knee with redness and warmth to touch. Resident also appears to be in pain as observed by facial grimacing.Recommendations.X-ray 2V [views] to right knee r/t [related to] pain/swelling. During a review of Resident 1's Radiology Results Report (RRR), dated 2/8/22, at 6:57 PM, the RRR indicated, Findings: There is a fracture involving right distal femur with displacement (acute knee fracture) During a review of Resident 1's Minimum Data Set (MDS-comprehensive assessment of each resident's functional capabilities), dated 11/21/21, the MDS indicated, Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position.Self-Performance.4 (indicating resident was total dependent on staff) .Support.3 (indicating resident required the assistance of two+ persons physical assist). During a review of Resident 1's Weekly Summary Nurse Progress Note (WSNPN), dated 1/30/22, at 12:31 AM, the WSNPN indicated, Physical Functioning/Structural Problems.Transfer: support provided.Two+ persons physical assist. During a review of Resident 1's MDS Kardex Report For [Facility Name] (MDSKRF-informs staff on how to care for resident), printed 4/6/22, at 9:40 AM, the MDSKRF indicated as of 2/1/22 (prior to the incident), Resident 1 required ADL (Activities of Daily Living) Transfer Total Dependence.Two+ persons physical assist During an interview on 2/10/22, at 1:35 PM, with Administrator, Administrator stated, Resident 1 had a fall, during a transfer, on 2/2/22. On 2/8/22 Resident 1 exhibited pain and swelling to the knee, an x-ray was done and results indicated a fracture. Administrator stated, the facility assumed the fracture occurred when Resident 1 fell on [DATE]. During an interview on 2/10/22, at 2:16 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was assigned to Resident 1 on the day of the fall. LVN 1 stated, when she entered Resident 1's room, Resident 1 was on the floor sitting on her bottom and Certified Nursing Assistant (CNA) 1 was holding her up. LVN 1 stated, CNA 1 reported that when she was transferring Resident 1 to her wheelchair and Resident 1 was unable to assist with the transfer into the wheelchair, so CNA 1 guided Resident 1 to the floor. LVN 1 stated, CNA 1 was transferring Resident 1 alone at the time of the fall. During an interview on 2/10/22, at 2:25 PM, with CNA 2, CNA 2 stated, Resident 1 was unable to follow commands and bear weight. CNA 2 stated, Resident 1 required two people for transfers because she was unable to bear weight. During an interview on 2/10/22, at 3:42 PM, with CNA 3, CNA 3 stated, Resident 1 was always a two person transfer because she was unable to bear weight. During an interview on 2/10/22, at 4 PM, with LVN 2, LVN 2 stated, Resident 1 was totally dependent upon staff for care. LVN 2 stated, if staff were to have Resident 1 bear weight at all she would not be able to. During an interview on 4/5/22, at 4:15 PM, with CNA 1, CNA 1 stated, on 2/2/22 she sat Resident 1 on the edge of the bed so she could stand and pivot Resident 1 into her wheelchair. CNA 1 stated, she was unable to lift Resident 1 into the wheelchair and Resident 1 began to get heavier, so she guided her to the floor and Resident 1 sat on her bottom. CNA 1 stated, she normally transferred Resident 1 by placing her arms under Resident 1's arms, and her knee in between her legs while grabbing the back of Resident 1's pants and transferring Resident 1 into the wheelchair. CNA 1 stated, Resident 1 was totally dependent with care and was unable to stand or bear weight. During an interview on 4/5/22, at 4:42 PM, with Director of Nursing (DON), DON stated, on 2/2/22 Resident 1 was transferred by one person and during the transfer Resident 1 was guided to the floor. DON stated, Resident 1 should have been transferred by two staff. During a review of the facility's policy and procedure (P&P) titled, Transfer Activities dated 2018, the P&P indicated, Transfer from Bed to Wheelchair 1. Obtain assistance of another individual if necessary for safe transfer.

Based on interview and record review the facility failed to notify the physician of a swollen hip and pain with movement for one of one sampled residents (Resident 1). This failure resulted in severe untreated pain for Resident 1 and a delay in acute medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During an interview on 6/24/21, at 1 PM, with Director of Nursing (DON), DON stated, the facility transferred Resident 1 to the acute hospital on 12/13/20 and the hospital diagnosed Resident 1 with a left hip fracture (break in bone). DON stated, Resident 1 did have pain on 12/12/20. During an interview on 6/24/21, at 3 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she worked with Resident 1 on 12/13/20 around 3 AM to 6 AM. LVN 1 stated, the outgoing shift had reported Resident 1 had swelling to her left leg area but there was, nothing to worry about. LVN 1 stated, there was no report given of Resident 1 having pain. LVN 1 stated, during her 3 hour shift Resident 1 remained asleep. LVN 1 stated, Resident 1 was repositioned and had her brief (adult diaper) changed throughout the shift with no reports from staff that there was any pain. During an interview on 6/24/21, at 3:10 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she had worked directly with Resident 1 on 12/12/20 starting around 2:45 PM until 11:15 that night. CNA 1 stated, Resident 1 was fine until after dinner time (after 5 PM). CNA 1 stated, after dinner time she went into Resident 1's room to change her brief and noticed Resident 1's left hip was Swollen. CNA 1 stated, the left hip was bigger than the right hip. CNA 1 stated, when she would move Resident 1 in bed, Resident 1 would moan out in pain. CNA 1 stated, she went to go get CNA 2 to confirm something was different about Resident 1's left hip since CNA 2 was usually assigned to Resident 1. CNA 1 stated, CNA 2 confirmed something was abnormal about Resident 1's left hip and together they both went to inform Registered Nurse (RN) 1. CNA 1 stated, RN 1 instructed her to keep an eye on Resident 1 and not place Resident 1 on her left side. CNA 1 stated, it was facility practice to check, change, and reposition residents every two hours. CNA 1 stated, for the rest of her shift she did not place Resident 1 on her left side. CNA 1 stated, whenever CNAs moved Resident 1, she moaned and showed signs and symptoms of pain. CNA 1 stated, she did not tell RN 1 again about Resident 1's moaning in pain because he was already aware of it. During an interview on 6/29/21, at 1:48 PM, with CNA 2, CNA 2 stated, she had worked from 2:45 PM to 11:15 PM on 12/12/20. CNA 2 stated, she had worked with Resident 1 in the past. CNA 2 stated, she was initially called in to confirm if Resident 1's left leg/hip area was different than usual. CNA 2 stated, when she saw Resident 1's left leg/hip area she had thought, Oh my gosh what happened. CNA 2 stated, there was a Big noticeable difference in the left leg, it was a big leg, it was swollen. CNA 2 stated, Resident 1 usually only required one CNA to assist with her care. CNA 2 stated, on 12/12/20, Resident 1 required two CNAs because of the amount of pain she was in when moved. CNA 2 stated, Resident 1 would scream in pain and strike out at staff with any type of movement throughout the shift. CNA 2 stated, they (CNAs) moved and repositioned Resident 1 every two hours. CNA 2 stated, they would use a pillow to move her left leg to attempt to minimize the amount of pain she was experiencing. CNA 2 stated, when moved Resident 1 would exhibit pain on a scale of eight or nine out of ten (zero being no pain, five being moderate pain, and ten being unbearable excruciating pain). CNA 2 stated, she would report to RN 1 about Resident 1's pain every time they moved her. CNA 2 stated, RN 1 instructed her not to place Resident 1 on her left side. CNA 2 stated, they endorsed (reported) the pain and left leg issues Resident 1 had to the next shift to make them aware. During an interview on 6/29/21, at 2:07 PM, with RN 1, RN 1 stated, he was the nurse in charge of Resident 1 on 12/12/20. RN 1 stated, CNA 1 had called him to check on Resident 1 around 4 PM. RN 1 stated, he noticed Resident 1 crying out in pain and grimacing with movement. RN 1 stated, Resident 1's left leg was Slightly swollen. RN 1 stated, he did not contact the Medical Doctor (MD) for Resident 1 because he did not consider it a change in condition for Resident 1. RN 1 stated, he did not check Resident 1's history or her care plans to help understand Resident 1's baseline status (initial condition). RN 1 stated, he did not try to move Resident 1's left leg because she would swat us away when we tried to move it. RN 1 stated, the CNAs never told him that Resident 1 was in pain throughout the shift. RN 1 confirmed, he did not give Resident 1 pain medication nor inform the MD of any left leg/hip issues. During an interview on 7/8/21, at 2:25 PM, with CNA 3, CNA 3 stated, she had worked with Resident 1 on the day she was sent to the hospital (12/13/20). CNA 3 stated, she worked the morning (6:45 AM to 3:15 PM) shift. CNA 3 stated, CNA 4 endorsed to her Resident 1 was in pain with movement. CNA 3 stated, when she went to change Resident 1's brief around 8 AM, she noticed Resident 1's left leg/hip had a large firm bump. CNA 3 stated, the bump was extremely noticeably different than her right [leg]. CNA 3 stated, Resident 1 was a very small lady, and you could see her bones on the right leg/hip, but on her left leg/hip there was just a large bump. CNA 3 stated, she reported this change to LVN 2. CNA 3 stated, LVN 2 came into Resident 1's room and observed Resident 1's left leg. CNA 3 stated, LVN 2 then said he was going to send Resident 1 to the hospital because something was noticeably wrong with Resident 1's left leg. CNA 3 stated, Resident 1 did not want to be touched. CNA 3 stated, Resident 1's pain level would be at a nine or ten out of ten when she was awake or being moved. During an interview on 7/23/21, at 8:27 AM, with CNA 4, CNA 4 stated, he worked the night shift on 12/12/20 to the morning of 12/13/20 (10:45 PM to 7:15 AM). CNA 4 stated, he was assigned Resident 1. CNA 4 stated, Resident 1's left leg/hip was really noticeable and bulging out. CNA 4 stated, Resident 1 was in pain only when moving or changing her. During a review of Resident 1's Imaging Report, dated 10/27/20, the Imaging Report indicated, Resident 1 had severe osteopenia (a severe form of bone loss). During a review of Resident 1's Care Plan, [undated], the Care Plan indicated, Resident 1 had a high risk for injuries, deformities, spontaneous fractures (break in bone occurring without injury) and pain related to osteopenia (bone loss). The Care Plan indicated, interventions for nursing to implement included notifying the MD of any change in condition, joint bone pain, and stiffness. During a review of the facilities policy and procedure (P&P) titled, Interact Signs and Symptoms (a facility tool used to determine a change of condition), dated 6/2018, the P&P indicated, a change of condition is considered Immediate when there is a New severe pain . During a review of the facilities policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 5/2017, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an). discovery of injuries of an unknown source. significant change in the resident's physical/emotional/mental condition. need to alter the resident's medical treatment significantly. A 'significant change' of condition. will not normally resolve itself without intervention by staff.

Based on interview and record review the facility failed to provide pain medication for one of one sampled residents (Resident 1). This failure resulted in Resident 1 experiencing unresolved pain due to a broken hip for approximately 12 hours during which she would scream and moan with pain, and swat away staff during provision of care. Findings: During an interview on 6/24/21, at 1 PM, with the Director of Nursing (DON), DON stated, the facility transferred Resident 1 to the acute hospital on 12/13/20 and the hospital diagnosed her with a left hip fracture. DON stated, Resident 1 did have some pain on 12/12/20. During an interview on 6/24/21, at 3:10 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she had worked directly with Resident 1 on 12/12/20 starting around 2:45 PM until 11:15 PM that night. CNA 1 stated, Resident 1 was fine until after dinner time (after 5 PM). CNA 1 stated, after dinner time she went into Resident 1's room to change her brief and noticed Resident 1's left hip was Swollen. CNA 1 stated, the left hip was bigger than the right hip. CNA 1 stated, when she would move Resident 1 in bed, Resident 1 would moan out in pain. CNA 1 stated, together with CNA 2, she informed Registered Nurse (RN) 1 of a change to Resident 1's hip and her pain. CNA 1 stated, RN 1 instructed her to keep an eye on Resident 1 and not place Resident 1 on her left side. CNA 1 stated, it was facility practice to check, change, and reposition residents every two hours. CNA 1 stated, for the rest of her shift she did not place Resident 1 on her left side. CNA 1 stated, whenever CNAs moved Resident 1, she moaned and showed signs and symptoms of pain. CNA 1 stated, she did not tell RN 1 again about Resident 1's moaning in pain because he was already aware of it. During an interview on 6/29/21, at 1:48 PM, with CNA 2, CNA 2 stated, she had worked from 2:45 PM to 11:15 PM on 12/12/20. CNA 2 stated, Resident 1 required two CNAs to assist with care instead of her usual one CNA because of the amount of pain she was in when they would move her. CNA 2 stated, Resident 1 would scream in pain and strike out at staff with any type of movement throughout the shift. CNA 2 stated, they (CNAs) moved and repositioned Resident 1 every two hours. CNA 2 stated, they would use a pillow to move her left leg to attempt to minimize the amount of pain she was experiencing. CNA 2 stated, when in pain Resident 1 would exhibit pain on a scale of eight or nine out of ten (zero being no pain, five being moderate pain, and ten being unbearable excruciating pain). CNA 2 stated, she would report to RN 1 about Resident 1's pain every time they moved her. CNA 2 stated, RN 1 instructed her not to place Resident 1 on her left side. CNA 2 stated, they endorsed (reported) Resident 1's pain and left leg issues to the next shift to make them aware. During an interview on 6/29/21, at 2:07 PM, with RN 1, RN 1 stated, he was the nurse in charge of Resident 1 on 12/12/20. RN 1 stated, CNA 1 had called him to check on Resident 1 around 4 PM. RN 1 stated, he noticed Resident 1 crying out in pain and grimacing with movement. RN 1 stated, Resident 1's left leg was Slightly swollen. RN 1 stated, he did not contact the Medical Doctor (MD) for Resident 1 because he did not consider it a change in condition for Resident 1. RN 1 stated, he did not check Resident 1's history or her care plans to help understand Resident 1's baseline status (the persons normal state of health). RN 1 stated, he did not try to move Resident 1's left leg because she would swat us away when we tried to move it. RN 1 stated, the CNAs never told him that Resident 1 was in pain throughout the shift. RN 1 stated, if he was aware Resident 1 was in pain, he would have given Resident 1 pain medication. RN 1 confirmed, he did not give Resident 1 pain medication nor inform the MD of any left leg/hip issues. During an interview on 7/8/21, at 2:25 PM, with CNA 3, CNA 3 stated, she had worked with Resident 1 on the day she was sent to the hospital (12/13/20). CNA 3 stated, she worked the morning (6:45 AM to 3:15 PM) shift. CNA 3 stated, CNA 4 endorsed to her Resident 1 was in pain with movement. CNA 3 stated, LVN 2 then said he was going to send Resident 1 to the hospital because something was noticeably wrong with Resident 1's left leg. CNA 3 stated, Resident 1 did not want to be touched. CNA 3 stated, Resident 1's pain level would be at a nine or ten out of ten when she was awake or being moved. During an interview on 7/23/21, at 8:27 AM, with CNA 4, CNA 4 stated, he worked the night shift on 12/12/20 to the morning of 12/13/20 (10:45 PM to 7:15 AM). CNA 4 stated, he was assigned Resident 1. CNA 4 stated, Resident 1's left leg/hip was really noticeable and bulging out. CNA 4 stated, Resident 1 was in pain only when moving or changing her. During a review of Resident 1's History and Physical Report (H&P), dated 12/13/20, the H&P indicated Resident 1 had a left hip fracture confirmed by x-ray. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. Monitor for pain Q [every] shift using the following numerical pain scale: 0 = No Pain, 1-3 = mild pain, 4-6 = mod [moderate] pain, 7-10 = severe pain .nonpharmacological [other than medication] interventions: 0 - not applicable 1 - Heat/Cold compress 2 - positioning . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . b. NOTE EPISODE of striking out/physical aggressiveness . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . c. NOTE EPISODE of verbally aggressively/yelling . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Progress Notes, dated 12/13/20, at 3:06 AM, the Progress Note indicated, L [left] hip swelling with no bruising. Resident c/o [complain of] pain and discomfort when moving lower extremities [legs] .Repositioning gives comfort. During a review of Resident 1's Progress Notes, dated 12/13/20, at 10:20 AM, the Progress Note indicated Resident noted to c/o pain to the left hip when reposition and when care is provided. Upon evaluation resident noted to have a prominence [bump, swelling] hard to touch and tender to the left hip.

Based on observation, interview, and record review, the facility failed to ensure the plan of care using a Hoyer lift ([a commonly use brand] mechanical lift are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical support) was followed for one of three sampled residents (Resident 1) during a transfer from her bed to a shower chair. This failure resulted in Resident 1's fall to the floor (sitting on her buttock next to her bed) on 11/05/20 with a fractured left femur (broken bone of the thigh, extending from the hip to the knee). Findings: During a review of Resident 1's Admission Record (AR), dated 11/19/20, at 9:27 AM, the AR indicated, Resident 1 was originally admitted to the facility on [DATE], was readmitted on [DATE] with Diagnosis Information .contracture [shortening and hardening of muscles, tendons, or other tissues often leading to deformity], right knee .contracture, left knee .contracture, right ankle .contracture, left ankle .other abnormalities of gait [manner of walking] and mobility .muscle weakness .morbid [severe] obesity .repeated falls. During a review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool), dated 9/26/20, the MDS indicated, BIMS [Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly] score of 3 which indicated severe impaired cognition. Resident 1 required total dependence [full staff performance] with two+ person physical assist for transfer [define in the MDS as how resident moves between surfaces including to and from: bed, chair, wheelchair, standing position.]. Resident 1 had Functional Limitation in Range of Motion [interfered with daily functions or placed resident at injury], on both sides of her lower extremities [hip knee, ankle, foot]. During a review of Resident 1's Fall Risk Assessment, (FRA) dated 9/25/20, the FRA indicated, .score 7. Moderate Risk During a review of Resident 1's Progress Notes (PN), dated 11/5/20, at 10:55 AM, the PN indicated, .2 [two] staff tried to transfer resident for shower and staff lost balance, resident was then guided to the floor on her bottom. During a review of Resident 1's Radiology Results Report (RR), dated 11/8/20, at 10:39 AM, the RR indicated, Pain in left knee.Conclusion; Acute fracture distal femur [broken bone of the leg just above knee joint]. During a review of Resident 1's Facility Reported Event (FRE), dated 11/9/20, at 10 AM, the FRE indicated, On 11/5/20 2 CNA's [Certified Nursing Assistants 2 and 3] were attempting to transfer resident and resident grabbed the side rail in the process of transferring, CNA's lost footing and were unable to complete the transfer and guided the resident to the floor.On 11/7/20 resident complained of pain [to] the left leg.MD notified and ordered x-ray for left leg. Received x-ray report on 11/8/20 and noted fracture of left femur [broken bone of the thigh, extending from the hip to the knee]. During a review of Resident 1's PN dated 11/10/20 at 3:11 PM, the PN indicated, Fall with fracture to left femur .Charge Nurse responded to staff calling out for help in [Resident 1's] room. Resident was found sitting on her buttock next to her bed.2 [two] CNA's [CNA 2 and CNA 3] were self-transferring resident to shower chair and was unable to complete transfer when resident grabbed side rail causing staff lose footing and slowly guided resident to the floor. During an interview on 11/19/20, at 9:33 AM, with Restorative Nursing Assistant (RNA - help residents gain and improve quality of life by increasing their level of strength and mobility), RNA stated, Resident 1 was unable to walk and required a Hoyer lift ([a commonly use brand] mechanical lift are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical support) for transfers. During an interview on 11/19/20, at 9:40 AM, with CNA 1, CNA 1 stated, Resident 1 was unable to bear weight and required the use of a Hoyer lift during transfers. During an interview on 11/19/20, at 9:50 AM, with CNA 2, CNA 2 stated, she was assigned to Resident 1 on the day of the incident (11/05/20) and she and CNA 3 were transferring Resident 1 from the bed to the shower chair. CNA 2 stated, she and CNA 3 put their arm under Resident 1's arms and attempted to transfer Resident 1. CNA 2 stated, Resident 1 grabbed the rail of the bed, would not let go. We lost control of her balance, could not hold her up anymore, and put on the floor because we did not want to drop her. During a concurrent interview and record review on 11/19/20, at 10:50 AM, with Facility Rehabilitation Coordinator (FRC), Resident 1's PT [Physical Therapy] Evaluation & Plan of Treatment (PTE/POT), dated 10/29/20, was reviewed. The PTE/POT indicated, Functional Assessment.Transfers = Total Dependence.Precautions Includes: Fall Risk, BLE [bilateral lower extremities] Contractures. FRC confirmed the findings and stated Resident 1 was total dependent for transfers and the staff were doing 100% of the work. During a concurrent observation and interview on 11/19/20, at 11:23 AM, with Resident 1, in Resident 1's room, Resident 1 was lying in the bed with a pillow brace (used to immobilize the broken bone) on her left leg. Resident 1 stated, When two CNA's were transferring me for a shower they dropped me. Resident 1 stated, she was supposed to be transferred with a lift but the CNA's decided to transfer her without it. During the transfer [Resident 1] told the CNA's I'm slipping, I'm slipping, they could not do nothing about it, I just fell . During an interview on 11/19/20, at 11:33 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 was non-weight bearing and cannot understand safety. Resident 1 was not safe to be transferred without a Hoyer lift. During an interview on 11/19/20, at 11:36 AM, with LVN 2, LVN 2 stated, the facility is a no lift (staff avoid manually lifting) facility and the CNA's should have transferred Resident 1 with a Hoyer lift. During an interview on 11/19/20, at 11:46 AM, with the Assistant Director of Nursing (ADON), the ADON stated, Resident 1 had to be transferred with a Hoyer lift. During an interview and record review, on 11/19/20, at 12:20 PM, with the Administrator, Resident 1's Care Plan (CP), revised 3/26/19, was reviewed. The CP indicated, [Resident 1] has a potential for impaired physical mobility related to limited movement.Assist during transfer with safety.Provide enough support during transfer.Hoyer lift for transfer. Administrator confirmed the findings and stated Resident 1 had to be transferred with a Hoyer lift. During an interview on 11/20/20, at 4:39 PM, with CNA 3, CNA 3 stated, she was assisting CNA 2 in transferring Resident 1 on the day of the incident (11/05/20). CNA 3 stated, during the transfer they attempted to stand Resident 1 utilizing a two-person transfer. One CNA stood on each side of the resident and placed an arm under each of Resident 1's arms. While attempting to stand Resident 1, Resident 1 began moving and CNA 2 and CNA 3 lowered Resident 1 to the ground. CNA 3 stated she was not aware how Resident 1 was transferred but assumed Resident 1 was a two-person assist in transfer. CNA 3 stated, the facility is a no lift facility, and only residents who can bear weight should be a two-person assist in transfer. During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure for Fall Prevention Program, dated, 5/23/17, the P&P indicated, Hoyer Lift Purpose: To move a resident by a mechanical means. To move and lift a resident safety [sic]. To prevent injury to staff members.

Based on observation, interview, and record review, the facility failed to protect one resident (1) from physical abuse from an Occupational Therapist (OT). This resulted in Resident 1 becoming very upset and short of breath. Findings: During an observation and concurrent interview of Resident 1 on 12/12/12 at 2:45 PM, she was lying in her bed, appropriately dressed and alert and oriented. Resident 1 described she was in physical therapy when her oxygen tank became empty and there was no oxygen tank to replace it. She was taken to her room by the OT. Resident 1 stated, "she didn't seem to be in any hurry and I told her to hurry I was out of breath, and OT told me to shut up." Resident 1 stated while in the room the OT did not get her oxygen hooked up quickly and she was feeling very short of breath and was upset. Resident I stated "OT told me to just do it myself and started walking out of the room. I called her a [***] , and the OT turned around and came back to me and slapped me on my arm and walked away. I started yelling at her for hitting me and then the nurse came in." Resident 1 described the nurse took care of her oxygen and the OT left the room. During an interview with Resident 1's roommate (Resident 2) on 12/12/12 at 2:45 PM, she confirmed Resident 1's story. Resident 2 stated, "I don't think OT knew I was sitting here in the corner watching. Resident 1 was short of breath and telling OT to hurry but the therapist didn't appear too concerned. OT got upset and started to leave and Resident 1 called her a [***] . OT came back into the room and walked over and slapped her on the arm and then left the room." During an interview with Licensed Vocational Nurse 1 on 1212/12 at 2:30 PM, she stated "I heard Resident 1 yelling 'you slapped me'. I quickly went into the room and asked what happened. Resident 1 said OT hit her and Resident 2 confirmed the incident. OT was standing behind Resident 1's wheelchair and she said 'I didn't do anything to her' and walked out of the room." During a review of the clinical record for Resident 1 on 12/12/12, Resident 1 was admitted to the facility for rehabilitation services. Resident 1 had a [DIAGNOSES REDACTED]. The "Face Sheet" indicated Resident 1 was her own responsible party. The Care Plan titled "Ineffective airway clearance, Potential for shortness of breath" dated 11/23/12, indicated a plan to "Monitor for and be present to render support to prevent anxiety if episode of shortness of breath occurs." A "Nurses Note" dated 12/5/12 at 3:15 PM, by the Director of Nurses indicated "Due to information obtained from Resident and witness statement from roommate, and also that of licensed nurse .....finding that alleged abuse against therapist ...is in fact substantiated." The contract between the Physical Therapy Department, "Orthopaedic and Neurological Rehabilitation, Inc. (ONR)" was reviewed on 1/7/13 at 5 PM. Under the Duties and Obligations section b. Compliance with Law, "ONR will provide services to facility's patients under the terms and conditions of this agreement, applicable requirements of Federal and State laws and the conditions of participation ...."

Based on interview and record review, the facility failed to obtain background checks for three out of nine contract employees at the facility, this had the potential to result in abuse of residents. Findings: During record review on 3/19/13 at 1:45 PM, the facility provided a copy of six out of nine contract employees who had background checks. During an interview with the Administrator he stated, "These should have all been done by now."