Every finding on record at Southern California Hosp at Culver City D/P SNF

Based on interview and record review, the facility failed to report an injury of unknown origin (the source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the number of injuries over time) to CDPH, Adult Protective Services (APS, the county agency responsible for investigating reports of abuse, neglect, or exploitation of elders and dependent adults), and the Ombudsman within 24 hours for one of three sampled residents (Resident 1) in accordance with state law and the facility's policy and procedure (P&P) titled Abuse, Elder & Dependent Adult.This deficient practice had the potential to place Resident 1 at risk for unidentified abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) and resulted in a delay in the investigation.Findings: During a review of Resident 1's face sheet (FS, summary document summarizing a patient's essential information, acting as the cover sheet for their medical record), dated 3/20/2026, the FS indicated that patient was readmitted to the facility on [DATE]. During a review of Resident 1's History & Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/13/2026, the H&P indicated Resident 1 was admitted due to chronic respiratory failure post tracheostomy (a long-term inability of the lungs to adequately exchange oxygen and carbon dioxide, necessitating a permanent or long-term surgical airway opening [tracheostomy, a surgical procedure creating an opening in the neck into the trachea to facilitate breathing, bypassing the mouth and nose] to breathe); anoxic brain injury (severe condition caused by a complete cutoff of oxygen to the brain, with cell death beginning after approximately four minutes), and chronic heart failure (a long-term, progressive condition where the heart muscle is weakened or stiff, failing to pump blood effectively). During a review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment care screening tool), dated 1/25/2026, the MDS indicated Resident 1 had severely impaired cognitive skills (ability to think, remember, and reason) for daily decision making and was dependent (helper does all of the effort, resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on and removing footwear, personal hygiene, rolling left and right, moving from sitting to lying and lying to sitting at the side of bed, sit-to-stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and car transfer. During a review of Resident 1's Nursing Narrative Note, dated 3/22/2026 at 5:49 pm, the Note indicated that Resident 1's primary nurse (RN1) notified the charge nurse (CN) that there was redness noted on Resident 1's forehead. The Note further indicated Resident 1's wife and daughter were at bedside and made aware of the redness on Resident 1's forehead; the nurse practitioner (NP, a licensed advanced practice clinician who can assess, diagnose, and manage patient conditions) was notified to assess the resident, vital signs (basic measurements of the body's essential functions, such as temperature, pulse, respirations, and blood pressure) were within normal limits, and Resident 1 appeared comfortable with no signs or symptom of pain or distress. During a review of Resident 1's Nursing Narrative Note, dated 3/22/2026 at 8:30 pm, the Note indicated Resident 1's wife was notified that the NP assessed Resident 1's forehead discoloration as a mild contusion (a bruise caused by injury to soft tissue resulting in discoloration without breaking the skin), and the plan was to monitor and administer pain medication as needed. During a review of Resident 1's Social Services Note, dated 3/24/2026 at 10:49 am, the Note indicated that the social worker (SW) consulted with Risk Management and the Social Services Manager regarding the need to report a bruise observed on Resident 1's forehead that was reported by nursing with an unknown cause, and Risk Management advised proceeding with consultation with the Long-Term Care (LTC) Ombudsman. The note indicated that the SW attempted to contact the LTC Ombudsman; however, there was no answer and the SW left a voicemail requesting a return call and provided contact information, which was two days (more than 24 hours) after the incident occurred. During a review of Resident 1's Reporting of Suspected Dependent Adult/Elder Abuse Form SOC341, dated 3/24/2026, the SOC341 form indicated that it (the SOC341 form) was completed and faxed on 3/24/2026, which was two days (more than 24 hours) after the incident occurred. During a review of the facility's incident report form, dated 3/26/2026, the incident report form indicated the incident occurred on 3/22/2026 at 1:10 pm, and the date of notification to CDPH was 3/26/2026, which was four days (more than 24 hours) after the incident occurred. During an interview on 4/30/2026 at 11:45 a.m. with the Director of Risk and Quality (DRQ), the DRQ stated that according to Resident 1's Nursing Narrative Note, Resident 1's forehead bruise was discovered on 3/22/2026 at 5:49 pm, and according to the Social Services Note, the SW sent the SOC341 form to APS and called the Ombudsman on 3/24/26, which was two days (more than 24 hours) after the incident occurred. The DRQ also verified the facility incident report was sent to CDPH on 3/26/2026 which was four days (more than 24 hours) after the incident occurred. DRQ stated that was a delay of reporting per state law and facility policy and that they were not aware of the reporting timeline regulation. During an interview on 4/30/2026 at 12:33 p.m. with the Social Worker (SW), the SW stated that according to Resident 1's Social Services Note on 3/24/2026 at 10:49 a.m., the SW was aware the incident happened on 3/22/2026, which was a Sunday, and she (SW) followed up on this incident on 3/24/2026. The SW confirmed she completed and faxed the SOC341 form to APS on 3/24/2026. The SW also confirmed she (SW) called the ombudsman on the same day (3/24/2026), which was two days (more than 24 hours) after the incident occurred. During a review of the facility's policy and procedure (P&P) titled, Abuse, Elder and Dependent Adult, Number SAU.002, dated 5/2025, the P&P indicated, Notify the state licensing agency within 24 hours by phone and within 72 hours by written report . and long term care ombudsman office by phone immediately. the following indicator do not always mean abuse or neglect has occurred, but they can be clues to the need for an abuse investigation. physical indicators, bruises, welts, discoloration, swelling cut lacerations, puncture wounds, cuts, lacerations, puncture wounds, pain or tenderness on touching.

Based on record review, the facility failed to: 1. Provide a Payroll Based Journal information for quarter 4.This failure had resulted in the facility not providing the required information regarding the quantity of staff assigned for safe and comprehensive care for all residents, as required by federal regulations.During a review of the Fiscal Year Quarter 4 2025 PBJ Staffing Data Report for the facility, dated 2/20/2026, the Fiscal Year Quarter 4 2025 PBJ Staffing Data Report indicated the facility failed to submit data for the quarter. During an interview on 02/27/2026 at 10:34 AM, with the NM, the NM stated the information was submitted, just as it was for the previous quarters. The NM explained that the same happened for the last recertification survey, the PBJ Q4 data was not received, and there was no confirmation email after uploading the Quarter 4 staffing information. The NM did not state there was a phone call to the District Office to resolve the matter for the fiscal year of 2024.During a record review of the State Operations Manual (SOM), dated 7/23/2025, the SOM indicates, the facility is responsible for submitting staffing data through the CMS Payroll-Based Journal (PBJ) system. The facility's failure to submit PBJ data as required will be reflected on their CASPER report and result in a deficiency citation.

Based on interview and record review, the facility failed to:1. Provide a signed document offering, or declining, the COVID, influenza, and pneumococcal immunizations to one of eight residents, Resident 4 and failed to provide a signed document offering, or declining, the influenza vaccine to one of eight residents, Resident 11.This failure had the potential to neglect Residents 4 and 11 rights to refuse or receive immunizations from seasonal respiratory infections.During a review of Resident 4's admission Note, dated 12/11/2025, the admission Note indicated Resident 4 has chronic respiratory failure (a long-term, ongoing condition where the lungs cannot properly exchange oxygen and carbon dioxide).During a review of Resident 4's History & Physical (H&P), dated 12/12/2025, the H&P indicated Resident 4 has hypertension (high blood pressure), congestive heart failure (a chronic, progressive condition where the heart muscle cannot pump efficiently enough to meet the body's oxygen needs, leading to fluid backup in the lungs and body) , and hyperlipidemia (high levels of cholesterol in the blood).During a review of Resident 4's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 4 is dependent on facility staff for oral, personal, and toileting hygiene, showering, upper and lower body dressing, putting on and taking off footwear. Resident 4 is dependent on staff repositioning themselves in bed, getting in and out of bed, and transferring from bed to chair and getting on and off the toilet.During a review of Resident 4's Care Plan Report (CP), dated 2/11/2025, the CP indicated Resident 4's ability to physically function is altered and staff are to anticipate Resident 4's functional needs.During a review of Resident 11's admission Note, dated 8/7/2025, the admission Note indicated Resident 11 has renal failure (kidneys loose function to filter water and waste products from the body).During a review of Resident 11's History & Physical, the History & Physical indicated Resident 11 has a medical history of Respiratory Failure (a condition when the lungs cannot get enough oxygen into the blood) , Diabetes Mellitus (a disease that result in too much sugar in the blood), and an open wound.During a review of Resident 11's Minimal Data Set (MDS), dated the MDS indicated Resident 11 has functional limitations in range of motion of the upper and lower extremities and is dependent on staff for oral hygiene, toileting hygiene, bathing, getting dressed, putting on and taking off footwear, and personal hygiene. Resident 11 is also dependent on staff for rolling left to right, transitioning from sitting to lying and lying to sitting, changing from sitting to a standing position, moving from bed to chair, and transitioning to the toilet and shower.During a review of Resident 11's Care Plan Report, dated 11/1/2023, the Care Plan Report indicated Resident 11 is unable to perform self-care due to activity intolerance, limited mobility and their disease process.During a record review and interview on 2/25/2025 at 4:08 p.m. with Infection Preventionist (IP), IP stated they did not have documentation of an offer of vaccines for Resident 4 and an offer of the influenza vaccine to Resident 11. The IP stated if there is no vaccine information documented for the residents they could deteriorate from an infection, or if there is no vaccine status known within 72 hours of admission it could affect the resident's health. IP also stated it important to know the vaccine status to keep immunizations up to date and offering vaccines is part of the admission process.During a review of the facility's policy and procedure (P&P) titled, Pneumococcal and Influenza Vaccine, dated 7/2019, the P&P indicated:C. 1. During the initial assessment, the RN (registered nurse) will complete the Pneumococcal/Influenza Vaccination Order to indicate if the vaccinations are indicated according to criteria in Allscripts.C. 2. If the patient meets any inclusion criteria and no exclusion criteria, the RN will inform the patient that they are eligible for the vaccination(s), give the patient the vaccination information sheet(s), and administer the vaccination(s).

Based on observation, interview, and record review, the facility failed to: 1. Perform hand hygiene for one of eight residents, Resident 11, after touching Resident 11's suction canister (a medical container used to collect and store mucus, blood, or saliva) .This failure had the potential to spread infectious organisms to other areas inside Resident 11's and outside Resident 11's room.Findings:During a review of Resident 11's admission Note, dated 8/7/2025, the admission Note indicated Resident 11 has renal failure.During a review of Resident 11's History & Physical, the History & Physical indicated Resident 11 has a medical history of Respiratory Failure, Diabetes Mellitus, and an open wound.During a review of Resident 11's Minimal Data Set (MDS), dated the MDS indicated Resident 11 has functional limitations in range of motion of the upper and lower extremities and is dependent on staff for oral hygiene, toileting hygiene, bathing, getting dressed, putting on and taking off footwear, and personal hygiene. Resident 11 is also dependent on staff for rolling left to right, transitioning from sitting to lying and lying to sitting, changing from sitting to a standing position, moving from bed to chair, and transitioning to the toilet and shower.During a review of Resident 11's Care Plan Report (CP), dated 11/1/2023, the CP indicated Resident 11 is unable to perform self-care due to activity intolerance, limited mobility and their disease process.During an observation on 2/24/2026, at 9:30 a.m., in room [ROOM NUMBER]-A, CNA1 touched the outside of Resident 11's suction canister, while identifying the date the canister was changed and did not perform hand hygiene upon exiting the room. During an interview on 2/24/2026, at 9:32 a.m., outside room [ROOM NUMBER]A, with CNA1, CNA1 stated they should perform hand hygiene upon exiting the room.During an interview on 2/27/2026, at 8:47 a.m., in the Activities Room, with CN1, CN1 stated staff are supposed to perform hand hygiene before entering a resident's room, before touching a resident, upon exiting the resident's room, before putting on gloves and after changing gloves, or any time they believe hands are not clean.During a review of the facility's policy and procedure titled, Hand Hygiene, dated 1/2026, the P&P indicated, alcohol-based hand rub (ABHR) is the preferred method for hand hygiene when hands are not visibly soiled. Use ABHR after contact with patient surroundings or medical equipment.

Based on observation, interview, and record review, the facility failed to ensure expired food items were discarded and open food packets were labeled.These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever potentially leading to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview, on 2/24/2026 at 9:03 a.m., in the kitchen, with the Dietary Services Supervisor (DSS), the following was observed:Dairy Fridge: A bottle of Italian dressing and a block of parmesan cheese was observed without a label or date. Walk-in Cooler #1: 1 open carton of heavy cream and 1 open gallon of milk were observed without a label or date and 1 opened container of garlic spread with an expiration date of 2/21/26. Walk in Cooler #2: An opened bag of oregano was observed unlabeled and undated.Walk-in Freezer: An open, unlabeled bag of tortillas with tilapia was observed on top of a shelf.Spices and Seasonings Rack: Three 5-pound opened containers of onion powder, black pepper, and garlic powder, and a box of opened corn starch was observed unlabeled and undated. During the interview, the DSS stated all food items should be labeled and dated. The DSS stated all expired items should be discarded. The DSS stated the risk of not labeling food items and discarding expired foods could result in residents contracting foodborne illnesses.During a review of the facility's policy and procedures (P&P), titled Proper Food Storage Techniques, dated 8/21/2023, the P&P indicated Discard all food or beverage items that are past the expiration date label and Cover, label, and date unused portions and open packages.

Based on observation and interview, the facility failed to ensure dignity was maintained for one of four sampled residents (Resident 3), who was left in bed exposed. This deficient practice had the potential to violate Resident 3's rights.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 diagnoses included chronic respiratory failure (a long-term, ongoing condition where the lungs cannot properly exchange gases, leading to chronically low oxygen or high carbon dioxide levels in the blood), dysphagia (difficulty swallowing), anoxic encephalopathy (a brain injury caused by a total lack of oxygen to the brain leading to cell death and impaired function) and a history of cardiac arrest (the sudden, unexpected stop of the heart's pumping function).During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 11/2/2025, the MDS indicated Resident 3's cognitive (thinking) skills for daily decision making were severely impaired. The MDS indicated Resident 3 was dependent on staff with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent observation and interview, on 2/26/2026 at 10:02 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 3 was observed non-verbal, lying in bed. The hospital gown was shifted up to Resident 3's waist, exposing her diaper, thighs, and legs. There was no sheet or blanket observed. Resident 3's curtain was open. LVN 1 stated all residents were offered blankets upon admission. LVN 1 stated if a resident could not speak and did not have a blanket, staff would feel their skin to determine if they were cold. LVN 1 stated if a resident felt cold, a sheet would be provided. LVN 1 stated all residents should have a blanket to cover themselves. LVN 1 stated the risk of not providing a blanket to a resident could result in the resident being exposed or feeling cold.The facility did not provide a policy and procedure upon request.

Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 1) medical order (a directive issued by a licensed physician) for a stat (immediately) electroencephalogram (EEG, a non-invasive test that records the brain's electrical activity to help diagnose conditions like epilepsy, head injuries, and other brain issues) was completed as directed by the physician.This deficient resulted in delay and can potentially cause the patient's condition to worsen or resulted in injury or harm such as prolonged seizures, permanent cognitive impairment, or the need for more invasive treatments, all of which can be prevented with timely action.During a review of Resident 1's Face Sheet (a summary of patient data), undated, the Face Sheet indicated Resident 1 was admitted to the skilled nursing facility (SNF 1, a licensed clinical care setting that provides 24-hour medical support and rehabilitation services to residents who require more intensive care than what can be delivered at home do not need acute hospitalization) on 5/29/2025 with the admitting diagnosis of acute respiratory failure (a serious condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide, leading to low oxygen and/or high carbon dioxide in the blood).During a review of Resident 1's Order Summary, dated 11/18/2025, the Summary indicated that a medical order for a stat EEG was placed on 11/18/2025 at 1:49 p.m.During an interview on 11/20/2025 at 11:42 a.m. with Facility Manager (FM) 1, FM 1 stated that a stat EEG order was placed by Medical Doctor (MD) 2 on 11/18/2025. MD 2 was covering MD 1 who was the primary care physician (the doctor who serves as the main point of contact for an individual's general health concerns, preventive care, and referrals to specialists) of Resident 1. The EEG test was a contracted service and was done by an outside company. The EEG technician was scheduled to come today (11/20/2025) at 5:30 p.m. MD 3 was the house neurologist (a medical doctor specializing in the diagnosis, treatment, and management of disorders affecting the brain, spinal cord, and nervous system), and he interpreted the EEG results. During an interview on 11/20/2025 at 12:59 p.m. with Director of Respiratory Department (DRD), DRD stated that the EEG Technician came on 11/19/2025 to do the EEG test on Resident 1 but was instructed by MD 3 to hold off from doing the EEG test. There was no written order to hold the EEG test. The EEG test was placed on hold until 11/20/2025. DRD added that it was a verbal order to hold the EEG test, but MD 3 was not the ordering provider. The EEG technician should have reached out to MD 2, who was the ordering provider, and/or inform the nurse assigned that the EEG order was on hold.During a review of the facility's policy and procedure (P&P) titled Telephone and Verbal Orders, last reviewed 7/2025, the P&P indicated:A. Verbal Orders- Non-emergent Verbal Orders shall not be accepted.- Emergent Verbal Orders, defined as those orders given on-site during the performance of an operative or invasive procedure, resuscitative event, or in the other life-threatening situations, shall be accepted by a RN, LVN, Pharmacist, or Respiratory Therapist within the scope of their practice.- The licensed staff shall read back the verbal orders to clarify; emergent verbal orders must be signed by the physician prior to leaving the nursing unit.

Based upon interview and record review, the facility failed to: 1. Ensure the facility's Payroll-Based Journal Staffing Data Report (PBJ- a system created by Center of Medicare/Medicaid Services to collect auditable and verifiable staffing data from nursing facilities) was submitted for Quarter 4 Fiscal Year (July 2024-September 2024). This deficient practice had the potential to result in a negative impact on quality of care. Findings: During a record review, on 12/12/2024, at 10:10 a.m., the facility's Payroll-Based Journal Staffing Data Report (PBJ) indicated staffing data for Fiscal Year Quarter 4 was not submitted to the Center of Medicare/Medicaid Services (CMS- a federal agency that provides services related to Medicare and Medicaid). During a concurrent interview and record review, on 12/15/2024, at 2:18 p.m., with the Administrator (ADM), the ADM stated the unit's Clinical Nurse Manager (CNM) was responsible for submitting staffing data to CMS. The ADM stated the PBJ was not submitted in a timely manner. The ADM stated the facility could not provide a validation report to show proof of data submission. The ADM stated the facility also did not have a policy regarding the PBJ Staffing Data Report. The ADM stated, I read the CMS policy regarding PBJ and yes this is a compliance issue. During a review of Center of Medicare/Medicaid Services policy, titled, Staffing Data Submission Payroll Based Journal (PBJ), revised 9/2024, indicated Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. and Below are the deadlines for each reporting period: Fiscal Year 4, Reporting Period: July 1st - September 30th (of 2024), Due Date: November 14th, 2024.

Based on observation and interview, the facility failed to: 1. Provide a Notice of Medicare Non-Coverage (NOMNC- a form that Medicare providers and health plans must give to beneficiaries when their Medicare-covered services are ending) appeal process form to 3 residents (Resident 1, Resident 10 and Resident 67). This deficient practice had the potential to result in residents and/or their responsible parties not being able to exercise their right to file an appeal. Findings: During an interview, on [DATE] 2:28 PM, with the Director of Quality and Risk Management (DQRM), the DQRM stated the process of the NOMNC form was to provide residents with the option to pay or not pay once their Medicare coverage had expired. The DQRM stated all NOMNC forms were missing for Resident 1, Resident 10 and Resident 67. The DQRM stated the risk of not providing a NOMNC form in a timely manner could result in violating resident's rights or a unwanted discharge. During a review of the facility's policy and procedures, titled Medicare Beneficiary Discharge Dispute Process, dated ,d+[DATE], indicated, Medicare patients have the right to dispute a discharge if they feel they are not ready to be released from the hospital. The hospital is required to inform the patients of their rights via the Important Message from Medicare (IMM) form.

Based on interview and record review, the facility failed to: 1. The facility failed to ensure annual competencies were signed and dated by 3 employees. This deficient practice had the potential to result in providing incompetent and inadequate care for all residents. Findings: During a record review of 5 randomly selected employee files, on 12/15/24, 8:07 a.m., Licensed Vocational Nurse 1, (LVN 1), LVN 1's Restraints, Skills Fair and Critical Clinical Alarm competencies was noted with missing employee and preceptor signatures. During a record review, on 12/15/24, 8:16 a.m., Licensed Vocational Nurse 2, (LVN 2), LVN 2's General Hiring Orientation form, Care of the Post-Op Bariatric Surgery Patient In-service quiz was noted with missing dates, and no facilitator's name or signature. During a record review of LVN 2's Nursing Intravenous (IV) Medication Mixing Skills Checklist, on 12/15/2024, at 8:23 a.m., the Nursing IV Medication Mixing Skills Checklist competency was incomplete with no date and the facilitator's name struck out. During a concurrent interview and record review, on 12/15/2024, at 2:28 p.m., with the Director of Quality and Risk Management (DQRM), the DQRM stated all staff competencies and skill fairs were complete upon hire and annually with the facility's education department and unit. The DQRM stated all competencies should had been signed by the employees, facilitators and dated once completed. The DQRM stated the risk of incomplete employee competencies could result in inadequate care and not knowing if the competency was truly authenticated with what was taught and what was learned. During a review of the facility's policy and procedures, titled Nursing Staffing Level, revised 6/2022, indicated, The Sub Acute Unit shall have sufficient nursing to provide nursing and related services to attain or maintain the highest practical physical, mental, and psychosocial well-being of each patient, as determined by patient assessments and individual care plans.

Based on observation and interview the facility failed to: 1. Ensure a thermometer was inside of the kitchen's walk-in refrigerator # 1. 2. Ensure frozen foods were dated and labeled in reach-in freezer # 1. This deficient practice had the potential to result in food expiration. Findings: During a concurrent observation and interview of the kitchen, on [DATE], at 8:42 a.m., with the Sous Chef (SC), the SC stated the walk-in refrigerator was stored with vegetables and fruits. Upon observation, the SC stated there was no thermometer (an instrument for measuring and indicating temperature) in the walk-in refrigerator. The SC stated a thermometer was required to be inside of the refrigerator to monitor the temperature. The SC stated, I think someone took it out of the fridge, it was there yesterday. The SC stated the risk of not having thermometer in fridge could result in the temperature rising, spoiling food. During a concurrent observation and interview, on [DATE], at 8:50 a.m., of the reach-in freezer, the reach-in freezer was noted to have opened and unlabeled Ziplock bag with Uncrustables peanut butter and jelly sandwiches. The reach-in freezer also contained unlabeled and undated pureed rice and breakfast kosher meals. The SC stated the risk of not labeling or dating frozen foods could result in not knowing if it was expired. During a review of the facility's policy and procedures, titled Food and Supply Storage, revised ,d+[DATE], indicated, Cover, label and date unused portions and open packages. Complete all sections on a [NAME] orange label or use the Medvantage/Freshdate labeling system. and Refrigerated display units must be capable of maintaining an internal product temperature of 41F during service periods, which may require a low ambient air temperature. During a review of the facility's policy and procedures, titled Cold Storage Temperatures, revised ,d+[DATE], indicated, Each refrigerator storage unit shall have an independent thermometer in addition to the built- in thermometer.

Based on observation, interview, and record review the facility failed to: 1. Ensure two out of six sampled residents (Resident 5 and 8) scheduled showers were conducted twice a week. 2. Ensure staff sat at eye level and not standing up towering over Resident 8 while feeding. This deficient practice had the potential to result in making the residents feel intimated or unkept. Findings: a. During a review of Resident 5's Admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 5 was admitted to the facility on [DATE]. The face sheet indicated Resident 5's diagnose was respiratory failure (a serious condition that occurs when your body has too little oxygen). During a review of Resident 5's History and Physical (H&P), dated 11/22/2024, the H&P indicated Resident 5 diagnoses were anoxic encephalopathy (a condition that occurs when the brain is deprived of oxygen), atrial fibrillation (a type of irregular heartbeat), and hypertension (when the pressure in your blood vessels is too high). The H&P indicated Resident 5 was poorly responsive. During a review of Resident 5's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 11/25/2024 the MDS indicated, Resident 5's cognition (ability to learn, reason, remember, understand, and make decisions) was persistent in a vegetative state. The MDS indicated Resident required oxygen therapy (a treatment that provided extra oxygen to people with breathing problems). The MDS indicated Resident 5 was dependent on staff for toileting hygiene, showering, and dressing. During an observation on 12/14/2024 at 9:00 a.m. in Resident 5 room, Resident 5 had the appearance of not being groomed (personal care tasks that help maintain a resident's hygiene and well-being). During an interview on 12/14/2024 at 12:46 p.m. with responsible party (RP) 1, RP 1 stated her father did not look cleaned around his ears and arms over the last few weeks since admission. RP 1 stated her father ears and arms had dirt on him after being bathed in the bed. RP 1 stated she had asked the staff about showers, and the staff stated her father was already cleaned. b. During a review of Resident 8's Admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 8 diagnoses were respiratory distress (difficulty breathing not getting enough oxygen), thyroid cancer (cancer that develops in the thyroid gland that produces hormones), neurogenic bladder (a condition when the brain, spinal cord, or nerves are damaged resulting in bladder control issues). During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/28/2024 the MDS indicated, Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 8 needed help with range of motion ([ROM]- the extent or limit to which a part of the body can be moved around a joint) with upper and lower extremities three days week. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 8 had an indwelling catheter (a tube inserted into the bladder to drain urine). During an interview on 12/14/2024 at 9:19 a.m. with Resident 8, Resident 8 stated he was not given a shower in weeks. Resident 8 stated the shower is broken and he only had been given bed baths (bathing a patient who is confined to a bed). Resident 8 stated he gets a shower twice a week. Resident 8 stated he did not feel fully cleaned after bed baths. Resident 8 stated it makes him feel frustrated that he cannot have a shower twice a week. During a concurrent interview and record review on 12/14/2024 at 5:36 p.m. with Registered Nurse (RN) 1, Residents 5 and 8 Sub-Acute Shower Log, dated 11/24/2024 to 12/12/2024 was reviewed. The Sub-Acute Shower Log indicated Residents 5 and 8 had did not receive showers from 11/24/2024 to 12/12/2024 twice a week. RN 1 stated the shower hose had broken on 11/24/2024. RN 1 stated the residents were not able to have showers until 12/12/2024. RN 1 stated the residents received bed baths until the shower hose was fixed. RN 1 she had placed a work order for maintenance to fix the shower on 11/28/2024. RN1 stated the residents have the right to be cleaned and to feel cleaned. RN 1 stated when residents did not receive their showers twice a week it could make the residents feel bad and frustrated. During a review of facility's policy and procedure (P&P) titled, Bathing Resident, dated 9/2022. The P&P indicated it is the policy of this facility to [NAME] the hygienic needs of residents will receive showers or tub baths at least twice weekly. The P&P indicated wash, rinse, and dry area around resident's ears and neck. The P&P indicated during the bath to continuously assess the resident's skin. During a review of facility's policy and procedure (P&P) titled, Resident Rights, date unknown, the P&P indicated the resident had the right to be provided with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. The P&P indicated the residents are to be treated with kindness, dignity, and respect in full recognition. 46832 c. During a review of Residents 8 Admission Record, indicated Resident 8 was admitted to the facility on [DATE] with the diagnosis of Respiratorty Failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood). During a concurrent dining observation and interview, on 12/14/24, at 1:13 p.m., Resident 8 was being assisted with eating lunch by Certified Nurse Assistant 1 (CNA 1). CNA 1 was observed standing with no chair at the bedside. CNA 1 stated he always stood while feeding residents. CNA 1 stated Maybe I should sit at eye level while assisting residents with meals? CNA 1 stated the risk of not sitting at eye level while feeding residents could result in low self-esteem for the resident. During an interview, on 12/15/24, at 4:09 p.m., with the Clinical Nurse Manager (CNM), the CNM stated the protocol when feeding residents was to sit at eye level and feed the residents carefully. The CNM stated the risk of not sitting when assisting residents with meals could result in a power imbalance sue to staff standing over a resident while being fed. The CNM added, It could make a resident feel intimated. During a review of the facility's policy and procedures, titled Dignity, dated 9/2022, indicated, The Sub Acute Unit staff members will promote patient independence and dignity in dining.

During an observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 8) had an indwelling catheter (a tube inserted into the bladder to drain urine) covered with a privacy bag. This deficient practice of not covering the indwelling catheter had the potential to make Resident 8 not feel humiliated (to feel ashamed). Findings: During a review of Resident 8's Admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 8 diagnoses were respiratory distress (difficulty breathing not getting enough oxygen), thyroid cancer (cancer that develops in the thyroid gland that produces hormones), neurogenic bladder (a condition when the brain, spinal cord, or nerves are damaged resulting in bladder control issues). During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/28/2024 the MDS indicated, Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 8 needed help with range of motion ([ROM]- the extent or limit to which a part of the body can be moved around a joint) with upper and lower extremities three days week. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 8 had an indwelling catheter (a tube inserted into the bladder to drain urine). During an interview on 12/14/2024 at 5:29 p.m. with Registered Nurse (RN) 1, RN 1 stated the indwelling catheter should be covered with the privacy bag to hide the indwelling catheter. RN 1 stated the cover is used to protect Resident 8 modesty. RN 1 stated when the indwelling catheter it's like a piece of his clothing and it would make him feel better about his appearance. During a review of the facility's policy and procedure (P&P) titled, Resident & Family Guidelines, dated unknown, the P&P while here at the Sub-Acute Unit, the resident will be as comfortable as possible. During a review of facility's policy and procedure (P&P) titled, Resident Rights, date unknown, the P&P indicated the resident had the right to be provided with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. The P&P indicated the residents are to be treated with kindness, dignity, and respect in full recognition.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the survey results and complaint investigation reports in the previous three years were posted in a place readily accessible to the residents and public. This failure had the potential for residents, visitors, family members, or family representative not being able to examine and compare the previous survey results, and facility's deficient practice and how they were corrected. Findings: During a concurrent observation and interview on 12/14/2024 at 9:59 a.m., with the Director of Quality and Risk Management (DQRM) at nursing station hallway, the DQRM stated the survey results and complaint investigation reports by the California Department of Public Health ([CDPH] state licensing and certification agency) was not available at the nursing station hallway. The DQRM stated the survey results and complaint investigation reports was placed in a separate binder and kept at her office. The DQRM stated the facility never posted and made it available to the public the survey results and complaint investigation reports identified by CDPH. During an interview on 12/14/2024 at 10:25 a.m., with the Clinical Nurse Manager (CNM), the CNM stated the survey results and complaint investigation reports should be available and easily accessible to the residents, visitors and family member at all times so they would know the facility was in compliance and maintaining standard quality of care. The CNM stated it was important to post the survey and complaint investigation results so the public could see if they did implement their plan of corrections of the findings identified by CDPH. During a review of the facility's undated document, titled Resident Orientation Packet, the Resident Orientation Packet indicated, Resident have the right to examine survey results and the plan of correction. These or notice of their location will be posted in a readily accessible place. During a review of the California Standard Admission Agreement for Skilled Nursing Facilities, issued by CDPH, dated 5/2011, titled Attachment F - Resident [NAME] of Rights, indicated A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents and must post a notice of their availability.

Based on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 4) who had diagnoses of anxiety disorder (a condition that involves excessive and persistent feelings of fear, dread, and worry that can interfere with daily life), depression (a mood disorder that causes a persistent feelings of sadness and loss of interest), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential for Resident 4 not to receive appropriate medical treatments for mental illness diagnoses. Findings: During a review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 4 was admitted to the facility on [DATE]. The Face Sheet indicated, Resident 4's diagnoses included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 4's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/3/2024, the MDS indicated, Resident 4's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 4's had active diagnoses of psychiatric disorder of anxiety, depression, and psychotic disorder. During an interview on 12/15/2024 at 9:40 a.m., with the Clinical Nurse Manager (CNM), the CNM stated the facility's process for PASARR was to ask the transferring facility to complete the Level 1 prior to transferring resident to the facility. The CNM stated the PASARR would give you an information about a resident's history of mental illness and treatment. During a concurrent interview and record review on 12/15/2024 at 9:49 a.m., with Registered Nurse 3 (RN 3), Resident 4's PASARR level I Screening completed by the facility on 12/13/2022, was reviewed. The PASARR Level I screening indicated, Resident 4 had no serious mental illness diagnosis and not receiving psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). The PASARR level I screening also indicated, Resident 4's case was closed and, and a PASARR level II mental health evaluation was not required. RN 3 stated she was responsible in completing a PASARR. RN 3 stated the facility should have completed and resubmitted a new PASARR Level 1, based on the MDS assessment, dated 12/3/2024, indicating Resident 4 had an active diagnoses of anxiety disorder, depression and psychotic disorder. RN 3 stated a positive Level 1 would trigger a Level II mental health evaluation. RN 3 stated it was important to complete the PASARR accurately so the resident with mental illness diagnosis would get proper psychiatric care and treatment from outside mental health provider. During a review of PASRR reference manual, dated 2/2023, the PASRR reference manual indicated, An additional requirement has been added for NF's to promptly notify the state mental health and/or intellectual or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of an individual who is mentally ill or has an intellectual or developmental disability. This would warrant a re-evaluation to determine if NF is still the most appropriate setting and/or if the individual could benefit from specialized services for his/her mental illness or intellectual disability.

Based on observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 5) ventilator tubing (the tubing carries oxygen and air to and from the patient) was labeled and dated. This deficient practice of not labeling and dating the respiratory tubing placed Resident 5 at risk for respiratory infection (infections that could affect parts of the body involved in breathing). Findings: During an observation on 12/14/2024 at 9:00 a.m. in Resident 5's room, there was no date on the ventilator tubing connected the ventilator (a machine that helps a patient breathe when they are unable to do so on their own) and to the resident tracheostomy (surgical procedure that creates an opening in the neck to help with breathing). During an interview on 12/14/2024 at 4:31 p.m. with Respiratory Therapist (RT) 1, RT 1 stated she had changed the tubing but did not put a date on the ventilator tubing. RT 1 stated it was important to place the date on the ventilator tubing after it is changed so we know how long it has been attached to the resident. RT 1 stated the ventilator tubing should have been dated after the respiratory tubing was changed to prevent bacterial growth and prevent respiratory infections. During an interview on 12/14/2024 at 5:24 p.m. with Registered Nurse (RN) 1, RN 1 stated the respiratory tubing should have a date. RN 1 stated the respiratory tubing is changed daily or as scheduled by the respiratory therapist. RN 1 stated if the respiratory tubing does not have a date, it could place the resident at risk for infection. During a review of facility's policy and procedure (P&P) titled, Mechanical Ventilation, dated 12/2023, the P&P indicated to establish a protocol for maintenance of the patient on a continuous mechanical ventilator. The P&P indicated infection is a complication of mechanical ventilation a common hazard associated with mechanical ventilation due to placement of artificial airway. The P&P indicated proper care of the airway and infection control practices in accordance with hospital wide infection control policy will be followed. The P&P did not disclose to date and label the varies ventilator tubing to prevent infections.

Based on observation, interview, and record review, the facility failed to: 1. Ensure intravenous ([IV] into or connected to vein) tubing was labeled and dated for one of two sampled residents (Resident 9) who was receiving IV antibiotic (drug that treats infection) treatment. This deficient practice had the potential to placed Resident 9 at risk for infection and IV therapy complications. Findings: During a review of Resident 9's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 9 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 9's diagnoses included tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person to breathe) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of review of Resident 9's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/13/2024, the MDS indicated, Resident 9 was on comatose (a resident is in a state of complete unresponsiveness, where they cannot be aroused and show no signs of awareness, including not opening their eyes, speaking, or moving extremities in response to stimuli. During a review of Resident 9's Patient Orders (a document containing active physician orders), dated 12/14/2024, the Patient Orders indicated, Resident 9 had an active order of Zosyn (medication to treat infection) 4.5 grams ([gm] - unit of measurement) IV every eight (8) hours for treatment of sepsis (a life-threatening medical emergency that occurs when the body has an extreme response to an infection). During a concurrent observation and interview on 12/14/2024 at 9:45 a.m., with Registered Nurse 1 (RN 1), in Resident 9's room. Resident 9 was observed to have a one vial (a medication bottle that is sealed with a rubber stopper and intended for one time use only) of Zosyn 4.5 gm connected to IV tubing unlabeled and not dated. RN 1 stated it was unknown when was the IV tubing was changed because it was not dated and labeled. RN 1 stated IV tubing should be changed twice a week every Thursday and Sunday. RN 1 stated an old IV tubing could harbor bacteria (bacteria that live in the human body, or to places in the environment where bacteria can be found) that would likely result in sepsis. During an interview on 12/15/2024 at 9:00 a.m., with the Clinical Nurse Manager (CNM), the CNM stated it was the responsibility of the licensed nursing staff who administered the IV medication to label the IV tubing with the date it was changed. The CNM stated it was a standard of practice to change the IV tubing twice a week and label so the facility staff could track when it needs to be changed. During a review of the facility's policy and procedure (P&P) titled, Intravenous Therapy - Initiation and Management of Peripheral Intravenous Lines, dated 6/2023, the P&P indicated, To provide standards for the management of peripheral intravenous therapy with consideration of patient's safety and comfort and the goals of intravenous therapy. The P&P also indicated IV tubing set changes are every 3 days and label tubing with date.

Based on observation and interview, the facility failed to: 1. Ensure expired medication was not kept in the medication storage refrigerator. This deficient practice had the potential to result in administering expired medication. Findings: During a review of resident 16's Admission Record, indicated Resident 16 was readmitted to the on [DATE] with the diagnosis of Respiratory Failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood). During an observation of the facility's Medication Storage room refrigerator, on [DATE], at 9:47 a.m., one medication was observed to be expired. The medication, Vancomycin, prescribed for Resident 16, was labeled with an expiration date and time of [DATE] at 7:30 a.m. During a concurrent observation and interview, on [DATE], at 9:51 a.m., with Registered Nurse 2 (RN 2), RN 2 stated the process of storing medication was to ensure whether a medication was to be refrigerated and check the expiration date. RN 2 stated the Vancomycin found in the refrigerator was expired. RN 2 stated the medication should had been returned to the pharmacy. RN 2 stated the risk of storing expired medication could result in a medication error. During a interview, on [DATE], at 4:09 p.m., with the Clinical Nurse Manager (CNM), the CNM stated the protocol for expired medication was to call the pharmacy and have the medication replaced. The CNM stated the risk of expired medication being in the medication storage refrigerator could result in Reaching the resident, if administered. During a review of the facility's policy and procedures, titled Medication Storage, dated ,d+[DATE], indicated, The hospital removes all expired, damaged and/or contaminated medications. They are store separately from medications available for administration.

Based on interview and record review the facility failed to: 1. Ensure one out six sampled residents (Resident 8) had completed laboratory ([labs] blood samples to assess a patient's health status) test. This deficient practice of not completing labs placed the resident at risk for not receiving accurate medication treatment. Findings: During a review of Resident 8's Admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE]. During a review of Resident 8's History and Physical (H&P), dated 5/11/2024, the H&P indicated Resident 8 diagnoses were respiratory distress (difficulty breathing not getting enough oxygen), thyroid cancer (cancer that develops in the thyroid gland that produces hormones), neurogenic bladder (a condition when the brain, spinal cord, or nerves are damaged resulting in bladder control issues). During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/28/2024 the MDS indicated, Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 8 needed help with ROM with upper and lower extremities three days week. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering, and dressing. The MDS indicated Resident 8 had an indwelling catheter (a tube inserted into the bladder to drain urine). During a review of Resident 8's Physician Orders, dated 11/4/2024, the Physician Orders indicated a thyroid stimulating hormone level ([TSH] a blood test that indicate if the thyroid hormone level is underactive or overactive) was completed as ordered. During an interview on 12/15/2024 at 2:13 p.m. with Registered Nurse (RN) 1, RN 1 stated the TSH level was not done for the month of November. RN 1 stated if the labs were not done it would place the resident at risk for not receiving the correct dose of the thyroid medication. During an interview on 12/15/2024 at 2:21 p.m. with Pharmacy, the Pharmacist stated the physician order for TSH level lab to be done for the month of November. The Pharmacist stated the TSH lab was ordered on 11/4/2024. The Pharmacist stated the TSH lab draw was to capture the TSH level. The Pharmacist stated it was important to keep track of the TSH levels to track if the thyroid levels were too low or too high. The Pharmacist stated if the thyroid levels are not within the normal range, it could aggravate the residents' thyroid. During a review of the facility's policy and procedure (P&P) titled, Resident & Family Guidelines, dated unknown, the P&P indicated the recommended and intended for a short stay to stabilize and complete pre-determined treatment. The P&P indicated lab test request from the physician will be provided to the resident from Southern California Hospital at Culver City laboratory as needed.

Based on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice by failing to: 1. Elevate the head of the bed while receiving formula through the gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of four sampled residents (Resident 4). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) that can lead to pneumonia (lung infection) for Resident 4. Findings: During a review of Resident 4's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 4 was admitted to the facility on [DATE]. The Face Sheet indicated, Resident 4's diagnoses included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and gastrostomy tube. During a review of Resident 4's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/3/2024, the MDS indicated, Resident 4's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS also indicated, Resident 4 on tube feeding. During a review of Resident 4's Patient Orders (a document containing active physician orders), dated 12/14/2024, the Patient Orders indicated, Resident 4 had tube feeding order of Vital AF (type of tube feeding formula) 1.2 kilocalorie ([kcal] unit of measurement) at 75 milliliters ([ml] unit of volume) per hour. During a review of Resident 4's Care Plan titled Resident requires tube feeding related to dysphagia (difficulty of swallowing) and respiratory failure dated 11/2/2022, indicated goal of resident will be free of aspiration. The Care Plan intervention indicated to keep head of bed elevated at 45 degrees. During an observation on 12/14/2024 at 9:11 a.m., Resident 4 was in bed receiving GT feeding of Vital AF 1.2 at 75 ml per hour, with head of the bed elevated at approximately 10 degrees. During a concurrent observation and interview on 12/14/2024 at 9:22 a.m., with Registered Nurse 2 (Registered Nurse 2), in Resident 4's room. Resident 4 was observed receiving continuous GT feeding of Vital AF 1.2 at 75 ml/hour. RN 2 stated Resident 4's head of bed was approximately 10 degrees. RN 2 stated residents receiving continuous tube feeding, the head of bed should be elevated at least 30 to 45 degrees to prevent aspiration. RN 2 stated Resident 4 was at risk for aspiration since her head of bed was at lowest position. During a review of the facility's policy and procedure (P&P) titled, Gastric Tube Feeding, dated 9/2022, the P&P indicated, Each patient fed by gastric tubes receives the appropriate treatment and services to prevent aspiration, pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers and to restore, if possible, normal feeding function.

Based on observation, interview, and record review, the facility failed to prevent further potential neglect and have evidence that all alleged violations were thoroughly investigated as indicated in the facility's Abuse Investigation policy for three of three sampled residents (Resident 1, 2 and 3) when: 1. Licensed vocational nurse (LVN - an entry-level health care provider who is responsible for rendering basic nursing care) 1 tied a sheet to the Resident 1 ' s bed frame and broken bedrail. This deficient practice resulted in Resident 1 falling out of bed and had the potential to result in unidentified neglect, mistreatment, and failure to protect Resident 1 from further neglect. 2. LVN 1 refused to assess Resident 2's wound vac (vacuum-assisted closure of a wound is a type of therapy to help wounds heal) and shut the door and turned off the light, leaving Resident 2 in the dark without assistance. This deficient practice resulted in Resident 2's wound not being assessed when an alarm indicating a potential issue that required immediate attention was ignored by LNV 1, which also resulted in Resident 2's mistrust of the facility care and stating, I do not feel safe around LVN 1. 3. LVN 1 failed to report Resident 3's KUB (diagnostic imaging for the kidney, ureter and bladder) used to assess the test result to the provider. This deficient practice resulted in the physician being unaware that Resident 3 ' s KUB results indicated a possible ileus (a condition where the intestine cannot push food and waste out of the body) or obstruction (a partial or complete blockage of the small intestine or large intestine) thus placing Resident 3 ' s well-being and safety at risk by delaying diagnosis and subsequent treatment. Findings: 1. During a review of Resident 1 ' s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/14/24, the H&P indicated that Resident 1's medical history included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood) with recent tracheostomy (a surgical hole created in the windpipe that provides an alternative airway for breathing), cardiac arrest (cessation of function of the heart), and anoxic encephalopathy (a cessation of blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/6/18, it indicated Resident 1 was nonverbal, quadriplegia (paralysis below the neck that affects all of a person's limbs), and cognitive (process of thinking) skills for daily decision-making were severely impaired. The MDS also indicated Resident 1 required assistance with all activities of daily living such as eating, toileting, oral hygiene, showering, and dressing. During a review of Resident 1 ' s Nursing Narrative Note, dated 8/6/24, the note indicated, Patient received at 7:07 am sleeping in bed; the report was received at bed site; per the assigned nurse (name of LVN 1), the patient's bed is broken; the sheet was placed on the rails by the night shift nurse to tighten up to work it out as a side rail; per the night shift nurse, the replacement bed was not ordered yet . By 7:50, the RT (respiratory therapist) called me to the room to assess Resident 1, who slid from the mattress on the floor . The patient is closely monitored for any change of condition s/p (status post) or unwitnessed fall or sliding off the mattress on the floor. During a review of Resident 1 ' s Assessment and Care, report dated from 8/1/24 through 8/23/24, the report indicated that LVN 1 continues to be assigned to the care for Resident 1. The report indicated LVN 1 documented care for Resident 1 on 8/8/24, 8/14/24, 8/18/24, 8/20/24, 8/22/24, and 8/23/24 after 8/6/24 when Resident 1 fell . During a concurrent observation and interview on 9/12/24 at 10:58 a.m. with the administrator (ADM) in Resident 1 ' s room (located at the end of the unit hallway), Resident 1 was lying in bed with both right and left bed rails raised up. The ADM stated Resident 1 was unable to move her extremities; however, Resident 1 was able to wiggle her torso which is how she fell . ADM also confirmed the bed was in its lowest position. The bed is approximately 2.5 feet from the ground. During an interview on 9/12/24 at 12:00 p.m. with the Manager of the Subacute (a unit that provides intensive care, but to a lesser degree than acute care) Unit (MS) 1, MS 1 showed photos of the bed sheet tied to the bedframe and to the bed rail. MS 1 stated the day shift nurse came in and saw the broken bedrail with the bedsheet tied and requested for a new bed. While the nurse took the report from the outgoing nurse, Resident 1 fell . The respiratory therapist (RT) found Resident 1 on the floor by the bed. MS 1 stated, The patient (Resident 1) had an unwitnessed fall. MS 1 further stated she asked LVN 1 why she did not report the broken bedrail to the house supervisor, and LVN 1 responded, It ' s up to the day shift to do that. MS 1 confirmed there was no corrective action such as coaching, counseling and/or disciplinary action completed with LVN 1. MS 1 stated the department reported each incident involving LVN 1 to Human Resource. During an interview on 9/12/24 at 12:10 p.m. with the Director of Risk Management (DRM), the DRM stated the root cause analysis was completed by the facility. DRM stated, The conclusion of the analysis is that (LVN 1) identified the bedrail as broken and nonfunctioning but did a workaround by fixing the bedrail herself with the sheets and leaving the patient unattended while the rail was not working. During a concurrent interview and record review on 9/12/24 at 4:00 p.m. with the Director of Quality and Risk (DQR), the facility ' s incident reports (a detailed, written account of the chain of events leading up to an adverse incident or potential adverse incident) dated from March 2023 to September 2024, involving LVN 1 was reviewed. The incident report listed 32 reports regarding quality of care, resident neglect, and professional behavior. During an interview on 9/12/24 at 3:40 p.m. and on 9/27/24 at 3:05 p.m. with the Director of Quality and Risk (DQR), the DQR stated the facility was unable to provide an investigation report that included gathering details and interviews from staff and or residents and intervention and or corrective actions that were taken by the facility for each of the alleged reports that involved LVN 1. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Elder and Dependent Adult, dated January 2023, the P&P indicated, To assure that State and Federal Law regarding mandatory reporting of all known or suspected incidents of abuse of dependent and elder adults is followed. To assure that the mandated training material for the California Department of Justice are utilized. This procedure applies to the Subacute Unit . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Deprivation by an individual, including a caretaker, of goods and services that were necessary to attain or maintain physical, mental and psychological wellbeing. Neglect: Failing to protect the resident from avoidable injury. An example of neglect would be to leave a resident, who is prone to falls, in the bathroom unattended .Staff member responsibility, If the incident was witnessed, take measures to protect the resident immediately .charge nurse or supervising nurse: Get the details of the incident from other staff members if appropriate or get any details of the incident from the resident if possible. Note: Any statements made by the resident/staff/visitor/family member on the back of the incident report. If the incident was witnessed, remove the person alleged to have committed the abuse. If it is a staff member, ask them to clock out immediately and to call the Director of Nursing about the incident. Administrator/Director of Nursing or Person Delegated to complete the investigation: The Nursing Manager for the facility will oversee the processes for reporting, investigating, interventions and corrective actions taken during abuse incidents. An investigation will be initiated immediately and completed within 5 days. This will include interviewing all individuals involved, including the resident. During a review of the facility ' s Employee Handbook, dated 2019, handbook indicated, Standards of Conduct: To foster a positive, collaborative working environment, and to ensure we are providing a safe and secure workplace where everyone is treated in a respectful and fair manner, we have established certain minimum standards of conduct regarding behavior towards co-workers, supervisors, and the overall organization. We expect all employees, and others who may from time to time be engaged to provide services, to conduct themselves in an ethical and dignified manner while on company premises, attending company functions or otherwise performing work-related activity . Safety and Security: Our employees know, understand and follow all health and safety policies and regulations that apply to their job and work environment including the reporting of personal injuries no matter how minor. Behavior that puts the safety of our patients/members, customers, employees or visitors in danger is not allowed .Corrective Action: Most employees are dedicated and hard working. Occasionally, however, an employee's work performance or behavior falls below standards. In these cases, we want to take corrective action to improve and prevent recurrence of undesirable behavior or performance. This can include coaching, counseling and corrective action, as is necessary and appropriate. 2. During a review of Resident 2 ' s History and Physical (H&P), dated 6/3/24, the H&P indicated, Resident 2 ' s neurological (a branch of medicine that define the structure and function of the brain) assessment is oriented to person (the person knows their name and usually can recognize significant others), place (the person knows where they are, such as the hospital, clinic, or town.), and time (the person knows the time of day, date, day of the week, and season). Resident 2 ' s medical history included chronic lower extremity ulcer (an open sore on an external or internal surface of the body), and recent right hip debrided (remove damaged tissue from a wound). The H&P further indicated Resident 2 was sent to the subacute unit for continuation of care. During a review of Resident 2 ' s Order Summary, dated 7/26/23 through 7/26/23, the order summary indicated vacuum assisted closure should be on continuously. During an interview on 9/12/24 at 11:00 a.m. with Resident 2, in Resident 2 ' s room, Resident 2 stated, I do not feel safe, and I do not think other patients are safe in the care of (name of LVN 1). Resident 2 stated and show a video recording in September while under LVN 1 care, his wound vac was alarming. Resident 2 stated when he requested for help from LVN 1, LVN 1 stood at the foot of bed with another nurse and looked at the machine without assessing Resident 2 ' s wound or the machine, and just left the room. Resident 2 stated they called LVN 1 for assistance again as the wound vac continued to alarm. The LVN 1 came in and shut off the wound vac. LVN 1 walked out of the room, turn off the room light and shut the door while Resident 2 was asking LVN 1, why did she turn off the wound vac. Resident 2 stated as LVN 1 was leaving, LVN stated, I do things my own way. During an interview on 9/27/24 at 11:05 a.m. with the former manager of the subacute unit (MS) 3, MS 3 stated Resident 2 reported to her that (that name of LVN 1) did not assist when the wound vac was alarming and turned off the light and closed the door. MS 3 stated after being made aware of the incident she spoke to LVN 1, but she did not write up LVN 1. MS 3 stated the nursing staff are not familiar with the wound vac. However, MS 3 confirmed that a standard of nursing care is to assess the patient wound and wound dressing as well as assess the tubing of the wound vac to see if there is kink that may cause the alarm. MS 3 further confirmed that from watching the video the nurse did not assess these areas and did get assistance from wound care nurse or nurses in the acute area that are more familiar with the wound vac. During a concurrent interview and record review on 9/16/24 at 4:00 p.m. with the Director of Quality and Risk, the facility ' s incident reports (a detailed, written account of the chain of events leading up to an adverse incident or potential adverse incident) dated from March 2023 to September 2024, involving LVN 1 was reviewed. The incident report listed 32 reports. regarding quality of care, resident neglect, and professional behavior. During an interview on 9/12/24 at 3:40 p.m. and on 9/27/24 at 3:05 p.m. with the Director of Quality and Risk (DQR), DQR stated the facility was unable to provide an investigation report that included gathering details and interviews from staff and/or residents and intervention and/or corrective actions that were taken by the facility for each of the alleged report that involved LVN 1. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Elder and Dependent Adult I, dated January 2023, the P&P indicated, To assure that State and Federal Law regarding mandatory reporting of all known or suspected incidents of abuse of dependent and elder adults is followed. To assure that the mandated training material for the California Department of Justice are utilized. This procedure applies to the Subacute Unit . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Deprivation by an individual, including a caretaker, of goods and services that were necessary to attain or maintain physical, mental and psychological wellbeing. Neglect: Failing to protect the resident from avoidable injury. Residents have the right to refuse treatment and care. An example of neglect would be to leave a resident, who is prone to falls, in the bathroom unattended .Staff member responsibility, If the incident was witnessed, take measures to protect the resident immediately. Remove the resident from the area to a safe place or ask the individual in question to please leave the room or the area .charge nurse or supervising nurse: Get the details of the incident from other staff members if appropriate or get any details of the incident from the resident if possible. Note: Any statements made by the resident/staff/visitor/family member on the back of the incident report. If the incident was witnessed, remove the person alleged to have committed the abuse. If it is a staff member, ask them to clock out immediately and to call the Director of Nursing about the incident. Administrator/Director of Nursing or Person Delegated to complete the investigation: The Nursing Manager for the facility will oversee the processes for reporting, investigating, interventions and corrective actions taken during abuse incidents. An investigation will be initiated immediately and completed within 5 days. This will include interviewing all individuals involved, including the resident. During a review of the facility ' s Employee Handbook, dated 2019, handbook indicated, Standards of Conduct: To foster a positive, collaborative working environment, and to ensure we are providing a safe and secure workplace where everyone is treated in a respectful and fair manner, we have established certain minimum standards of conduct regarding behavior towards co-workers, supervisors, and the overall organization. We expect all employees, and others who may from time to time be engaged to provide services, to conduct themselves in an ethical and dignified manner while on company premises, attending company functions or otherwise performing work-related activity . Safety and Security: Our employees know, understand and follow all health and safety policies and regulations that apply to their job and work environment including the reporting of personal injuries no matter how minor. Behavior that puts the safety of our patients/members, customers, employees or visitors in danger is not allowed .Corrective Action: Most employees are dedicated and hard working. Occasionally, however, an employee's work performance or behavior falls below standards. In these cases, we want to take corrective action to improve and prevent recurrence of undesirable behavior or performance. This can include coaching, counseling and corrective action, as is necessary and appropriate. 3. During a review of Resident 3 ' s History and Physical (H&P), dated 3/30/24, the H&P indicated, Resident 3 ' s medical history that included chronic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), and dysphagia (difficulty swallowing.) with a percutaneous endoscopic gastronomy (a surgery to place a feeding tube to deliver nutrition through the tube). During a review of Resident 3 ' s KUB result report, dated 4/3/24, the report indicated, Gaseous distention of bowel loops measuring up to 9.6 cm, could be due to ileus (a condition where the intestine cannot push food and waste out of the body) or obstruction. During a concurrent interview and record review on 9/16/24 at 4:00 p.m. with the Director of Quality and Risk (DQR), the facility ' s incident reports (a detailed, written account of the chain of events leading up to an adverse incident or potential adverse incident) dated from March 2023 to September 2024, involving LVN 1 was reviewed. The incident report listed more than 30 reports, among the incidents reported was a report dated 4/3/24, indicated LVN 1 did not report a result of Resident 3 ' s KUB (A imaging of the kidney, ureter, and bladder, may be performed to assess the abdominal area for causes of abdominal pain). The outgoing nurse gave report that Resident 3 had a KUB completed and to notify the physician when result comes back. The reporting nurse came back to work 3 days later and decided to look into the result of the KUB and discovered the KUB result indicated and obstruction (a blockage that keeps food or liquid from passing through the small intestine or large intestine). The reporting nurse called the physician, the physician stated he did not get notified of the KUB result indicating an obstruction. During an interview on 9/12/24 at 3:40 p.m. and on 9/27/24 at 3:05 p.m. the DQR, the DQR stated the facility was unable to provide an investigation report that included gathering details and interviews from staff and/or residents and intervention and/or corrective actions that were taken by the facility for each of the alleged report that involved LVN 1. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Elder and Dependent Adult I, dated January 2023, the P&P indicated, To assure that State and Federal Law regarding mandatory reporting of all known or suspected incidents of abuse of dependent and elder adults is followed. To assure that the mandated training material for the California Department of Justice are utilized. This procedure applies to the Subacute Unit . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Deprivation by an individual, including a caretaker, of goods and services that were necessary to attain or maintain physical, mental and psychological wellbeing. Neglect: Failing to protect the resident from avoidable injury. An example of neglect would be to leave a resident, who is prone to falls, in the bathroom unattended .Staff member responsibility, If the incident was witnessed, take measures to protect the resident immediately .charge nurse or supervising nurse: Get the details of the incident from other staff members if appropriate or get any details of the incident from the resident if possible. Note: Any statements made by the resident/staff/visitor/family member on the back of the incident report. If the incident was witnessed, remove the person alleged to have committed the abuse. If it is a staff member, ask them to clock out immediately and to call the Director of Nursing about the incident. Administrator/Director of Nursing or Person Delegated to complete the investigation: The Nursing Manager for the facility will oversee the processes for reporting, investigating, interventions and corrective actions taken during abuse incidents. An investigation will be initiated immediately and completed within 5 days. This will include interviewing all individuals involved, including the resident. During a review of the facility ' s Employee Handbook, dated 2019, handbook indicated, Standards of Conduct: To foster a positive, collaborative working environment, and to ensure we are providing a safe and secure workplace where everyone is treated in a respectful and fair manner, we have established certain minimum standards of conduct regarding behavior towards co-workers, supervisors, and the overall organization. We expect all employees, and others who may from time to time be engaged to provide services, to conduct themselves in an ethical and dignified manner while on company premises, attending company functions or otherwise performing work-related activity . Safety and Security: Our employees know, understand and follow all health and safety policies and regulations that apply to their job and work environment including the reporting of personal injuries no matter how minor. Behavior that puts the safety of our patients/members, customers, employees or visitors in danger is not allowed .Corrective Action: Most employees are dedicated and hard working. Occasionally, however, an employee's work performance or behavior falls below standards. In these cases, we want to take corrective action to improve and prevent recurrence of undesirable behavior or performance. This can include coaching, counseling and corrective action, as is necessary and appropriate.

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures were followed for of one of three sampled residents (Resident 1), when Resident 1's bedrail was tied with a sheet after it was found to be broken and the facility staff failed to monitor Resident 1 while the bedrail remained broken. This failure resulted in Resident 1 falling out of bed and had the potential for risk of entrapment or strangulation due to the sheet tied from the bed rail to the lower bed frame. Findings: During a review of Resident 1' s History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/14/24, the H&P indicated that Resident 1's medical history included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood) with recent tracheostomy (a surgically whole created in the windpipe that provides an alternative airway for breathing), cardiac arrest (cessation of function of the heart), and anoxic encephalopathy (a cessation of blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated June 6, 2018, the MDS indicated Resident 1 was nonverbal. Resident 1 is quadriplegia (paralysis below the neck that affects all of a person's limbs). Resident 1 cognitive skills for daily decision-making are severely impaired. Resident 1 required assistance with all activities of daily living such as eating, toileting, oral hygiene, showering, and dressing. During a review of Resident 1 ' s Nursing Narrative Note, dated 8/6/24, the note indicated, Patient received at 7:07 am sleeping in bed; the report was received at bed site; per the assigned nurse (name of LVN 1), the patient's bed is broken; the sheet was placed on the rails by the night shift nurse to tighten up to work it out as a side rail; per the night shift nurse, the replacement bed was not ordered yet . By 7:50, the RT (respiratory therapist) called me to the room to assess the patient (name of Resident 1) who slid from the mattress on the floor . The patient is closely monitored for any change of condition s/p (status post) or unwitnessed fall or sliding off the mattress on the floor. During a concurrent observation and interview on 9/12/24 at 10:58 a.m. with the administrator (ADM) in Resident 1 ' s room, Resident 1 was lying in bed with both right and left bed rails raised up. Resident 1 eyes were opened; however, when Resident 1 name was called, Resident 1 was unable to respond. The ADM confirmed that Resident 1 was nonverbal and unable to make her needs known. The bed was in its lowest position. The bed is approximately 2.5 feet from the ground. During an interview on 9/12/24 at 12:00 p.m. with the Manager of the Subacute (a unit that provides intensive care, but to a lesser degree than acute care) Unit (MS) 1, MS 1 showed photos of the bed sheet tied to the bedframe and to the bed railed. MS 1 stated the day shift nurse came in and saw the broken bedrail with the bedsheet tied and requested for a new bed. While the nurse took the report from the outgoing nurse, the patient (Resident 1) fell . The respiratory therapist found the patient (Resident 1) on the floor by the bed. MS 1 stated, The patient (Resident 1) had an unwitnessed fall. MS 1 further stated she asked LVN 1 why she did not report the broken bedrail to the house supervisor, and LVN 1 responded, it is not her responsibility. MS 1 further stated the LVN 1 responded and said, It is up to the day shift to do that. During an interview on 9/12/24 at 12:10 p.m. with the Director of Risk Management (DRM), the DRM stated the root cause analysis was completed by the facility. DRM stated, The conclusion of the analysis is that (name of LVN 1) identified the bedrail as broken and nonfunctioning but did a workaround by fixing the bedrail herself with the sheets and leaving the patient unattended while the rail was not working. During a review of the facility 's policy and procedure (P&P) titled, Medical Equipment Failure and Clinical Intervention, dated January 2024, the P&P indicated, It is the policy of (name of the facility) to respond to a failure of medical equipment and provide emergency clinical interventions when appropriate . In the event of malfunction or failure of a piece of High-Risk Equipment, staff shall follow the Clinical Intervention Protocol until replacement equipment can be obtained. In the event of an emergency involving a medical equipment malfunction or failure, the medical and clinical staff members are instructed to take the required steps to ensure the safety of the patient and attempt to locate the appropriate replacement equipment. Medical equipment that is involved in an event that caused or has the potential for serious injury to patient, or is involved in the death of a patient, will be removed from service immediately and secured to prevent tampering until the appropriate individuals arrive for further inspection. During a review of the facility' s P&P titled, Falls Prevention Program, dated December 2022, the P&P indicated, To establish a framework for assessing risk factors for patient falls, reducing the risk for falling, protecting patients from injury if a fall should occur, and monitoring the effectiveness of the hospital fall prevention program . Plan of Care Strategies; General strategies for patients at risk for falls may include, but are not limited to: Use of up to 2 or 3 side rails to assist turning side to side. Placing the bed in the lowest position possible. Call light within patient reach. Remind patient to use call button to call for assistance. Reorientation as necessary while awake. Place patient in rooms close to the Nurses Station. Personal items (e.g., glasses, hearing aids, dentures) within reach. Referral to appropriate discipline for specific assessment.

Based on observation, interview and record review, the facility failed to maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (F, A unit of temperature measurement) for 17 of 17 residents (Resident 1 to Resident 17) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit. This deficient practice placed the 17 residents on the Sub-Acute Unit at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). On 9/09/2024, at 10:50 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death of a resident) situation for the facility's failure to provide a safe environment to the residents by failing to maintain an acceptable residents' rooms temperature range of 71 to 81 degrees Fahrenheit in the presence of the Chief Nursing Officer (CNO) and the Chief Operational Officer (COO). On 9/10/2024, at 1:30 p.m. the facility submitted an IJ Removal Plan (immediate action that includes all actions the entity has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), which was not accepted. On 9/10/2024, at 4:30 p.m., the survey team conducted an exit conference with the CNO, the assistant CNO (ACNO), the Director of Quality and Risk (DQR), the Director of Plant Operations (DPO), and the Sub-Acute Manager (SAM) and exited the facility, with the IJ situation not removed. Findings: According to an internet article from the California's Governor Office of Emergency Services (Cal OES) https://news.caloes.ca.gov/cal-oes-urges-californians-to-take-precautions-amid-extreme-heat-in-southern-california/ published on September 5th 2024, the article indicated As extreme heat blankets Southern California with high temperatures now expected through Monday evening, Cal OES has moved to Phase II of the Extreme Temperature Response Plan, .Heat can be deadly and it often catches people by surprise, said the Chief Deputy Director of the Governor's Office of Emergency Services. It's important for all Californians to do their part and take steps to stay safe in dangerously hot conditions. During a concurrent interview and record review on 9/9/2024 at 7:01 p.m. with the Chief Nursing officer (CNO) and Chief Operating Officer (COO), they indicated that the facility's sub-acute area is located in the 3rd floor and it is dubbed tower 3 (T3). Both the CNO and the COO stated that T3 unit is composed of ten bedrooms (rooms 370-380) with a census of 17 residents as of 9/9/2024; the census note was printed at 9:53 p.m. on 9/9/2024. During a concurrent observation and interview on 9/9/2024 at 7:00 p.m. with the DPO in T3, upon exiting the elevator, four spot coolers (a portable air conditioning unit that cools a specific area) were observed being prepared by the technician. There was a hallway, and the rooms in a row starts from 370 and ends in 380. room [ROOM NUMBER] was the first room in the row, and it was located to the left side facing the hallway, on the right side was T3 nurses' station. The following temperatures were obtained with the use of the digital laser thermometer (temperature-sensing instrument) at the time of the observation on 9/09/2024 from 7:01 p.m. to 8:36 p.m.: Room # Temp Time room [ROOM NUMBER] 83.1F 7:01 p.m. room [ROOM NUMBER] 83.3 F 7:03 p.m. room [ROOM NUMBER] 82.2F 7:04 p.m. room [ROOM NUMBER] 83.1F 7:04p.m. room [ROOM NUMBER] 82.9F 7:05 p.m. room [ROOM NUMBER] 83.4F 7:07 p.m. room [ROOM NUMBER] 87.2F 8:35 p.m. room [ROOM NUMBER] 87.7F 8:36p.m. room [ROOM NUMBER] 84.4F 7:10 p.m. room [ROOM NUMBER] 89.7F 8:36 p.m. T3 Hallway 87.5F 8:05 p.m. During an interview on 9/9/2024 at 7:05 p.m. with the director of planning and operation (DPO), the DPO stated that the issue with the temperature was first noticed on Sunday 9/8/2024 at approximately 10:00 p.m. by the engineer on campus who notified the DPO that the temperatures were out of range and this engineer on campus was requesting to increase the chiller's (transfers heat away from a space that requires climate control) capacity. The DPO stated that the HVAC (Heating, Ventilation and Air Conditioning- sytem that regulates and moves air throughout the building to keep it comfortable and maintain good air quality) in the facility was a 100-ton chiller running at its full capacity. DPO stated we are over (the temperature) range, we need to be around 81F, and we are above. DPO said that they brought spot coolers, a total of ten to the sub-acute unit to assist with the heat. During a concurrent interview and record review on 9/9/2024 at 8:01 p.m. with the CNO in room [ROOM NUMBER], the facility's policy and procedure (P&P) titled, Temperature and Humidity, and Air Exchange monitoring and control, last revised 01/2023, was reviewed. The P&P indicated acceptable temperature of 70-75F for most of the hospital rooms and departments except for the main operating room suites which is 68-75F. CNO stated we are above the normal (between 71-81F) for the building. During a concurrent observation and interview on 9/9/2024 at 8:28 p.m. with Resident 1 in room [ROOM NUMBER], the temperature in room [ROOM NUMBER] was 83.3F (Fahrenheit, a unit of measurement). Resident 1 pleasantly agreed to the interview. Observed that the room has spot cooler inside. Although a double bedroom, Resident 1 was a single occupant of this room. Resident 1 stated that the temperature is hot in my room. Resident 1 stated that he complained about it (hot temperature) to them (facility) yesterday and they put the coolers today (9/9/2024). It started getting hot since the early week when the hot days before yesterday (9/8/2024). Resident 1 said that they (the facility) installed the cooler, and it was not working to bring the temperature down. During a concurrent observation and interview on 9/9/2024 at 8:28 p.m. with Resident 2 in room [ROOM NUMBER], the temperature in room [ROOM NUMBER] was 84.5F. Resident 2 pleasantly agreed to the interview. Observed that the room has a running spot cooler in place. Although a double bedroom, Resident 2 was a single occupant of this room. Resident 2 stated that it had been very hot in the facility. Resident 2 stated that he (Resident 2) complained about it to the staff yesterday (9/8/2024) and they (Facility staff) brought the chiller in and Resident 2 added that it is barely working in my room. Resident 2 stated it's not just the rooms, also the hallways. During a concurrent observation and interview on 9/9/2024 at 8:36 p.m. with Licensed Vocational Nurse 1 (LVN 1), observed that LVN 1, who was sitting in her working computer- station right outside the door of room [ROOM NUMBER], had an installed portable mini fan attached to the handle. LVN1 stated it is hot in here; today is hot. LVN 1 said that she keeps her fan on and wear light clothing. During a review of Resident 1's history and physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/14/2023, the H&P indicated, Resident 1 was admitted with a chief complaint of respiratory failure (is the ineffective gas exchange by the respiratory system). During a review of Resident 2's history and physical (H&P), dated 1/17/2023, the H&P indicated, Resident 2 was admitted with a chief complaint motor vehicle accident with traumatic brain injury (occurs when the brain is damaged by a sudden force, such as a blow to the head). During a review of the facility's daily temperature readings in the sub-acute department log, dated 9/9/2024, the log indicated the following temperatures: Room # Temp Time room [ROOM NUMBER] 88.1F 4:32 p.m. room [ROOM NUMBER] 83.3 F 4:33 p.m. room [ROOM NUMBER] 81.4F 4:34 p.m. room [ROOM NUMBER] 83.8F 4:35p.m. room [ROOM NUMBER] 84.3F 4:36 p.m. room [ROOM NUMBER] 88.8F 4:37 p.m. room [ROOM NUMBER] 83.5F 4:38 p.m. room [ROOM NUMBER] 82.9F 4:39 p.m. room [ROOM NUMBER] 85.5F 4:40 p.m. Nurses' station 87.1 4:44 p.m. Med room [ROOM NUMBER].8 F 4:45 p.m. Kitchen 89.6F 4:46 p.m. During an interview on 9/9/2024 at 9:45 p.m. with DPO, the DPO indicated that he (DPO) has reached out to the vendor and planning to get a secondary chiller, but it will have to go for approval from administration. DPO said that the secondary chiller will be able to provide cool air to the other rooms. DPO stated that there was one engineer stationed on site on three different (6a.m-2 p.m., 2p.m-10:00 p.m., and 10:00 pm. -6:00 a.m.) shifts that will help to capture any changes in temperatures in the facility. During an interview on 9/9/2024 at 10:02 p.m. with the CNO, in room [ROOM NUMBER], CNO stated that to place the residents in different rooms; the facility will need to find another facility that could house sub-acute residents and we don't know if all the residents can be relocated at this time. During a review of the facility's policy and procedure (P&P) titled, Environmental Conditions, last revised 7/2022, the P&P indicated, the sub-acute unit will provide a safe, functional, sanitary, and comfortable environment for patients, staff members, and the public. During a review of the facility's policy and procedure (P&P) titled, Physical Environment, revised 12/2022, the P&P indicated, provide a comfortable and adequate light, temperature and sound levels.