Every finding on record at Southern Inyo Hospital D/P SNF

Based on interview and record review, the facility failed to ensure the services of a registered nurse (RN) were provided for at least eight consecutive hours a day, seven days a week, for the facility. This failure had the potential to result in delays in clinical assessment, changes in resident conditions not being identified timely, and increased risk for adverse outcomes due to lack of RN oversight.Findings: During an interview on April 27, 2026, at 8:23 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there are times when an RN is not available. LVN 1 further stated there are about two or three full-time RN staff available overall in the facility. During an interview on April 28, 2026, at 1:33 PM, with the Director of Staff Development (DSD), the DSD stated the facility does not consecutively have a registered nurse scheduled for eight consecutive hours a day, seven days a week. The DSD further stated there are currently total of three full-time registered nurses, but they are not always available on the weekends, so there would be some weekends where the facility would not have an RN for 24 hours. During a concurrent interview and record review on April 28, 2026, at 1:38 PM, with the DSD, the facility's [name] Skilled Nursing-Per Patient Day, dated August 7, 2025, through August 31, 2025, were reviewed. There were no RNs listed for the following dates: On August 7, 2025On August 10, 2025On August 11, 2025On August 23, 2025On August 24, 2025On August 30, 2025On August 31, 2025 The DSD confirmed that the facility did not schedule an RN seven days a week from August 7, 2025, through August 31, 2025. During an interview on April 29, 2026, at 3:59 PM, with the Director of Nursing (DON), the DON stated the facility has had difficulty with finding RN coverage consistently as required by the federal regulations. The DON stated the facility did not have a policy addressing RN staffing. The DON further stated it was important to have an RN oversight in order to ensure quality patient care and safety.

Based on observation, interview, and record review, the facility failed to ensure an effective, and active system wide infection control program for the prevention, control, and investigation of infections and communicable diseases for a universe of 23 residents, when: 1. The facility failed to keep its infection prevention and control policies updated annually. 2. For three Residents (Resident 3, 28 and 4), the facility did not implement Enhanced Barrier Precautions (EBP- infection control measures for nursing homes, requiring staff to wear gowns and gloves during high-contact care to stop the spread of infection) specifically for residents with multidrug-resistant organism (MDROs- bacteria and other microorganisms that have developed resistance to multiple classes of antimicrobial drugs, making them difficult to treat), indwelling catheter (medical instruments designed to remain inside the body for a prolonged period), or chronic wounds. These failures had the potential to result in cross-contamination (spread of infection), healthcare-associated infections (infection acquired while receiving care in the facility), bloodstream infections, urinary tract infections (UTI-infection in the bladder/urine system), and other serious complications, placing residents at risk for illness, delayed recovery, hospitalization, or worsening of their medical conditions.Findings: 1. During an interview on April 28, 2026, at 2:05 PM, with the Infection Preventionist (IP), the IP stated that the infection control policies are to be updated on an annual basis. During a concurrent interview and record review on April 28, 2026, at 2:10 PM, with the IP, the facility's policy and procedures (P&P) titled Infection Prevention and Control Plan, dated December 2024, was reviewed. The Infection Prevention and Control Plan indicated, The administration of [facility name] shall delegate the oversight and management of the Infection and Prevention and Control Plan to the. Infection Control Professionals. infection control professional (s) shall use evidence based national evaluation of the organization's Infection Prevention and Control Plan shall be conducted at least on an annual basis and whenever risk significantly change.The IP stated that she believed she had renewed the policy and would check to see if there was an updated policy. During a follow-up interview on April 29, 2026, at 8:50 AM, with the IP, the IP stated that the facility could not provide any documented evidence that the infection control program had been reviewed within the last year, and it is important to review infection control policies to ensure the facility is meeting regulations and ensure residents safety. 2a. During a review of Resident 3's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 3 was admitted on [DATE], with diagnoses of diabetes (DM- high blood sugar), dementia (a condition that affects the brain, making it difficult to think, remember, and make decisions), and obstructive and reflex uropathy (a condition where there is a functional blockage in the urinary tract that causes urine to back up, potentially damaging the kidneys). During an interview on April 26, 2026, at 12:48 PM, with Charge Nurse (CN1), CN 1 stated, the facility did not have any residents who were on (TBP- safety steps used to stop infections from spreading from one person to another, depending on the way the germ transmits through contract, coughing, sneezing, or air) or on EBP. CN 1 stated, the green flag above the door indicates that the residents are not on any type of isolation (one method of TBP) and that the residents are on standard precautions (basic hand hygiene and protection applied to all patient care activities). CN 1 added, three residents (Resident 3, 4, and 28) did have indwelling catheters. CN 1 confirmed all residents had a green flag above the door. During an observation on April 26, 2026, at 2:00 PM, outside of Resident 3's room, there was no personal protective equipment (PPE- equipment used to protect yourself and the residents from germs or infection that includes gowns and gloves) cart, no EBP poster (a poster used to identify what type of PPE is needed when caring for the residents), and the green flag was noted above the door. Inside the room, Resident 3 was observed to have indwelling foley catheter (a soft tube that stays inside the bladder used to drain urine) bag hanging to the right side of the bed with about 25 Milliliters (ML—unit of measurement) of light-yellow urine. A review of Resident 3's Orders, dated September 5, 2025, indicated Change 16 F [size of catheter] Suprapubic catheter [a tube inserted through a small abdominal incision directly into the bladder to drain urine] every 21 days and as needed. There was no active order for EBP in Resident 3's medical record. 2b. During a review of Resident 28's FS, the FS indicated Resident 28 was admitted on [DATE], with diagnoses of dementia, hydronephrosis (swelling of one or both kidneys caused by buildup or urine), and retention of urine (The inability to fully or partially empty the bladder). During an observation on April 26, 2026, at 1:50 PM, outside of Resident 28's room, there was no PPE cart, no EBP poster, and the green flag was above the door. Inside the room, Resident 28 was observed to have an indwelling foley catheter bag with 100 ML of light-yellow urine. A review of Resident 28's Orders, dated March 25, 2026, indicated 16 French foley catheter. There was no active order for EBP in Resident 28's medical record. 2c. During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including active primary progressive multiple sclerosis (disease where the immune system attacks the nerves, causing problems with how the brain and body communicate, and gradually gets worse over time), UTI and sialolithiasis (condition where salivary gland stones form and block saliva flow). During an observation on April 26, 2026, at 12:24 PM, in Resident 4's room, Resident 4's room had a sign outside of the room indicating standard precautions. Resident 4 was observed resting in bed with a foley catheter hanging on the side of the bed. Resident 4 confirmed she has had the foley catheter for a while. Resident 4 further stated, staff conducts perineal care (cleaning of genital and anal area) every day and flushes the catheter. During an interview on April 26, 2026, at 3:38 PM, with CN1, CN1 confirmed Resident 4 has a suprapubic catheter for a few years, and that Resident 4 is currently not on any specific type of precautions. CN 1 was unsure of what other precautions Resident 4 would be on besides standard precautions. During an interview on April 27, 2026, at 11:10 AM, with Certified Nurse Assistant (CNA 1), CNA 1 stated, EBP does not sound familiar. CNA 1 added, currently there are no residents on EBP. During an interview on April 27, 2026, at 11:15 AM, with CNA 2, CNA 2 stated EBP Doesn't [does not] ring a bell [does not recall] and does not believe any residents are currently on EBP. During an interview on April 27, 2026, at 11:20 AM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated he thinks he is supposed to gown up (wearing protective cloth covering) for EBP but is not sure what EBP is. LVN 2 stated it is important to wear appropriate PPE for residents on any type of TBP to prevent the spread of infection. During an interview on April 27, 2026, at 11:31 AM, with the Director of Staff Development (DSD) and Director of Nursing (DON), the DSD could not explain what EBP was. The DON stated EBP is when staff further gowns up for residents with Methicillin-resistant Staphylococcus Aureus (MRSA- a type of germ that has developed a resistance to many common antibiotics that used to kill it.) The DON stated that currently the facility did not have any residents on EBP. During an interview on April 28, 2026, at 10:54 AM, with the IP, the IP stated the last in-service (training) provided to the staff for EBP was in 2024, however, most of the employees that received the training are no longer working at the facility. The IP stated that EBP is important to prevent transmission and spread of infection amongst residents. A follow-up interview on April 28, 2026, at 10:56 AM, with the IP, the IP stated no residents were on EBP, however, Resident 3, 4 and 28 should have been because those residents had indwelling catheters. During an interview on April 28, 2026, at 3:48 PM, with the DON, the DON stated that the facility does not have an EBP policy. The DON added it is important to follow EBP in residents with indwelling devices as it is a portal for infection and the nursing staff should prevent the spread of infection in residents. During a concurrent interview and record review on April 29, 2026, at 8:51 AM, with the IP, the facility's P&P titled, Infection Prevention and Control Plan dated December 2024, was reviewed. The P&P indicated, .the goal of the Infection Prevention and Control Plan include: .limited the transmission of infections. ensuring policies and procedures follow current infection control guidelines and recommendations.the development, review and revision of organizational infection prevention and control policies and procedures.staff competency, i.e., infection control processes. The IP stated that the policy was not followed. The IP stated the facility has not developed a policy for EBP and should have to prevent the spread of MDROs.

Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement interventions to prevent accidents related to smoking for four of 12 sampled residents (Residents 1, 4, 11, and 29), when smoking materials were not maintained in accordance with the facility's policy and procedure (P&P). These failures had the potential to result in serious injury, including burns, fire hazards, or harm to residents, staff, and the facility environment. Findings: 1a. During a review of Resident 1's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus (condition where the body does not use insulin properly, causing high blood sugar) with diabetic neuropathy (type 2 diabetes that has caused nerve damage) and primary osteoarthritis (condition where the cartilage in the joints slowly wears down over time). During a concurrent observation and interview on April 27, 2026, at 8:53 AM, with Licensed Vocational Nurse 1 (LVN 1), in Resident 1's room, Resident 1 was observed sleeping in bed with oxygen running via a nasal cannula (device with small tubes that sit in the nostrils to give patient extra oxygen), and four lighters were observed on Resident 1's nightstand table. LVN 1 confirmed the lighters belonged to Resident 1 and stated he was a lighter hoarder and would keep multiple lighters in his room. LVN 1 further stated Resident 1 would only use oxygen when he is in his room but not when he goes outside. During a review of Resident 1's Active Orders, dated April 26, 2026, the document indicated, Resident 1 had an order of PRN [as needed] Oxygen @ [at] 2L [liters—unit of measurement] via nasal cannula related to decreased O2 [oxygen] sats [saturation—percentage of oxygen in blood] to maintain oxygen saturations above 90%. During a concurrent interview and record review on April 27, 2026, at 3:40 PM, with LVN 2, Resident 1's care plan (individual plan that includes residents' health problems, preferences, and goals), dated April 26, 2026, was reviewed. The care plan indicated, Current Tobacco, Marijuana, and vape user.GOAL: Resident will Adhere to the Tobacco/Smoking Policies of the Facility; Nurse Will Provide Tobacco Cessation Information to Resident.INTERVENTIONS: Complete Smoking safety assessment (an evaluation to determine whether a resident can smoke safely without harming themselves or others) quarterly and as needed. Educate Resident / Family on risks & health effects of tobacco use. Resident is able to light own cigarettes. The resident needs supervision when smoking. LVN 2 confirmed Resident 1 is a smoker and keeps his cigarettes and lighters in his possession. 1b. During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including active primary progressive multiple sclerosis (disease where the immune system attacks the nerves, causing problems with how the brain and body communicate, and gradually gets worse over time), urinary tract infection (UTI – infection in the bladder/urine system), and sialolithiasis (condition where salivary gland stones form and block saliva flow). During an observation on April 26, 2026, at 12:24 PM, in Resident 4's room, Resident 4 was observed in bed, and a pack of cigarettes were noted on Resident 4's nightstand table. Resident 4 confirmed the pack of cigarettes belonged to her and that she smokes at least two to three times a week. During a concurrent interview and record review on April 27, 2026, at 3:45 PM, with LVN 2, Resident 4's care plan, dated April 26, 2026, was reviewed. The care plan indicated Tobacco Use.GOAL: Resident will Adhere to the Tobacco/Smoking Policies of the Facility.INTERVENTION: Conduct Smoking Safety Evaluation on admission and PRN (as needed). Educate Resident / Responsible Party on the facility's tobacco / smoking policy(s); Educate resident to the facility's policy regarding recreational substance use. If a smoking facility, orient Resident to smoking times and procedures. Smoking safety assessment performed quarterly and as needed. LVN 2 confirmed Resident 4 is a smoker and keeps her cigarettes and lighters in her possession. 1c. During a review of Resident 11's FS, the FS indicated, Resident 11 was admitted on [DATE], with diagnoses of nicotine dependence (occurs when the body craves nicotine or a highly addictive stimulant drug that is found in tobacco), congestive heart failure (CHF- a condition where the heart muscle is unable to pump blood effectively enough to meet the body's needs), and chronic obstructive pulmonary disease (COPD- a long term lung condition that makes it hard to breathe because the airways are damaged and narrowed). During a concurrent observation and interview on April 26, 2026, at 1:20 PM, in Resident 11's room, with Resident 11, Resident 11 was observed pulling out his lighter from his jean pocket. Resident 11 stated he always keeps his lighters with him. During a review of Resident 11's care plan, dated February 11, 2025, to July 4, 2026, the care plan indicated interventions. complete smoking safety assessment quarterly. provide smoking cessation information/assistance/ resources.resident is able to safely use a lighter. 1d. During a review of Resident 29 FS, the FS indicated Resident 29 was admitted on [DATE], with diagnoses of nicotine dependence, and hypotension (low blood pressure). During a concurrent observation and interview on April 26, 2026, at 1:11 PM, in Resident 29's room, with Resident 29, Resident 29 had his lighter on the bedside table. Resident 29 stated he is a smoker and always keeps his lighters. During a review of Resident 29's smoking and safety assessment, dated April 21, 2026, the smoking and safety assessment indicated the resident uses tobacco and displays balance problems while sitting or standing. During a review of Resident 29's care plan, dated April 21, 2026, to July 13, 2026, the care plan indicated interventions. instruct resident about the facility policy on smoking: location, times, safety concerns. The resident required supervision while smoking. During an interview on April 28, 2026, at 2:59 PM, with LVN 2, LVN 2 stated, the nursing staff is not in charge of keeping the residents' smoking materials and believes that the residents keep their materials. During an interview on April 28, 2026, at 3:36 PM, with the activity Director (AD), the AD stated that she is only in charge of keeping one resident's smoking materials, the other smokers keep their own materials. The AD stated it is important for a staff member to keep the smoking materials to ensure that the residents do not smoke inside their rooms. During a concurrent interview and record review on April 28, 2026, at 3:48 PM, with the DON the facility's P&P titled, Smoking Safety Policy, dated November 13, 2025, was reviewed. The P&P indicated, . A smoking risk assessment will be completed on admission, quarterly, annually, any change of condition.D. Smoking materials. residents may not keep cigarettes, lighters, matches, or any smoking supplies in their personal possession. Smoking materials will be stored securely by nursing staff. Staff will give the residents the needed materials at the start of the smoking session and return them to storage immediately after. The DON stated that the policy was not followed and should have been. The DON stated it is important to follow the policy to ensure that the residents do not burn themselves.

Based on observation, interview, and record review, the facility failed to ensure a physician's medication order was completed and administered in accordance with acceptable nursing standards of practice for one of 12 sampled residents (Resident 28), when nursing staff administered ceftriaxone sodium (Rocephin-an antibiotic used to treat severe infections) without clarifying the physician's order for the intravenous (IV) administration method and the appropriate diluting agent (liquid solution to mix medication). This failure had potential to cause medication administration error (preventable events from inappropriate medication administer) from IV delivery methods between IV push (IVP-a rapid, direct injection of medication into a vein) and IV piggy back (IVPB-slow medication administration into a vein), and incompatible solution mixture, which could negatively affect Resident 28's health from reduced medication effectiveness, local reddening, pain at the site, and lead to actual physical harm.Findings: During a review of Resident 28's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated Resident 28 was admitted on [DATE], with diagnoses of dementia (a condition that affects the brain, making it difficult to think, remember, and make decisions), hydronephrosis (swelling of one or both kidneys caused by buildup or urine), and retention of urine (the inability to fully or partially empty the bladder. During a medication administration observation on April 27, 2026, at 10:11 AM, with the Director of Nurse (DON) in Resident 28's room, The DON was observed with one (1) gram (GM-unit of dosing medication) Rocephin in 100 milliliters (ml-unit of measurement) bag of normal saline (NS-salt water as the diluting solution). The DON was noted to attach Rocephin bag to Resident 28's IV access and set up the delivery rate at 200 ml per hour (30 minutes delivery time). During a concurrent interview and record review on April 28, 2026, at 2:40 PM, with the DON, Resident's 28's Orders, dated April 28, 2026, to May 1, 2026, were reviewed. The Orders indicated, CefTRIAXone Sodium Intravenous Solution reconstituted 1 GM. use 1 gram intravenously one time a day related to chronic kidney disease [kidney slowly losing the ability to clean the blood over time] . for 3 days. The DON stated, typically any antibiotic that is given to the resident's is sent by [pharmacy company], however the pharmacy had not sent over the antibiotic yet, which is why she pulled the medication out of the Antibiotic Emergency Kit (EKIT- a sealed box with medications that are used for emergencies and contains antibiotics). The DON verified and confirmed that the order did not indicate the exact delivery method between IVP and IVPB, and there was no specific diluting agent to use. During a concurrent interview and record review on April 28, 2026, at 3:55 PM, with the DON, the facility's policy and procedures (P&P) titled, IV Therapy- Single/Piggyback/push, dated December 12, 2012, was reviewed. The P&P indicated, procedure:.Ensure that a physician's order for IV medication or solution, including medication name, classification, dosage, route, and frequency, is in the patient's medical record.verify the rate of infusion and/or length of time needed for infusion.recheck medication for the patient's name and medical record number, dosage, route, strength, time and method of administration with Electronic Medication Administration Record (eMAR) and physician's medication order. The DON stated that the policy was not followed for IV medication delivery method and diluting agent. The DON further stated it is important to follow the policy to ensure the residents receive the proper method of administration for the residents' comorbidities (multiple medical conditions that affect patient's health and treatment).

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public when four staff members complains of black material on ceiling and water leaks stains in the resident's activity room, front office, control room and ADON's (Assistant Director of Nursing) office. This failure has a potential to put residents, staff and visitors. health, safety and wellbeing at risk. Based on Interview with Licensed Vocational Nurse (LVN 1), on April 2, 2025, at 10:00 AM. LVN1 stated that there's water leak spots in some areas of the building, most especially in the activity room. LVN 1stated I have not seen the black materials on the ceiling, but our ADON has it in her office. I believe it has been reported to maintenance . She also stated I was sick 3 weeks ago with Flu- Coughing, sneezing, wheezing, weakness, fatigue, body aches, nasal congestion and fever. The IPN (Infection Preventionist Nurse) tested me for covid, and it was negative. I did not get tested for Mold exposure and we have few residents with respiratory symptom that started around February, and some were treated with antibiotics. Based on interview with Assistant Director of Nursing (ADON), on April 2, 2025, at 10:15 AM. ADON stated There's some Black Material/ Spot on the ceiling in my office, after the rain we had back in February, it got worse. One area in the ceiling were all black. I reported it to [NAME], our maintenance. He told me that he will get it tested for Molds. I have had a bad respiratory issue. I was coughing, wheezing, sneezing, and fatigue . ADON also stated. Maintenance was telling me that the result of the Mold testing has a low reading. He wiped all the BLACK stuff on the ceiling with a spray. He tested it after cleaning/wiping the black material. My respiratory symptoms got worse after maintenance wiped the black material off the tiles . Based on interview and concurrent record review of the Infection Control monitoring log with IPN (Infection Preventionist Nurse) on April 2, 2025, at 10:30AM. IPN stated Yes. We have had a few residents with respiratory symptoms. Two residents were diagnosed with Pneumonia and received antibiotics treatment. There were 7 residents with respiratory symptoms from February/March 2025. We did chest X-ray on all 7 residents, and we tested them for covid with negative results. We also have 10 staff with respiratory symptoms that started around February/March 2025 with sore throat, congestion, body aches and chills and 1 with fever . Based on interview with Staff 1, on April 2, 2025, at 10:45 AM. Staff 1 stated I'm in the same office with ADON. I've been having issues with my sinuses. I've seen the ENT specialist. Symptoms all started after the maintenance wiped the Black material /Spots off the ceiling. We relocated to a different area now. They contained that room. They removed the tiles that had the black material on it. We've seen that black discoloration from the ceilings since November and we reported to maintenance back in February 2025 . Based on interview with Maintenance on April 2, 2025, at 11:00 AM. Maintenance stated Yes. I received a report regarding the Black material in the ADON's office. We contained the area and relocated both ADON and STAFF 1. We already removed the tiles out from the ceiling, and we will replace it with a new one. I did a testing for presence of Mold and the report shows that it has a low reading When asked about the water leaks, Maintenance stated There's some water leaks in the activity room and front office and in the process of replacing the tiles. We have not tested it for molds. I can do the test myself; we don't have to call the Mold specialist to test it. We have the kit, and we can do it ourselves . Based on observation with Maintenance on April 2, 2025, at 11:15 AM, Noted water leak spots in the activity room's ceiling, front office and inside the control room. No black material/spots noted on the ceiling. Inside the ADON's office, noted some tiles had been removed from ceiling. Old Tiles that were removed had some black stained noted on it. No water leaks noted inside random' resident's room in the acute unit or Skilled facility Unit (SNF). Based on interview with Staff 2 on April 2, 2025, at 11:30AM, Staff 2 stated I've been complaining about the black material/Mold in the ceiling in the drug room. Every time it rains, it leaks. I've been e-mailing and reporting it to the maintenance, and nothing's being done. Management and Maintenance are aware of the Black material /water leaks in the buildings . Based on interview and record review of the policy's titled SAFE ENVIRONMENT with ADON on 4/2/2025 at 11:50 AM. Policy stated It is the policy of this facility to ensure the safety and wellbeing of residents by maintaining a hazard free environment 4. e. The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. When ADON was asked if the policy was followed, she stated it is not a comfortable environment due to not having a Specialist on Mold Prevention and Treatment , doing the proper testing for the presence of mold in the facility for the safety and wellbeing of our residents, staff and visitors .

Based on interview and record review, the facility failed to protect and prevent residents from an inappropriate resident-to-resident sexual contact for two of two residents (Resident A and Resident B) when Resident A was seen hovering over Resident B and kissing. This failure resulted in Resident A and Resident B engaging in resident-to-resident sexual contact while under the supervision of the facility ' s staff which had the potential to cause unsafe environment such as unsafe sexual activity that could negatively affect Resident A and Resident B ' s health and safety. Findings: During a review of Resident A ' s History and Physical (H&P), the H&P indicated, Resident A is a [AGE] year old male with medical histories which included epilepsy (neurological disorder characterized by recurrent, unprovoked seizures [sudden burst of abnormal electrical activity in the brain which can cause a wide range of symptoms depending part of the brain]), severe intellectual disabilities, and diabetes (medical condition that occurs when the body either does not produce enough insulin or cannot effectively use the insulin it produces). During a review of Resident A ' s Basic Interview for Mental Status (BIMS-a standardized assessment tool used primarily in healthcare settings, particularly nursing homes and other long term care facilities, to evaluate a resident ' s cognitive or thinking function), Resident A ' s BIMS score is 99, which indicates that the responses were incomplete and cannot provide baseline information about Resident A ' s cognitive function. During a record review of Resident ' s B H&P, the H&P indicated that Resident B is a [AGE] year-old female with medical diagnoses of multiple sclerosis (chronic autoimmune disease that affects the central nervous system and spinal cord, dementia (decline of cognitive function), anxiety disorder, and major depressive disorder. During a record review of Resident ' s B BIMS score, Resident B ' s BIMS score is 14, which indicated normal cognitive function. During a phone interview on August 19, 2024, at 12:03 PM, with Certified Nurse Assistant 1 (CNA1), CNA 1 stated Resident A was observed hovering on Resident B kissing. CNA 1 then approached Resident A and Resident B with CNA 2. CAN 1 stated, Resident A was then seen removing his hand from Resident B shirt and wipe his mouth. CNA 1 further stated, it was inappropriate for Resident A and Resident B to be involved. During a phone Interview on August 20, 2024, at 8:12 AM with CNA 2, CNA 2 stated that CNA 1 called her to accompany CNA 1 to outside the facility. CNA 2 further stated, when they went outside, CNA 2 witnessed Residents A and B were kissing. CNA 2 further explained Resident A and Resident B separated when CNA 1 asked what ' s going on? CNA 2 stated, she saw Resident A removed his hand from Resident B ' s shirt and wiped his mouth. CNA 2 further stated that this was an inappropriate incident and reported to the Registered nurse. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, undated, the P&P indicated, .Purpose: To ensure all facility staff including contract staff observe residents ' rights . Be free from abuse, neglect, misappropriation of resident property, and exploitation . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals .

Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available onsite at least eight (8) hours a day, seven (7) days a week for all admitted residents from April 1, 2024, through July 11, 2024 when the facility did not have RN onsite for 17 days and had fewer RN hours than eight (8) hours requirement for three (3) days. This failure had a potential to negatively affect residents care from an oversight of RN which may increase risk of avoidable resident safety events such as medication errors or delayed in comprehensive assessment that could jeopardize residents' health, safety, and lead to actual harm. Findings: During an observation on July 11, 2024, from 8:00 AM, through 10:00 AM, there was no RN working in the unit. During an interview on July 11, 2024, at 11:10 AM, with the Assistant Director of Nursing (ADON) 1, the ADON 1 stated that besides the Director of Nursing (DON) 1 as an RN, they have two other RNs (RN 1, RN 2). The ADON 1 claimed that there was no RN scheduled for today, and the facility was aware of the policy that requires eight (8) hours of RN on duty seven (7) days a week. During an interview on July 11, 2024, at 2:59 PM, with the Director of Human Resources (DHR) 1, the DHR 1 stated that the facility was unable to find RN to cover for DON 1 today. During a concurrent interview and record review on July 12, 2024, at 9:15 AM, with the ADON 1, the DON 1's timecard, dated April 9, 2024, April 17, 2024, and July 11, 2024, were reviewed. The ADON 1 clarified that the reason the DON 1's timecard showed hours on April 9 and April 17 was because DON 1 was working for the hospital on those days. She went on to say that although the DON 1's timecard showed hours on July 11, the DON 1 was not physically present at the facility. A continuous concurrent interview and record review on July 12, 2024, at 9:15 AM, with the ADON 1, RN staffing schedule and timecard, dated April 2024, were reviewed. The ADON 1 confirmed that for the month of April 2024, there were no RN hours on April 1, April 2, April 4, April 9, April 17, and April 29. On April 3, RN hours were 4.5 hours short. A continuous concurrent interview and record review on July 12, 2024, at 9:15 AM, with the ADON 1, RN staffing schedule and timecard, dated May 2024, were reviewed. The ADON 1 confirmed that for the month of May 2024, there were no RN hours on May 16, May 20, May 21, May 22, May 23, and May 27. On May 6, RN hours were 6 hours short, and on May 7, RN hours were 3.75 hours short. A continuous concurrent interview and record review on July 12, 2024, at 9:15 AM, with the ADON 1, RN staffing schedule and timecard, dated June 2024, were reviewed. The ADON 1 confirmed that for the month of June 2024, there were no RN hours on June 18, June 19, and June 27. A continuous concurrent interview and record review on July 12, 2024, at 9:15 AM, with the ADON 1, RN staffing schedule and timecard, dated July 1, 2024, through July 11, 2024, were reviewed. The ADON 1 confirmed that for the month of July 2024, there were no RN hours on July 4 and July 11. A review of the facility's policy and procedure (P&P) titled, RN/Director of Nursing Coverage, dated July 9, 2020, indicated, . 4. A registered nurse will be present 7 days a week for at least 8 consecutive hours a day .

Based on observation, interview, and record review, the facility failed to protect residents from food contamination for a universe of 29 residents when one kitchen staff was not wearing a hair net during food preparation. This failure had the potential to contaminate food, equipment, and utensils. Findings: During a concurrent observation and interview on July 8, 2024, at 02:08 PM, in the kitchen, Kitchen Aide (KA) 1 was not wearing a hair net while preparing food. When pointing out the absence of a hair net on, she then walked to the kitchen entrance and put on a hair net. KA 1 stated she should have put a hair net on, and the facility have said many times that staff are to wear hair net while in the kitchen. During an interview on July 12, 2024, at 11:07 AM, with the Dietary Services Supervisor (DSS) 1, the DSS stated staff should wear the hair net due to potential contamination of food, equipment, or utensils. During a review of the facility's policy and procedure (P&P) titled, Hair nets & personal permitted in FNSD (Food and Nutrition Services Department), dated September 2023, the P&P indicated, All Food and Nutrition staff are required to wear hairnets or caps or other suitable coverings to confine hair when required to prevent the contamination of food, equipment, or utensils.

Based on interview and record review, the facility failed to ensure nursing staff were certified and kept current in cardiopulmonary resuscitation (first aid technique to help a person who has stopped breathing) for five (5) of 18 Certified Nurse Aide (CNA) (CNA 1, 2, 3, 4, and 5) when the facility was unable to provide documented evidence of current CPR certification. This failure had the potential to negatively affect residents' care due to unqualified or incompetent staff during emergencies at the facility. Findings: During a concurrent interview and record review on [DATE], at 11:10 AM, with the Assistant Director of Nursing (ADON) 1, and the Director of Staff Development (DSD) 1, CNA 1's file, undated, was reviewed. There was no CPR's certification on file. The ADON 1 and DSD 1 explained that when CNA 1 was hired on [DATE], the facility failed to check if the CNA 1 had a CPR card. The DSD 1 further stated that for the last six months, he has not kept track of the staff CPR certification status. During an interview on [DATE], at 1:58 PM, with the DSD 1, the DSD 1 stated that there are three other CNAs (CNA 2, 3, and 4) that did not have CPR cards, and one CNA (CNA 5) CPR card has expired in [DATE]. The DSD 1 stated he has forgotten to check the employee's CPR status. A review of the nursing staff CPR certificate list indicated that four CNAs (CNA 1, 2, 3, and 4) did not have CPR cards. A review of the CNA 5 CPR card issued on [DATE], indicated that the CPR card expired in [DATE]. During an interview on [DATE], at 2:59 PM, with the Director of Human Resources (DHR 1), the DHR 1 stated it was completely an oversight; it was an assumption that the CNAs had to have a CPR card before they received their CNA certification. The DHR further stated, It was their fault for not verifying. A review of the facility's policy and procedure (P&P) titled, C.P.R. Certification-Required dated [DATE], indicated, .1. All certified and licensed staff shall hold current cardiopulmonary resuscitation certification through the American Red Cross, the American Heart Association, or another accrediting or certifying agency. 2. C.P.R. certifications shall be kept current at all times .

Based on observation, interview, and record review, the facility failed to maintain a safe operating equipment for one (1) of 29 residents (Resident 27) when Resident 27's bedrail had sharp edges on it. This failure resulted in Resident 27 sustaining an abrasion on her right elbow from the sharp edges which may cause an infection and putting Resident 27's health in jeopardy. Findings: A review of resident 27's Admission Record (which contains demographic and medical information), indicated, Resident 27 was admitted to the facility on [DATE], with diagnoses that included elevated white blood cell count, abnormality of albumin (a protein in your blood plasma), insomnia (difficulty falling asleep, staying asleep, or both), and weakness. During a concurrent observation and interview on July 8, 2024, at 4:14 PM, Resident 27's right elbow was observed in wound dressing. Resident 27 stated, she got a cut from a sharp edge of her bedrail. Upon closer inspection, the right-side bedrail's far end was found to have sharp edges. During an interview on July 9, 2024, at 10:18 AM, with the License Vocational Nurse (LVN) 1, LVN 1 stated that Resident 27 reported a cut on her right elbow coming from a sharp edge on the bedrail. LVN 1 further stated she cleaned the wound and put dressing on it. LVN 1 denied reporting the incident to the facility's management. LVN 1 confirmed, Resident 27's bedrail had a sharp edge. During an interview on July 10, at 8:35 AM, with the Director of Nursing (DON) 1, the DON 1 stated she was unaware of the sharp edge on resident 27's bedrail. The DON 1 further explained that one of her staff members reported that Resident 27 sustained an abrasion but did not chart how the wound occurred. The DON 1 stated that she has not followed up on the bedrail yet. During an interview on July 12, 2024, at 09:06 AM, with the Environmental Services Manager (EVSM) 1 filling in for the Director Facilities, the EVSM 1 stated he was unaware of any sharp edges on Resident 27's bedrail and that there was no report on the subject. A review of the facility's policy and procedure (P&P) titled, Safe Environment, dated July 20, 2022, indicated, .2. The facility will maintain all essential mechanical, electrical and patient care equipment in safe operating condition .

Based on observation, interview, and record review, the facility failed to ensure their post-fall protocol and prevention was implemented in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1) when Resident 1 had a fall incident on December 2, 2023. This failure had the potential to place Resident 1 at risk for further falls and injuries. Findings: During an observation on Resident 1, on January 4, 2024, at 12:15 PM, in Resident 1's room, Resident 1 was lying in bed with the head of the bed elevated. A review of Resident's 1's Admission Record (a document that gives summary of the resident's information) indicated Resident 1 was admitted to the facility on [DATE] with a diagnoses that included dementia(a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood disturbance (feeling of distress or sadness, or symptoms of depression and anxiety), and anxiety(feeling of fear, dread, & uneasiness). A review of Resident's 1 nursing notes, dated December 2, 2022, at 3:22 PM, indicated Slipped out wheelchair at 14:05 (2:05 PM) in activity area. unwitnessed. Head to toe assessment done. Take to ER by gurney . Back from ER at 14:35. No injuries reported upon return to SNF. Need to consider a wheelchair alarm . During a review of Resident 1's clinical records provided by the facility on January 9, 2024, there was no documented evidence to indicate that a Physical Therapist evaluated Resident 1 following a fall incident on December 2, 2023. During a telephone interview with a Physical Therapist (PT 1), on January 16, 2024, at 5:17 PM, PT 1 stated that PT evaluation was not ordered after Resident 1's fall incident on December 2, 2023. PT further stated the purpose of PT evaluation post fall, as per facility protocol, was to identify the risk factors of the fall incident, such as incontinence, confusion, weakness, and environmental hazards, and for them [PT] to recommend measures to prevent fall incidents such as resident reorientation, bed and chair alarm, placing of bed mat, frequent monitoring and toileting. During a telephone interview with the Assistant Director of Nursing, on January 18, 2024, at 10:55 AM, the ADON stated that a Physical Therapist did not evaluate Resident 1 following a fall incident per facility protocol because the nurse on duty failed to place an order for Physical Therapy evaluation. During a record review of the facility's undated policy and procedure titled, Fall Protocol & Prevention indicated .Physical Therapy will be notified via email and order entered (per Dr .) for assessment post fall .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1.There was no air gap (a separation between the water supply and potentially contaminated [dirty] water in a sink or other plumbing fixture) found at the food preparation sink. When installed and maintained properly, the air gap works to prevent drain water from backing up into the sink and possibly contaminating the area used for washing food.), which had the potential for back flow from the drain to contaminate the sink. This had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food). 2.The bench can opener (counter mounted) had dried crusted food on the shank (blade) which could transfer to residents' foods. This had the potential to cause foodborne illness. The facility's failures to ensure a safe and sanitary kitchen resulted in the increased risk of resident harm from food-borne illness to a population of 28 immuno-compromised (decreased ability to fight off infections and diseases) residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Certified Dietary Manager (CDM), on May 15, 2023, at 11:18 AM, in the kitchen, one sink used for food preparation did not have an air gap. The CDM verified, the sink drainpipes did not have an air gap. The CDM stated, air gaps are important to ensure there is good water flow through the pipes and that water does not get stuck and backflow (water flowing back) or overflow. This could lead to contamination (dirty) of food and is an infection control issue. During a concurrent observation and interview with the Director of Materials Management (DMM), on May 16, 2023, at 11:34 AM, verified, there was no visible air gap under the food preparation sink and there was a risk for dirty water to backflow into the food preparation sink, which would contaminate the food preparation area. The DMM stated, the air gap needed to be added. During an interview with the Facility Director (FD), on May 16, 2023, at 2:56 PM, the FD stated, it was brought to his attention that the food preparation sink does not have a visible air gap. The FD stated, an air gap will need to be added. During a concurrent interview and record review, on May 16, 2023, at 3:00 PM, with the CDM, the facility's Policy and Procedure (P&P) titled, Backflow Preventers, dated October 2022, was reviewed. The P&P indicated, . Policy: to maintain a safe water supply from backflow .Procedure: . 5. PIC (person in charge) must demonstrate: identifying the source of water used and measures taken to ensure that it remains protected from contamination such as providing protection from backflow and precluding the creation of cross contamination (movement or transfer of harmful bacteria (germs) from one person, object or place to another) . The CDM stated, the P&P was not followed when there was no airgap in the kitchen sink. During a review of the FDA Federal Food Code 2022 5-202.13 indicated, .Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch) . Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow . 2. During a concurrent observation and interview with the Certified Dietary Manager (CDM) on May 15, 2023, at 11:20 AM, the bench can opener was noted to have old crusty food along the shank (blade of the can opener). The CDM stated, the can opener should not be dirty, and the current condition of the can opener placed the residents at risk for infection and food borne illnesses (nausea, vomiting, and/or diarrhea). The CDM stated, the expectation is that the can opener is cleaned after each use (if dirty) and the process is to manually wash the can opener with soap and water and then run it through the dishwater. During an interview with the Cook, on May 15, 2023, at 4:59 PM, the Cook stated, the bench can opener should be cleaned whenever dirty or twice a week, and the process for cleaning the can opener is to first manually clean with soap and water and then clean in the dishwasher. The cook further stated, there should never be caked on food on the can opener. During a concurrent interview and record review, on May 16, 2023, at 3:05 PM, with the CDM, the facility's Guideline titled, Cleaning Procedure #42 - Bench can opener, undated, was reviewed. The guideline indicated, the shank and top of the base (of the can opener) are to be cleaned and sanitized after each use .Remove shank of can opener- take to dish machine, air dry . The DM stated, the guideline for cleaning the can opener was not followed, because there was dry food on the shank.

Based on observation,interview and record review, the facility failed to follow their policy and procedure (P&P) for smoking for one of six sampled residents (Resident 10) when the facility did not perform a Smoking Risk Assessment of Resident 10. This failure had the potential to delay in identification and implementation of necessary interventions to address the resident's care and which could jeopardize the health and safety of the other residents in the facility. Findings: During a review of Resident 10's Admission Record (clinical record of resident's admission information) indicated, Resident 10 was admitted on [DATE]. During a concurrent observation and interview with Resident 10, on May 16, 2023, at 4: 42 PM, Resident 10 was awake alert, able to verbalize her needs. Resident 10 stated, she uses six to seven regualr cigarettes per day. During a review of Resident 10's admission Smoking Safety Evaluation, dated June 3, 2022, at 6:46 PM, indicated, Resident 10 utilizes tobacco. During a review of Resident 10's Assessments on May 16, 2023, Smoking Risk Assessments were not completed . During a concurrent interview and record review on May 16, 2023, at 5:20 PM, with Licensed Vocational Nurse (LVN 2), Resident 10's SmokingRisk Assessments was reviewed. LVN 2 stated, Resident 10's Smoking Risk Assessments were not done quarterly as indicated in the facility's Smoking P&P. During a concurrent interview and record review on May 17, 2023, at 3:14 PM, with the Assistant Director of Nursing (ADON), the facility's P&P titled, Smoking, dated March 2019, was reviewed. The P&P indicated, .4. Smoking risk assessments are performed quarterly with recommended changes, which could affect the safety of the Resident. The assessments are reviewed by the interdisciplinary team (team members from different areas of practice working together with a common purpose) for agreement and planning of interventions, as needed. The ADON further reviewed Resident 10's Smoking Risk Assessments records and stated Resident 10's Smoking Risk Assessment was incomplete. The ADON stated, Smoking Risk Assessments should have been completed and documented quarterly. The ADON further stated, facility did not follow the Smoking P&P when the facility did not complete the Smoking Risk Assessments quarterly.

Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a computerized clinical assessment tool ) Significant Change in Status Assessment (SCSA-a comprehensive assessment that must be completed when the resident meets the significant change guidelines for either major improvement or decline) within 14 days, for one of six sampled residents (Resident 24) who was reviewed for a fall with fracture (broken bone) of first lumbar vertebra (backbone within the lower back). This failure had the potential to delay in identification and implementation of necessary interventions to address the resident's care and support needs. Findings: During a review of Resident 24's Admission Record (contains demographic information), indicated, Resident 24 was admitted to the facility on [DATE], with a diagnoses included dementia (loss of cognitive functioning with thinking, memory which affects a person's daily activities), current pathological fracture of vertebrae and depression . During a review of Resident 24's clinical record titled, Nursing Progress Notes, by Licensed Vocational Nurse (LVN 1), dated April 23, 2023, at 1:07 PM, indicated, resident had a fall incident on April 19, 2023, and sent to emergency room for further evaluation. During a review of Resident 24's MDS, indicated, MDS SCSA Sections I (Active Diagnoses) and J (Health Conditions) were incomplete. During a concurrent interview and record with the Assistant Director of Nursing (ADON), on May 17, 2023, at 3:10 PM, Resident 24's MDS SCSA was reviewed. The ADON stated, the MDS SCSA should have been completed on May 8, 2023. The ADON further stated, it should have been completed within 14 days from the resident's fall incident. During an interview with the MDS Nurse on May 18, 2023, at 7:50 AM, the MDS Nurse stated, Resident 24's MDS SCSA was created on April 24, 2023, for the fall incident that resulted in a lumbar fracture. The MDS Nurse stated it should have been completed on May 8, 2023. The MDS Nurse further stated, the timeframes for completion and submission of assessments are based on the current requirements published in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessment and Reassessment, indicated, .A comprehensive reassessment shall be completed within 14 days after it is determined that there has been a significant change in the resident's physical or mental condition. During a review of CMS RAI Version 3.0 Manual (helps nursing staff in gathering definitive information on a resident's strengths and needs), dated October 2019, indicated, An SCSA is appropriate when there is a determination that a significant change (either improvement or decline) in a resident's condition from his/ her baseline has occurred as indicated by comparison of the resident's current status . The ARD [assessment reference date] must be less than or equal to 14 days after the IDT's [interdisciplinary team] determination that the criteria for an SCSA are met (determination date + 14 calendar days).

Based on interview and record review, the facility failed to report an allegation of controlled drug diversion (medications that can cause physical and mental dependence such as pain medicines, stimulants), within 24 hours to the California Department of Public Health (CDPH) in a timely manner for three residents (Residents 1, 2 and 3) in a universe of 29 residents. This failed practice had the potential for other unusual occurrences (an incident that threatens the welfare, safety and health of the resident) to go undetected and unreported which could compromise the health and safety of residents at the facility. Findings: During a review of the facility ' s letter notifying CDPH of suspected diversion, dated November 28, 2022, indicated, This letter is to inform you of a suspected medication diversion incident in our skilled nursing department. On November 15th, 2022, a nurse reported to the Director of Nursing of suspicious activity regarding controlled substance log and a possible discrepancy from an LVN. During an interview on November 29, 2022, at 12:48 PM, with the Director of Nursing (DON), the DON stated she was notified of an unresolved narcotic count irregularity on Monday, November 14, 2022. During an interview on December 6, 2022, at 1:45 PM, with the ADON, The ADON stated, if there is a suspected medication diversion, DON/ADON will report it to CDPH as soon as possible, but not later than 24 hours. I should have reported it within that time frame. During a review of the facility ' s policy and procedure (P&P) titled, Controlled Substances, revised February 4, 2021, the P&P indicated, it did not include the element of reporting to the State Agency . any reasonable suspicion of a crime against any individual who is a resident .of the facility. And the policy and procedure did not include the element of not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury.

Based on interview, and record review, the facility failed to ensure that a witnessed allegation of verbal altercation (a noisy, heated angry dispute) was reported to the California Department of Public Health (CDPH) for one of three (3) sampled residents (Resident 1) in a timely manner . This failed practice had the potential for other unusual occurrences (an incident that threatens the welfare, safety, and health of the resident) to go undetected and unreported which could compromise the health and safety of Resident 1 and other residents at the facility. Findings: A fax received from the facility on October 7, 2022, at 6:47 PM, regarding the incident indicated: The incident occurred on September 25, 2022, involving Resident 1 and Certified Nurse Assistant (CNA). The CNA raised their voice and clapped loudly in Resident 1 ' s face and yelled using profanity telling Resident 1 to stop crying. This caused the resident to shrink back in their chair and continue to cry. During an interview on October 11, 2022, at 3:30 PM, in the conference room, with the Infection Control Preventionist (ICP), the ICP stated, this allegation of verbal abuse should have been reported on September 25, 2022, when it was observed. The ICP further stated, a delay in reporting puts the resident at an increased risk for emotional or psychological detriment to the wellbeing of the resident. During a concurrent interview and record review on October 12, 2022, at 12:00 PM, in the conference room, with the Assistant Director of Nursing (ADON), the facility's policy and procedure (P&P) titled, Abuse Prevention/Reporting and Elder Justice Act, dated May 18, 2020, was reviewed. The Abuse Prevention/Reporting and Elder Justice Act policy indicated: Scope: All SNF Staff and ancillary departments involved in patient care of skilled nursing residents Policy Statement: It is the policy of .to comply with Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act. Furthermore, it is the policy of .to implement requirements for screening and training of employees; Protection of patients/residents; Prevention; Reporting; Identification; Investigation of abuse, neglect, mistreatment, and/or misappropriation of property in order to assure that the facility is doing all that is within its control to prevent occurrences . Procedure: A. Staff Reporting Requirements . 7. If the reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming suspicion . The ADON verified and confirmed that this incident should have been reported within 24 hours of observation. The ADON further stated, not reporting this incident could have put the resident at risk for continued verbal abuse till it was reported on October 3, 2022.

Based on observation, interview and record review, the facility failed to ensure one of three sampled Residents (Resident A) was supervised appropriately leading to an elopement (A resident with cognitive challenges who wanders, runs away from the facility). This failure placed the resident at risk for harm and endangerment in the community and had the potential to affect other residents with supervision needs in a universe of 22 residents. Findings: An unannounced visit was made to the facility on [DATE], at 11:45 AM, to investigate Resident A ' s elopement. During a reviewed of Resident A's face sheet (a document with basic information about the resident), indicated, Resident A was admitted to the facility on [DATE], with diagnoses which included depressive disorder (a condition which causes sadness), anxiety disorder (a condition which causes constant worrying), and hallucinations (seeing things that are not there). During an observation of Resident A on August 9, 2022, at 12:00 PM, Resident A was in her room. Resident A had a wander guard (a type of alarm which is used to notify staff when resident attempt to leave the facility) on her left wrist. Resident A observed to be confused and disoriented. During an interview with Resident A on August 9, 2022, at 12:10 PM, Resident A was unable to state what happened. During a review of Resident A ' s Minimum Data Set Assessment (MDS-a comprehensive assessment which includes functional, medical, psychosocial, and cognitive status) section C, dated May 22, 2022, indicated, Resident A scored a 5 (a score of 0 to 7 is means severe impairment) on the Brief Interview for Mental Status (BIMS- an interview to determine cognitive status of a Resident). During a review of Resident A ' s Elopement Evaluation, dated July 30, 2022, indicated, Resident A was at risk for elopement . During a review of Resident A ' s physician ' s orders dated August 12, 2021, indicated, Wander guard to be worn at all times and checked each shift to be in working order to prevent wandering/elopement two times a day for elopement/wandering check skin integrity and function each shift two times a day for elopement/wandering Check skin integrity and function each shift. During an interview with Certified Nursing Assistant (CNA 1) on August 9, 2022, at 12:25 PM, CNA 1 stated, The resident is confused and disoriented and tries to get out. I was the CNA assigned to her when she eloped. I was changing some body and the alarm went off, the LVN went to check and did not see anybody. I did not check. During a review of Resident A ' s nursing progress notes dated August 7, 2022, at 11:57 AM, documented, Around 11:15 AM, we received a call from a person named [named of person] regarding resident wondering around [name of the street] Street. Nursing staff left the facility and went to the location described by [name of person] Resident was found outside with multiply people . During an interview with Director of Staff Development (DSD) on August 9, 2022, at 1:20 PM, the DSD stated, I went to pick up the resident and bring her back to the facility. The DSD further stated, A citizen called the facility and informed us the resident was outside wandering. That is how we found out the resident was missing. During an interview with Licensed Vocational Nurse (LVN 1) on August 9, 2022, at 1:00 PM, he stated, The alarm went off and I went to go see. I did not see anyone. I went back inside. I did not check the residents inside the facility. I should have checked. During an interview with the Assistant of Director of Nurses (ADON) on August 9, 2022, at 1:25 PM, ADON acknowledged a head count inside the facility was not done . ADON stated, They should have checked the residents in the facility. During a review of the facility's P&P on August 9, 2022, at 2:00 PM, titled, Elopement/wandering and prevention, dated June 9, 2018, indicated, A. Staff will monitor the whereabouts of residents at risk of wandering, including the monitoring of responses/reaction to events/activity in surrounding at time of wandering, and report unusual behaviors to supervisor immediately.

Based on Observation, Interview, and Record Review the facility failed to provide adequate assistance for a totally dependent resident which resulted in a fall. This fall resulted in the resident receiving a Mildly Displaced Complete Fracture of the Left Femoral Neck and a skin tear to Left Elbow, 5 centimeters in length. Findings: During a Record Review of the Resident, a [AGE] year old female, the admission record facesheet from February 22, 2021 gave a description of her diagnosis from her first admission on December 31, 2018 as [CONDITION(S)], [CONDITION(S)]( Chronic Obstructive Pulmonary Disease), Muscle Weakness, Related Falls, Age Related Physical Debility, and Chronic Pain. During a Record Review of the Resident admission record on February 22, 2021, the description of her diagnosis from the second admission on September 3, 2020 showed a Mildly Displaced Complete Fracture of the Left Femoral Neck and Skin Tear to Left Elbow. During a Record Review of the Progress Note on August 29, 2020 at 07:30 AM , the Certified Nursing Assistant (CNA) stated that she observed the Resident standing at bedside, ambulating without assistance, the CNA ran to help her and did not make it in time. Resident fell to the floor at the bedside. After attempting to get up the CNA asked the Resident what happened, the Resident stated she was getting a ring out of the drawer. During a Record Review of the Renaissance Imaging Center impression of the Resident Xray of Pelvis and Left Hip on August 29, 2020 at 7:31 AM, the impression stated Mildly displaced complete fracture of the Left Femoral Neck and Mild [CONDITION(S)] changes of the Left Hip. During a Record Review of a letter sent to California Department of Health Services on September 3, 2020 states Prior to her fall prevention care plan included a bed alarm to be applied at all times while in bed. Nursing staff reported that the bed alarm did not sound prior to her falling. During investigation, it was discovered that the bed alarm was not working. During a Record Review of the sign in sheet for the month of August 2020, states Safety Bed Alarm while resident is in bed D/T Hx Falls, Check Every Shift for Placement Every Shift Start Date 01/05/2020, 0645. There are no initials in the box for the morning of August 29, 2020, the morning that the Resident had her fall. It appears the Bed Alarm was not checked prior to Resident experiencing a fall. During a Record Review of 20 Maintenance Work Orders form August 1. 2020 to August 31, 2020, stated no Work Order for batteries to be replaced in a bed alarm. During an interview with CNA 2 on February 22, 2021 at 2:34 PM she stated the CNA's test the Bed Alarms when placing residents to bed. CNA 2 stated there is a log sign in sheet to show that batteries have been checked on the Bed Alarms. She checks the alarm prior to assisting residents to bed. During an interview with Licensed Vocational Nurse (LVN) on February 22, 2021 at 2:42 PM she stated all the staff monitor the Bed Alarms to see if they are working properly or it may depend on who is putting the resident to bed on who checks the alarm. The LVN stated there is a sign in sheet for every shift who checks that the batteries are working on the Bed Alarms. During an interview with the Assistant Director of Nursing on February 22, 2021 at 3: 41 PM she stated Bed Alarms are supposed to be checked every shift by the nursing staff. If an alarm doesn't sound the staff has access to batteries. The ADON was shown a sign in sheet that should be signed by staff showing the Bed Alarm is in working order. Under the date of August 29, 2020 morning shift there was no initials or signature showing that the Bed Alarm had been checked. The ADON stated it is embarrassing that the log sheet was not signed knowing the Resident fell due to no alarm sounding and broke her hip. During an interview with Director of Nursing (DON) on February 22, 2020 at 3:15 PM stated the staff should be checking the Bed Alarms every shift. Maintanence is supposed to change the batteries at the end of each month. When shown the sign in log for nurses to sign every shift, under the date August 29, 2020 for the AM shift there was no initials or signature in the AM box. The DON stated the nurse should have initialed the box showing the Bed Alarm was checked without anything documented it looks like she didn't check the alarm. An attempted interview was made on February 22, 2021 with the Resident, but she did not remember the incident and was not a good historian regarding the incident from August 29, 2020. During a Record Review of an email from the Assistant Director of Nursing on March 4, 2020, she stated It wasn't until Resident 1 fall that the battery changes was an issue. The facility implemented the battery changes after the incident to be changed at the end of every month. It was a paper maintenance log to be initialed by the night shift nurses at the end of every month, Unfortunately, it was something that fell through the cracks during our Covid [NAME] in the months of October thru December and was not properly documented. Though we have not had any issues with bed alarms not properly functioning since her fall, it is a fail on our part. A paper log which was implemented was attached for review. Now the facility has every resident that has a bed alarm with the following in our EHR system: 1. Order for bed alarm with consent, 2. Order to check functioning Q shift, 3. Order to check and change batteries on the first of every month, 4. Care plan reflecting fall risk and bed alarm. During a Record Review of the Bed Alarm Battery Change on March 4, 2020, stated Noc Shift Please Change the Following Bed Alarm Batteries Monthly on the 30th of Each Month: 10 residents listed. with verbage to Please initial next to the date and please date the batteries. The dates September 30th, October 30th, November 30th, and December 30th are listed. More verbage stated: Remember to check the function of bed alarms every shift to make sure they are on and working. During a Record Review of the Care Plan on February 22, 2021 stated Focus: The resident is (HIGH) risk for falls r/t poor safety awareness, 10/30/20: Unwitnessed fall. No physical injuries . Fall Score 14.0, Dated Initiated 03/29/20, Revision on: 10/25/2020. Interventions: The resident uses bed alarm, electronic alarm. Ensure the device is in place as needed. Date initiated: 03/29/2020, Revision on: 08/31/2020. A facility policy and procedure titled, Saftey Devices Reviewed on 09/04/2020, indicated Scope: Nursing, Poliy Statement: Bed alarms, tab alarms, chair alarms, and wander guard systems may be for residents found deemed unsafe through the nursing assessment and interdisciplinary team meetings. Procedure: J. Nurse must document placement and functionality of device every shift. K. Safety Alarm batteries will be changed on the last day of every month.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for nine of 10 residents, considered persons under investigation (PUI's) for COVID-19 (a contagious and potentially fatal respiratory virus), when facility staff were observed entering and exiting resident's rooms without donning the appropriate personal protective equipment (PPE). This failure had the potential to spread COVID-19 within this area of the facility designated the, Yellow Zone, for PUI's, which requires PPE (isolation gowns, gloves, mask, and a face shield) for droplet precautions (Prevents transmission of diseases spread by large respiratory droplets through coughing, sneezing, or talking). Findings: During an observation on December 16, 2020, at 1:15 PM, the laundry personnel (LNDRY) was observed entering and exiting residents' rooms in the yellow zone wearing an N95 mask (a mask that filters 95% of airborne particles) and donning (putting on) no other required PPE, which includes isolation gowns, gloves, mask, and a face shield. During an observation on December 16, 2020, at 1:20 PM, the certified nursing assistant (CNA 3), was observed entering and exiting residents' rooms in the yellow zone wearing an N95 mask and donning no other required PPE, which includes isolation gowns, gloves, mask, and a face shield. During an interview on December 16, 2020, at 1:25 PM, with the Infection Preventionist/Director of Staff Development (IP/DSD), when asked what PPE should be worn in the yellow zone, the IP/DSD responded, If they (residents) are not symptomatic and not on contact precautions, just gloves and a mask. During an observation on December 16, 2020, at 1:30 PM, housekeeping (HSK 2), was observed entering a residents room at the left end of hall 2, in the yellow zone, wearing an N95 mask and donning no other required PPE, which includes an isolation gowns, gloves, mask, and a face shield. During an interview on December 16, 2020, at 1:35 PM, with Chief Nursing Officer/Interim Director of Nursing (CNO/DON) and the Assistant Director of Nursing (ADON), when asked what PPE should be worn in the yellow zone, the CNO/DON responded, Right now, don't wear full PPE, we wear masks and gloves. The Assistant Director of Nursing (ADON), responded, If a resident starts developing signs and symptoms we would wear an isolation gown, booties, mask, gloves, faceshield and a hairnet. When asked if facility staff should be wearing full PPE in the yellow zone, the CNO/DON responded, Yes. During an interview on December 16, 2020, at 1:37 PM, with the Assistant Director of Nursing (ADON), when asked what PPE should be worn in the yellow zone, the ADON responded, Gown, gloves, N95, faceshield and change PPE between residents. During an interview on December 16, 2020, at 1:40 PM, with the IP/DSD, when asked why residents were in the yellow zone, the IP/DSD responded, Yellow zone, risk of getting COVID. Full PPE has been used for some of the residents in the yellow zone, but not all. Nine of 10 residents are not on contact precautions (Health care personnel caring for patients on Contact Precautions must wear a gown and gloves for all interactions that involve contact with the patient and the patient environment) but need to be. Residents in the yellow zone should be on droplet precautions. During a follow-up interview on December 16, 2020, at 2 PM, with the CNO/DON, the CNO/DON confirmed nine of ten residents in the yellow zone were not on contact precautions, the one resident (Resident 4) that was on contact precautions had just come out of the COVID-19 positive unit after recovering. A review of the facility document titled, COVID-19 Mitigation Plan (facility name), undated, indicated, .In Response to Positive cases within the facility: .4. For resident with known or suspected COVID-19: staff is required to wear gloves, isolation gown, eye protection, and an N95 mask. A review of the Centers for Disease Control and Preventions' (CDC) document titled, COVID-19 ([MEDICAL CONDITION] Disease): Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated, December 14, 2020, indicated, .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (COVID-19) infection .Personal Protective Equipment (PPE): HCP (health care provider) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (The National Institute for Occupational Safety and Health)-approved N95 (filters at least 95% of airborne particles) or equivalent or higher-level respirator .gown, gloves, and eye protection.

Based on interview and record review, the facility failed to employ a registered nurse (RN) for eight (8) consecutive hours a day to oversee the skilled nursing unit, and to have a registered nurse (or two registered nurses sharing the position) of the Director of Nursing (DON) . The facility employed a Licensed Vocational Nurse (LVN 1) to serve as the DON. This failure placed the health and safety of the facility's residents at risk when the DON lacks the skills and qualification to oversee the care of the residents, and there is a lack of consistent oversight by a registered nurse assigned specifically to the skilled nursing unit for eight hours a day. Findings: During an interview with the Interim Chief Nursing Officer (CNO) on July 3, 2020, at 2:56 PM, the CNO stated LVN 1 was promoted from Assistant Director of Nursing (ADON) to the position of DON for the skilled nursing facility. The CNO further stated the DON has been in the position for approximately two months. During continued interview with the Interim CNO regarding promoting an LVN to the DON position versus the required registered nurse, she stated, We didn't have anyone else to fill the RN position. We don't have an RN with skilled nursing experience, most of our RNs are the emergency room nurses. She explained that there is not a specific nurse assigned for the eight consecutive hours a day as required by regulation. The RNs are assigned to the ER (emergency Department) department, but when there is down time the RN is designated to be in the skilled nursing facility. The Interim CNO said when an ER nurse in unavailable they pull a nurse from the acute care floors. During a review of the RN staffing with the Interim CNO from March 29, 2020 through July 3, 2020, the schedule reflected all RN's were assigned to either the Emergency Department or the acute care floors. There was no RN listed specifically to cover the skilled nursing unit for eight consecutive hours, or to be the Director of Nursing. There was no indication that two RNS were sharing the role of the DON with their duties specified as would be allowed by a waiver. During a concurrent interview and record review with the Administrator (ADM) on July 3, 2020, at 6:13 PM, the ADM reviewed the document titled, Competency Based Job Description/Performance Evaluation: SNF Director of Nursing Services, dated August 2009. The ADM acknowledged the document was the facility's DON job description. The document indicated the position required a California RN license. The ADM stated the facility felt LVN 1 was qualified and that was the basis for the why the facility hired the DON internally. He stated the DON is not a RN and the facility was in the process of submitting a waiver to allow LVN 1 to serve as the DON. A review of a letter written by the ADM dated March 18, 2020, at 11:48 AM, indicated . (LVN 1) has been appointed our new SNF Director of Nursing. A review of a letter signed by the Human Resources Manager (HRM) addressed to LVN 1 dated March 18, 2020, indicated, I am writing this letter on behalf of (Facility) to offer you a promotion from your current position to the position of Director of Nursing. No waiver for RNs or the Director of Nursing position had been granted by the California Department of Public Health, could be provided.

Based on observation, interview and record review the facility failed to ensure: 1. Resident 2 was free from harm from Resident 1 when Resident 1 pulled Resident 2 ' s hair. 2. Resident 1 was being monitored closely to prevent reoccurrence of harming other residents. These failures resulted in Resident 2 not having the right to be free from any form of abuse behaviors from other residents while residing in the facility. Findings: 1. During observation on July 23, 2014, at 10:00 AM, Resident 1 was walking in the hallway near Nursing Unit 2 by herself with no staff supervision by her side. A review of Resident 1's clinical record on July 23, 2014 at 10:15 AM, indicated Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED].) A review of licensed personnel weekly progress notes documented a late entry written on July 21, 2014 at 1:25 PM for an the incident which occurred on July 20, 2104 at 6:00 PM. The nursing notes indicated that Resident 1 reached out and grabbed a handful of Resident 2's hair tightly while Resident 1 was yelling unintelligible words. A review of Resident 2's clinical record indicated she was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation of Resident 2 in the activity room area, when asked how she was, Resident 2 stated, "I am fine." A review of Resident 2's licensed personnel weekly progress notes dated July 21, 2014, documented a late entry for the incident that occurred on July 20, 2014, at 6:00 PM. The late entry noted, "Resident 2 was wheeling herself around Nursing Unit 2 while Resident 1 was pacing up and down the hallways, entering other resident's rooms, taking bedding off the bed and putting the linen in other resident's bed. It was noted that Resident 1 approached Resident 2 and grabbed a handful of Resident 2's hair tightly. Nurse's notes documented that no injury was noted." During an interview with LVN 1 (licensed vocational nurse) on July 23, 2014 at 10:20 AM, she confirmed the July 20, 2014 incident between Residents 1 and 2 had occurred. She stated for Resident 1 to let go of Resident 2's hair. When asked how Resident 2 reacted to the incident, LVN 1 stated Resident 1 was surprised. When asked if there was anybody assigned to supervise Resident 1 or if Resident 1 was on 1:1 supervision, she stated, "nobody." A review of Resident 1's Nursing Care Plans titled, "Low to Moderate Cognitive Function, Mood and Behavior and Activities," dated May 9, 2014, documented no recent updates. The Nursing Care Plans were last updated on July 10, 2014, and showed no revision or follow-up on the interventions for Resident 1's supervision to prevent from harming other residents. During an interview with the Administrator and DON (Director of Nursing) on July 23, 2014, at 12:30 PM, Resident 1's repeated occurrences was discussed after harming other residents and there was no preventive measures indicated in the Resident 1's care plan intervention section. Administrator and DON acknowledged there were no updates in the care plan. A review of the facility policy and procedure titled, "QRR" (quality review report) revised December 2011, stipulated in Procedure 6b: " ...Devise and initiate methods to avoid similar incidents in the future ..." The failure of the facility to follow their own policy and procedure to develop new interventions to prevent Resident 1 from repeated occurrences of abusing other residents or being a victim of retaliation, constituted an Immediate Jeopardy situation against the facility.

Based on record review and interview, the facility failed to implement their policy and procedure to prevent abuse occurrences for 3 of 10 sampled residents (Residents 2, 4, and 8) and 1 unsampled resident ( Resident A). This failure resulted in injuries to the residents and had the potential for further abuse and injuries to occur. Findings: 1. A review of the clinical record for Resident 8 on July 16, 2014, indicated Resident 8 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of an MDS (Minimum Data Set Form-resident assessment tool), , with an assessment reference date of April 8, 2014, indicated a BIMS (Brief Interview for Mental Status-a brief screener that aids in detecting cognitive impairment) score of 9 (8-12 indicated moderately impaired). A review of the physician orders for Resident 8, indicated the resident received [MEDICATION NAME] (blood thinner) for prevention of blood clots, and aspirin (blood thinner) for prevention of stroke (a condition that occurs when the blood supply to part of your brain is interrupted) and or MI ([MEDICAL CONDITION] infarction-a condition when blood flow to a part of the heart is blocked). A review of Resident 2's clinical records on July 16, 2014, indicated Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of an MDS (Minimum Data Set - a resident assessment tool), with an assessment reference date of April 25, 2014, indicated Resident 2 had short and long term memory problems and severely impaired decision making ability. During an interview with the licensed vocational nurse (LVN) supervisor, on July 16, 2014 at 9:50 AM, and a concurrent review of Resident 2 and 8's licensed nurses notes, she confirmed the notes indicated the following: On April 22, 2014 at 6:30 PM, Resident 8 sustained a skin tear on the left elbow that had a "flap, 0.5 cm (centimeters). Resident 8 at first stated "unknown" how the skin tear was sustained but later stated "was pushed by resident (Resident 4) into doorway." There was no documented evidence of a follow up observation for any changes in Resident 8's condition, or for complications following the incident. There was a care plan regarding the skin tear but not one which addressed the incident nor interventions to prevent a further incident. On May 18, 2014 at 5:40 PM, the certified nurse assistant (CNA) reported that Resident 4 slapped Resident 8 on the right side of face; "no broken skin swelling noted-other resident redirected away..." There was no documented evidence the physician was notified of the incident, nor of a follow up observation for any changes in Resident 8's condition following the incident. There was no care plan to address the incident and no interventions to prevent further incidents. On May 29, 2014 at 1 PM, Resident 8 was grabbed by another resident (Resident 2) while trying to go out of the facility. There was no documented evidence the physician was notified of the incident, nor an immediate assessment of Resident 8's condition, or follow up monitoring for any possible changes in condition following the incident. There was no care plan to address the incident with interventions to prevent a further occurrence. On May 31, 2014 at 7:25 AM, Resident 8 was "grabbed by another patient and bit on the (left) upper arm; no skin breakage..." The note did not indicate who the other resident involved was. There was no documented evidence of a follow up observation for a possible change of condition or complications following the incident. There was no care plan to address the incident and no interventions to prevent a further occurrence. On June 27, 2014 at 5:20 PM, Resident 8 was "slapped" on the left side of the face by another resident, knocking Resident 8's glasses off. The note did not indicate who the other resident was. There was no documented evidence of a follow up observation for any possible change of condition for Resident 8, nor for complications following the incident. There was no care plan to address the incident or interventions implemented to prevent a further occurrence. During a concurrent interview with the licensed vocational nurse (LVN) supervisor and a review of the clinical record, when asked what the facility's process was for incidents involving the residents, she stated that both residents involved should have been assessed for injuries, the physician and the responsible parties should have been notified, and the residents should have been placed on observation or monitoring for any further complications following the incident. She stated that an "unusual occurrence form" should have been completed for both residents, and submitted to the director of nurses (DON), and an investigation regarding the incident should have been conducted. An interview with the DON, assistant director of nurses (ADON), LVN supervisor and the administrator on July 16, 2014 at 11:45 AM, and a concurrent review of the clinical record for Residents 2 and 8, the facility policy and procedure for a change of resident condition/status, and unusual occurrence was conducted. The ADON stated that upon identification of a problem or a change in a resident's condition or status, the staff should have indicated and documented what should have been done to help solve the problem. The ADON stated there should have been documented evidence that the residents involved were assessed immediately, the physician and the responsible party should have been notified, and both residents should have been observed for any injuries, complications or any changes following the incident. The licensed nurses notes dated May 29, 2014, revealed an incident involving Resident 2 and Resident 8 was documented. During a concurrent interview, the DON stated she conducted an "internal" investigation of the incident involving Resident 2 and Resident 8 for May 29, 2014 incident, the day after the incident happened. The DON stated that Resident 8 was noted with a small bruise on the left arm, which, upon her interview with Resident 8 about the bruise, Resident 8, "thought she got it (bruise) from hitting the table." The DON stated that upon her investigation, it was determined that the incident between these 2 residents was not considered a "resident-to-resident abuse." She explained that since the bruise was not considered a "serious bodily injury," the incident on May 29, 2014 was handled internally by the facility. The DON and the ADON confirmed Resident 2 should have been monitored for any increase or further episodes of behavior, and Resident 8, who received anticoagulant medications, should have been monitored for complications including bleeding, and further bruising. The ADON confirmed according to the facility's policy and procedure, observation of the resident's condition "should be no less than 72 hours," at a minimum of 24 hours to 48 hours, or until the condition is stable. During an interview with the LVN supervisor on July 17, 2014 at 8:45 AM, and a concurrent review of Resident 8's clinical record, when asked what Resident 8's level of cognition was, she stated that Resident 8 was able to make simple needs known, was frequently confused, and would forget but was mostly calm. The LVN supervisor confirmed Resident 8 received [MEDICATION NAME] and aspirin (blood thinner medications), which placed Resident 8 at a high risk for complications including bleeding and bruising. The LVN supervisor stated that Resident 8 should have been immediately assessed following the incidents, and should have been observed and monitored for injuries and complications for approximately 7-14 days following the incident. During an interview with the social services director (SSD) and a concurrent review of the clinical record of Residents 2 and 8 on July 17, 2014 at 11:30 AM, when asked what the social service director's role was on a resident-to-resident incident, he stated he would follow up and check the residents for any complications and would provide interventions to address the resident's behavior such as activities. He stated he would ensure that CDPH (California Department of Public Health), the family and the Ombudsman or the police were notified regarding the incident. He further stated that he would make a note on the residents' clinical records, of the incident and of the interventions provided. During a concurrent review of the Resident 2 and 8's clinical records, the SSD confirmed there was no documented evidence on a social service note for either residents, regarding the incidents nor any interventions provided by the SSD. During an interview with the ADON, on July 17, 2014 at 1:25 PM, when asked what Resident 8's level of cognition was, the ADON stated Resident 8 had episodes of "confabulation" (a memory disturbance defined by production of fabricated memories without intent to deceive). During a phone interview with LVN 3 on July 17, 2014 at 3 PM, when asked what Resident 8's level of cognition was, LVN 3 stated Resident 8 "makes things up." LVN 3 stated, according to a family member, Resident 8 would not admit to anything because Resident 8 did not want to get anyone in trouble. During an interview on July 17, 2014 at 5 PM, when asked about any concerns for safety or comfort that the resident might have during the stay in this facility, Resident 8 verbalized feeling safe and comfortable in the facility; "This is my home." Resident 8 then indicated (Resident 4) who happened to walk by during the interview," (Resident 4) hit me on the left shoulder; (Resident 4) gets antsy and grabs and I try to stay out of (Resident 4's) way. (Resident 4's) temperament is changing." Resident 8 could not remember exactly when the incident happened and verbalized, "I'm OK." When asked if there were any other incidents with any other residents that may have occurred in the past, Resident 8 stated that there were none. A review of the physician progress notes [REDACTED]. A review of the Resident 2 and 8's care plans did not reflect a plan with approaches to prevent further reoccurrences of incidents. 2. During a review of the clinical record for Resident A on July 15, 2014, at 1:00 PM, the licensed personnel weekly progress notes, dated June 28, 2014 at 5:25 PM, indicated Resident A struck another resident (Resident 4) on the left cheek. Resident A did not like Resident 4 pushing another resident on a wheelchair. This led Resident A to strike Resident 4 on the left cheek. No injuries were noted. During a clinical record review for Resident A, the face sheet indicated Resident A was admitted on [DATE] with [DIAGNOSES REDACTED]. There was no care plan done for striking another resident on the cheek. There was no documented evidence of a report made to the ombudsman or other State agencies as required, about Resident A striking another resident on the left cheek. During a telephone interview with the Activity Aide on July 17, 2014, at 10:30 AM, she stated she observed Resident 4 pushing a resident sitting in a wheelchair when unsampled Resident A got angry and struck Resident 4 on the left cheek. She further stated that Resident 4 thought it was her (Activity Aide) and struck her in the back of head. The Activity Aide stated she then took Resident 4 to LVN 3 and did not know what happened after that. During an interview with the Director of Nursing (DON) on July 16, 2014 at 3:00 PM, the DON was asked about the report generated to the ombudsman or other State agencies. The DON stated, "I do not have the report. I cannot find out. No report. " During an interview with the Administrator on July 16, 2014 at 4:35 PM, the Administrator was asked about a resident hitting another resident on the cheek and stated, " It should have been reported (ombudsman or other State agencies). " The Administrator further stated, " A quality report review (QRR) should have been initiated. " The Administrator stated that there was no QRR made. A review of Resident 4's plan of care discussion notes written on July 17, 2014, indicated Resident 4 continues to be combative with staff. A review of the care plan titled Low to Moderate Cognitive Function indicated, under risk and challenges : not easy to redirect, combative with staff, resident touching others uninvited. During an interview with the ADON (Assistant Director of Nursing) on July 17, 2014 at 4:40 PM, she stated that Resident 4's behavior was unpredictable at times, and the resident became more agitated in the afternoon, like sundowners (a condition where an individual experiences abnormal behaviors when the sun sets transitioning to the evening hours). She stated Resident 4 touches other residents and can be combative with staff. One of the interventions indicated, "try to keep hands to herself." One of the problems in the care plan indicated, " difficulty " making even simple decisions related to dementia. During an interview with the Administrator on July 17, 2014 at 4:45 PM, she acknowledged that Resident 4 would be at risk to get hurt due to her behavior of touching others and resident outbursts were quick. She stated that the Activity Director tried to redirect Resident 4 by taking her for a walk. She stated that a specialized approach with training on how to curtail behavior and possibly consultation with a geriatric psychiatrist may be helpful. A review of the facility policy and procedure titled " Abuse Prevention/Reporting ", dated February 11, 2014, indicated under Procedure: " A. Staff Reporting Requirements 1. When staff ( " staff" refers to covered individuals) suspects a crime has occurred against a resident at SIHD, they must report the incident to the California Department of Public Health (CDPH), local law enforcement and the Ombudsman. "

Based on interview and record review, the facility failed to identify issues and implement appropriate action plans to correct quality deficiencies to maintain an effective Quality Assessment and Assurance (QAA) Committee in a universe of 31 residents, by failing to provide documented evidence that the facility's QAA Committee identified recurrent falls for 2 of 10 sampled residents (Residents 2 and 5), as a quality concern that required the implementation of an action plan for all residents at risk for falls.. Findings: For Resident 1, the facility failed to complete post fall risk assessments and update and revise the fall care plan after each fall. The facility also failed to implement interventions on the fall care plan, ensure that the Interdisciplinary Team (IDT) met and made recommendations for interventions to prevent recurrent falls after each fall and the facility failed to implement all interventions recommended by the IDT. These cumulative failures resulted in Resident 1 having nine (9) falls, two (2) which resulted in the resident sustaining a [MEDICAL CONDITION] and a broken tooth. For Resident 5, the facility failed to complete a post fall risk assessment, update and revise the fall care plan after each fall, and implement interventions to prevent initial and recurrent falls from occurring. These failures resulted in Resident 5 sustaining two falls. The first fall resulted in a [MEDICAL CONDITION] which required surgical repair and caused pain. The second fall resulted in a laceration to the left side of the resident's head which required stitches, in addition to a laceration to her left knee. During an interview with the Chief Executive Officer/Administrator (CEO/Admin), on 10/12/12 at 9:20 AM, she failed to provide documented evidence that the facility's QAA Committee had identified recurrent falls, as a quality issue, that required an action plan by the committee. During the interview, the CEO/Admin reviewed QAA Committee minutes, but was unable to find and present documentation to show that the Committee had discussed falls or recurrent falls as a quality concern. The facility policy and procedure titled, "Quality Assessment/Assurance" dated 7/14/08 indicated that the intent of the committee, "is to identify quality deficiencies and develop and implement plans of action and to correct theses quality deficiencies."

Based on observation, interview and record review the facility failed to follow their fall policy and procedure, to prevent and/or reduce the occurrence of falls in the facility, for 2 of 10 sampled residents (Residents 1 and 5). For Resident 1, the facility failed to complete post fall risk assessments and update and revise the fall care plan after each fall. The facility also failed to implement interventions on the fall care plan, ensure that the Interdisciplinary Team (IDT) met and made recommendations for interventions to prevent recurrent falls after each fall and the facility failed to implement all interventions recommended by the IDT. These cumulative failures resulted in Resident 1 having multiple recurrent falls which resulted in the resident sustaining a fractured hip and a broken tooth. For Resident 5, the facility failed to complete a post fall risk assessment, update and revise the fall care plan after each fall, and implement interventions to prevent initial and recurrent falls from occurring. These failures resulted in Resident 5 sustaining two falls. The first fall resulted in a fractured hip which required surgical repair and caused pain. The second fall resulted in a laceration to the left side of the resident's head which required stitches, in addition to a laceration to her left knee. Findings: 1. During observations on 10/9/12 at 9:30 AM and 12:30 PM, and on 10/10/12 at 8:35 AM, Resident 1 was observed sitting in her wheelchair, moving about the facility, by propelling herself using her legs and feet. Resident 1 was observed to be alert, and able to make her needs known to the staff. An attempt was made to interview Resident 1 on 10/10/12 at 8:35 AM, but she would not answer any questions that were asked. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 10/10/12 at 8:35 AM, she stated that upon admission, Resident 1 was able to walk around the facility with a front wheel walker, before she fell and fractured her hip. After the fall, LVN 2 stated that Resident 1 had been using a wheelchair. LVN 2 stated that Resident 1 has had multiple falls since her admission to the facility. During the interview, LVN 2 stated that Resident 1 had not been compliant with asking for assistance to go to the bathroom. During a review of the clinical record, for Resident 1 on 10/9/12, the "Admission Face Sheet" dated 2/21/12, indicated that Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During further review of the clinical record on 10/9/12, the Minimum Data Set (MDS-a comprehensive resident clinical assessment) dated 11/3/11, indicated that Resident 1 had a fall in the facility after her admission on 10/21/11. The MDS indicated that Resident 1 required supervision with walking and transfers. The MDS also indicated that Resident 1 had frequent bladder incontinence (uncontrolled leakage of urine). The clinical record indicated that Resident 1 had a fall care plan that was initiated on 11/1/11. The care plan indicated that Resident 1 was at risk for an initial fall and at risk for repeat falls. During a review of the clinical record for Resident 1 on 10/11/12, with LVN 1, the "Licensed Personnel Weekly Progress Notes" dated October 2011 through August 2012 indicated that Resident 1 had a total of 9 documented falls that occurred on: 10/24/11, 11/13/11, 3/28/12, 5/18/12, 7/1/12, 7/2/12, 7/4/12, 8/11/12, and 8/25/12. The progress notes indicated that 3 of the 9 falls occurred while the resident was attempting to go to the bathroom and 2 of those 3 falls (on 3/28/12 and 8/11/12) resulted in injuries. The facility policy and Procedure titled, "Fall Mitigation/Assessment" dated March 12, 2002, was reviewed on 10/09/10. The policy indicated the following: "It is the policy of (name of facility) to implement Fall Mitigation (to lessen) Program for each resident admitted to the SNF (Skilled Nursing Facility)." "5. When a fall occurs:" "LVN completes post fall assessment ..." "LVN initiates first aid and calls MD" "LVN initiates any new orders and updates care plan" "IDT (Interdisciplinary Team) meets weekly to review assessment ...and makes recommendations to prevent incident from reoccurring in IDT section of the chart." "IDT initiates action plans, updates care plan and communicates goals and interventions to care givers and family." Further review of the clinical record, with LVN 1 on 10/11/12, indicated that Resident 1's first fall in the facility occurred on 10/24/11. The "Licensed Personnel Weekly Progress Notes" dated 10/24/11 indicated that Resident 1 lost her balance and fell on [DATE]. The "Licensed Personnel Weekly Progress Notes" dated 11/13/11 indicated that Resident 1 had another fall and was found on the floor. There was no documented evidence in the clinical record that indicated that the facility completed post fall assessments to determine what factors contributed to the resident's falls, or that the IDT made recommendations for interventions to prevent the reoccurrence of future falls, as directed in the facility's fall policy and procedure. During a review of Resident 1's fall care plan, initiated on 11/1/11, there was no update or revision to the care plan after the resident's falls that occurred on 10/24/11 and 11/13/11. During an interview with LVN 1, on 10/11/12 at 11:00 AM, LVN 1 verified that there was no documented evidence in the clinical record that indicated that the facility completed post fall risk assessments after each fall, that the IDT made recommendations for interventions, and that staff updated and revised Resident 1's existing fall care plan with new interventions in an attempt to prevent future falls. During the interview LVN 1 verified that Resident 1 had another fall on 3/28/12, which resulted in a right hip fracture. During review of the clinical record on 10/11/12, with LVN 1, The "Licensed Personnel Weekly Progress Notes" dated 3/28/12 at 8:20 PM, indicated that Resident 1 "fell while attempting to use the toilet." Review of an x-ray report of the right hip dated 3/29/12, indicated that Resident 1 had sustained a right hip fracture as a result of the fall that occurred on 3/28/12. Resident 1 was transferred out to an acute care hospital. The resident returned to the facility on [DATE], after having surgery to repair her right hip fracture. Further reviews of Resident 1's fall care plan, initiated on 11/1/11, indicated that an existing intervention included checking the resident for incontinence every two hours and keeping the resident clean and dry. There was no documented evidence in the clinical record that indicated that facility staff had been supervising Resident 1 while walking and transferring, nor was there documented evidence to show that Resident 1 was being checked for incontinence every two hours as directed in her care plan, prior to her fall in the bathroom on 3/28/12. During further review of the clinical record on 10/11/12, the "Interdisciplinary Progress Notes" indicated that there was no documented evidence in the clinical record to show that the IDT met and discussed the resident's first fall that occurred on 10/24/11, as directed in the facility's policy and procedure. Review of the "Interdisciplinary Progress Notes" dated 11/15/11 and 3/29/12, indicated that the IDT met and discussed Resident 1's falls that occurred on 11/13/11 and 3/28/12, but there was no documented evidence to show that the IDT made recommendations for new interventions to prevent the reoccurrence of falls, as directed in the facility's policy and procedure. During an interview with LVN 1 on 10/11/12 at 11:00 AM, LVN 1 verified that Resident 1 had a fall on 3/28/12 that resulted in a right hip fracture. LVN 1 verified that the MDS dated [DATE], indicated that Resident 1 required supervision with walking and transfers and had frequent bladder incontinence. LVN 1 verified that Resident 1's fall care plan initiated on 11/1/11 included the intervention of checking the resident for incontinence every two hours and keeping the resident clean and dry. LVN 1 verified that there was no documented evidence in the clinical record that indicated that facility staff had been supervising Resident 1 while walking and transferring, nor was there evidence to show that she was being checked for incontinence every two hours as directed in her care plan, prior to her fall in the bathroom on 3/28/12. During further review of the clinical record for Resident 1 on 10/11/12, with LVN 1, the "Licensed Personnel Weekly Progress Notes" dated 7/2/12 and 8/11/12, indicated that the resident had two additional falls in her bathroom. There was no documented evidence in the clinical record that indicated that facility staff had been supervising Resident 1 while walking and transferring, nor was there evidence that she was being checked for incontinence every two hours as directed in her care plan, prior to her falls on 7/2/12 and 8/11/12. During further review of the clinical record for Resident 1 on 10/11/12, with LVN 1, the "Licensed Personnel Weekly Progress Notes" dated 8/11/12 at 8:20 PM, indicated that when Resident 1 had fallen in her bathroom, it was noted that the resident's clothes were soaked with urine. It was also noted that Resident 1 was bleeding from her mouth and had a broken bottom tooth. During further review of the clinical record on 10/11/12, the "Interdisciplinary Progress Notes" dated 7/2/12, indicated that the IDT had discussed the fact that Resident 1 had been going to the bathroom unassisted, and urine had been observed on the floor, but there was no documented evidence to show that the IDT had made recommendations for interventions to prevent the resident from going to the bathroom unassisted or to assist with her incontinence. The "Interdisciplinary Progress Notes" dated 7/5/12, indicated that the IDT met and discussed the fact that Resident 1 was "slipping in her BR (bathroom) in her own urine ..." The IDT recommended "slip free shoes" for the resident. There was no documented evidence on the care plan or anywhere in the clinical record that indicated that the intervention of the "slip free shoes" had been implemented by the facility prior to the resident's next fall that occurred in the bathroom on 8/11/12, which resulted in a broken tooth. During an interview with LVN 1 on 10/11/12 at 12:25 PM, she verified that Resident 1 had fallen in her bathroom on 7/2/12 and 8/11/12. LVN 1 verified that there was no documented evidence that the facility staff had been supervising Resident 1 while walking and transferring, and verified there was no documented evidence that she was being checked for incontinence every two hours as directed in her care plan, prior to her falls in the bathroom on 7/2/12 and 8/11/12. LVN 1 verified that there was no documented evidence in the clinical record that indicated the intervention of "slip free shoes" had been implemented by the facility prior to the resident's next fall on 8/11/12, which resulted in a broken tooth. During the interview, LVN 1 stated that after the resident's 8th documented fall on 8/11/12, the IDT met and recommended the use of incontinence pads. During further review of the clinical record , the "Interdisciplinary Progress Notes" dated 8/13/12 indicated that the IDT had recommended the use of incontinence pads as a intervention to prevent Resident 1 from having future falls in the bathroom. During an observation on 10/11/12 at 12:30 PM, Resident 1 was observed sitting in her wheelchair in her room. LVN 1 verified that Resident 1 had incontinence pads at her bedside. During a second attempt to interview Resident 1 on 10/11/12 at 12:30 PM, the resident refused to be interviewed. Further review of the resident's fall care plan initiated on 11/1/11 indicated that there had been no updates or revisions to the care plan to include the use of incontinence pads. During an interview with LVN 1 on 10/11/12 at 12:50 PM, LVN 1 stated that Resident 1 was probably having recurrent falls in the bathroom, because she was rushing to get on the commode because she did not like to wet herself. LVN 1 stated Resident 1 had not had any recurrent falls in the bathroom since the implementation of the incontinence pads. LVN 1 verified that the care plan had not been updated and revised to reflect the use of the incontinence pads. During the interview, LVN 1 verified that the facility had not followed their policy and procedure regarding actual falls for Resident 1. LVN 1 acknowledged that the falls in the bathroom that resulted in injuries, could have possibly been avoided if the facility had identified the present fall hazards by completing the post fall risk assessments, ensured that the IDT met after each fall and recommended interventions to prevent recurrent falls, implemented those recommendations suggested by the IDT and updated and revised the fall care plan with new interventions after each fall, as directed in the facility's policy and procedure. 2a. During a review of the clinical record for Resident 5 on 10/9/12, the clinical record indicated that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an initial record review on 10/9/12, the physician's initial assessment, dated 4/2/11, indicated that Resident 5 was capable of understanding, making medical decisions, and participating in her treatment plan. During an initial record review on 10/9/12, the minimum data set (MDS - a comprehensive clinical resident assessment), dated 4/14/11, section G indicated that Resident 5's ambulation on the unit and in the facility's corridors required staff supervision and set up assistance. During a clinical record review on 10/11/12 at 10:35 AM, the following information regarding Resident 5 was noted: An admission resident assessment, dated 4/2/11, and completed by Licensed Vocational Nurse (LVN) 3, indicated that Resident 5 required one person assistance with ambulation, as well as the use of a front wheel walker to ambulate. A review of resident care plan number 17, initiated 4/1/11, indicated that Resident 5 was at risk for an initial fall related to the use of assistive devices and weakness. During a record review on 10/9/12, a late entry nursing note, dated 3/28/12 at 9:45 PM, indicated that Resident 5 sustained a fall with an injury to the left hip when she was going out to the patio to smoke. Per this entry, Resident 5 left her walker at the doorway of the smoking patio, and as a result sustained a fall with injury to the left hip. Resident 5 was found on the ground by CNA 2. The resident was escorted to the emergency room for an x-ray of the left hip. A medical record review on 10/9/12 of an x-ray report, dated 3/28/2012, indicated that Resident 5 sustained a fracture to the left hip as the result of the fall sustained on 3/28/12. During a record review on 10/9/12, nursing note dated 3/29/12 at 11:00 AM, indicated that Resident 5 was being transferred to an acute care hospital for further care of the hip fracture. During an initial record review on 10/9/12, a nursing note dated 4/3/12 at 7:10 PM, indicated Resident 5 was readmitted to the facility from the acute care hospital, after having surgery to repair her left hip fracture (Open Reduction Internal Fixation (a surgical procedure to fix a severe bone fracture)). During a concurrent interview on, 10/11/12 at 10:35 AM with the Assistant Director of Nursing (ADON), the ADON confirmed that there was no documented evidence that interventions to prevent recurrent falls were implemented by nursing staff after the fall on 3/28/12 or after Resident 5's readmission to the facility on [DATE]. During a review of the physician's progress notes on 10/11/12 at 10:35 AM, the physician progress notes [REDACTED]. During an interview on 10/10/12 at 9:30 AM with Resident 5, Resident 5 stated that currently her gait (pattern of movement of the limbs) is a "little off" and that she needs assistance when ambulating because of her "hip surgery." During a review of Resident 5's fall care plan, on 10/11/12 at 10:35 AM, it was noted that Resident 5's fall care plan was not updated following the fall on 3/28/12. During a concurrent interview on 10/11/12 at 10:35 AM with the ADON, the ADON confirmed that the fall care plan was not updated following the fall on 3/28/12. The ADON acknowledged that staff was unable to determine which interventions to implement from the fall care plan in place to prevent additional falls. During a review on 10/11/12 at 10:35 AM, of Resident 5's clinical record, it was noted that a post fall assessment was not completed following the fall on 3/28/12. During a concurrent interview on 10/11/12 at 10:35 AM, the ADON confirmed that there was no documented evidence that a post fall assessment was completed following the fall on 3/28/12. During a review of interdisciplinary progress notes, on 10/11/12 at 10:35 AM, the following was noted: Interdisciplinary progress note, dated 4/5/12, after the fall on 3/28/12 and after Resident 5 was readmitted back to the facility, did not include a post fall evaluation and specific interventions to prevent recurrent falls. Interdisciplinary progress note, dated 4/9/12, did not include a post fall evaluation and specific interventions to prevent recurrent falls. Interdisciplinary progress note, dated 4/12/12, did not include a post fall evaluation and specific interventions to prevent recurrent falls. Interdisciplinary progress note, dated 4/17/12, did not include a post fall evaluation and specific interventions to prevent recurrent falls. During a concurrent interview on 10/11/12 at 10:35 AM, the ADON confirmed that there was no documented evidence that the interdisciplinary team made recommendations or revised interventions to prevent future falls after the fall on 3/28/12. The ADON also confirmed that there was no documented evidence that the interdisciplinary team updated care plans after the fall on 3/28/12. A review of the facility policy and procedure on 10/10/12 titled "Fall Mitigation/Assessment" (dated 3/12/02), indicated that after a resident fall the following occurs: Assessments of vital signs, pain, extremity movement, pupil reaction, and skin are completed. First aid is given and physician is notified. This policy and procedure also indicated that the "LVN completes post fall assessment..." and "...updates care plan." The interdisciplinary team (IDT) "...meets weekly to...determine causal factors and makes recommendations to prevent incident from reoccurring...initiates action plans, updates care plan...evaluates residents response to interventions and progress toward goals within 72 hours and at least quarterly." 2b. During an initial review on 10/9/12, the clinical record of Resident 5 indicated that Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an initial record review on 10/9/12 of the physician's initial assessment, dated 4/2/11, it was noted that Resident 5, was capable of understanding, making medical decisions, and participating in her plan of treatment. During a record review on 10/9/12 of the minimum data set (MDS- comprehensive clinical resident assessment), dated 4/15/12, section G: Functional Status, it was noted that Resident 5's ambulation in her room and transfer ability included limited assistance with one person physical assist. Section V: Care Area Assessment, indicated that a care area pertinent to Resident 5 was "Falls" and that a "Care Planning Decision" was made by the facility for this care area. During further review on 10/9/12, a nursing note dated 10/7/12 at 3:45 PM, indicated that Resident 5 was found on the floor on 10/7/12 at 3:15 PM after she attempted to lean forward on her bedside table, which had "wheels". As a result Resident 5 obtained a laceration to the left "brow" and left "knee area". Resident 5 was escorted to the emergency room (ER) to treat the "...brow laceration." During a review on 10/11/12 at 11:00 AM, a physician progress notes [REDACTED]." During an observation of Resident 5's room on 10/10/12 at 9:30 AM, Resident 5 was observed sitting on the edge of her bed, with both of her lower extremities dangling on the edge of the bed, with a bedside table with wheels without locks, positioned directly in front of Resident 5. During an interview on 10/10/12 at 9:30 AM with Resident 5, Resident 5 stated that her gait (pattern of movement of the limbs) was a "little off" and that she needs assistance "when walking or moving." Resident 5 confirmed that the bedside table with wheels positioned directly in front of her was the bedside table that she attempted to lean on when she fell on [DATE]. The resident stated that the wheels on the bedside table did not lock, and demonstrated this by moving the bedside table and pointing to the wheels. Resident 5 stated that the facility had not attempted to change out this bedside table to a bedside table that did not move or to one that had wheels which could be locked. During a review on 10/11/12 at 11:00 AM, of Resident 5's clinical record, it was noted that a post fall assessment was not completed following the fall on 10/7/12. During a concurrent interview on 10/11/12 at 11:00 AM with the Assistant Director of Nurses (ADON), the ADON confirmed that there was no documented evidence that a post fall assessment was completed following the fall on 10/7/12. During a review of Resident 5's fall care plan, on 10/11/12 at 11:00 AM, the fall care plan did not show documented evidence that it was updated following the fall on 10/7/12. During a concurrent interview on 10/11/12 at 11:00 AM, the ADON confirmed that the fall care plan was not updated following the fall on 10/7/12. The ADON acknowledged that staff was unable to determine which interventions to implement from the fall care plan already in place, to prevent additional falls. During a review of interdisciplinary progress notes, on 10/11/12 at 11:00 AM, progress note entry dated 10/8/12, did not include a post fall evaluation or specific interventions to prevent recurrent falls. During a concurrent interview on 10/11/12 at 11:00 AM, the ADON confirmed that there was no documented evidence that the interdisciplinary team made recommendations or revised interventions to prevent future falls after the fall on 10/7/12. The ADON also confirmed that there was no documented evidence that the interdisciplinary team updated care plans after the fall on 10/7/12. A review of the facility policy and procedure on 10/10/12 titled "Fall Mitigation/Assessment" (dated 3/12/02), indicated that after a resident fall the following occurs: Assessments of vital signs, pain, extremity movement, pupil reaction, and skin are completed. First aid is given and physician is notified. This policy and procedure also indicated that the "LVN completes post fall assessment..." and "...updates care plan." The interdisciplinary team (IDT) "...meets weekly to...determine causal factors and makes recommendations to prevent incident from reoccurring...initiates action plans, updates care plan...evaluates residents response to interventions and progress toward goals within 72 hours and at least quarterly."