Every finding on record at Stonebrook Health and Rehabilitation

Based on interview and record review, the facility failed to investigate and report an injury of unknown origin for one of 3 residents (Resident 1) when a family member (FM) reported that she saw a bruise on Resident 1's head. This failure had the potential to put residents at risk of injury without an investigation of the cause, and could possibly compromise Resident 1's safety.Findings:Review of Resident 1's clinical record, indicated she was admitted with diagnoses which included Urinary Tract Infection (UTI, an infection in the urinary system), dysarthria (a motor speech disorder caused by neurological damage [stroke, brain injury, or diseases like Parkinson's] that weakens or impairs control over muscles used for speech, including the tongue, lips, and throat), and muscle wasting and atrophy (the loss or thinning of muscle tissue, resulting in reduced muscle mass, weakness, and smaller-looking limbs).During an interview with Resident 1 on 12/10/25 at 2:31 p.m., she stated she could not remember what had happened that gave her the bruise beside her outer right eye.Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 10/4/25, indicated Resident 1 had brief interview for mental status score of 7 (score of 0-7 indicates cognition is severely impaired).During an interview with the treatment nurse (TN) on 12/10/25 at 2:40 p.m., the TN stated Resident 1 had a skin discoloration in the beginning of December of 2025 and it was being monitored.During an interview with the director of nursing (DON) on 12/10/25 at 2:55 p.m., the DON stated Resident 1's FM had stated there was a bruise on her head. The DON stated that she and the assistant director of nursing (ADON) went with Resident 1's FM into the room, and explained to the family that it was not a bruise, it was a greenish discoloration from the vein.During a review of Resident 1's physician orders dated 12/5/25, the physician order indicated skin discoloration beside the outer right eye area, and to observe for signs and symptoms of swelling, skin breakdown, and bleeding every shift for 30 days.A review of Resident 1's care plan, dated 12/5/25, indicated altered skin integrity related to skin discoloration beside right outer eye. The Interventions/Tasks which indicated to Inform responsible party and surrogate decision maker for presence of skin discoloration/bruise and to notify MD for presence of skin discoloration/bruise. During a review of Resident 1's Weekly Non-pressure Ulcer Observation Tool, dated 12/5/25, it indicated that Resident 1's family member stated it looked like Resident 1 had a bruise.The Weekly Non-pressure Ulcer Observation Tool further indicated a skin discoloration beside outer right eye which measured 0.5 centimeters (cm, a small unit of length in the metric system) in length by 0.1 cm in width.During a telephone interview with the DON on 1/30/2026 at 2:03 p.m., the DON stated Resident 1's greenish discoloration, beside the right eye, had went away.During an interview with the DON on 2/4/2025 at 9:57 a.m., the DON stated if a family member would say a resident has a bruise, she would go assess the resident, do the skin assessment, monitor, notify the MD, and investigate. The DON further stated the facility would investigate, interview all the nurses, then go from there if it was an abuse or injury of unknown origin. The DON added, she would let the doctor know, and if there is a suspicion of an abuse facility would report it.During a review of Resident 1's Progress Notes, dated 12/15/25 at 9:52 a.m., the Progress Notes indicated the skin discoloration beside the outer right eye area was resolved and MD was made aware.Further review of Resident 1's Progress Notes and Weekly Non-pressure Ulcer Observation Tool indicated the physician was made aware of the discoloration, however there was no additional documentation how Resident 1 had acquired the discoloration of the outer right eye area.During a review of the facility's policy and procedure (P&P) titled Abuse Reporting Policy, revised 08/2022, the P&P indicated .Type of Abuse: .7. Injury of unknown source is defined as an injury that meets both the following conditions: (1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time.V. Investigation: a. The facility shall thoroughly investigate allegation of abuse by identifying and interviewing all involved including the alleged victim, alleged perpetrator, witness(es), and other who might have seen, heard, or have knowledge of the allegations, and with documented evidences that support the investigation.b. The facility's abuse prevention coordinator/designee shall initiate the investigation process immediately within the required time frame in accordance to the regulation after the alleged incident occurred - focusing on determining if allegations have occurred, the cause and its extent, and by providing complete and thorough documentation of the investigation and exercising caution in handling possible evidence(s).VII. Reporting/Response: a. The Facility shall report any and all allegation of abuse to the District CDPH, Local Ombudsman, and Local Law enforcement, either by phone, email, or facsimile, within 2-hour timeframe.

Based on observation, interview, and record review, the facility failed to ensure to post the daily staffing information daily. This failure had the potential to result in nurse staffing misinformation to residents, families, and visitors.Findings: During an observation on 12/29/25 at 9 a.m., the Census and Direct Care Service Hours Per Patient Day (DHPPD-a form containing daily staffing information) form dated 12/10/25 (19 days past) was posted in the hallway next to the facility's entrance lobby. During an interview and observation with licensed vocational nurse (LVN) A on 1/29/25 at 9:16 a.m., LVN A confirmed the observation. LVN A stated the infection preventionist (IP, a specialized healthcare professional who prevents the spread of germs and infections in the facility)) nurse who was the one in charge of initiating, posting, and updating the DHPPD postings was on vacation since 12/11/25, and LVN A was covering the duty during the IP nurse's vacation period. LVN A further stated he forgot to update the facility's current DHPPD daily. LVN A acknowledged the facility should have updated and posted the DHPPD daily. During an interview with the administrator (ADM) on 12/29/25 at 1:01 p.m., the ADM stated the facility should post the DHPPD daily. During a review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated, Direct care daily staffing numbers (the number of nursing personnel responsible for providing direct care to residents) are posted in the facility for every shift.

Based on observation, interview, and record review, the facility failed to ensure proper drying of cooking/serving equipment, when a large baking pan and three steam table pans were stacked while still wet. This failure had the potential to cause foodborne illness (illness resulting from contaminated food) for 67 residents who received food from the kitchen. Findings:During an initial inspection of the kitchen, 1 large baking pan was observed wet in the stack of baking pans that had been put away for storage, 1 steam table pan in a stack of steam table pans which had been put away for storage, and three other steam table pans in a different stack of steam table pans which had been put away for storage.During an interview with the dietary manager (DM) on 7/28/25 at 8:53 a.m., he acknowledged that there were one large baking pan and four steam table pans which had been stacked for storage and were still wet.During a review of the facility's undated policy and procedure (P&P) titled, Dish Washing, the P&P indicated .5. Dishes are to be air dried in racks before stacking and storing.

Based on observation, interview, and record review, the facility failed to ensure that alternatives were attempted and documented prior to using side rails (devices attached to the side of a bed) for 32 of 68 sampled residents (Residents 1, 4, 6, 12, 16, 17, 18, 25, 26, 31, 32, 33, 43, 48, 50, 51, 56, 59, 70, 82, 83, 84, 86, 87, 88, 89, 93, 94, 95, 96, 100, and 101) reviewed for side rail use.Findings:During multiple observations on 7/28/25 between 9:00 a.m. and 3:00 p.m., Residents 1, 4, 6, 12, 16, 17, 18, 25, 26, 31, 32, 33, 43, 48, 50, 51, 56, 59, 70, 82, 83, 84, 86, 87, 88, 89, 93, 94, 95, 96, 100, and 101 were observed with both upper side rails raised.Review of the Alternative Measures Tried section on the facility's Siderails Screening Tool showed no evidence that alternatives were attempted or documented prior to using side rails for all 32 residents reviewed.During an interview with the Director of Nursing (DON) on 7/30/25 at 11:10 a.m., when asked what alternatives were tried before using side rails, the DON stated that on admission, the charge nurse asked the resident if they want the side rails up or down. The DON stated that the use of side rails were based on resident's preference. The DON stated that nurses documented the alternatives in the Alternative Measures Tried section of the Siderail Screening Tool.During concurrent record review of the facility's Siderail Screening Tool with the DON for one resident, the DON confirmed the section was blank. The DON acknowledged this section should have been completed and stated she would address the issue.During a interview with the Assistant Director of Nursing (ADON) on 7/30/25 at 3:10 p.m., the ADON stated that on admission, staff informed the residents that side rails were considered enabler (a device that helps a resident move or reposition) or were used for repositioning. If residents agreed to have side rails, they are used.During a concurrent record review with the ADON of the Siderail Screening Tool of 68 sampled residents, the ADON confirmed the Alternative Measures Tried section of the Side rails Screening Tool were blank for the 32 residents with side rails. The ADON stated that this section should have been completed.Review of the facility's policy, Proper Use of Side rails revised 12/2016, indicated Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of siderails.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by:1. Licensed nurses did not know the process to disinfect a glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions;2. Resident 52's urinary catheter bag (a bag that is attached to a tube that is connected to the bladder) was touching the floor; and3. The Certified Nursing Assistant (CNA) did not perform hand hygiene after removing her gloves and prior handling the new clean bed linens.These failures had the potential to compromise resident's health and safety in the facility.1. During a medication administration observation on 7/28/25 at 11:40 a.m. with Registered Nurse (RN) A, RN A completed a blood sugar check on Resident 48. RN A used a disinfectant “Sani-Cloth” wipe and wiped the front and back of glucometer device for 4 seconds and then placed the glucometer in a small plastic basket. When RN A was asked what the contact time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) was, she stated “5 seconds.” A review of the product labeling for the Sani-Cloth disinfectant wipes used by RN A indicated “Disinfects in 2 minutes” and further label information indicated “Contact time: Use wipe to thoroughly wet surface. Allow surface to remain visibly wet for two (2) minutes. Let air dry.” RN A read the label on the disinfectant Sani-Cloth wipes and confirmed the contact time was 2 minutes, not 5 seconds. During an interview on 7/30/25 at 7:18 a.m. with RN B, she stated she has 16 residents who require blood sugar checks in the morning before breakfast. RN B stated she uses a shared (used for multiple residents) glucometer to check the resident's blood sugar levels. When asked what the contact time was for disinfecting a shared glucometer, RN B stated “30 seconds.” RN B stated she uses Sani-Cloth disinfectant wipes to disinfect the glucometer. RN B read the label on the disinfectant Sani-Cloth wipes and confirmed the contact time was 2 minutes, not 30 seconds. During an interview with the Infection Director of Staff Development/Infection Preventionist (DSD/IP) on 8/1/25 at 8:15 a.m., she was asked about the contact time for disinfecting shared glucometers. The DSD/IP stated the facility uses the product “Sani-Cloth” wipes, which has a contact time of 2 minutes. She further stated all staff should know the contact times for disinfectants to ensure proper use of the product for disinfecting. Review of the facility's policy titled “Obtaining a Fingerstick Glucose Level,” revised October 2011, indicated “Clean and disinfect reusable equipment between uses according to manufacturer's instructions and current infection control standards of practice.” 2. During a concurrent observation and interview on 7/28/25 at 10:01 a.m. with Certified Nursing Assistant (CNA) D in Resident 52's room, CNA D showed Resident 52's urinary catheter bag, which was positioned behind the wheelchair, covered with a white pillowcase and touching the floor. During an interview with CNA D on 7/30/2025 at 2:57 p.m., CNA D confirmed that the urinary catheter bag of Resident 52 was touching the floor following Resident 52's care on Monday, 7/28/25. During an interview with the Director of Staff Development/Infection Preventionist (DSD/IP) on 7/31/25 at 10:01 a.m., the DSD/IP stated, The catheter bag should be off the floor, even if it's covered with a pillowcase. A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2014, the P&P indicated, Be sure the catheter tubing and drainage bag are kept off the floor. 3. During an observation on 7/29/25 at 9:15 a.m. in Resident 26's room, CNA E was observed wearing gloves while assisting Resident 12 to the bathroom. While Resident 12 was in the bathroom, CNA E changed the bed linens, bundled the soiled bed linens in a plastic bag, and disposed them in the dirty bin outside the room. Subsequently, CNA E removed her gloves without performing hand hygiene, and proceeded to grab clean bed linens from the rack in the hallway, which she then placed on Resident's bed. During an interview on 7/29/25 at 10:26 a.m. with CNA E, CNA E confirmed that she did not perform hand hygiene after removing her gloves and prior to handling the new clean bed linens. CNA E further stated that it was not okay to remove gloves and touch anything without first performing hand hygiene. An interview with the DSD/IP on 7/31/2025 at 3:17 p.m., the DSD/IP stated that staff were expected to practice hand hygiene before putting on gloves and after taking them off, and that no staff should wear gloves while in the hallway. During an interview on 7/31/25 at 3:32 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that staff were expected to wash their hands or use hand sanitizer before and after using gloves to avoid cross-contamination. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised August 2015, the P&P indicated that the facility considers hand hygiene the primary means to prevent the spread of infection - use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations include: after removing gloves .

Based on observation, interview, and facility document review, the facility failed to maintain resident's rights to privacy and confidentiality to one of 17 sampled residents (Resident 72) when Resident 72's personal information and care instruction was posted in the room visible to roommates and visitors. This failure had the potential to compromise residents' rights and dignity.Findings:During an initial observation on 7/28/25, at 10:01 a.m. in Resident 72's room, an ENT [ear, nose, and throat] Doctor note was observed posted on the wall above Resident 72's head of bed (HOB). The note, which was written in blank ink, indicated a request from Resident 72's daughter for the ENT doctor to examine Resident 72's ears. The note also provided Resident 72's full name and identified Resident 72's diagnosis of bilateral (affecting two sides) hearing loss due to Cerumen [earwax] impaction.During an interview with the Assistant Director of Nursing (ADON) on 7/31/25 at 3:30 p.m., the ADON confirmed that the note titled ENT Doctor which was posted to the wall above Resident 72's HOB contained Resident 72's full name and diagnosis. The ADON mentioned that Resident 72 shares a room with other residents who often have visitors, thereby allowing the visitors the opportunity to view the note. Furthermore, the ADON explained that the note should be covered if requested by the family.A review of the facility's policy and procedure (P&P) titled, Dignity, revised August 2009, the P&P indicated, in number 9. Staff shall maintain an environment in which confidential clinical information is protected, for example: Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door). and in number 10. Staff shall promote, maintain and protect resident privacy .

Based on interview and record review, the facility failed to document the status of Advance Directive for two of 24 residents (Resident 8 and 44), when no advance directive was located in the electronic records, nor was section D of the POLSTs filled out. This failure had the potential of the facility not following the wishes of the residents in the event of incapacitation and need for life saving treatment. Findings:1. During a record review of Resident 8's advance directive status, no advance directive was located, nor any documentation of whether Resident 8 had one or not. On Resident 8's POLST (physician's order for life sustaining treatment), section D had no check marks pertaining to the status of Resident 8's advance directive. There were three check boxes for: 1) Advance Directive dated; 2) Advance Directive not available; and 3) No Advance Directive. All of these check boxes were blank.During an interview with the Assistant Director of Nursing (ADON) on 7/31/25 at 1:33 p.m., she acknowledged there were no boxes check related to advance directive in section D of Resident 8's POLST form, and there should have been.2. During a record review of Resident 44's advance directive status, no advance directive was located, nor any documentation of whether Resident 44 had one or not. On Resident 44's POLST (physician's order for life sustaining treatment), section D had no check marks pertaining to the status of Resident 44's advance directive. There were three check boxes for: 1) Advance Directive dated ___; 2) Advance Directive not available; and 3) No Advance Directive. All of these check boxes were blank.During an interview with the ADON on 7/31/25 at 1:37 p.m., she acknowledged there were no boxes check related to advance directive in section D of Resident 44's POLST form, and there should have been.During a review of the facility's policy and procedure (P&P) titled Advance Directives, revised December, 2016, the P&P indicated1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives.7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.

Based on observation, interview, and record review, the facility failed to ensure that resident's enteral feeding (liquid nutrition directly delivered to the stomach using a tube) bottle was properly labeled for one of three sampled residents (Resident 2). This failure had the potential to cause an error during administration of the enteral feeding formula for Resident 2.Findings:Review of Resident 2's clinical record indicated she had diagnoses including dysphagia (difficulty of swallowing) and presence of a gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply nutrition or liquid medication). Resident 2's physician order dated 7/28/25 indicated Jevity 1.2 (liquid nutrition) at 70 milliliters (ml, unit of measurement) per hour for 12 hours from 9 p.m. to 9 a.m. via a feeding pump.During an observation in Resident 2's room on 7/30/25 at 8:05 a.m., there was a GT formula bottle with formula running via an enteral feeding pump attached to a pole next to Resident 2's bed. The feeding formula bottle indicated a net volume of 1500 ml and the reading on the pump indicated the volume of formula delivered was 792 ml. Resident 2's GT formula bottle was not labeled or dated.During a follow-up observation and concurrent interview with Registered Nurse A (RN A) on 7/30/25 at 8:10 a.m., RN A confirmed Resident 2's GT formula bottle was unlabeled and undated. RN A stated the bottle should have been labeled with the resident's name, the rate at which the formula was to be administered, and the date and time the feeding was initiated.During an interview with the Director of Nursing (DON) on 7/31/25 at 7:55 a.m., she confirmed GT feeding formula bottles should be labeled with the resident's name and date the formula is started. The DON further stated the label should indicate the tube feeding order and rate on the label.Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, revised November 2018, indicated On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order.

Based on observation, interview, and record review, the facility failed to ensure intravenous (IV) therapy (the administration of parenteral fluids or medications through an IV catheter to treat a condition) was labeled for one of four sampled residents (Resident 31).This deficient practice had the potential to compromise Resident 31's health and well-being.Findings:During an initial observation on 7/28/25 at 9:51 a.m., in Resident 31's room, Resident 31 was observed receiving IV therapy with 0.45% Sodium Chloride (a parenteral solution containing sodium chloride in water for injection intended for IV administration). The IV fluid did not have labels indicating Resident 31's name, the start date and time, medication instructions, and the initials of the nurse who administered.During a concurrent observation and interview on 7/28/25 at 10:15 a.m. with Registered Nurse (RN) A in Resident 31's room, RN A confirmed that the IV fluid containing 0.45% Sodium Chloride (also known as half normal saline, a hydrating solution) administered to Resident 31 lacked the necessary labels, including the Resident's name, the date and time the IV was initiated, medication instructions or IV rate, and the initials of the administering nurse. During an interview with the Nurse Supervisor (NS) on 7/28/25 at 10:54 a.m., the NS indicated that nurses were expected to label IV fluids, including the start date and time, as well as the initials of the administering nurse. The NS mentioned that the nurse on the night shift had initiated Resident 31's IV fluids but it was not labeled and dated.A review of Resident 31's Medication Administration Record (MAR), dated 7/1/2025 - 7/31/2025, the MAR indicated, on 7/27/25 at night shift, Sodium Chloride IV Solution 0.45% for hydration was administered.A review of the facility's policy and procedure (P&P) titled, General Policies for IV Therapy, dated March 2023, the P&P indicated, Nurses shall not alter any prescription label prepared by the pharmacy with the exception of the IV rate. With an MD order, rate may be changed when accompanied by the date and nurse's initial. All additive labels will be completed by the nurse administering the IV fluid/medication and are to include the nurse's initials, date and time.

Based on interview, and record review, the facility failed to provide adequate monitoring for three of 17 sampled residents (Resident 72, 52, and 31) when:Resident 72 was not monitored for psychotropic side effects on abnormal involuntary movement based on Medication Regimen Review (MRR); andResident 52 and 31 were not monitored for signs and symptoms of hypo/hyperglycemia (too low/high blood sugar) as indicated in the care plan.These failures had the potential for side effects to go undetected or recognized for timely interventions.Findings:During a concurrent interview and record review on 8/1/25 at 10:10 a.m. with Licensed Vocational Nurse (LVN) C, Resident 72's Medication Administration Record (MAR) was reviewed. LVN C confirmed that there were no tardive dyskinesia (repetitive movements mostly affecting the face) monitoring indicated in Resident 72's antipsychotic side effect monitoring.During a concurrent interview and record review on 8/1/25 at 10:27 a.m. with Registered Nurse (RN) A, Resident 72's MAR was reviewed and no tardive dyskinesia included in the antipsychotic side effect monitoring. RN A explained that the side effect of antipsychotic medication includes mouth dryness, dehydration, and tardive dyskinesia. RN A agreed that tardive dyskinesia should be part of the antipsychotic side effect monitoring. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 8/01/2025 at 10:15 a.m., the ADON explained that the MRR process involves notifying the doctor and considering nursing measures. The ADON further explained that these measures include monitoring medication side effects, resident behavior, and black box warnings. The ADON confirmed that tardive dyskinesia had not been included in Resident 72's antipsychotic side effect monitoring.During a follow-up interview with the ADON on 8/1/25 at 2:58 p.m., the ADON stated that assessments were conducted based on the side effect monitoring conducted by the nurses.A review of Resident 72's clinical record indicated Resident 72 was admitted to the facility on [DATE] with diagnosis including Schizophrenia, unspecified (a serious mental disorder that may interfere with a person's ability to think clearly, manage emotions, make decisions and relate to others).A review of Resident 72's Order Summary Report, active order as of 7/31/25, the medication order dated 1/3/25 indicated, Resident 72 had been receiving risperidone (a type of antipsychotic medication that treats mental health conditions schizophrenia) oral tablet, 0.5 milligram (mg, unit of measurement) by mouth at bedtime for SCHIZOPHRENIA.A review of Resident 72's Order Summary Report active order as of 7/31/25, the monitoring order for the side effect of antipsychotic medication (Risperdal) dated 1/3/25 and 2/24/25 did not reflect the tardive dyskinesia monitoring such as tremors, muscle rigidity, and other abnormal motor movements.A review of facility's Consultant Pharmacist's Medication Regimen Review (MRR), dated 2/1/2025 to 2/25/2025 and 3/1/25 to 3/31/25, the MRR indicated missing psychotropic monitoring behavior.A review of Resident 72's Care Plan focused on Alteration in Behavior pattern R/T [related to] (Schizophrenia) M/B [manifested by] angry outburst such as yelling, date initiated 2/24/25, the Care Plan interventions indicated Monitor side effect of Anti-psychotic medication: extrapyramidal reaction [group of side effects that affect the movement usually cause by antipsychotic], . Special Attention for: Tardive dyskinesia .A review of the facility's policy and procedure (P&P) titled Consultant Pharmacist Reports, effective date April 2008, the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber. The director of nursing or designated licensed nurse addresses and documents recommendations that do not require a physician intervention . A review of the facility's policy and procedure (P&P) titled Antipsychotic Medication Use, revised December 2016, the P&P indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications; Nursing staff shall monitor for and report any of the following side effects and adverse consequences of the antipsychotic medication to the Attending Physician: Neurologic (Akathisia [a movement disorder that makes it hard for you to stay still], dystonia [ a movement disorder that causes involuntary contractions of your muscles], extrapyramidal effects [drug-induced movement disorders], akinesia [inability to perform a clinically perceivable movement] ; or tardive dyskinesia, stroke or TIA [Transient Ischemic Attack (a temporary blockage of blood flow to the brain, causing stroke-like symptoms]. 2a. A review of Resident 52's clinical record indicated, Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Type 2 Diabetes Mellitus (DM) without complications (a disease in which your blood glucose [main source of energy], or blood sugar, levels are too high) without complications .A review of Resident 52's Order Summary Report, active order as of 7/31/25, the medication order dated 6/20/25 indicated, Resident 52 had been receiving insulin (a medication used in the treatment and management of diabetes) Lispro Injection Solution (a fast-acting type of insulin)100 UNIT/ML [milliliter] inject subcutaneously (insertion of medications beneath the skin) per sliding scale before meals and at bedtime for DM. The medication order revealed no monitoring of signs and symptoms of hypo/hyperglycemia 2b. A review of Resident 31's clinical record indicated, Resident 31 was admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes Mellitus without complications .A review of Resident 31's Order Summary Report, active order as of 7/31/25, the medication order dated 6/22/25 indicated, Resident 31 had been receiving insulin Lispro Injection Solution 100 UNIT/ML inject subcutaneously per sliding scale before meals and at bedtime for DM. The medication order revealed no monitoring of signs and symptoms of hypo/hyperglycemia During a concurrent interview and record review on 8/1/25 at 10:10 a.m. with LVN C. Resident 52 and 31 Medication Administration Record (MAR) were reviewed. LVN C confirmed that Resident 52 and 31 were both on insulin Lispro injection. LVN C indicated that there were no hypo/hyperglycemia monitoring indicated in the MAR. LVN C stated that signs and symptoms of hypo/hyperglycemia should be monitored.During a concurrent interview and record review on 8/1/25 at 10:27 a.m. with RN A. Resident 52 and 31 Medication Administration Record (MAR) were reviewed. RN A confirmed that Resident 52 and 31 were both on insulin and no hypo/hyperglycemia monitoring indicated in the MAR. RN A explained that, in addition to checking blood sugar levels, signs and symptoms of hypo/hyperglycemia include confusion and sweating, which should be included in the monitoring process.During a concurrent interview and record review on 8/1/25 at 10:15 a.m. with ADON. Resident 52 and 31 Medication Administration Record (MAR) were reviewed. The ADON confirmed that there were no hypo/hyperglycemia signs and symptoms monitoring for Resident 52 and 31. The ADON mentioned that nursing measure include monitoring of the side effect of the medication, resident behavior, and the black box warning. The ADON indicated that signs and symptoms of hypo/hyperglycemia should be included in the monitoring process.A review of the facility's policy and procedure (P&P) titled, Insulin Administration, revised September 2014, the P&P indicated, Notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved by the following the facility protocol for hypoglycemia management.A review of the facility's policy and procedure (P&P) titled, Nursing Care of the Resident with Diabetes Mellitus, revised December 2015, the P&P indicated the purpose is to prevent recurrent hyperglycemia/hypoglycemia and recognize, manage, and document the treatment of complications commonly associated with diabetes, and the Medication Management includes the nurse will closely monitor the diabetes management of cognitively impaired residents.According to the CDC's online publication named Living with Diabetes, dated 9/30/22, many causes such as insulin use, changes in diet or drinking, and illnesses could lead to hypo/hyperglycemia. Hypoglycemia symptoms may include fast heartbeat, sweating, nervousness or anxiety, irritability or confusion, dizziness, and hunger. Hyperglycemia symptoms included feeling very tired, thirsty, blurry vision, and needing to urinate more often. It indicated to monitor for signs and symptoms of diabetes complication and .catch low blood sugar early and treat it . Low blood sugar can be dangerous and should be treated as soon as possible. Regarding hyperglycemia, the publication indicated, Over time, high blood sugar can lead to long-term and serious health problems. (https://www.cdc.gov/diabetes/managing/manage-blood-sugar.html; accessed 5/16/23)

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were appropriately stored and labeled during an inspection of randomly selected two of three medication storage when the following were found:1. An injectable medication pen was opened and used with no date.2. Medication that required refrigeration was stored inside the medication cart.These failures had the potential for the administration of expired or deteriorated medications or biologicals.Findings:1. During a random inspection of medication cart Y on Station BB with Registered Nurse A (RN A) on [DATE] at 1:35 p.m., an opened and undated multi-use Lantus insulin (long-acting insulin used to control high blood sugar) pen was observed. RN A confirmed the insulin was in use and there was no date on the pen indicating when the medication was opened. RN A stated there should be an open date. 2. During a random inspection of medication cart X on Station AA with Licensed Vocational Nurse C (LVN C) on [DATE] at 2:00 p.m., an unopened vial of Procrit (used to treat anemia [low levels of red blood cells]) was observed with a label that read KEEP MEDICINE IN REFRIGERATOR. LVN C verified the label and confirmed the medication should be refrigerated.During an interview with the Director of Nursing (DON) on [DATE] at 7:55 a.m., she was asked about the facility's policy for storage of medications. The DON stated medications requiring refrigeration should not be kept in the medication carts if the label/directions indicate to refrigerate. The DON further stated all insulin pens should be dated when opened and discarded per manufacturer's recommendations.A review of the facility's policy Medication Storage and Labeling, dated 3/2010, indicated to store and label medication for resident safety and pharmaceutical product integrity. The policy indicated that insulin should be dated and initialed when opened when currently in use.

Based on observation, interview, and record review, the facility failed to ensure proper technique was used for checking the quaternary sanitizer (a group of chemicals used for a variety of purposes including as preservatives, surfactants, antistatic agents, and as active ingredients in disinfectants and sanitizers), when a kitchen staff member did not follow the instructions on the container for the test strips that were used. This failure had the potential of the strength of the sanitizer not being appropriate to kill any microbes, thus spreading food borne pathogens and illness to the facility occupants, which there were 67 of 68 residents who ate food from the kitchen. Findings:During an observation and subsequent interview in the kitchen on 7/29/25 at 1 p.m. with the Dietary Aide (DA F), she demonstrated how to check the strength of the quaternary (use as disinfectant) sanitizer, which is used in the three-compartment sink. The DA F dipped the sanitizer strip for 12.54 seconds. The DA F then compared the reagent square on the dip stick to the results picture on the container. The dip stick result read 400 ppm. The DA F stated she had held the dip stick in the sanitizer water for 10 seconds.During a review of the instructions on the container of Insta-Test Analytic: sanitized water test strips, QAC 50-400 ppm the container instructions indicated: 1. Dip and take out. 2. Shake off excess water. 3. Wait 5 seconds. 4. Compare.

Based on observation, interview and record review, the facility failed to ensure food preferences were honored for one of 17 sampled residents (Resident 90). This failure resulted in Resident 90 receiving food items she disliked.Findings:During a meal observation and interview on 7/28/25 at 12:54 p.m., in the resident's room, Resident 90 was seated in a wheelchair with a family friend, eating lunch. The meal included fish, carrots, and zucchini. Resident 90 stated she did not like zucchini but it was still served to her.During a concurrent review of Resident 90's meal tray ticket, zucchini was listed in Resident 90's dislikes.During an interview with the Dietary Manager (DM) on 8/1/25 at 1:45 p.m., the DM stated the resident's preferences should be followed.Review of the facility's policy Resident Food Preferences revised July 2017, indicated, Individual food preferences will be assessed upon admission, quarterly and as needed.when possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes.if the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.

Based on interview and record review, the facility failed to offer pneumococcal vaccines (vaccines that help prevent serious infections caused by pneumonia, a lung infection) as required for two of five sampled residents (Residents 36 and 72). This failure had the potential to place residents at risk for preventable disease. Findings: 1. Review of Resident 36's clinical record indicated Resident 36 was admitted on [DATE]. The Pneumococcal Immunization Consent form, dated 6/17/24, indicated the resident/family refused the Pneumococcal vaccine.During a concurrent interview with the Director of Staff Development/Infection Preventionist (DSD/IP) on 7/31/25 at 4:50 p.m., the DSD/IP confirmed Resident 36 was not offered the pneumococcal vaccine again after admission. The DSD/IP stated that when offering the pneumococcal or flu vaccines, staff complete the consent form again or document the offer in the progress notes, but this was not done.2. Review of Resident 72's clinical record indicated resident was admitted on [DATE]. The Pneumococcal Immunization Consent form indicated the vaccine was refused on 6/27/24.During a concurrent interview and record review on 8/1/25 at 11:09 a.m., the DSD/IP acknowledged that Resident 72 was not offered the pneumococcal vaccine again after admission, as required by the facility's policy.Review of the facility's policy, Pneumococcal Vaccination revised 2/2022, indicated, .Pneumococcal and Influenza vaccine shall be offered and consent will be obtained on admission and quarterly, if eligible.

Based on interview and record review, the facility failed to complete and submit an investigation summary regarding an alleged abuse incident that occurred between two of three sampled residents (Residents 1 and 2). This failure had the potential to compromise the facility's ability to determine the circumstances surrounding the incident and could have compromised the residents' safety. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnosis of cellulitis (a skin infection that causes swelling and redness) of left and right limb, peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs), abnormal posture and history of falling. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 3/18/25, indicated she had a (Brief Interview for Mental Status, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) BIMS of 12 meaning her cognition was moderately impaired. Review of Resident 2's medical record indicated she was admitted on [DATE] and had the diagnosis of alcohol dependence with withdrawal, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormal posture and history of falling. Resident 2's MDS dated [DATE], indicated she had a BIMS of 7 meaning her cognition was severely impaired. Review of Resident 1's Change in Condition Evaluation, dated 4/1/25, indicated an incident had occurred between Resident 1 and Resident 2. The documentation indicated, nurse heard yelling and argument with roommate Resident 2. During a concurrent interview and record review on 6/4/25 at 9:40 a.m., with the Director of Nursing (DON), she reviewed interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) IDT note dated 4/5/25 and stated that on 4/1/25 around 11:50 p.m., staff heard Resident 1 and Resident 2 yelling to each other and charge nurse transferred Resident 2 to another room. In the morning of 4/2/25, Resident 1 told the DON and the Social Services Director (SSD) that her roommate Resident 2 tapped her on the back of the head, and she was not comfortable. The DON and charge nurse assessed Resident 1 and no visual injury noted and denies pain or discomfort and the primary doctor (MD) was notified. During an interview with the administrator (ADM) on 6/3/25 at 12 p.m., he stated the above incident between Residents 1 and 2 was reported to the police, the Ombudsman (resident advocate), and the California Department of Public Health (CDPH, state survey agency). During a concurrent interview and record review with the ADM on 6/3/25 at 1:15 p.m., he confirmed that when an alleged abuse incident occurs, the facility must submit an investigation summary to CDPH within five days. The ADM stated he was not able to find a fax transmittal confirmation that the five-day summary or an investigation summary for the incident that occurred between Residents 1 and 2 on 4/2/25 was faxed to CDPH except for the fax transmittal confirmation dated 6/3/25 at 1 p.m. Review of the facility's policy and procedure, revised 7/2017, titled Abuse Investigation and Reporting, indicated, All reports of resident's abuse, neglect, exploitation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview, record review, and document review, the facility failed to complete and transmit discharge Minimum Data Set (MDS) assessments for 2 (Resident #38 and Resident #51) of 2 sampled residents reviewed for resident assessment. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, indicated, Discharge assessment refers to an assessment required on resident discharge from the facility. 1. An Admission Record revealed the facility initially admitted Resident #38 on 12/13/2023. According to the Admission Record, the resident had a medical history that included diagnoses of pleural effusion, atrial fibrillation, and peripheral vascular disease. An admission MDS, with an Assessment Reference Date (ARD) of 12/19/2023, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Resident #38's Progress Notes, dated 02/20/2024 at 6:08 PM, revealed Resident #38 discharged from the facility. Review of Resident #38's medical record, revealed no evidence to indicate a discharge MDS was completed. 2. An Admission Record revealed the facility initially admitted Resident #51 on 01/03/2024. According to the Admission Record, the resident had a medical history that included diagnoses of left radius fracture, type two diabetes mellitus, and morbid obesity. An admission MDS, with an Assessment Reference Date (ARD) of 01/21/2024, revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Resident #51's Progress Notes, dated 02/17/2024 at 6:50 PM, revealed Resident #51 discharged from the facility. Review of Resident #51's medical record, revealed no evidence to indicate a discharge MDS was completed. During an interview on 05/30/2024 at 12:04 PM, the MDS Coordinator stated the facility's electronic medical record system generated a report which showed when a resident's MDS assessments were due. The MDS Coordinator stated when a resident discharged from the facility, the facility was required to complete and submit a discharge MDS within 14 days. The MDS Coordinator stated Resident #38 and Resident #51 should have had a completed and submitted discharge MDS assessment. During an interview on 05/30/2024 at 12:10 PM, the Director of Nursing stated she expected the discharge MDS to be completed and submitted within the required 14 days. During an interview on 05/30/2024 at 12:53 PM, the Administrator stated he expected MDS assessments to be submitted timely and expected the nursing department to complete a resident's MDS assessment as required.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician's order to go out on pass (to leave the premises). This failure had the potential to compromise the resident's safey. Also for Resident 1, the facility failed to ensure a written summary of the baseline care plan (plan that includes the minimum information necessary to properly care for the resident upon admission) was given to the responsible party (RP, person designated to make decisions on behalf of the resident). This failure had the potential to compromise the resident's right to be informed of and participate in the plan of care. Findings: 1. Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnoses of hemiplegia (one side of the body is paralyzed), metabolic encephalopathy (a disease that affects brain function), and history of falling. Review of Resident 1's Progress Notes indicated she went out on pass on 11/1/23, 11/13/23, 11/15/23, 11/16/23, 11/20/23, 11/22/23, 11/24/23, 11/30/23, 12/4/23, 12/7/23, and 12/11/23. Review of Resident 1's physician's orders indicated she had an order, dated 10/24/23 for, Out o[n] pass on lunch time one time only until 10/24/23. There was no physician's order that indicated Resident 1 could go out on pass on any of the other dates mentioned above. During an interview and concurrent record review with licensed nurse A (LN A) on 12/14/23 at 11:15 a.m., LN A explained that in order for a resident to go out on pass, the physician has to give an order. LN A reviewed Resident 1's medical record and confirmed there was a one-time order to go out on pass on 10/24/23, but no order that indicated Resident 1 could go out on pass on any of the other dates mentioned above. 2. Review of Resident 1's medical record indicated she was admitted on [DATE] and had a RP. Review of Resident 1's Progress Notes, dated 8/8/23, indicated the facility developed a Baseline Care Plan Summary. On the bottom of the Baseline Care Plan Summary, there was a section titled signature, followed by a section titled, Relationship to Resident. Both of these sections were blank. Further review of Resident 1's electronic and paper medical record indicated there was no documentation that indicated a copy of the Baseline Care Plan Summary was given to Resident 1's RP. During an interview and concurrent record review with LN A on 12/13/23 at 2:10 p.m., LN A confirmed that when the facility develops a Baseline Care Plan Summary, a copy should be given to the resident or RP. LN A reviewed Resident 1's Baseline Care Plan Summary and acknowledged the sections designated to obtain a signature and to specify the person's relationship to the resident were left blank. LN A further reviewed Resident 1's medical record for any documentation indicating a copy of the Basline Care Plan Summary was given to the RP. During a follow-up interview with LN A on 12/14/23 at 11:15 a.m., LN A confirmed they could not find any documentation that indicated a copy of Resident 1's Baseline Care Plan Summary was given to the RP. The facility's policy titled Care Plans - Baseline, revised 12/2016, indicated the resident and their representative will be provided a summary of the baseline care plan.

Based on interview and record review, the facility failed to carry out and implement a physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure had the potential to negatively affect Resident 1 ' s health and well-being. Findings: Review of Resident 1 ' s medical record indicated she was admitted to the facility on [DATE] and had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1 ' s Laboratory Report, dated 7/23/21, indicated a sample of Resident 1's blood was collected on 7/23/21 at 6:00 a.m. The Laboratory report indicated Resident 1 had a glucose (blood sugar) level of 30 milligrams per deciliter (mg/dL, unit of measurement). The Laboratory Report indicated this glucose level was critically low (far below healthy levels; normal glucose level is between 65 and 99 mg/dL). Further review indicated the facility received this laboratory result on 7/23/21 at 8:06 p.m. (over 14 hours after the blood sample was collected). A hand-written note on the bottom right corner of the Laboratory Report indicated a nurse called Resident 1 ' s doctor and reported the laboratory result to him on 7/23/21 at 9:00 p.m. During an interview with the assistant director of nursing (ADON) on 8/3/22 at 1:46 p.m., the ADON confirmed she was the one who communicated Resident 1 ' s critically low glucose level to the doctor on 7/23/21. The ADON stated when she called the doctor, he gave several new orders. One of the orders was to check Resident 1 ' s finger stick blood glucose (FSBG, a way of checking a resident ' s blood sugar at bedside) before each meal and at bedtime. The ADON reviewed Resident 1 ' s medical record and confirmed there was no documentation that the facility checked Resident 1 ' s FSBG at bedtime on 7/23/21 (the day the facility received the critically low glucose result and the doctor gave the FSBG order). The ADON acknowledged Resident 1 ' s FSBG should have been checked at bedtime on 7/23/21. She confirmed there was no documentation that Reisdent 1's FSBG was checked until 7/24/21 at 6:30 a.m. (9 and a half hours after the doctor gave the FSBG order and over 24 hours after Resident 1's blood sample was collected). Resident 1 ' s 7/2021 Order Summary Report was reviewed. Resident 1 did have an order to check her FSBG before meals and at bedtime. However, the Order Details for this order indicated the ADON did not put the order into the computer system until 7/24/21 at 2:26 a.m. During a follow-up interview with the ADON on 8/15/22 at 10:40 a.m., the ADON confirmed she did not put Resident 1 ' s FSBG order into the computer system until 7/24/21 at 2:26 a.m. (nearly five and a half hours after she called the doctor and obtained the order). The ADON acknowledged she should have put Resident 1 ' s order into the computer system sooner. The ADON stated orders should be carried out and put into the computer system right away. The ADON explained that even though she put the order in late, Resident 1 ' s FSBG still should have been checked at bedtime on 7/23/21 because she verbally informed the resident ' s nurse about the order. Review of the facility ' s policy titled physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to inform the responsible party (RP, person designated to receive information and make decisions on behalf of a resident) when one of four sampled residents (Resident 1) had a fall. This failure had the potential to compromise the right to be fully informed of the resident's total health status. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE], and a family member was designated as her RP. Review of Resident 1's Change in Condition Evaluation, dated 6/7/21, indicated she was found sitting on the floor in front of her wheelchair. Resident 1 tried to get out of her wheelchair, lost balance and fell on the floor. The Change in Condition Evaluation indicated Resident 1's RP was notified on 6/7/21 at 8:00 p.m. Review of Resident 1's Progress Notes, dated 6/7/21 at 8:00 p.m. indicated, The family not answering their phone. Will call in am [morning]. Further review of the medical record indicated that after the family not answering their phone, there was no documentation that the facility made any further attempts to inform Resident 1's RP about the fall. During an interview with registered nurse A (RN A) on 3/14/22 at 1:43 p.m., she confirmed the facility was supposed to notify the RP after Resident 1 fell . RN A reviewed Resident 1's medical record and confirmed that after the family not answering their phone, there was no documentation that the facility made any further attempts to notify Resident 1's RP about the fall. Review of the facility's policy titled Change in a Resident's Condition or Status, revised 5/2017 indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.

Based on interview and record review, the facility failed to develop a care plan to address a breathing disorder and the use of a continuous positive airway pressure machine ([CONDITION(S)], machine that keeps the airways open during sleep) for one of four sampled residents (Resident 2). This failure had the potential to compromise the facility's ability to provide necessary care and interventions. Findings: Review of Resident 2's medical record indicated he was admitted on [DATE] and had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Order Summary Report indicated he had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident 2's medical record indicated there was no care plan to address obstructive sleep apnea and the resident's use of a [CONDITION(S)] machine. During an interview and concurrent record review with the assistant director of nursing (ADON) on 3/14/22 at 12:17 p.m., she reviewed Resident 2's medical record and confirmed the facility did not develop a care plan to address obstructive sleep apnea and the resident's use of a [CONDITION(S)] machine. The ADON acknowledged the facility should have developed a care plan. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated the comprehensive care plan will incorporate identified problem areas and describe the services that are to be furnished to attain or maintain the resident's well-being.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and failed to implement the fall care plan interventions to prevent accidents and injuries for two of three sampled residents (Resident 1 and Resident 2). For Resident 1, the facility failed to implement the high risk for fall care plan (a care provided to the resident) intervention to keep the bed in low position to prevent fall and injury. For Resident 2, the facility failed to implement the high risk for fall care plan interventions to keep the bed in low position and failed to supervise the resident during transfer, ambulation to prevent fall and injury. These failures resulted in Resident 1 sustaining a [MEDICAL CONDITION] femur (thighbone) and Resident 2 sustaining a vertebral fracture (backbone). Findings: 1. Review of Resident 1's clinical record indicated he had [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 10/12/18, indicated the resident had impaired cognition (memory problem), required staff assistance for bed mobility, transfer, toileting, personal hygiene, bathing, eating, and personal hygiene. Resident 1 had was not steady and able to stabilize with staff assistance. He had a history of [REDACTED]. Review of Resident 1's High Risk for Fall and Injury care plan dated 8/8/18, indicated the interventions was to keep the bed in low position to prevent fall and injury Review of Resident 1's Physical Therapy Treatment Encounter Note dated 10/9/18, indicated the resident was a fall risk and required assistance for transfer and bed mobility. Review of Resident 1's Morse Fall Risk Screen dated 9/28/18, indicated he had a score of 56 (a score of 45 and higher was high risk for fall). Review of Resident 1's Progress Notes dated 10/10/18, indicated Resident 1 had an unwitnessed fall on 10/10/18 at 10:10 a.m. when he tried to go to the bathroom and fell . Review of Resident 1's Radiology Interpretation dated 10/10/18, indicated he had an incomplete [MEDICAL CONDITION] femur. During an interview with the Occupational Therapist (OT) on 10/30/18 at 10:50 a.m., she stated Resident 1 was found on the floor when he tried to go to the bathroom. The OT stated Resident 1's bed was not in a low position when she found him on the floor. During an interview with the director of nursing (DON) on 11/1/18 at 12:35 p.m., she stated Resident 1's high risk for fall and injury care plan should have been implemented for keeping the bed in a low position. Resident 1 was transferred to the acute hospital for surgery. 2. Review of Resident 2's clinical record indicated she had [DIAGNOSES REDACTED]. Review of Resident 2's Interdisciplinary Team (IDT, group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) notes dated 3/8/17, indicated the resident had an unwitnessed fall on 3/5/17 in her room while walking to the bathroom. The intervention was to keep the bed in a low position. Review of Resident 2's High Risk for Fall and Injury Care Plan dated 11/1/17, indicated Resident 2 was at a high risk for fall related to poor judgement, poor safety awareness, and limitation of mobility. The intervention to prevent a fall and injury was to keep the bed in a low position. Review of Resident 2's Rehabilitation Screen Form dated 6/5/18, indicated the resident ambulated with a front wheel walker (a device for easier mobility) with supervision to minimal assist with activities of daily living (ADL's, such as bed mobility, transfer, toileting, ambulation, and personal hygiene). Review of Resident 2's Morse Fall Risk Screen dated 8/10/18, indicated she had a score of 46 (a score of 45 and higher was high risk for fall). Review of Resident 2's MDS dated [DATE], indicated the resident was cognitively intact and required assistance for bed mobility, transfer, ambulation, toileting, and personal hygiene. Her balance during transition and walking was not steady and required staff for assistance. Review of Resident 2's Progress Note dated 10/16/18, Resident 2 had an unwitnessed fall on 10/16/18 and found lying on the floor next to her bed. Resident had a bump on the right side of her head and complained of lower back pain. Resident was transferred to an acute hospital for evaluation. Review of Resident 2's Acute Hospital Discharge Summary dated 10/18/18, indicated Resident 2 had a fall after she stood up from her bed and fell which resulted in a vertebral fracture with minimal loss of height. During an observation on 10/29/18 at 8:10 a.m. and 10/30/18 at 8 a.m., Resident 2 was observed lying in her bed and the bed was not in a low position. During an interview with Resident 2 on 10/29/18 at 8:15, she stated she fell on [DATE] and the bed was not in a low position with no staff was present. During an interview with RN B (RN B) on 10/29/18 at 12:29 p.m., she stated she was the assigned charge nurse for Resident 2's fall on 10/16/18. She stated Resident 2 walked in room without assistance and her bed was not in a low position. RN B stated she was not aware Resident 2's bed had to be in a low position. During an observation and concurrent interview with RN C (RN C) on 10/30/18 at 12:30 p.m., Resident 2 was lying in her bed which was not in a low position. RN C confirmed the observation. She stated Resident 2 required supervision and staff assistance during ADL's such as bed mobility, transfer, ambulation, toileting, and personal hygiene to prevent fall. Review of the facility's 3/2010 policy, Falls Management Program, indicated to provide resident with hazard free environment, adequate supervision, and reduce risk factors leading to falls and injury. The facility will also investigate the circumstances surrounding each resident fall, implement actions to reduce the incidence of falls, and minimize potential for injury.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent one of 3 sampled residents (Resident 1) from falling. The failure resulted in Resident 1 sustaining a brain hemorrhage (bleeding). Findings: Resident 1's clinical record was reviewed. Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Sets (MDS, an assessment tool) dated 5/20/16, indicated the resident was cognitively intact and required extensive assistance (the resident is involved in activity, but staff provide weight-bearing support) with one person physical assistance for her toileting. It indicated the resident was unsteady and only able to stabilize with staff assistance when she moved from a seated to a standing position, walked, turned around, and moved on and off the toilet. Review of Resident 1's Morse Fall Risk Screen (an assessment tool) dated 5/26/16, indicated the resident's score was 90. (A score of 45 and higher is high risk of falling.) Review of Resident 1's Medication Administration Record (MAR) dated 6/2016, indicated the resident took daily aspirin (a blood thinner to prevent blood clots) and clopidogrel bisulfate (a blood thinner). One of the side effects of a blood thinner includes easy bruising and bleeding. Review of Resident 1's Nurses Notes (NN) dated 2/24/16, indicated the resident attempted to transfer from a wheelchair to her bed and fell . Review of Resident 1's NN dated 4/9/16, indicated the resident stood up with a cane, lost her balance, fell backward, hit her head, and sustained a scalp laceration (a cut), and a hematoma (a solid swelling of clotted blood within tissues). Review of Resident 1's NN dated 6/18/16, indicated the resident tried to move by herself from a bedside commode to her bed after using the bedside commode and fell on the floor. It indicated the resident complained of headache with a pain scale of 9 (a numeric pain scale identifies the severity of pain from one to ten, with ten being the most severe pain) and was transferred to an acute care hospital for evaluation. Review of Resident 1's Critical Care Progress Notes from the acute care hospital, dated 6/19/16, indicated the result of a computerized tomography scan (CT scan, a diagnostic medical test) indicated Resident 1's head had a small volume of intracranial (inside the skull) blood on the left side in back of the ear, along with a bump and scrape. Review of Resident 1's NN on 6/19/16 at 11:30 a.m., documented the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. During observations on 6/27/16 at 8:10 a.m., and 11:15 a.m., and on 6/28/16 at 7:50 a.m., and 1:05 p.m., the call button (a button to call staff for help) was next to the top side rail farthest from the door, which was on the opposite side of the bed from where Resident 1 had been sitting on the bedside commode. During an interview on 6/27/16 at 8:10 a.m., Resident 1 said on 6/18/16, she was seated on a bedside commode for approximately 30 minutes and wanted to get up. Resident 1 stated the call button was on the opposite side of the bed and she could not reach it, so she had no way to call for help. Resident 1 stated she got up, lost her balance, fell backward hitting her head on the wall, and after she hit the wall, she fell to the floor, landed on her left hand and bruised it. Resident 1 stated after she fell she had a headache and neck pain for two to three days. During an interview on 6/27/16 at 1:55 p.m., certified nursing assistant D (CNA D) said she helped Resident 1 to situate on the bedside commode and CNA D stepped out of the room. CNA D stated no one needed to stay in the room when the resident was on the bedside commode and the resident might not be able to use a call light since her left hand was paralyzed (partly or wholly incapable of movement). CNA D stated Resident 1's legs were weak and she could not walk well. CNA D said on 6/18/16, while Resident 1 was on a bedside commode, CNA D cleaned a resident in another room which was across the hall. CNA D stated she heard someone calling when she was about half-way through cleaning the other resident. CNA D stated she left Resident 1 on the bedside commode for approximately 10 minutes. During another interview on 7/7/16 at 3:40 p.m., Resident 1 said she had not asked the CNA to leave the room for privacy. She stated the CNAs situated her on the bedside commode, pulled the curtain, left the room, and closed the door. During an interview on 7/7/16 at 3:50 p.m., CNA E stated when she transferred a resident to a bedside commode, she gave the resident the call button, closed the curtain, and stayed outside the room with the door open. CNA E stated when the resident had an history of falls and the resident asked her to close the bathroom door, she would explain she could not close the door for the resident's safety. During an interview on 7/7/16 at 4 p.m., CNA F stated when she assisted a resident using a bedside commode, she would give the resident the call button, close the curtain, and stay outside the room with the door open. During an interview on 7/7/16 at 4:20 p.m., CNA H stated after transferring the resident to a bedside commode, she gave the resident the call button, closed the curtain, and stayed on the other side of the curtain. CNA H said when the resident wanted to have privacy, she stepped out of the room, but left the door open so she could watch in case the resident tried to stand up. During an interview on 7/7/16 at 4:35 p.m., the director of nursing (DON) explained, when helping a resident on a commode, the CNA should give the resident the call button, close the curtain, and if the resident is alert, the CNA can leave the room, but leave the door open, and stay near door. During a telephone interview on 7/21/16 at 11:20 a.m., the neurosurgeon (NS)'s assistant (NSA) stated the NS said Resident 1's intracranial hemorrhage was due to the 6/18/16 fall incident. Review of the manufacturer's instruction Commodes indicated users with limited physical capabilities should be supervised or assisted when using the commode. Review of the facility's policy Falls Management Program dated 3/2010, indicated the facility will provide residents with adequate supervision and assistive devices to prevent accidents.