Every finding on record at Sunrise Post Acute

Based on interview and record review the facility failed to ensure an allegation of physical abuse was reported to the State agency immediately, but not later than two hours after the allegation was made, for one of two residents reviewed for abuse (Resident 1).This failure had the potential to delay investigation of the allegation and implementation of measures necessary to ensure resident safety and prevent further abuse. Findings:On May 21, 2026, at 1:05 p.m., the California Department of Public Health received an online complaint reporting an allegation of abuse involving residents at the facility.On June 1, 2026, at 11:57 a.m., an unannounced visit was conducted to investigate an allegation abuse. A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (having worried thoughts).A review of Resident 1's Minimum Data Set (an assessment tool) dated August 14, 2025, indicated a Brief Interview for Mental Status (a cognitive assessment) score of 15 indicating the resident was cognitively intact.A review of Resident 1's Change of Condition dated November 18, 2025, indicated, .accusing the chairbound residents that they kicked her.Further review of Resident 1's record indicated there was no documented evidence the allegation of physical abuse was reported to the State Agency or that an abuse investigation was initiated. On June 2, 2026, at 10:35 a.m., a concurrent interview and record review was conducted with the Licensed Vocational Nurse (LVN). The LVN stated on November 18, 2025, Resident 1 reported to her that she was kicked by other residents in the facility. The LVN stated she reported the incident to the Director of Nursing (DON) and was unsure whether the allegation had been reported to CDPH. The LVN stated the facility process was for the allegation of abuse to be reported immediately to the DON and Administrator. The LVN stated the DON would complete the abuse report form and notify CDPH. On June 2, 2026, at 11:20 a.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). The RN stated Resident 1's report of being hit was an allegation of physical abuse and any allegation of abuse should be reported to the state agency by the licensed nurse, if the DON was not available within two hours. The RN stated the Director of Nursing (DON) and the Administrator should be informed of allegations of abuse so that protective measures could be implemented and an investigation could be initiated.On June 3, 2026, at 8:49 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated any allegation of abuse, including verbal and physical, should be reported to the state agency within two hours by the licensed nurse. The DON stated the allegation of physical abuse on November 18, 2025, was not reported to the state agency, and it should have been reported within two hours in accordance with the facility policy. A review of the facility policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .All alleged violations involving abuse.will be reported.to.The State licensing/certification agency.will be reported immediately, but not later than.Two (2) hours if the alleged violation involves abuse.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavioral symptoms for one of two residents reviewed (Resident 1).This failure had the potential to result in staff lacking appropriate guidance and interventions to consistently address the resident's behavioral symptoms and monitor the effectiveness of interventions. Findings:A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included anxiety disorder (having worried thoughts).A review of Resident 1's Minimum Data Set (an assessment tool) dated August 14, 2025, indicated a Brief Interview for Mental Status (a cognitive assessment) score of 15 (cognitively intact).A review of Resident 1's Change of Condition dated November 18, 2025, indicated, .False accusations. Resident noted screaming in the hallways, accusing the chairbound residents that they kicked her, verbally aggressive towards the staffs and the residents.Further review of Resident 1's record indicated no documented evidence that a care plan was developed or implemented to address Resident 1's behavioral symptoms, including false accusations, yelling, and verbal aggression.On June 1, 2026, at 4 p.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). The RN stated the licensed nurse was responsible for completing the change of condition and initiating the care plan related to the change. The RN stated there was no care plan initiated to address Resident 1's behavioral symptoms on November 18, 2025. The RN stated a care plan should have been initiated to provide staff with appropriate interventions and to evaluate the effectiveness of those interventions. On June 3, 2026, at 8:49 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the licensed nurse who identified the change of condition should have initiated a care plan to address Resident 1's behavioral symptoms. The DON stated that a care plan addressing those behaviors had not been initiated and should have been. The DON stated it was important to initiate a care plan to inform staff of the treatment plan and interventions. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, .comprehensive, person-centered care plan is developed within seven (7) days of.Significant Change in Status.interdisciplinary team reviews and updates the care plan.when there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated annually and as needed.This failure resulted in an inaccurate evaluation of the facility's population and resources needed to provide the necessary care and services for the residents.Findings:On September 11, 2025, at 4:03 p.m., a concurrent interview and record review was conducted with the Administrator (ADM). The ADM stated he was responsible for conducting the facility assessment. The ADM stated the last facility assessment was on July 24, 2024. The ADM stated the facility assessment should have been done annually. During a review of the facility assessment dated [DATE], the ADM stated the facility assessment should reflect the accurate census of the facility and the cultural needs and services being rendered to that served population. The ADM stated that the facility assessment dated [DATE], failed to accurately detail the cultural assessment, staff types, services rendered, and building plant needs and should have accurately reflected these areas.A review of the facility policy and procedure titled Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities .Rules and Regulations, dated August 18, 2017, indicated .The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for it's residents competently during both day-to-day operations and emergencies.The facility must review and update that assessment, as necessary, and at least annually.

Based on interview and record review, the facility Quality Assurance and Performance Improvement Program (QAPI) failed to identify and address their deficient practice involving physician visits (cross reference F0712).This failure has the potential to put residents at risk for unidentified medical conditions which could result in inadequate quality of care and services.Findings:On September 11, 2025, at 4:33 p.m., an interview was conducted with the Administrator (ADM) and Medical Records (MR). The MR stated the QAPI Committee meets on a quarterly basis and as needed. The MR stated the last QAPI meeting was held on July 23, 2025, where they discussed falls, weight variance, elopement, and theft and loss. The ADM stated the QAPI team was unaware of the deficient practice regarding the nurse practitioner (NP) completing the initial visits. The ADM stated the facility did not have a system in place to ensure initial resident visits were conducted by the primary physician. A review of the facility policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program - Analysis and Action, dated March 2020, indicated .QAPI committee is designed to identify and address quality deficiencies.The QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and reporting findings to the Administrator and governing board.

Based on interview and record review, the facility failed to ensure the fluid intake and output in 24 hours was accurately monitored, recorded, and evaluated as ordered by the physician for one of one resident reviewed (Resident 19). This failure had the potential for the resident to experience complications associated with fluid deficit and/or fluid overload.Findings:On September 9, 2025, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease (ESRD - severe and irreversible loss of kidney function that requires ongoing treatment to maintain life), congestive heart failure (CHF - chronic condition where the heart cannot pump blood effectively enough to meet the body's needs leading fluid buildup in the lungs, legs, and other parts of the body),dementia (progressive impairment of intellectual functioning, memory, and abstract thinking), and dependence on renal dialysis (medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so).The following medical records were reviewed, -The History and Physical, dated August 5, 2025, indicated Resident 19 did not have the capacity to understand and make decisions;-The Physician's Order, dated August 26, 2025, indicated Resident 19 was to receive dialysis treatment three times a week every Tuesday, Thursday, and Saturday;- The ,Physician's Order, dated August 22, 2025, indicated, .Intake and Output Monitoring .every evening shift Calculate and record total Intake and Output FOR THE DAY .Order Date 08/22/2025 .Intake and Output Monitoring .every shift Monitor and record OUTPUT, include urine, emesis (vomiting), and other drainage .Order Date 08/22/2025 .Intake and Output Monitoring .every shift Monitor and record PO (oral) .;- The electronic Medication Administration Record (eMAR) dated August 1 to 31, 2025, indicated the Licensed Nurses (LN) did not consistently monitor, calculate, and record, Resident 19's total fluid intake and output every evening shift from August 22 to 31, 2025. The recorded average fluid intake per shift was from (lowest) 240 cc (cubic centimeter - unit of measurement) to (highest) 600 cc. The total fluid output recorded per shift varied from a combination of fluid measurement (cc) and/or number of episodes Resident 19 urinated during the shift (e.g. x 1);- The eMAR dated September 1 to 30, 2025, indicated the LN did not consistently monitor, calculate, and record, Resident 19's total fluid intake and output every evening shift from September 1 to 9, 2025. The recorded average fluid intake per shift was from (lowest) 120 cc to (highest) 480 cc. The total fluid output recorded per shift varied from a combination of fluid measurement (cc) and number of episodes Resident 19 urinated during the shift;- The NUTRITIONAL RISK ASSESSMENT, completed by the Registered Dietitian (RD) and dated August 25, 2025, indicated, .Estimated Nutritional Needs .Fluids: 1750-2100 mL(milliliter- unit of measurement)/day .; and- The following Care Plan Report, indicateda.Focus .Resident is at risk for malnutrition due to anemia, dementia, depression, malnutrition, mechanically altered diet, recent acute illness, protein calorie malnutrition .Goal .Will maintain adequate nutritional status .Intervention .Assist with meals/fluids as needed .Encourage adequate nutrition and hydration . Dated August 22, 2025;b.Focus .Resident requires .Hemodialysis .Interventions .Calculate the total intake and output at the end of each 24-hour period to determine fluid balance . Dated August 22, 2025, andc.At risk for dehydration or electrolyte imbalance related to acute illness, cognitive deficit, Dementia .ESRD .Poor fluid intake .Encourage increased PO fluids if not contraindicated .On September 10, 2025, at 9:44 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she was the CNA assigned to Resident 19. CNA 2 stated Resident 19 was a dialysis resident. CNA 2 stated she was told Resident 19 was not on a fluid restriction and he was not monitored for fluid intake and output.On September 10, 2025, at 9:42 a.m., an interview with concurrent record review was conducted with Registered Nurse (RN) 1. Resident 19's physician orders for fluid intake and output monitoring, eMAR for August and September 2025, and Nutritional Risk Assessment (August 25, 2025) were reviewed with RN 1. In a concurrent interview, RN 1 stated:-The LNs were monitoring the fluid intake in the August and September 2025 eMAR but they are not recording the total fluid intake in 24 hours as ordered by the physician. RN 1 stated the total fluid output in 24 hours were also not accurately recorded in the eMAR because some LN are documenting the fluid output through fluid cc and some LN are recording the number of episodes Resident 19 urinated during the shift.-She did not know why the physician ordered a fluid intake and output monitoring on Resident 19 since he was not on fluid restriction even if he was a dialysis resident. RN 1 verified the Registered Dietician (RD)'s Nutritional risk Assessment, dated August 25, 2025, indicated Resident 19's estimated fluid nutritional needs was at 1750-2100 mL/day. RN 1 further stated, basing it on the total fluid amount recorded per day since August 22, 2025, Resident 19's total fluid intake intake was from approximately 800 cc to 920 cc per day. -Resident 19 did not meet the fluid nutritional needs of 1750-2100 mL/day as indicated on the Nutritional Assessment by the RD on August 25, 2025.-The LNs were documenting the fluid intake every shift but were not recording the total fluid intake in the evening shift as ordered by the physician. She was not sure how the LNs were recording Resident 19's fluid intake per shift;-There was no evaluation done on Resident 19's fluid intake and output since it ordered by the physician on August 22, 2025, and Resident 19 did not have a care plan developed specific to address Resident 19's fluid intake and output monitoring.-There was no documentation Resident 19's fluid intake in a day, was less than the required nutritional needs, was referred to the physician. RN 1 stated if the fluid intake in a day was too high, Resident 19 might develop fluid overload, and/or if he was not taking much fluid he might get dehydrated (having lost a large amount of water from the body).On September 11, 2025, at 11:05 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated, if Resident 19's fluid intake in a day was below the required nutritional fluid intake in a day, Resident 19 might get dehydrated. The DON stated the low fluid intake per day should have been reported to the physician and Resident 19 should have been monitored for signs and symptoms of dehydration and/or other complications such as fluid overload. The DON stated this was not done.The facility's policy and procedure titled, .Intake, Measuring and Recording, dated October 2010, was reviewed. The policy indicated, .The purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period .Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy .General Guidelines .Record the fluid intake as soon as possible after the resident has consumed all the fluids .At the end of your shift, total the amounts of all liquids the resident consumed .Record all fluid intake on the intake and output record in cubic centimeters .Documentation .The following should be recorded in the resident's medical record, p[er facility guidelines .The date and time the resident's fluid intake was measured and recorded .The amount (in MLs) of liquid consumed .The type of liquid consumed .If the resident refused treatment, the reason (s) why and the intervention taken .Reporting .Notify the supervisor if the resident refuses the procedure .Report other information in accordance with the facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure a physician conducted the initial visit for five of ten sampled residents (Residents 28, 35, 26, 22, 47).These failures had the potential to result in unidentified medical conditions and/or insufficient provision of medical treatment.Findings:On September 10, 2025, Resident 28's record was reviewed. Resident 28 was admitted to the facility on [DATE].The document titled, History and Physical, dated June 25, 2025, indicated Resident 28 had the capacity to make decisions. The document further indicated, .More than 30 minutes was spent in the evaluation and treatment of this patient during this encounter including: history and physical examination, review of nursing notes, medication reconciliation, review of pertinent diagnostic testing, documentation in the clinical record, patient counseling and communication with the nursing staff and responsible parties .I have discussed my evaluation and findings with my supervising physician, (Physician 1) who agrees with the evaluation, assessment, and plan .electronically signed (NP 1) .On September 10, 2025, at 3:11 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated NP 1 conducted the initial History and Physical (H&P) comprehensive assessment on Resident 28 and not the primary physician. The DON stated Physician 1 should have conducted the initial H&P comprehensive assessment on Resident 28.On September 10, 2025, at 3:30 p.m., a record review with a concurrent interview was conducted with Medical Records (MR). The MR stated NP 1 was the NP under the supervision of Physician 1. The MR stated NP 1 usually did the initial H&P on Physician 1's new admit residents.On September 11, 2025, at 11:25 p.m., a record review with concurrent interview was conducted with the DON. The following residents' initial H&P assessment was conducted by NP 1:-Resident 35 was admitted to the facility on [DATE]. A change in physician, per resident request, from Physician 2 to Physician 1 was done on August 11, 2025. NP 1 did the initial H&P assessment on August 11, 2025;-Resident 26 initial H&P assessment on August 6, 2025;-Resident 22 initial H&P assessment on July 18, 2025; and-Resident 47 initial H&P assessment on July 26, 2025.In a concurrent interview, the DON stated NP 1 conducted the initial H&P assessments on Residents 35, 26, 22, and 47. The DON stated Physician 1 countersigned NP 1's initial H&P report but it was NP 1 who came and did the assessments. The DON stated the primary physician (Physician 1) should have conducted the initial H&P assessments on these residents.The facility policy and procedure titled, .Attending Physician Responsibilities, dated August 2014 was reviewed. The policy indicated, .The Attending Physicians shall be the primary practitioner's responsible for providing medical services and coordinating the healthcare of each resident in the facility .Each Attending Physician will be responsible for the initial and subsequent resident care .The Attending Physician will assess new admission in timely fashion, according, to the individual medical stability .

Based on observation, interview, and record review the facility failed to ensure residents' right to self-administer medications for one of two residents (Resident 26) reviewed, when one opened box of Systane (eyedrops to prevent dryness of the eyes), a box of Lmnoop eczema relief cream (eczema-skin condition causing itching and dryness), and a bottle of Migrastil pain roll-on (pain relief cream) were observed on top of the resident's bedside table.This failure had the potential for Resident 26 to self-administer medications without a physician's order.Findings:On September 8, 2025, at 9:34 a.m., Resident 26 was observed lying in bed, watching television. One box of Lmnoop eczema cream, one box of Systane eyedrops, and one bottle of migrastil pain block roll-on were observed inside of a small box on top of Resident 26's bedside table. The box of Systane eyedrops, the box of Lmnoop eczema cream, and the bottle of migrastil pain roll-on were not labeled with Resident 26 identifiers. In a concurrent interview with Resident 26, she stated she self-administers the eye drops to herself five times daily. She further stated she administers the Lmnoop eczema cream and migrastil pain roll-on as needed. Resident 26 stated she has had all three medications at the bedside since shortly after her admission. Resident 26 further stated the facility has never evaluated her for self-administration of medication.On September 8, at 10:01 a.m., during a concurrent observation and interview, Licensed Vocational Nurse (LVN) 2 verified there was one box of Lmnoop eczema cream containing one unlabeled tube of cream, one unlabeled box of Systane eyedrops containing one open unlabeled bottle of eye drops, two unopened unlabeled bottles of eyedrops, and one unlabeled bottle of Migrastil pain roll-on. LVN 2 was observed removing the three named medications from Resident 26's bedside table.On September 8, 2025, Resident 26's medical record was reviewed.The admission record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (widespread body pain), osteoarthritis (stiffness and swelling of joints), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).The history and physical completed on August 6, 2025, indicated Resident 26 had the capacity to make informed decisions.Resident 26's medical record did not indicate a physician's order for the medications Lmnoop eczema cream, Systane eye drops, or Migrastil pain roll-on.Resident 26's medical record did not indicate an assessment for self-administration of medications was conducted.On September 9, 2025, at 3:40 p.m., a concurrent interview and record review was conducted with LVN 2. LVN 2 stated Resident 26 should not have medications at the bedside without an assessment for self-administration. LVN 2 stated the facility process for self-administration is for the physician to be notified for resident's desire to self-administer medication, assess the resident, obtain a physician's order to educate resident on self -administration, label residents bedside medication, and inform resident to notify nursing of administration of the bedside medication. LVN 2 stated Resident 26 did not have a physician's order dated on or before September 8, 2025, for the medications Lmnoop eczema cream, Systane eye drops, and Migrastil pain roll-on. LVN 2 stated there was no documented evidence that the Interdisciplinary Team (IDT - group of individual facility members who plan care for the resident) assessed Resident 26 for self- administration of medication. LVN 2 stated Resident 26 did not have a care plan for self-administration of medication. LVN 2 stated Resident 26 should have had a physician orders for the Lmnoop eczema cream, Systane eyedrops, and Migrastil pain roll-on. LVN 2 further stated residents have the right to self-administer and Resident 26 should have been evaluated for self-administration.On September 9, 2025, at 3:47 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated she was not aware of the facility policy and procedure for self-administration of medication. The DON stated the facility does not allow residents to self-administer medication. The DON further stated residents should not have medications at their bedside without a physician's order. The DON stated the nursing staff should be checking residents' rooms for bedside medications.A review of the facility policy and procedure titled Self-Administration of Medications, dated 2001, indicated .As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.self-administering residents.the nursing staff determines who is responsible.for documenting that medications are taken. any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.A review of the facility policy and procedure titled Administering Medications, dated 2001, indicated .Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have decision-making capacity to do so safely.

Based on interview and record review, the facility failed to ensure one of five residents (Resident 6) was free from unnecessary medications when adequate indications (clinical rationale) for antipsychotic (drug to reduce disordered thinking) use were not documented. This failure had the potential for the resident to experience adverse outcomes from the unnecessary use of the antipsychotic medication such as Neuroleptic Malignant Syndrome (life-threatening reaction), tardive dyskinesia (chronic, involuntary movements), and increased risk of falls that could impair their ability to function at their highest level of physical, mental, and psychosocial well-being.Findings:During a review of Resident 6's Preadmission Screening and Resident Review (PASRR) Level 1 Screening (screening to identify residents if they have a suspected mental illness), dated June 12, 2025, completed by the general acute care hospital prior to the resident's nursing home admission, the PASRR indicated, No, for the Section III - Serious Mental Illness.9. Diagnosed Serious Mental Illness. Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia [mental illness that affects how a person thinks, feels, or behaves] / Schizoaffective [person also experiences mood symptoms] Disorder, or symptoms of Psychosis [severe mental condition where people lose contact with reality], Delusions, and/or Mood Disturbance? Continued review of the PASRR indicated, No, for Section III - Serious Mental Illness.10. Suspected Mental Illness. After observing the individual or reviewing their records, do you believe the individual may be experiencing serious depression or anxiety, unusual or abnormal thoughts, extreme difficulty coping, or significantly unusual behaviors or does the individual actively engage in community mental health services. Further continued review of the PASRR indicated No, for Section III - Serious Mental Illness.11. Psychotropic Medication. Has the individual been prescribed psychotropic medications for Serious Mental Illness. The result of the PASRR Level I Screening was negative for mental illness. During a review of Resident 6's HISTORY AND PHYSICAL [H&P - comprehensive patient assessment] dated June 20, 2025, was reviewed. The H&P indicated Resident 6 was admitted on [DATE], with a history of prostate (part of the male reproductive system) cancer, hypertension (high blood pressure), and atrial fibrillation (medical condition with irregular heart rhythm). During a review of Resident 6's medical record, the physician orders indicated a medication order dated June 18, 2025, for Seroquel (brand name for the antipsychotic medication quetiapine) 100 milligrams (mg - a unit of measurement for dose) by mouth two times a day for Psychosis m/b [manifested by] Striking out with a start date of June 19, 2025, and an end date of July 8, 2025. A continued review of Resident 6's Medication Administration Record (MAR) indicated Seroquel 100 mg was given to the resident two times a day from June 19, 2025, to July 8, 2025. During a review of Resident 6's Minimum Data Set (MDS - clinical assessment of nursing home residents) dated June 25, 2025, the MDS for Section E was reviewed. The box was checked None of the above for E0100. Potential Indicators [signs] of Psychosis. For E0200. Behavioral Symptoms - Presence & Frequency the coding was zero (behavior was not exhibited) for A. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), B. Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) and C. Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds. During a review of Resident 6's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated June 29, 2025, completed by the MDS Nurse (MDS RN), the PASRR indicated, No, for the Section III - Serious Mental Illness.9. Diagnosed Serious Mental Illness. Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia [mental illness that affects how a person thinks, feels, or behaves] / Schizoaffective [person also experiences mood symptoms] Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? Continued review of the PASRR indicated, No, for Section III - Serious Mental Illness.10. Suspected Mental Illness. After observing the individual or reviewing their records, do you believe the individual may be experiencing serious depression or anxiety, unusual or abnormal thoughts, extreme difficulty coping, or significantly unusual behaviors or does the individual actively engage in community mental health services. The result of the PASRR Level I Screening was negative for mental illness. During a review of Resident 6's IDT [Interdisciplinary Team - a group of healthcare professionals] PSYCHOTHERAPEUTIC [medication to control behavior or treat thought disorder processes] REVIEW, dated July 8, 2025, the facility document indicated 2.NPI's [non-pharmacological interventions] usually effective. A continued review indicated, 6. IDT/Pharmacist Recommendations, the facility document indicated the Behavior Management Team met with the Psychiatrist [physician with specialized experience in mental health] who reviewed Resident 6's current medication regimen and behaviors. During a review of Resident 6's Nurse Practitioner Note, dated July 8, 2025, the facility document indicated no psychiatric [person's past and current mental health experiences] history. During a review of Resident 6's PSYCHOTROPIC [any drug that affect brain activities associated with mental processes and behavior] SUMMARY SHEET, dated July 10, 2025, the number of behavior episodes/shifts were zero behaviors for the time period from June 1, 2025, to June 30, 2025. During an interview on September 11, 2025, at 10:33 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated they have known Resident 6 for a few months. CNA 1 stated, He is alert and can express whatever he needs. He needs a little assistance. Sometimes he puts on clothes himself. [His] personality is pretty good. He is a gentleman. He talks to us very nicely. I have never seen him in a bad mood. When I work with him, he is very nice to me. He cooperates with everything. During an interview on September 11, 2025, at 2:05 p.m., with the MDS Nurse (MDS RN), the MDS RN stated Resident 6's diagnosis was psychosis manifested by striking out. The MDS RN stated, We can't diagnose. It's just a symptom. We have to wait for the Psychiatrist to evaluate. The MDS RN stated the Psychiatrist evaluated Resident 6 on July 8, 2025 (the resident was admitted on [DATE]). During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, the P&P indicated, Policy Statement.6. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes.Management.10. When medications are prescribed for behavioral symptoms, documentation will include: a. Rationale for use.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were followed and implemented when two employees from a consulting doctor's office did not follow an Enhanced Barrier Precautions (EBP - infection control intervention designed to reduce transmission of resistant organisms that required use of gown and glove during high contact resident care activities) for one of five residents reviewed (Resident 59).This failure had the potential to increase the spread of pathogens (germs) and infections by staff to the residents. Findings:On September 9, 2025, at 10:49 a.m. an observation was conducted on Resident 59's room. Observed outside Resident 59's room was a sign indicating Resident 59 and his room mate were both on EBP. PPE (Protective Personal Equipment - items of protective clothing or equipment designed to guard against health and safety hazards, e.g. mask, gown, gloves) supplies, including gown, mask, and gloves were observed stored by the door. The EBP sign by the door indicated, .Enhanced Barrier Precautions .Room Bed A and Bed B .Caring for devices and giving medical treatments .Inside the room, Resident 59 was observed in bed, alert, with his upper body half exposed. Cardiac Sonographer (CS) 2 was observed seated on a chair about less than two to three feet away from Resident 59's bed. CS 1 was observed standing next to her. Both employees were observed wearing gloves but did not have a gown on. A medical equipment was observed next to Resident 59. CS 2 stated they were doing an ultrasound (non-invasive medical procedure using a machine that detects images of internal organs or tissues) on Resident 59.On September 9, 2025, at 11:05 a.m., an observation with a concurrent interview was conducted with CS 1 and 2. CS 2 was observed coming out from Resident 59's room, while CS 1 fixed and/or moved Resident 59's bed before coming out of the room. In a concurrent interview, CS 1 stated they were employees from the cardiologist's (a doctor who specializes in heart medical conditions) office and they did an ECG (electrocardiogram- non-invasive test that measures the heart's electrical activity through electrodes {sensors used in ECG} applied on the chest) on Resident 59. CS 1 stated they started conducting the ECG at 9:50 a.m.CS 2 was asked about the EBP sign by Resident 59's door. CS 2 stated they thought the EBP was for Resident 59's roommate. CS 2 stated none of the facility staff informed them on the EBP required for Resident 59. CS 2 stated both her and CS 1 only used gloves during the ECG test. CS 2 stated both she and CS 1 should have worn mask, gown, and gloves when they did the ECG test on Resident 59.On September 9, 2025, at 2:41 p.m., an interview was conducted with Infection Prevention Nurse (IPN). The IPN stated Resident 59 was on EBP because he had a foley catheter (thin, flexible tube inserted into the bladder to drain urine). The IPN stated Resident 59 was on EBP to help prevent him from getting infection from other people because he was prone to infection. The IPN stated the EBP was also a protection from infection for the staff as well. The IPN stated the staff should wear gown, glove, and mask, when providing patient care. The IPN stated CS 1 and 2 should have followed and implemented the proper EBP when they entered Resident 59's room to do the ECG test. The IPN stated CS 1 and 2 came from outside and they are coming here, they can give infection, to Resident 59.On September 9, 2025, Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE], with diagnoses including neuromuscular dysfunction of the bladder (condition where the nerves and muscles that control bladder are impaired).The Physician's Order, dated July 21, 2025, indicated, .Enhanced Barrier Precaution during high contact resident care activities secondary to due to indwelling foley catheter .The Care Plan, dated, May 16, 2025, indicated, .Enhanced Barrier Precautions: Resident requires enhanced barrier precautions during high-contact resident care activities due to the presence of: indwelling device .urinary catheter .Goal .Enhanced barrier precautions will be appropriately utilized to reduce the risk of transmission of multidrug-resistant organisms .Interventions/Tasks .Utilize PPE (gown and gloves .during high contact resident care activities) .The facility's policy and procedure, titled, Enhanced Barrier Precautions, dated March 2024 was reviewed. The policy indicated .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to the residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .gloves and gown are applied prior to performing the high contact resident care activity .Residents, families, and visitors ARE Notified of the implementation of EBPs throughout the facility .

Based on observation, interview, and record review the facility failed to ensure nutrition services were provided for two of three residents (Resident 22 and Resident 26) reviewed, when:1.Resident 22, dietary preferences were not met; and2.Resident 26 annual (yearly) nutritional assessment had not been conducted.These failures had the potential for Resident 22 and Resident 26 to have inadequate dietary intake because reasonable efforts were not made to accommodate Resident 22's food preferences and Resident 26's annual nutritional assessment were not performed.Findings:1.On September 8, 2025, at 9:34 a.m., Resident 26 was observed sitting up in bed alert and oriented. During a concurrent interview with Resident 26, she stated the facility food is a mushy mess and did not receive what is on the menu. Resident 26 further stated if she did not like what is on the menu she ordered her own food. One box of Cheerios cereal and a case of cup of noodles soup was observed stored on Resident 26's closet.On September 8, 2025, at 12:23 p.m., Resident 26 was observed sitting up in bed eating lunch. During a concurrent interview with Resident 26, she stated the roast beef was full of fat, the brussels sprouts were over cooked, and that she could not eat the food and requested an alternate meal. Resident 26 meal ticket indicated Regular Consistent Controlled Carbohydrate Diet (diet to stabilize blood sugar), thin liquids, add extra oz (ounce) of meat or entree. Resident 26 lunch tray consisted of cooked sprouts, mashed potatoes, roast beef with gravy, side salad, chocolate ice cream, fruit juice and water.On September 8, 2025, Resident 26's medical record was reviewed.The admission record indicated Resident 26 was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (widespread body pain), osteoarthritis (stiffness and swelling of joints), hypertension (high blood pressure), and diabetes mellitus (high blood sugar).The history and physical completed on August 6, 2025, indicated Resident 26 had the capacity to make informed decisions.The annual nutritional assessment dated [DATE], indicated Resident 26's diet preferences and nutritional needs. There was no documented evidence that an annual nutritional assessment was conducted for Resident 26 to update her nutritional needs and preferences.2.On September 8, 2025, at 12:32 p.m., Resident 22 was observed sitting on the side of her bed eating lunch. During a concurrent interview with Resident 22, she stated she had received cooked vegetables again instead of raw vegetables. Resident 22's meal ticket and lunch tray was observed. Resident 22's meal ticket indicated preference of raw vegetables and Resident 22's lunch tray consisted of cooked sprouts, mashed potatoes, roast beef with gravy, side salad, chocolate ice cream, coffee and milk. Resident 22 further stated she could not eat the side salad because of the red chopped bell peppers which she dislikes.On September 8, 2025, Resident 22's medical record was reviewed.The admission record indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included dementia (memory impairment), hypertension (high blood pressure) and hyperlipidemia (high cholesterol).The history and physical completed on July 18, 2025, indicated Resident 22 was unable to make informed medical decisions. The dietary order dated September 3, 2025, indicated .No added salt diet.regular texture.thin consistency.patient request no red or green peppers.The care plan dated May 21, 2025, indicated .Focus.resident is at risk for malnutrition due to.mechanically altered diet.poor intake.Intervention.cater to food preferences.refer to RD as needed.On September 10, 2025, at 2:45 p.m., a concurrent interview and record review was conducted with the Dietary Supervisor (DS). The DS stated the DS manages resident dietary needs and preferences through quarterly interviews. The RD then conducts annual assessments to coordinate each resident's dietary care plan. The DS reviewed Resident 22 medical record and stated Resident 22's preference was raw vegetables and dislikes are red and green bell peppers. The DS reviewed a picture of Resident 22's meal ticket and lunch tray and stated the expectations of dietary are residents receive their dietary preferences. The DS stated Resident 22's should have received her preference of raw vegetables.The DS reviewed Resident 26's medical record and stated Resident 26's last annual nutritional assessment was conducted on April 17, 2024. The DS stated there was no documented evidence Resident 26's annual nutritional assessment was conducted. The DS stated Resident 26 should have had an annual nutritional assessment. The DS further stated potential outcomes of residents not receiving their dietary preferences and annual nutritional assessment could result in undesired weight loss.A review of the policy and procedure titled Resident Food Preferences, dated 2001, indicated .Upon the resident's admission, staff will identify a resident's food preference.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.A review of the facility policy and procedure titled Comprehensive Assessments, dated 2001, indicated .annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis at least every 366 days.

Based on observation, interview, and record review, the facility failed to ensure safe and effective medication labeling and controlled (narcotics) drug storage when: 1. Three of three artificial tears (drug to lubricate dry eyes) medication bottles were not properly labeled with sufficient information to identify the specific resident. This failure had to potential to cause preventable infections from cross-contamination from eye drops were inadvertently mixed up with other residents. 2. The keys to the discontinued controlled substances were stored in an unlocked drawer in the half-opened Director of Nursing (DON) office. This failure had the potential for drug diversion (theft or preventable loss) and impaired (under the influence) staff providing care for a universe of 62 residents. Findings:1. During a concurrent observation and interview on September 8, 2025, at 3:33 p.m., an inspection of a medication cart was conducted with Registered Nurse 1 (RN 1). When the medication cart was opened, three opened carton boxes of artificial tears eye drops (National Drug Code 57896-181-05) were observed stored inside the medication cart. The three artificial tears eye drops indicated the resident's last name on the medication carton box but not on the medication container bottle. RN 1 acknowledged the three residents eye drop cartons were only labeled with the residents last names. RN 1 stated if the unlabeled medications fell outside of the medication cartons, the eye drops could be exchanged with another resident which could result in cross contamination. RN 1 stated the eye drop bottles should have been labeled with two resident identifiers. During an interview on September 11, 2025, at 3:10 PM, with the Director of Nursing (DON), the DON stated the resident's full name should be both on the medication carton and the medication container bottle. The DON acknowledged that one of the resident's last names was misspelled on the medication carton box. During a review of the facility's policy and procedures (P&P) titled, Labeling of Medication Containers, dated April 2019, the P&P indicated, .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. 2. During an observation on September 8, 2025, at 12:40 p.m., in the DON office, the DON showed where the discontinued controlled substances were stored in the DON office using the narcotic keys. During a concurrent observation and interview on September 11, 2025, at 3:05 p.m., three individuals from the facility's corporate team were observed in the DON office without the DON. The door to the DON office was observed to be half-open. The DON stated the narcotic keys were being stored in an unlocked drawer. The DON stated it was possible that someone might enter the half-opened DON office and use the narcotic key to access the discontinued controlled substances. The DON stated, Maybe I can put a lock on the drawer. During a review of the facility's P&P titled, Storage of Medications, dated November 2020, the P&P indicated, .1.Only persons authorized to prepare and administer medications have access to locked medications . During a review of the facility's P&P titled, Controlled Substances, dated November 2022, the P&P indicated, .13. Controlled substances remaining the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed .

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to a vulnerable facility population.Findings:On September 8, 2025, at 8:50 a.m., during the initial tour of the kitchen, an observation and concurrent interview was conducted with the Dietary Supervisor (DS) and the Dietary Aide (DA). One prune juice carton labeled with a use-by- date of August 30, 2025, was observed in the refrigerator, readily available for use. The DA stated the August 30, 2025 date was the date when the juice carton was opened, and it should have been discarded five days after the open date. In a concurrent interview, the DS stated the date of August 30, 2025 was the date when the prune juice was opened and once opened, it was good for five days. The DS stated the prune juice should have been discarded and not stored in the refrigerator passed the use-by-date.The facility policy and procedure, titled, Dry Goods Storage Guidelines, dated 2023, was reviewed. The policy and procedure indicated, .Juices, fruit.Opened-Refrigerated .5 days .

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when: 1. For two of two residents (Resident 34 and Resident 35), inhalers were not appropriately administered. This failure had the potential for the residents to experience preventable breathing problems and/or other adverse clinical outcomes. 2. One of one opened blood glucose (sugar) test strip vial stored in the medication cart was undated in accordance with the manufacturer's instructions. This failure had the potential for unusable test strips to be used to measure residents' fingerstick blood glucose levels to determine the dose of insulin to be administered. Findings:1a. During a review of Resident 34's HISTORY AND PHYSICAL EXAMINATION [H&P - comprehensive patient assessment], dated March 19, 2025, the H&P indicated a past medical history of COPD [chronic obstructive pulmonary disease - ongoing lung condition]. During a review of Resident 34's medical record, the medical record indicated a physician's orders dated August 27, 2025, for fluticasone-salmeterol (combination of two medications to improve breathing) 250 micrograms / 50 micrograms (mcg - a unit of measurement for dose) diskus (inhalation device). The fluticasone-salmeterol medication order indicated one (1) puff by mouth two times a day. During a review of Resident 34's medical record, the Medication Administration Record (MAR) for August and September 2025 indicated the fluticasone-salmeterol inhalation device was documented as administered twice a day. During a concurrent observation and interview on September 8, 2025, at 3:30 p.m., an inspection of a medication cart was conducted with Registered Nurse 1 (RN 1). When the medication cart was opened, an opened fluticasone-salmeterol inhalation device for Resident 34 was observed stored inside the medication cart. The fluticasone-salmeterol 250 mcg / 50 mcg inhalation device was observed to be undated. The medication carton box for fluticasone-salmeterol inhalation device was labeled 8/27 [August 27, 2025]. The undated fluticasone-salmeterol 250 mcg / 50 mcg inhalation device was observed with 51 puffs remaining out of 60 puffs. RN 1 acknowledged the undated and opened fluticasone-salmeterol inhalation device, the medication carton box dated August 27, 2025, and 51 puffs out of 60 puffs were remaining. During an interview on September 9, 2025, at 2:30 p.m., with RN 1, RN 1 stated the inhaler medication order was routine and not PRN (as needed). RN 1 stated the DON was aware and the facility was investigating. During a concurrent interview and record review on September 11, 2025, at 3:17 p.m., with the Director of Nursing (DON), Resident 34's medical record, medication orders, and MAR were reviewed. The DON stated there should have been approximately 38 puffs remaining on Resident 34's fluticasone-salmeterol 250 mcg / 50 mcg inhalation device when the medication cart was inspected on September 8, 2025. 1b. During a review of Resident 35's History & Physical [H&P], dated August 11, 2025, the H&P indicated a past medical history of COPD. During a review of Resident 35's medical record, the medical record indicated a physician's orders dated December 23, 2024, for albuterol 90 mcg inhaler. The albuterol inhaler medication order indicated two (2) puffs by mouth two times a day. During a review of Resident 35's medical record, the MAR for August and September 2025 indicated the albuterol inhaler was documented as administered twice a day. During a concurrent observation and interview on September 8, 2025, at 3:33 p.m., an inspection of a medication cart was conducted with RN 1. When the medication cart was opened, an opened albuterol 90 mcg inhaler for Resident 35 was observed stored inside the medication cart. The medication carton box for albuterol 90 mcg inhaler was labeled 8/30/25 [August 30, 2025]. The albuterol 90 mcg inhaler was observed with 193 puffs remaining out of 200 puffs. RN 1 acknowledged the albuterol medication carton box dated August 30, 2025, and 193 puffs out of 200 albuterol puffs were remaining. During an interview on September 9, 2025, at 2:30 p.m., with RN 1, RN 1 stated the inhaler medication order was routine and not PRN (as needed). RN 1 stated the DON was aware and the facility was investigating. During a concurrent interview and record review on September 11, 2025, at 3:22 p.m., with the DON, Resident 35's medical record, medication orders, and MAR were reviewed. The DON stated there should have been approximately 168 puffs remaining on Resident 35's albuterol inhaler when the medication cart was inspected on September 8, 2025. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, .4. Medications are administered in accordance with prescriber orders, including any time frame . 2. During a concurrent observation and interview on September 8, 2025, at 3:18 p.m., an inspection of a medication cart was conducted with RN 1 and Licensed Vocational Nurse 1 (LVN 1). An opened and undated blood glucose test strip vial was observed stored in the medication cart. RN 1 and LVN 1stated the opened vial contained 24 test strips remaining out of 50 test strips. LVN 1 stated the vial should have been dated as soon it was opened and stored in the medication cart. During an interview on September 11, 2025, at 3:09 p.m., with the DON, the DON stated their expectation was for everything that was opened to be dated. During a review of the [the name of the test strips manufacturer] insert, dated December 2023, provided by the facility, the manufacturer's insert indicated, .When you first open the vial, write the date on the vial label. Use the test strips within 3 months of first opening the vial.During a review of the facility's P&P titled, Obtaining a Fingerstick Glucose Level, dated October 2011, the P&P indicated, .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level.Steps in the Procedure.2. If using the blood glucose monitoring system (blood glucose meter with test strips), use test strips before their expiration date. Do not use test strips that have been wet, bent or otherwise damaged. For test strips, follow the manufacturer's guidelines.

Based on observation, interview, and record review, the facility failed to ensure, an assessment was conducted by Licensed Vocational Nurse (LVN) 1, prior to obtaining a pain medication order to treat migraine ( severe headache) for one of eight residents reviewed (Resident 35). This failure has the potential to result to inadequate pain management for Resident 35. Findings:On September 9, 2025, at 11:41 a.m., an observation with a concurrent interview was conducted with Resident 35. Resident 35 was in bed, alert, and interviewable. Resident 35 stated she had been requesting to see her physician because she needed to talk to him about her pain medications.On September 9, 2025, Resident 35's record was reviewed. Resident was admitted to the facility on [DATE] with diagnoses including fibromyalgia (condition that causes pain in muscles and soft tissues all over the body).The Physician's Order' dated August 21, 2025, indicated to give Nurtec Oral Disintegrating (brand name medication used to treat migraine) Tablet 75 milligrams (mg- unit of measurement) give one tablet by mouth every 24 hours as needed for migraine prevention.The nursing Progress Notes, documented by Licensed Vocational Nurse (LVN) 1, dated August 21, 2025, indicated, .Resident request for Migraine (sic.). States she use to take it before, MD (Medical Doctor) (Name of MD) made order recd (received) Nurtec Oral Tablet Disintegrating 75 MG Give 1 tablet by mouth every 24 hours for Migraine Prevention. order noted and carried out .The Care Plan dated September 9, 2025, indicated, .At risk for pain or discomfort due to general body .Fibromyalgia, headaches/migraines .Chronic Pain, Migraine.Pain will be relieved to a tolerable level as indicated. Assess for non-verbal indicators of pain .Assess pain every shift and as indicated .Dimmed lighting for photosensitivity .Offer nonpharmacological interventions to relieve discomfort or pain .Notify physician if resident experiences unmanageable or intolerable pain .Offer non pharmacological interventions to relieve discomfort or pain .There was no documented evidence LVN 1 conducted a pain assessment on Resident 35 prior to obtaining the order for Nurtec Oral Tablet Disintegrating 75 MG Give 1 tablet by mouth every 24 hours for Migraine Prevention on August 21, 2025.On September 9, 2025, at 4:35 p.m., an interview was conducted with LVN 1. LVN 1 stated she was the licensed nurse who obtained the order for Nurtec Oral Tablet Disintegrating 75 MG Give 1 tablet by mouth every 24 hours for Migraine Prevention on August 21, 2025. LVN 1 stated: -On August 21, 2025, at 10:53 a.m., Resident 35 asked her if she could get a medication order for her migraine because she was on it before. LVN 1 stated she just told me that.-Resident 35 did not look like she was in pain and complained of migraine at the time she made the request.-She did not conduct a pain assessment before calling the physician and obtained an order for migraine medication as per resident request.-She should have conducted an assessment, checked for the pain level, frequency, and vital signs prior to obtaining a medication order from the physician.On September 11, 2025, at 3:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated when a resident complained of pain, the Licensed Nurses (LN) are to assess the resident's pain, offer non-pharmacological interventions, if ineffective, then offer the prescribed pain medication. The DON stated LVN 1 obtaining a medication for migraine without conducting a proper assessment on Resident 35 was not an acceptable standard of practice. The DON stated LVN 1 should have conducted an assessment first, offered non-pharmacological interventions, offered the prescribed pain medication, monitored the resident for 72 hours, and then referred to the physician the complete assessment on Resident 35's complain of migraine, before obtaining an order.The facility's policy and procedure titled, Pain Assessment and Management, dated 2001 was reviewed. The policy indicated, .The purpose of this procedure are to help staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address underlying causes of pain .General Guidelines .Pain management is a multidisciplinary process that includes the following .identifying signs and symptoms of and assessing existing pain .recognizing situations and conditions with the potential for pain .identifying the underlying causes, intensity, duration, type, and characteristics of pain .addressing the undertluy9ong cause of pain .developing and implementing approaches top pain management based on accepted standards of practice .monitoring effectiveness and interventions .Steps in the Procedure .Recognizing pain .Assessing Pain .Identifying Underlying Causes of Pain .Defining Goals and Appropriate Interventions .Implementing Pain Management Strategies .Monitoring and Modifying Approaches .

Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident reviewed for oxygen administration (Resident 4), when the physician's order for oxygen administration was not followed. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.Findings:On September 8, 2025, at 11:23 a.m., a concurrent observation and interview was conducted with Resident 4. Resident 4 was observed in bed with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 4's oxygen administration was observed at 6 liters per minute (LPM). Resident 4 stated she needed O2 because she was short of breath. Resident 4 stated she had to take off the NC because it was making her nose dry. Resident 4 stated she did not know what rate her O2 should be on.On September 8, 2025, at 11:29 a.m., a concurrent observation, interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 confirmed the O2 level for Resident 4 was at 6 LPM. LVN 1 verified the physician order and stated the O2 level should be between 2 and 4 LPM, as per physician's order. LVN 1 stated the physician's order was not followed.On September 10, 2025, at 8:41 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON confirmed the O2 level should have been between 2-4 LPM, as per physician's order for Resident 4. The DON stated the physician's order was not followed.Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing).The physician's order dated August 27, 2025, indicated, .May use O2 @ 2LPM PRN (as needed) via nasal cannula and titrate up to 4LPM .The facility policy and procedure titled, Oxygen Administration, revised October 2010, was reviewed. The policy indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure, a left elbow skin discoloration, identified on September 9, 2025, was reported and referred to the physician in a timely manner for treatment orders, for one of eight resident's reviewed (Resident 8).This failure has the potential for the resident to experience complications due to the delay in monitoring and treatment.Findings:On September 9, 2025, at 9:43 a.m., an observation with a concurrent interview was conducted with Resident 8. Resident 8 was in bed, alert, and interviewable. Observed on Resident 8's left elbow was a purplish skin discoloration, with skin intact, and with no redness or swelling noted on the surrounding skin area. In a concurrent interview, Resident 8 stated she has had the purplish skin discoloration on her elbow for days and it did not hurt. Resident 8 stated she must have gotten it when the nurses pulled her up for repositioning or when her elbow probably hit the side table on her bed.On September 11, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses including dementia (progressive impairment of intellectual functioning, memory, and abstract thinking).The History and Physical, dated March 18, 2025, indicated Resident 8 can make needs known but cannot make medical decisions.The Physician's Order, dated June 24, 2024, indicated to monitor Resident 8 every shift for bleeding, bruising, and skin discoloration related to Plavix (brand name of a blood thinning medication that helps prevent platelets from sticking together, common side effect is bleeding or bruising more easily than usual). The Shower Skin Sheet, dated September 9, 2025, indicated Resident 8 had a shower provided by the Certified Nursing Assistant (CNA). The Shower Skin Sheet indicated the CNA marked no apparent skin issues on Resident 8.The electronic Medication Administration Record (eMAR) dated September 1 to 30, 2025, indicated the Licensed Nurses (LN), monitored Resident 8 for bleeding, bruising and skin discoloration every shift from September 1 to 10, 2025. The eMAR indicated the LNs have not identified new bruising or skin discoloration on Resident 8 during that period.The care plan dated August 30, 2025, indicated, .Resident is at risk for potential bleeding and bruising due to anticoagulant (medication that has the effect of retarding or inhibiting the coagulation {action or process of a liquid, especially blood, changing to a solid or semi-solid state} of blood) therapy .Goal .Signs and symptoms of bruising or bleeding will be promptly identified with interventions to alleviate initiated timely .Interventions .Monitor for bruising or bleeding. Report abnormal findings to the physician .There was no documented evidence the purplish skin discoloration on Resident 8's elbow identified on September 9, 2025, was reported, assessed, and referred to the physician for treatment orders.On September 11, 2025, at 10:10 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she was the day shift LN assigned to Resident 8 since Tuesday, [DATE]. LVN 1 stated she did not receive a report from the CNA or LN, on the purplish skin discoloration on Resident 8's left elbow.On September 11, 2025, at 10:20 a.m., an interview with concurrent record review was conducted with the Treatment Nurse (TN). The TN stated she worked as TN on September 9, 2025, and she has not received a report from the nurses that Resident 8 had a skin discoloration on her left elbow. The TN stated Resident 8 was being monitored for bruising and skin discoloration due to Plavix use but the September 2025 eMAR did not indicate Resident 8 had a new skin discoloration on her left elbow.On September 11, 2025, at 10:30 a.m., an observation with a concurrent interview was conducted with the TN and Resident 8. Resident 8 was in her wheelchair doing exercises in the therapy room. TN 1 saw the purplish skin discoloration on Resident 8's elbow and stated, the purplish skin discoloration was not reported to her and it did not have a current treatment order or care plan. The TN further stated when a new skin problem was identified, it was considered a Change in Condition (COC), the LN will inform the physician and obtain an order for monitoring on change sin the skin integrity such as color, size, and pain. The TN stated the skin discoloration could become worse if it was not addressed timely.On September 11, 2025, at 3:15 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the purplish skin discoloration on Resident 8's elbow should have been identified on Tuesday, September 9, 2025, and referred to the physician immediately. The DON stated the staff's failure to identify, assess, determine cause and notify physician for treatment orders resulted to a delay in treatment for Resident 8.The facility's policy and procedure titled, SKIN INTEGRITY, dated September 2013, was reviewed. The policy indicated, .The purpose of this procedure is to guide the prevention and treatment of .discolorations .and other skin integrity inssues .to promote healing .General Guidelines .Staff will inspect skin during care, monitor affected area and notify Physician for new skin integrity issue .Documentation .Assess the affected area .Assess for pain and discomfort .Reporting .Report other information in accordance with facility policy/guideline and professional standards of practice .The facility's policy and procedure titled, .Acute Condition Changes-Clinical Protocol, dated march 2018, was reviewed. The policy indicated, .Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example .changes in skin color of condition) and how to communicate these changes to the Nurse .Nursing assistants are encouraged to communicate subtle changes in the resident to the nurse .The nursing staff will contact the physician based on the urgency of the situation .The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results .Treatment and Management .The physician will help identify and authorize appropriate treatment .Monitoring and Follow-Up .The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly .

Based on interview and record review, the facility failed for one of two sampled residents (Resident 2), to protect the resident ' s rights to be free from physical abuse by a resident, when a resident (Resident 1), diagnosed with dementia, and anxiety with no identified behavioral triggers, was moved rooms multiple times due to intolerance to noise without assessing the resident ' s individual needs. The failure of the facility in assessing resident ' s need for appropriate room placement resulted in Resident 1 assaulting Resident 2 who exhibited frequent moaning, mumbling, and yelling. Resident 2 sustained lacerations (a cut in the skin) to the head, extensive facial fractures (a break in a bone), two right rib fractures and L1 vertebra fracture (a break on the first bone on the lower back) and later passed away in the hospital. On May 13, 2025, at 4:45 p.m., the Administrator (ADM) and Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to assess residents ' needs and preferences during room changes. Resident 1 ' s preferences of a quiet room was not assessed, and his care plan was not revised to ensure his needs were met. On May 14, 2025, at 9:30 a.m., the ADM and DON were notified an extended survey would be conducted due to the substandard quality of care issues. On May 14, 2025, at 5:25 p.m., the ADM and DON presented an acceptable IJ removal plan. On May 14, 2025, at 6:03 p.m., the immediate jeopardy was removed in the presence of the ADM and the DON, upon verification of the implementation of the IJ removal plan. Findings: On May 9, 2025, Resident 2 ' s admission record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), impulse disorder (a mental health condition) and hospice care services (specialized end-of-life care). A review of Resident 2's History and Physical, dated April 9, 2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Minimum data Set (MDS-an assessment tool), dated March 25, 2025, indicated a Brief Interview for Mental Status (BIMS - a tool used to identify the cognitive condition of a resident) score of 3 (severe cognitive impairment). A review of Resident 2's IDT (Interdisciplinary Team) Note, dated May 8, 2025, indicated, at 2 a.m. on 5/8/2025, a Certified Nursing Assistant (CNA) visited Resident 2 in his room and found him with blood stain on his face and both hands. The document further indicated it was reported immediately to the charge nurse and 911 was called. The police department, hospice services, physicians, the California Department of Public Health (CDPH), long term care Ombudsman (resident advocate) and the family were notified, and Resident 2 was transferred to the hospital for further treatment. A review of Resident 2's Nurse ' s Note, documented by Licensed Vocational Nurse (LVN) 1, on May 8, 2025, at 3:22 a.m., indicated that on May 8, 2025, at 2 a.m., a CNA went to the nursing station and reported there was a blood bath in Resident 2 ' s room. The document further indicated, the staff found Resident 2 in bed lying on his right side, awake, and was responsive to touch and noted to have lacerations to both sides of his face, hands, and arms. There was blood noted on Resident 2 ' s pillow and on the ceiling and wall away from his immediate bed area. The document further indicated, staff called 911 and the incident was reported to the local police department. At approximately 2:15 a.m., police arrived and assessed the residents and questioned the suspected abuser in bed A (Resident 1). At 2:25 a.m., the paramedics arrived and took Resident 2 to a local hospital. Staff made police and paramedics aware that Resident 2 was on hospice care. A review of Resident 2's Social Service Notes, dated May 8, 2025, at 9:55 a.m., indicated, .resident (Resident 2) was transfer to (initials of hospital) due to altercation with roomate (sic) overnight . A review of Resident 2's Care Plan, dated June 10, 2022, indicated, .Problem with behavior related to socially inappropriate/disruptive behavior manifested by constant shouting .Goal: Will have 0-1 episode of constant crying daily x3 months .Interventions: observe and assess for possible cause of shouting and intervene immediately .report to MD if with uncontrollable shouting . A review of Resident 2 ' s Emergency Department Note - Physician, dated May 8, 2025 at 5:36 a.m., indicated, .exam reveals extensive complex laceration ranging from right forehead across the bridge of the nose to the left eyelid .nose is unstable .bilateral (both) eyes are swollen shut .when opened there is severe chemosis (eye swelling) .ecchymosis (bruising) to the chest .small laceration to the upper gum .patient has extensive facial fracturing .has an inferior (below) blowout fracture on the right .with muscle protrusion (sticking out) .rib fractures .and fracture of L1 (lumbar area - lower part of back) vertebra . On May 9, 2025, Resident 1' s admission record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and a history of being a registered sex-offender on parole (an individual convicted of a sex crime required to register with law enforcement and released from prison under parole supervision) and wore an ankle bracelet (a device used to track the location and movements of an individual under the supervision of the criminal justice system) for monitoring. A review of Resident 1's History and Physical, dated January 15, 2025, indicated Resident 1 has the capacity to make needs known but not able to make medical decisions. A review of Resident 1's MDS, dated [DATE], indicated a BIMS score of 3 (severe cognitive impairment). A review of Resident 1's IDT Note, dated May 8, 2025, indicated at around 2 a.m., a report of an unwitnessed interaction occurred in Resident 1 ' s room. Resident 1 was found on his bed, covered with the sheet and refused to be assessed and interviewed. There was blood stain noted on the wall and ceiling in the room, and both Residents 1 and 2 were lying on their beds. The document further indicated the two residents (Residents 1 and 2) had no prior history and Resident 1 had no prior history of aggressive behaviors towards Resident 1. During interview with the law enforcer, Resident 1 admitted hitting Resident 2 because he made too much noise. Resident 1 was taken into custody by the local police department. A review of Resident 1's eINTERACT Change of Condition, dated May 8, 2025, indicated, at around 2 a.m., a CNA reported a blood bath in Resident 1 ' s room. Resident 1 was lying face down in bed with sheet covering his entire body, and he refused to be interviewed and assessed by LVN. Staff called 911 and police. The document further indicated Resident 1 was interviewed, and he stated he (Resident 2) makes too much noise, and I hit him. The document further indicated Resident 1 was observed to have blood on his hands and body and was escorted by the police. A review of Resident 1's Care Plan, dated December 12, 2024, indicated, .Resident is at risk for physical and verbal aggression r/t Dementia, and is a registered sex offender on parole, wears an ankle bracelet .Goal: Will have no evidence of behavior problems by review date .Interventions: monitor behavior episodes and attempt to determine underlying cause .consider location, time of day, persons involved, and situations .document behavior and potential causes . Further review of Resident 1 ' s records indicated that he had room changes, since admission, on the following dates: - 1/24/25 - moved from 14A to 19A - 1/26/35 - moved from 19A to 31A - 2/13/25 - moved from 31A to 19A - 3/1/25 - moved from 19A to 14B - 3/19/25 - moved from 14A to 25A - 5/5/25 - moved from 25A to 34B - 5/7/25 - moved from 34B to 31B - 5/8/25 - moved from 31B to 30A On May 9, 2025, at 2:11 p.m., Resident 3 was interviewed. Resident 3 stated three days ago, Resident 1 was his roommate and then was transferred to another room. Resident 3 stated, Resident 1 yelled at him regarding his music and got out of bed as if he was going to come at me. Resident 3 stated, Resident 1 stood at him and with clenched fist. Resident 3 stated, the Licensed Vocational Nurse (LVN) 2 overheard and intervened. On May 9, 2025, at 3:05 p.m., LVN 2 was interviewed. LVN 2 stated Residents 1 and 3 used to be roommates before. LVN 2 stated he recalled Resident 1 complained about Resident 3 ' s loud television and radio and he had to intervene because Resident 1 became upset at Resident 3. LVN further stated, he notified the Director of Nursing (DON) and Resident 1was moved to a different room due to the roommate's (Resident 3) noise. On May 9, 2025, at 4:32 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 1 recently had been upset about his ankle bracelet and would refuse to charge it. CNA 1 stated she was instructed to report any changes in Resident 1 ' s behavior to the charge nurses. CNA 1 stated, she knew Resident 1 and he did not like noise. CNA 1 further stated, it was a terrible idea to place him in the same room with Resident 2 who constantly moaned and yelled. On May 12, 2025, at 3:22 p.m., a concurrent interview and records review of Resident 1 ' s room change forms was conducted with the Case Manager. The CM stated nursing staff would let her know if there was a room change request, and she would complete a room change form for the residents. The CM stated nursing would assess for compatibility, and she would only write the resident ' s names on the form and indicate the old and new room numbers for each resident. The CM stated she did not know the reasons of why Resident 1 had those room changes. The CM stated there were no assessments or reason of the move documented on the forms. The CM further stated it would help to have them written on the forms to help track the room changes and avoid any problems with incompatibilities. On May 13, 2025, at 10:09 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated room change process included identifying the reasons for the move and assessing for compatibility. RN 1 stated staff were conducting assessments, but not documenting the assessments or the reason for the room change in the residents ' records. RN 1 stated staff should have identified that Resident 1 did not like noise and should not have been placed with Resident 2 who constantly moaned and yelled. RN 1 further stated, staff should have documented the assessments and reason for moving Resident 1 to a new room to make staff aware of any incompatibilities and avoid any arguments or harm. On May 13, 2025, at 10:20 a.m., a concurrent interview and record review of Resident 1 ' s room changes since admission were conducted with the DON. The DON stated there were no documented evidence room preference and assessments conducted for Resident 1. The DON further stated, there were no documentation of the reasons for moving Resident 1 into a new room on his records and on the room change forms for all the room changes that had occurred for Resident 1. The DON further stated staff should have been documenting them to track compatibility and identify any issues between Resident 1 and other residents; and to avoid an altercation or injury. A review of facility policy and procedures titled Room Change, revised 2021, indicated, .changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change .resident preferences are taken into account when such changes are considered .the patients involved with room change will be assessed by facility staff for compatibility and appropriateness .final approval for room changes will be approved by DON, if DON is not available, MDS or RN Supervisor will provide final approval .documentation or a room change is recorded in the resident ' s medical records .inquiries concerning room changes should be referred to the administrator . A review of facility policy and procedures titled Resident-to-Resident Altercations, revised September 2022, indicated, .all altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff .behaviors that may provoke a reaction by residents or others include .physically aggressive behavior, such as hitting, kicking, grabbing .pushing/shoving .threatening gestures .

Based on interview and record review, the facility failed to review and revise the care plan (a document that outlines a patient's current health status, diagnoses, treatment goals, and interventions) to address the potential risk for physical agression related to the resident's preference for a quiet environment for one of two sampled residents (Resident 1). This failure resulted in Resident 1 being placed in a room with a resident (Resident 2), who exhibits behaviors of moaning and yelling, which subsequently resulted in Resident 1 assaulting Resident 2, with Resident 2 sustaining lacerations, extensive facial fractures, rib fractures and vertebra fracture. Resident 2 was transferred to the general acute care hospital (GACH), where the resident expired. Findings: On [DATE], Resident 2 ' s admission record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), impulse disorder (a mental health condition) and hospice care services (specialized end-of-life care). A review of Resident 2's History and Physical, dated [DATE], indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Minimum data Set (an assessment tool), dated [DATE], indicated a Brief Interview for Mental Status (BIMS - a tool used to identify the cognitive condition of a resident) score of 3 (severe cognitive impairment). A review of Resident 2's IDT (Interdisciplinary Team) Note, dated [DATE], indicated, at 2 a.m. on [DATE], a CNA visited Resident 2 in his room and found him with blood stain on his face and both hands. The document further indicated it was reported immediately to the charge nurse and 911 was called. The police department, hospice services, physicians, the California Department of Public Health (CDPH), long term care Ombudsman (resident advocate) and the family were notified, and Resident 2 was transferred to the hospital for further treatment. A review of Resident 2's Nurse ' s Note, documented by Licensed Vocational Nurse (LVN) 1, on [DATE], at 3:22 a.m., indicated that on [DATE], at 2:00 a.m., a Certified Nursing Assistant (CNA) went to the nursing station and reported there was a blood bath in Resident 2 ' s room. The document further indicated, the staff found Resident 2 in bed lying on his right side, awake, and was responsive to touch. There was blood noted on Resident 2 ' s pillow and on the ceiling and wall away from his immediate bed area. LVN 1 further documented, Resident 2 was observed to have lacerations to both sides of his face, hands, and arms. LVN 1 called 911 and Resident 2 was transferred to the hospital on [DATE], at around 2:25 a.m. LVN 1 further documented, police and paramedics were made aware that Resident 2 was on hospice care. LVN 1 indicated that physicians, family, facility Administrator (ADM) and DON (Director of Nursing) and reported the incident to the Ombudsman and CDPH were all notified of the incident. A review of Resident 2's Social Service Notes, dated [DATE], at 9:55 a.m., indicated, . resident was transfer to (initials of hospital) due to altercation with roomate (sic) overnight A review of Resident 2's Care Plan, dated [DATE], indicated, .Problem with behavior related to socially inappropriate/disruptive behavior manifested by constant shouting .Goal: Will have 0-1 episode of constant crying daily x3 months .Interventions: observe and assess for possible cause of shouting and intervene immediately .report to MD if with uncontrollable shouting . On [DATE], Resident 1' s admission record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and a history of being a registered sex-offender on parole (an individual convicted of a sex crime required to register with law enforcement and released from prison under parole supervision) and wore an ankle bracelet (a device used to track the location and movements of an individual under the supervision of the criminal justice system) for monitoring. A review of Resident 1's Care Plan, initiated on [DATE], indicated, .Resident is at risk for physical and verbal aggression r/t Dementia, and is a registered sex offender on parole, wears an ankle bracelet .Goal: Will have no evidence of behavior problems by review date .Interventions: monitor behavior episodes and attempt to determine underlying cause .consider location, time of day, persons involved, and situations .document behavior and potential causes . A review of the care plan did not indicate that the facility reviewed and revise the care plan to address the individualized need of Resident 1, which was a quiet room. A review of Resident 1's History and Physical, dated [DATE], indicated Resident 1 has the capacity to make needs known but not able to make medical decisions. A review of Resident 1's MDS, dated [DATE], indicated a BIMS score of 3 (severe cognitive impairment). Further review of Resident 1 ' s records indicated that he had room changes, since admission, on the following dates: - [DATE] - moved from 14A to 19A - [DATE] - moved from 19A to 31A - [DATE] - moved from 31A to 19A - [DATE] - moved from 19A to 14B - [DATE] - moved from 14A to 25A - [DATE] - moved from 25A to 34B - [DATE] - moved from 34B to 31B - [DATE] - moved from 31B to 30A. A review of Resident 1's IDT Note, dated [DATE], indicated at around 2 a.m. a resident interaction had occurred in Resident 1 ' s room. There was blood stain noted on the wall and ceiling in the room, and both Residents 1 and 2 were lying on their beds. The document further indicated, from an interview with Resident 1 by the law enforcer, Resident 1 admitted hitting Resident 2 because he made too much noise. Resident 1 was then escorted by a law enforcer and was sent out under the custody of (name of police department). A review of Resident 1's eINTERACT Change of Condition, dated [DATE], indicated, at around 2 a.m., a CNA reported a blood bath in Resident 1 ' s room. Resident 1 was lying face down in bed with sheet covering his entire body, and he refused to be interviewed and assessed by LVN. The law enforcement and 911 were notified. The document further indicated Resident 1 admitted to the law enforcer that he hit Resident 2 because he made too much noise. Resident 1 was observed to have blood on his hands and body as he was being escorted by the law enforcer to be taken in custody. On [DATE], at 2:11 p.m., Resident 3 was interviewed. Resident 3 stated three days ago, Resident 1 was his roommate and then was transferred to another room. Resident 3 stated, Resident 1 yelled at him regarding his music and got out of bed as if he was going to come at me. Resident 3 stated, Resident 1 stood at him and with clenched fist. Resident 3 stated, the Licensed Vocational Nurse (LVN) 2 overheard and intervened. On [DATE], at 3:05 p.m., LVN 2 was interviewed. LVN 2 stated Residents 1 and 3 used to be roommates before. LVN 2 stated a few days ago, he recalled Resident 1 complain about Resident 3 ' s loud television and radio and he had to intervene because Resident 1 became upset at Resident 3. LVN 2 stated Resident 1 preferred a dark and quiet room and was moved to a different room that time. LVN 2 stated Resident 1 usually kept to himself and was on behavioral monitoring for refusing to charge his ankle monitor. LVN 2 stated he was not sure if he had a care plan about not liking noise. LVN 2 stated, he should have checked with the charge Registered Nurse (RN) 1 so that Resident 1 ' s preferences were addressed and could have prevented Resident 1 from hitting Resident 2. On [DATE], at 2:17 p.m., a concurrent interview and record review of Resident 1 ' s behavior monitoring was conducted with RN 1. RN 1 stated Resident 1 was usually quiet and kept to himself, she further stated, she recalled last month, Resident 1 complained about his ankle monitor and had multiple episodes of agitation. RN 1 stated they started to monitor his behaviors that time and had an order for Hydroxyzine (medication to help control anxiety) as needed. RN1 stated Resident 1 ' s care plan should have been revised to include assessing the resident during room changes and providing a quiet environment. RN 1 further stated, the interventions could have helped prevent Resident 1 from being triggered by Resident 2 ' s frequent talking and yelling behaviors. On [DATE], at 4:28 p.m., a concurrent interview and record review of Resident 1 ' s care plan was conducted with the DON. The DON stated Resident 1 had multiple room changes and she identified that he preferred a quiet room. The DON stated Resident 1 ' s care plan should have been revised to address his quiet room preferences, she further stated, she had been focused on moving him away from the noise instead of addressing his needs. The DON stated his care plan and interventions were updated, it could have prevented the incident and assault on Resident 2. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised [DATE], indicated .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making .When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change .The interdisciplinary team reviews and updates the care plan .when there has been a significant change in the resident ' s condition .when the desired outcome is not met .

Based on interview and record review, the facility failed to ensure a report with sufficient information to describe the alleged physical abuse that occurred between two residents (Residents 1 and 2) was provided to the State Agency (SA) and Long Term Care (LTC) Ombudsman (a resident advocate) on May 8, 2025. This failure had the potential for the SA and other officials to receive misleading informations which could negatively affect the investigation compromising the safety of the residents at the facility. Findings: On May 9, 2025, Resident 2 ' s admission record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), impulse disorder (a mental health condition) and hospice care services (specialized end-of-life care). A review of Resident 2's History and Physical, dated April 9, 2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's IDT (Interdisciplinary Team) Note, dated May 8, 2025, indicated, at 2 a.m. on 5/8/2025, a Certified Nursing Assistant (CNA) visited Resident 2 in his room and found him with blood stain on his face and both hands. The document further indicated it was reported immediately to the charge nurse and 911 was called. The police department, hospice services, physicians, the California Department of Public Health (CDPH), long term care Ombudsman (resident advocate) and the family were notified, and Resident 2 was transferred to the hospital for further treatment. A review of Resident 2's Nurse ' s Note, documented by Licensed Vocational Nurse (LVN) 1, on May 8, 2025, at 3:22 a.m., indicated that on May 8, 2025, at 2 a.m., a CNA went to the nursing station and reported there was a blood bath in Resident 2 ' s room. The document further indicated, the staff found Resident 2 in bed lying on his right side, awake, and was responsive to touch and noted to have lacerations to both sides of his face, hands, and arms. There was blood noted on Resident 2 ' s pillow and on the ceiling and wall away from his immediate bed area. The document further indicated, staff called 911 and the incident was reported to the local police department. At approximately 2:15 a.m., police arrived and assessed the residents and questioned the suspected abuser in bed A (Resident 1). At 2:25 a.m., the paramedics arrived and took Resident 2 to a local hospital. Staff made police and paramedics aware that Resident 2 was on hospice care. On May 9, 2025, Resident 1' s records was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and a history of being a registered sex-offender on parole (an individual convicted of a sex crime required to register with law enforcement and released from prison under parole supervision) and wore an ankle bracelet (a device used to track the location and movements of an individual under the supervision of the criminal justice system) for monitoring. A review of Resident 1's History and Physical, dated January 15, 2025, indicated Resident 1 has the capacity to make needs known but not able to make medical decisions. A review of Resident 1's IDT Note, dated May 8, 2025, indicated at around 2 a.m., a report of an unwitnessed interaction occurred in Resident 1 ' s room. Resident 1 was found on his bed, covered with the sheet and refused to be assessed and interviewed. There was blood stain noted on the wall and ceiling in the room, and both Residents 1 and 2 were lying on their beds. The document further indicated the two residents (Residents 1 and 2) had no prior history and Resident 1 had no prior history of aggressive behaviors towards Resident 1. During interview with the law enforcer, Resident 1 admitted hitting Resident 2 because he made too much noise. Resident 1 was taken into custody by the local police department. A review of Resident 1's eINTERACT Change of Condition, dated May 8, 2025, indicated, at around 2 a.m., a CNA reported a blood bath in Resident 1 ' s room. Resident 1 was lying face down in bed with sheet covering his entire body, and he refused to be interviewed and assessed by LVN. Staff called 911 and police. The document further indicated Resident 1 was interviewed, and he stated he (Resident 2) makes too much noise, and I hit him. The document further indicated Resident 1 was observed to have blood on his hands and body and was escorted by the police. A review of the faxed (facsimile - telephonic transmission of scanned-in printed material) transmittal document titled SOC 341 form, dated May 8, 2025, did not indicate pertinent details on the alleged physical abuse involving two residents (Resident 1 and 2). On May 12, 2025, at 2:05 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when reporting an incident, a brief description of the event, time, date, names of residents involved should be included on the SOC 341 form. RN 1 stated after the incident between Residents 1 and 2 on May 8, 2025, she was asked to fax the form to SA and the Ombudsman. RN 1 stated she did not complete the form and did not realize it only said allegation on it. RN 1 stated she should have checked it for accuracy before faxing it. RN 1 further stated when reporting an incident, the form should have included important details to ensure the agencies being reported to were made aware of the safety of residents and could advocate for them. On May 13, 2025, at 1:02 p.m., a concurrent interview and record review of the SOC 341 faxed by the facility to the Ombudsman, was conducted with the Administrator (ADM). The ADM stated for reporting any incident, the expectation was for staff to complete the SOC 341 form with the important information so that local agencies and Ombudsman would be made aware of the details of the incident being reported. The ADM stated the staff should not have only put allegation on the form and should have included more information so that agencies were aware of the incident and the Ombudsman could offer assistance and advocate for the residents involved and the other residents in the facility. A review of facility policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, indicated, .all reports of resident abuse are reported to local, state and federal agencies and thoroughly investigated by facility management .verbal/written notices to agencies are submitted via .fax, e-mail, or by telephone .notices include, as appropriate .the resident ' s name, the resident ' s room number, the type of abuse that is alleged, the date and time the alleged incident occurred, the names of all persons involved in the alleged incident, and what immediate action was taken by the facility .the investigator notifies the ombudsman that an abuse investigation is being conducted .the ombudsman is notified of the results of the investigation as well as any other corrective measures taken .

Based on observation, interview, and record review, the facility failed, for one of three residents (Resident 1), to ensure an Advance Directive Acknowledgement (AD- written instruction such as living will or durable power of attorney for health care about the provision of care and services the resident preferred when he is no longer able to decide for himself), Consent to Treat, POLST (Physician Orders for Life Sustaining Treatment - a physician's order that outlines a plan for end of life care reflecting both a resident's preference and a physician's judgement based on medical evaluation), and Bed Hold Notification Policy were initiated and/or discussed with the resident, family member, and/or legal representative upon admission to the facility. This failure had the potential for the residents to receive unnecessary care/treatment and services. Findings: On January 2, 2025, at 10:55 a.m., an interview with a concurrent record review was conducted with the Social Service Director (SSD) regarding Resident 1. Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a progressive disease that affects memory and other important mental functions). Resident 1's face sheet did not indicate an appointed responsible person (an individual authorized by the resident to act for him as an official delegate or agent) for Resident 1. The history and physical, dated December 18, 2024, indicated Resident 1 had a diagnosis of dementia and he can make needs known but cannot make medical decisions. The following records located in Resident 1's chart were undated, not completely filled out, and did not have a Resident Representative signature: - Advanced Directive Acknowledgement; - Bed Hold Notification Policy; - Consent To Treat; -Physician Orders for Life-Sustaining Treatment (POLST); The following duplicate documents, dated December 27, 2024, and signed by Resident 1's family member, were also located in Resident 1's chart. - Consent to Treat; - Advance Directives/Medical Treatment Decision The document titled, (Name of acute Hospital), dated December 14, 2024 was reviewed. The document indicated Resident 1 was brought to the hospital on December 14, 2024, due to concerns of neglect by the appointed power of attorney (a court-ordered arrangement where a judge appoints a person to make decisions for another adult who cannot care for themselves) of Resident 1. The Adult Protective Services (APS - provides services to adults who are at risk of abuse, neglect, or exploitation) referred Resident 1's case to Public Guardians office for Conservatorship (a court-ordered arrangement where a judge appoints a person to make decisions for another adult who cannot care for themselves). In a concurrent interview the SSD stated Resident 1 did not have the capacity to make medical decisions for himself. The SSD further stated Resident 1 currently did not have an assigned Responsible Party since his admission to the facility on [DATE]. The SSD stated the facility should have contacted APS again within the first 24 hours of admission to check the status of the case and locate next of kin. The SSD stated this had not been done because she had been overwhelmed with other cases. The SSD stated the Consent to Treat and the Advance Directives/Medical Treatment Decisions, signed by Resident 1's family member on December 27, 2024, were invalid because the family member was not the legally appointed decision-maker. The SSD further stated when Resident 1's physician determined that Resident 1 did not have the capacity to make medical decisions, the facility should have made attempts to locate family members and apply for Conservatorship (a guardian or protector appointed by the judge to manage financial affairs and and/or daily life of another due to physical or mental limitations). On January 2, 2025, at 12:27 p.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated she was aware, from admission, that Resident 1 did not have a legal representative to sign the Consent to treat, Advance Directive Acknowledgement, Bed Hold Notification Policy, and POLST. RN 1 stated Resident 1's lack of a legal representative should have been addressed with the bioethics committee (a group within the facility that is responsible for addressing and advising on issues related to patient care) and/or IDT team (is a group of professionals from various disciplines who collaborate to provide care for residents) as soon as it was identified upon admission. RN 1 stated this was not done. RN 1 stated the reason the Consent to Treat and other documents needed to be signed by a responsible party from the time of admission was due to the need for implied consent. The facility's policy and procedure titled,Bioethics Policy, dated December 2015 was reviewed. The policy indicated, .The Center will strive to uphold the resident's rights of individual choice regarding treatment options and life-sustaining measures .To provide an avenue for care providers, physicians, patients and/or their families to express concerns, participate in decision - making and see guidance in approaching situations that are actual or potential ethical dilemmas Issues that may necessitate Bioethics Council . A cognitively impaired resident without a surrogate decision maker needs specific medical treatment .

Based on observation, interview and record review, the facility failed to ensure a comfortable environment was provided, for eight of eight residents (Residents 40, 36, 28, 15, 17, 32, 48, and 53), when the temperature in the resident's rooms were above 81 degrees Fahrenheit. On August 5, 2024, at 7:51 p.m., the Administrator (ADM), the Director of Nursing (DON), and the Director of Staff Development (DSD), were verbally notified of the Immediate Jeopardy (IJ-situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death, to a resident), due to the facility's failure to provide a comfortable environment for eight residents (Residents 40, 36, 28, 15, 17, 32, 48, and 53) when the resident's room temperature were above 81 degrees Fahrenheit. These failures resulted in the discomfort for Residents 40, 36, 28, 15, 17, 32, 48, and 53, particularly for Resident 17 who could not breathe properly and for Resident 53 who experienced agitation. In addition, this failure had the potential for the residents to experience exacerbation of respiratory and chronic illnesses. On August 6, 2024, 10:36 a.m., the facility presented an acceptable plan of actions which included the following: -The facility purchased additional five large swamp coolers and 10 free standing air-conditioning (AC) units on August 5, 2024. The swamp coolers (a device that cools air through the process of evaporation [liquid turns to gas])were placed in the hallways and the free-standing AC were placed in the hot and uncomfortable residents' rooms. -The facility identified the affected residents (Residents 15, 40, 36, 28, 17, 32, 53, and 48) and were assessed and monitored for adverse effects. -The facility-initiated room temperature checks in the affected resident rooms on August 5, 2024, starting 8 p.m., then every two hours and documented in the temperature log. -The facility staff will provide hydration every two hours from 10 a.m. to 8 p.m. -The ADM signed a contract to replace the AC units on August 6, 2024, and scheduled to install the AC units on August 13 to 15, 2024. -The affected residents will be interviewed by the activities staff during morning shift and the Certified Nursing Assistants (CNAs) during afternoon and evening shifts. If the resident's room temperature will not be controlled, the facility will provide room changes and close the affected rooms until the new AC will be installed. If there will be no available beds to accommodate room changes, the facility will utilize emergency transfer to other facilities. -New window treatment heat reduction film/tint will be placed on the windows and sliding doors of affected rooms on August 6, 2024; and -The ADM will report average room temperature levels in the affected rooms every quarterly Quality Assurance (QA) meeting. On August 6, 2024, at 1:52 p.m. the Immediate Jeopardy was removed in the presence of the ADM, upon onsite verification of the implementation of the plan of actions. On August 6, 2024, at 2:03 p.m., the ADM was notified an extended survey would be conducted due to the substandard quality of care issues. Findings: 1. On August 5, 2024, at 10:56 a.m., an observation and interview with Resident 40 was conducted. Resident 40 was observed sitting up at the side of the bed watching television. Resident 40 stated it was warm in her room. On August 6, 2024, Resident 40's ADMISSION RECORD was reviewed. Resident 40 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder (mental health condition associated with emotional highs and lows), hypertension (high blood pressure), and anxiety (feelings of worry about something of an uncertain outcome). A review of Resident 40's Minimum Data Set (MDS - an assessment tool), dated February 8, 2024, indicated a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact). 2. On August 5, 2024, at 11:10 a.m., a concurrent observation and interview were conducted with Resident 36, who was observed lying in bed. Resident 36 stated she felt warm in the room. On August 5, 2024, at 5:16 p.m., a concurrent observation and interview were conducted with the Maintenance Supervisor (MS). The MS checked the temperature in Resident 36's room on the wall above Resident 36's bed using the handheld infrared thermometer gun (a device that measured an object's temperature without making physical contact with it). The temperature read 87.4 degrees Fahrenheit. The MS stated the room temperature in Resident 36's room was not within the required comfortable range of 71 to 81 degrees Fahrenheit. On August 6, 2024, Resident 36's ADMISSION RECORD was reviewed. Resident 36 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a common lung disease that causes breathing problems and restricted airflow) hypertension (high blood pressure), and dementia (loss of cognitive function, memory and thinking). A review of Resident 36's MDS, dated [DATE], indicated a BIMS score of 3 (severe cognitive impairment). 3. On August 5, 2024, at 11:18 a.m., a concurrent observation and interview was conducted with Resident 28. Resident 28 was observed lying in bed, receiving oxygen via nasal canula (a device that delivers extra oxygen through a tube and into your nose) which was connected to an oxygen concentrator [a machine which delivers supplemental oxygen]. The oxygen concentrator had cluttered personal items on top of it. A floor fan was observed blowing directly on Resident 28's face. In a concurrent interview, Resident 28 stated it was hot in the room and she had informed the nursing staff, the MS, and the maintenance assistant about the heat, but nothing was done. Resident 28 stated the heat problem in the room had been over a month. Resident 28 stated the facility provided a cooler outside her door, but they were so noisy, especially with the television on. On August 5, 2024, at 11:35 a.m., a concurrent observation and interview were conducted with the MS. The MS was observed to use a portable infrared handheld thermometer gun to check the temperature in Resident 28's room. The MS checked the temperature in the following areas of Resident 28's room with the following readings: - On the wall above Resident 28's head: 83.7 degrees Fahrenheit; - Above Resident 28's bed (at the level of bed light): 82.9 degrees Fahrenheit; and - The wall by the bathroom: 82.4 degrees Fahrenheit. During further interview with the MS, the MS stated the temperature should be between 65 to 85 degrees Fahrenheit. On August 5,2024, at 2:31 p.m., a concurrent observation and interview were conducted with the MS. The clock thermometer in Resident 28's room showed a reading of 85 degrees Fahrenheit, while Resident 28's personal room thermometer showed a reading of 84.4 degrees Fahrenheit. The MS was observed checking the temperature by the head of Resident 28's bed using a thermometer gun, which showed a reading of 87.7 degrees Fahrenheit. On August 5, 2024, Resident 28's ADMISSION RECORD was reviewed. Resident 28 was admitted to the facility on [DATE], with diagnoses which included asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe) and chronic respiratory failure (long-term condition that occurs when the body's respiratory system cannot exchange oxygen and carbon dioxide properly). A review of Resident 28's MDS, dated [DATE], indicated a BIMS score of 12 (cognitively intact). 4. On August 5, 2024, at 11:20 a.m., Resident 15 was observed lying in bed. Resident 15 was not able to answer questions appropriately when asked about the heat inside her room. On August 5, 2024, Resident 15's ADMISSION RECORD was reviewed. Resident 15 was admitted on [DATE], with diagnoses which included Alzheimer's disease (progressive disease that destroys the memory), and hypertension. A review of Residents 15's MDS, dated [DATE], indicated a BIMS score of 3 (severe cognitive impairment). On August 5, 2024, at 2:42 p.m., the Administrator (ADM) was interviewed. The ADM stated he was initially made aware the air conditioning (AC) was broken around the first week of July 2024. The ADM stated the facility received a recommendation order for AC units 4 and 5 and obtained price quotes on July 10, 2024 and August 2, 2024. The ADM stated the facility acquired portable cooler fans and placed them in the hallway near the back hall station. The ADM stated the facility was not achieving the appropriate temperature level for resident's comfort. The ADM stated the MS checked the facility temperature daily and the facility's policy indicated the room temperature should be between 68 and 85 degrees Fahrenheit. The ADM stated he felt the humidity in Resident 28's room and found it uncomfortable. On August 5, 2024, at 4:45 p.m., the MS was interviewed. The MS stated two AC units had broken sometime in July 2024. The MS stated these broken AC units affected the rooms of Residents 15, 40, 36, 17, 32, 53, and 48. The MS stated they called an AC professional who recommended replacing the two broken AC units. The MS stated he received several price quotes for the AC units in July 2024, and submitted to the ADM. The MS stated the two broken AC units had not yet been replaced as of this time. The MS stated they have placed portable AC units in the hallways outside the affected residents' rooms. The MS stated the portable AC units were not sufficient to provide cooler air in the residents' rooms. The MS stated the required room temperature should be 71 to 81 degrees Fahrenheit. On August 5, 2024, at 4:47 p.m., a concurrent interview and review of room temperature monitoring log from July 2024 to August 2024, were conducted with the MS. The MS stated room temperatures were checked twice a day by him, and two other maintenance staff members. The MS stated, the temperature monitoring log did not indicate any temperature readings below 71 degrees Fahrenheit or above 81 degrees Fahrenheit. The MS stated the facility did not have a policy and procedure on how to accurately check a resident's room temperature using the infrared thermometer gun. 50122 5. On August 5, 2024, at 5:15 P.M., during a concurrent observation in Resident 17's room and interview with Resident 17, Resident 17 was observed lying in bed, awake. Resident 17 stated she felt hot. Resident 17 stated she had spoken to her Family Member (FM) about her concerns related to the room temperature. On August 5, 2024, at 5:19 P.M., an observation with a concurrent interview was conducted with the MS. The MS used a thermometer gun to check the room temperature in Resident 17's room. The MS pointed the thermometer gun at the wall above Resident 17's headboard which showed a temperature of 91 degrees Fahrenheit. The MS stated the required comfortable room temperature was from 71 degrees Fahrenheit to 81 degrees Fahrenheit. The MS stated Resident 17's room temperature was not good. On August 6, 2024, at 8:45 A.M., an interview was conducted with Resident 17's FM. The FM stated the room temperature in Resident 17's room was uncomfortable since early June 2024. The FM stated the room temperature in Resident 17's room was hot and uncomfortable. The FM further stated the temperature in Resident 17's room was hot and uncomfortable and Resident 17 had complained about the heat, which made it difficult for her to breathe properly. The FM stated the air conditioner (AC) felt like it was blowing hot air which made Resident 17 uncomfortable in her room. The FM stated she was unaware if the facility staff had offered Resident 17 a room change. On August 7, 2024, Resident 17's ADMISSION RECORD was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), anxiety (type of mental disorder), diabetes (high blood sugar), and hypertension (high blood pressure). A review of Resident 17's Minimum Data Set, dated dated [DATE], indicated Resident 17's BIMS score was 8 (moderate cognitive impairment). 6. On August 5, 2024, at 5:20 P.M., a concurrent observation and interview was conducted with Resident 32 in her room. Resident 32 was observed sitting on the edge of bed and was awake. Resident 32 stated it had been hot in the room for the past month and the fan was not helping. Resident 32 stated the room temperature was unusually hot and the facility had never offered a room change due to the increased room temperature. Resident 32 stated she was not aware of any issue with the AC units. On August 5, 2024, at 5:22 p.m., an observation with a concurrent interview were conducted with the MS. The MS used a thermometer gun to check the room temperature in Resident 32's room. The MS pointed the thermometer gun at the wall above Resident 32's headboard. The thermometer gun read the temperature at 90.5 degrees Fahrenheit. The MS stated the required comfortable room temperature was from 71 degrees Fahrenheit to 81 degrees Fahrenheit. The MS stated Resident 32's room temperature was not good. On August 7, 2024, Resident 32's 'ADMISSION RECORD was reviewed. Resident 32 was admitted to the facility on [DATE], with a diagnosis that included bilateral osteoarthritis of knee (bone disease of both knees), fibromyalgia (a chronic disorder that causes widespread pain and tenderness in the body), dementia, and depression (feeling of hopelessness). A review of Resident 32's MDS, dated [DATE], indicated Resident 32's BIMS score was 15 (cognitively intact). 7. On August 5, 2024, at 5:23 p.m., a concurrent observation and interview were conducted with Resident 48 in his room. Resident 48 was observed lying on bed and was awake. Resident 48 stated the temperature in the room was hotter than usual and this was the first time he had experienced such high temperatures. Resident 48 stated staff had never offered any help or a room change due to increased room temperature. On August 5, 2024, at 5:23 p.m., an observation with a concurrent interview were conducted with the MS. The MS used a thermometer gun to check the room temperature in Resident 48's room. The MS pointed the thermometer gun at the wall above Resident 48's headboard which showed a temperature of 88.7 degrees Fahrenheit. The MS stated the required comfortable room temperature range is from 71 degrees Fahrenheit to 81 degrees Fahrenheit. The MS stated Resident 48's room temperature does not meet required criteria for a safe room temperature. On August 7, 2024, Resident 48's ADMISSION RECORD was reviewed. Resident 48 was admitted to the facility on [DATE], with a diagnosis of cerebral infarction (disrupted blood flow in the brain) with left sided deficit (weakness), diabetes mellitus (abnormal blood sugar), morbid obesity, depression (feeling of sadness), and cardiomegaly (enlarged heart). A review of Resident 48's MDS, dated [DATE], indicated Resident 48's BIMS score was 13 (cognitively intact). 8. On August 5, 2024, at 5:24 p.m., a concurrent observation and interview were conducted with Resident 53 in his room. Resident 53 was observed lying on bed and was awake. Resident 53 stated the temperature in the room had been hot for the past two months and the staff had not offered assistance, or a room change despite the increased temperature. Resident 53 stated he had told nursing staff multiple times over the past month about the discomfort, but no help was offered. Resident 53 stated he was not aware of any issues related to the AC. Resident 53 became agitated and yelled at the MS due to the extreme heat and the lack of information about why the temperature was elevated. On August 5, 2024, at 5:25 p.m., a concurrent observation and interview were conducted with the MS. The MS was observed using the thermometer gun to check the temperature above Resident 53's bed. The thermometer gun recorded a temperature of 87.3 degrees Fahrenheit. A review of the facility's policy and procedure titled, Quality of Life-Homelike Environment, dated 2002, indicated, .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .Comfortable and safe temperatures (71 F - 81 F) . A review of the undated facility's policy and procedure titled, Providing Comfortable and Safe Temperature Levels for Residents, indicated, .It is the policy to provide comfortable and safe temperature levels for the residents. The facility will maintain a temperature range of 71-81 F .The facility will follow regulations and maintain an acceptable temperature level for the residents. The facility will measure the air temperature above floor level in resident rooms, dining areas, and common areas. If the temperature is out of the 71-81-degree range, the staff will report this to the maintenance department who then will check the system. Actions will be taken by maintenance department and staff when residents complain of heat or cold, e.g., check and fix air conditioning system .provide extra fluids during heat waves .

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary food preparation and storage practices in the kitchen, for 51 of 53 residents receiving an oral diet, when the ice machine's evaporator (where ice was formed) was noted to have brown residue build-up, and the ice chute had slimy yellowish-brown residue build-up. In addition, the facility was not monitoring the cleanliness of the ice machine. These failures had the potential to cause food-borne illness in a highly susceptible population of 51 out of 53 residents who were on an oral diet. On November 1, 2021, at 5:25 p.m., the Administrator (AD), the Director of Nursing (DON), and the Food and Nutrition Supervisor (FNS) were verbally notified that an immediate jeopardy situation (situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) existed regarding unsanitary conditions of the ice machine in the kitchen. The failure to properly clean the ice machine had the potential to cause food-borne illness to the highly susceptible population of 51 out of 53 residents, using ice in bedside pitchers and iced tea if requested. On November 1, 2021, at 5:55 p.m., the facility presented to the California Department of Public Health (CDPH) with an acceptable plan of action that indicated the following: All bedside pitchers containing ice coming from the ice machine were replaced with fresh ice from outside provider. Bedside pitchers were washed and sanitized before distribution. The ice chest was removed from the staff lounge and was cleaned and sanitized before use. The facility provided bottled water to every resident while waiting for the fresh ice. Nursing staff monitored residents every shift for any adverse reaction and reported to the Director of Nurses and Administrator. The ice machine was removed at around 6:25 p.m., on November 1, 2021, from the Dietary Department for thorough cleaning and sanitizing by a certified professional provider. The Maintenance staff will monitor the ice machine for any unnecessary build up in the compartment on the monthly basis going forward. On November 1, 2021 at 6:18 p.m., the immediate jeopardy was removed, in the presence of the AD, the DON, and the FNS, after the facility implemented the immediate plan of action of removing the ice pitchers, removing the ice machine, providing bottled water to residents, and monitoring residents for adverse reactions. Findings: On November 1, 2021, at 3:01 p.m., during a concurrent observation and interview with the Maintenance Supervisor (MS), the following were observed: a. The MS removed the plastic cover in the ice bin that covered the ice chute. A swipe of the ice chute with a white paper towel showed a build-up of yellowish-brown slimy residue; and The MS stated that the ice machine was past due on its quarterly cleaning. b. The MS opened the evaporator where ice was formed, a swipe with a white paper towel showed a brown residue. He stated that this was the first time he ever opened this part of the ice machine. On November 1, 2021, at 3:06 p.m., during an interview, the MS stated he was responsible for cleaning the ice machine monthly and every three months, a contracted company would perform deep cleaning of the ice machine. He stated the last deep cleaning by the contractor was completed on July 27, 2021 (past three months). The MS stated he cleaned the inside of the ice bin and the outside of the machine monthly. However, the MS stated he had never opened the ice machine to inspect the inside where the ice was made. He stated he does not monitor the cleanliness of the inside of the ice machine where the ice was made. In addition, the MS explained the steps for monthly cleaning were as follows: 1. Empty the ice out from the ice storage bin and clean and sanitize the inside of the bin. 2. Clean the air filter, and the entire outer shell of the machine. 3. Use the ice machine de- solution scaler (used to clean and maintain ice machine) to clean the outer surface of the machine as well as the filter. The MS stated he followed the procedures provided by the facility and that he has never referenced or used the ice machine user manual for cleaning guidance. On November 1, 2021, at 3:16 p.m., an interview was conducted with the Food and Nutrition Supervisor (FNS). The FNS stated she does not check the inside of the ice machine, where ice was made, for cleanliness. She stated that she relied on the MS and the contracted company to keep the ice machine clean. The FNS stated the ice in the ice machine was used for the water pitchers in the resident's rooms and iced tea if requested by the residents. On November 2, 2021, at 02:26 p.m., during a telephone interview with the Office Manager of the (name of contracted company), that cleaned the ice machine quarterly, she stated during the July 2021 cleaning, the technician noticed the ice machine was grungy and dirty. She stated if the technician had noted the ice machine is still dirty on the next scheduled visit (every 3 months), then he would have recommended a second cleaning before the next scheduled visit. On November 3, 2021, at 10:03 a.m., an interview was conducted with the facility Registered Dietitian (RD). The RD stated she would conduct a monthly walkthrough of the kitchen and she would assess the cleanliness of the ice machine. She stated she would look at the outside of the entire machine, the front filter, and the inside of the ice bin. The RD stated she had never inspected the inner parts of the machine where ice is made or inside of the ice chute. She stated it was her understanding the MS monthly cleaning involved the inside parts of the machine, such as the ice chute and the evaporator. The RD stated that at no time should there be any residue inside of the machine. She stated ice was food, and if the ice was not stored in a clean and sanitized environment, it could cause foodborne illness. A review of the Dietary Services Kitchen Sanitation Food Storage Checklist/Report, dated October 13, 2021, indicated the RD check marked the box that read ice Machine is clean and scoop clean; stored separately. A review of the ice machine service manual, dated December 2014, indicated the ice machine had to use the manufacturer brand cleaning solution for the cleaning procedure and the use of a scale remover into a reservoir and for the interior surfaces of the ice storage bin. The manual did not provide instructions about using the scale remover on any other portion of the ice machine other than the interior surfaces of the ice storage bin. A review of the facility document titled: (brand name of the ice machine) Preventive Maintenances, undated, indicated, .Sanitize the ice storage bin as frequently as local health codes require, and every time the ice machine is cleaned and sanitized . At some sites the water supply to the ice machine will contain significant quantities of minerals, and that will result in a water system becoming coated with these minerals, requiring more frequent maintenance than twice per year .or more frequently as needed . A review of facility document titled, Ice machine cleaning and sanitizing log, undated, indicated that the last contract maintenance to the ice machine was done on July 27, 2021. A review of the facility document titled, (name of the contracted company) invoice, indicated, .ice machine maintenance occurred on July 27, 2021 .performed maintenance on the (brand name) kitchen ice machine .cleaned all removable parts .put unit back together and ran two cleaning cycles .One with cleaner the other with sanitizer .Cleaned bin with cleaner and sanitizer .briefed kitchen on discarding first bath of ice. Unit working normally at this time . A review of the 2017 FDA Federal Food Code, indicated, .equipment such as ice bins and ice machines shall be cleaned at a frequency necessary to preclude accumulation of soil or mold .ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (organism which is so small that cannot be seen with a naked eye). Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic (medical term that describes viruses, bacteria, and other types of germs that can cause some kind of disease) microorganisms will not be allowed to accumulate . A review of the facility policy and procedure titled, Ice Machine Cleaning Procedure, dated 2018, indicated, .The ice machine (bin and internal components), need to be cleaned monthly and the date recorded when cleaned .Information about the operation, cleaning and care of the ice machine can be obtained from the owner's manual, the manufacturer and/or in the directional panel on the inside of the ice machine .

Based on observation, interview, and record review, the facility failed to, for two of five residents (Resident 47 and 253) : 1. Ensure Resident 47 was free from use of multiple unnecessary [MEDICAL CONDITION] ( medication capable of affecting the mind, emotions, and behavior) medications, when: a. [MEDICATION NAME], and [MEDICATION NAME], all antipsychotic medications, were being used to treat the same behavior of [MEDICAL CONDITION] (mental disorder) for Resident 47; and b. [MEDICATION NAME], an antipsychotic medication, was increased in dose without a documented rationale for necessity. These failures resulted in Resident 47's being oversedated while on multiple pyschotropic medications. 2. Ensure Resident 253 was appropriately assessed on admission for adequate indication on [MEDICATION NAME] (an [MEDICAL CONDITION] medication) use. This failure resulted in the lack of monitoring for the effectiveness of [MEDICATION NAME]. Furthermore this failure had the potential to result in behavior worsening without being detected and/or treated for [REDACTED]. Findings: 1. On (MONTH) 11 to 14, 2019, Resident 47 was observed: *On (MONTH) 11, 2019, at 9:25 a.m. - The resident was sleeping on the couch in the activity room, during activities; *On (MONTH) 11, 2019, at 11:16 a.m. - The resident was sleeping on the couch in the activity room, during activities; and *On (MONTH) 12, 2019, at 1:34 p.m. - The resident was sleeping and slumped-over in her wheelchair, being wheeled around by staff. *On (MONTH) 14, 2019, at 9:39 a.m. - The resident was sitting in her wheelchair at the activity room, head down with her eyes closed. On (MONTH) 14, 2019, at 9:41 a.m., Resident 47's sitter (provided by hospice-care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms) was interviewed. The sitter stated she could only recall Resident 47 having one episode of psychotic behavior aggresive with staff since (MONTH) 2019. She also stated the facility had just administered medications that made the resident a little off (sleepy during the time of interview). Resident 47's record was reviewed. Resident 47 was admitted to the facility under hospice care on (MONTH) 4, 2019, with [DIAGNOSES REDACTED]. Review of Resident 47's medication regimen included the following: a. [MEDICATION NAME] (an antipsychotic): Physician order: *On (MONTH) 4, 2019- [MEDICATION NAME] capsule 20 milligrams (mg) by mouth at bedtime for anxiety manifested by (m/b) agitation, restlessness, and combative behavior. Review of Lexicomp (a nationally recognized drug reference) indicated that [MEDICATION NAME]'s drug classification is an antipsychotic, and did not include the use of [MEDICATION NAME] as an anti-anxiety. The Medication Administration Record [REDACTED] *For (MONTH) 4 to (MONTH) 31, 2019 - 28 days (26 doses given, 2 doses held); *For (MONTH) 1 to (MONTH) 28, 2019 - 18 days (16 doses given, 2 doses held); *For (MONTH) 1 to 12, 2019 - 13 days (11 doses given, 2 held). There was no documented evidence of an assessment on admission providing an explanation and/or history for the use of [MEDICATION NAME]. b. [MEDICATION NAME] (an antipsychotic): Physician orders: *On (MONTH) 7, 2019 - [MEDICATION NAME] 25 mg by mouth twice daily for hallucinations (false sensory experiences); *On (MONTH) 17, 2019 - [MEDICATION NAME] was increased to 50 mg twice daily; and *On (MONTH) 29, 2019 - [MEDICATION NAME] was increased to 50 mg three times daily. The Medication Administration Record [REDACTED] *For (MONTH) 7 to (MONTH) 31, 2019 - 22 days (50 doses given, 1 dose held); *For (MONTH) 1 to (MONTH) 28, 2019 - 28 days (79 doses given, 5 doses held);and *For (MONTH) 1 to (MONTH) 13, 2019 - 13 days (35 doses given, 4 doses held). There was no documented evidence indicating the necessity of starting [MEDICATION NAME] and subsequently increasing the dosage. c. ABHR cream - ([MEDICATION NAME] (an anti-anxiety), [MEDICATION NAME] ([MEDICATION NAME] - used for itching/allergy), [MEDICATION NAME] (an antipsychotic), [MEDICATION NAME] (used for stomach reflux); all four medications compounded (mixed) together as one medication): Physician order: *On (MONTH) 21, 2019 - Apply 1 milliliter (ml) to inner wrist every four hours for anxiety (m/b) fidgeting. The Medication Administration Record [REDACTED] *For (MONTH) 21 to (MONTH) 31, 2019 - 10 days (64 doses given, 15 held); *For (MONTH) 1 to (MONTH) 28, 2019 - 28 days (160 doses given, 8 held); and *For (MONTH) 1 to (MONTH) 14, 2019 - 14 days (65 doses given, 12 dosed held). There was no documented evidence indicating the necessity of starting the ABHR cream. d. [MEDICATION NAME] (an antipsychotic): Physician order: *On (MONTH) 28, 2019 - Inject 1 mg intramuscularly (IM-directly into the muscle) every 12 hours for [MEDICAL CONDITION] disorder (psychotic diagnosis) m/b (manifested by) mood swings, agitation striking out, hitting, yelling, and incoherent speech. The Medication Administration Record [REDACTED] *For (MONTH) 28 to (MONTH) 31, 2019 - 4 days (7 doses given, 2 doses held); *For (MONTH) 1 to (MONTH) 28, 2019 - 28 days (42 doses given, 14 held); and *For (MONTH) 1 to (MONTH) 12, 2019 - 12 days (16 doses given, 7 held) . There was no documented evidence indicating the necessity of starting [MEDICATION NAME] and subsequently increasing the dosage. Review of Resident 47's Progress notes indicated the following: - On (MONTH) 4, 2019 at 9 a.m, [MEDICATION NAME] 1 mg was coded 9 (Other/ See Progress Notes). The Progress Notes Order - Administration Note indicated hold to prevent over sedation . - On (MONTH) 12, 2019 at 9 a.m., [MEDICATION NAME] 1 mg was coded 9. The Progress Notes Order - Administration Note indicated resident is in deep sleep at this time. medication held to prevent oversedastion (sic) . - On (MONTH) 20, 2019 at 9 a.m., [MEDICATION NAME] 1 mg was coded 9. The Progress Notes Order - Administration Note indicated resident is in deep sleep at this time. medication held to prevent oversedation . - On (MONTH) 11, 2019 at 9 a.m., [MEDICATION NAME] 1 mg was coded 9. The Progress Notes Order - Administration Note indicated held due to increase lethargy and to prevent oversedation - On (MONTH) 11, 2019 at 9 a.m., [MEDICATION NAME] 50 mg was coded 9. The Progress Notes Order - Administration Note indicated held due to increase lethargy and to prevent oversedation Review of the above documentations indicated Resident 47 was on [MEDICATION NAME], ABHR, and [MEDICATION NAME] routinely, since (MONTH) 11, 2019. Review of Resident 47's [MEDICAL CONDITION] Summary Record provided by the facility, indicated the following: a. medications: [REDACTED] b. Diagnosis: [REDACTED]. c. Behavioral Manifestation: mood swings, agitation. angry outburst, striking out, hitting, yelling. d. Behavior data: (MONTH) 1-31, 2019- total of 11, and for (MONTH) 1 to 28, 2019- total of 7. The [MEDICAL CONDITION] summary record did not fully reflect the behavior manifestation for each medication, but rather the combination of the three medications ([MEDICATION NAME]/[MEDICATION NAME]) The facility Medication Review Report (MRR) for Resident 47, was reviewed and indicated: *January 15, 2019 - Resident is currently on multiple psych meds (medications) .Caution for excess sedation, lethargy, drowsiness, respiratory depression and fall .[MEDICATION NAME] and [MEDICATION NAME]: Recommend .a psychiatry consult to evaluate for possible duplicate therapy, evaluate for behaviors .[MEDICATION NAME] for anxiety M/B agitation, restlessness: Not acceptable DX (diagnosis) behaviors. This order may possibly be an unacceptable med . *February 27, 2019 - This resident is currently receiving the following antipsychotic meds (medications): [MEDICATION NAME] IM, [MEDICATION NAME], and [MEDICATION NAME] .there is a concern of increased side effects with 2 or more antipsychotic agents being used for the same condition .may I suggest the following changes: A gradual reduction of one and eventually DC (discontinue) if clinically indicated and psychiatry consult to evaluate? . There was no documented evidence the facility acted upon these recommendations provided by the facility's Pharmacy Consultant. On (MONTH) 14, 2019, at 11:33 a.m., the Consultant Pharmacist's Medication Regimen Review (MRR) for Resident 47 dated (MONTH) 27, 2019, was reviewed with Registered Nurse Supervisor (RNS) 1. The MRR indicated, This resident is currently receiving the following antipsychotic meds (medications): [MEDICATION NAME] IM, [MEDICATION NAME] and [MEDICATION NAME] .there is the concern of increased side effects with 2 or more antipsychotic agents being used for the same condition .a gradual reduction of one and eventually DC (discontinue) if clinically indicated and psychiatry consult to evaluate . There was no documented evidence in Resident 47's record indicating the MRR dated (MONTH) 27, 2019, was addressed. In a concurrent interview with RNS 1, RNS 1 stated he is currently working on the (MONTH) recommendations and the MRR was not done. On (MONTH) 14, 2019, at 3:20 p.m., Resident 47's record was reviewed with the Director of Nursing (DON). The DON was not able to provide justification for the use of multiple [MEDICAL CONDITION] medications ([MEDICATION NAME], ABHR, and [MEDICATION NAME]), specifically having multiple antipsychotic medications. The DON stated there should have been an assessment justifying the need for the medications. The DON stated there should also be documented evidence of non-pharmacological interventions being provided and that had failed prior to initiating [MEDICAL CONDITION] medications while Resident 47 was already in the facility. According to a CMS (Centers for Medicare and Medicaid) document titled, Atypical Antipsychotic medications: [REDACTED].atypical antipsychotics have been associated with increased mortality when used to treat behavioral disorders in elderly patients with dementia .quetiapine ([MEDICATION NAME] .) in elderly demented patients with behavioral disorders .None of the atypical antipsychotic medications are FDA (Food and Drug Authority) approved for this indication . According to Lexicomp, a nationally recognized drug reference, [MEDICATION NAME] (generic name for [MEDICATION NAME]) had the following US (United States) boxed warning: Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients .Although the causes of death were varied, most of the deaths appeared to be cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. [MEDICATION NAME] contains the following US Boxed Warning: Increased Mortality in Elderly Patients with Dementia-Related [MEDICAL CONDITION]. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death .[MEDICATION NAME] is not approved for the treatment of [REDACTED]. According to Practice Guideline for the treatment of [REDACTED]. . Antipsychotics .The absence of evidence for combinations of antipsychotics does not mean that there are no patients who are best treated with such a combination. However, their use should be justified by strong documentation that the patient is not equally benefited by monotherapy with either component of the combination. Practitioners should be aware of the problems inherent in combination therapies, including increased side effects and drug interactions as well as increased costs and decreased adherence . According to The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition, Copyright (YEAR), by APA: .More detailed consideration and documentation of the risks and benefits of treatment options may also be needed in the following circumstances: when the planned treatment is a relatively costly, nonstandard treatment approach (e.g., multiple antipsychotic medications, off-label use of a medication) . 2. On (MONTH) 13, 2019 Resident 253's records were reviewed. Resident 253 was admitted on (MONTH) 6, 2019. The acute hospital history and physical dated (MONTH) 27, 2019 was reviewed. The record indicated [MEDICATION NAME] was used for Resident 253's [MEDICAL CONDITION] disorder (mental illness) The admitting physician order [REDACTED]. .[MEDICATION NAME] ER Tablet Extended Release .Give 1500 mg (milligrams) orally at bedtime for [MEDICAL CONDITION] . On (MONTH) 13, 2019, at 3:31 p.m., a concurrent interview and record review was conducted with Registered Nurse Supervisor (RNS) 2. RNS 2 stated she transcribed the order for [MEDICATION NAME] with an indication for [MEDICAL CONDITION] on admission. RNS 2 stated she was not aware [MEDICATION NAME] was being used for Resident 253's [MEDICAL CONDITION] disorder. RNS 2 further stated there was no documented evidence of behavior monitoring for the use of [MEDICATION NAME]. On (MONTH) 14, 2019, at 10:57 a.m., the Director Of Nursing (DON) was interviewed. The DON stated, on admission licensed nurses should check the indication of each medication prior to calling the physician to ensure all the information were accurate. The DON stated RNS 2 should have verified and confirmed the use of [MEDICATION NAME] was for [MEDICAL CONDITION] disorder. The DON further stated, for [MEDICAL CONDITION] medications, there should be a behavior assessment prior to giving the medication. The DON stated there was no documented evidence an assessment was done on admission and prior to the use of [MEDICATION NAME]. The facility policy titled, ANTIPSYCHOTIC DRUG USE dated 2013, was reviewed. The policy indicated, .The indication for each medication used shall be documented in the physician's orders [REDACTED].