Every finding on record at The Meadows of Napa Valley

Based on observation, interview and record review, the facility did not store resident medications in a safe and sanitary manner for 31 residents, when safe temperature ranges were not established in the medication storage room, and when loose pills, dust and dried substances, expired laboratory items, damaged medication storages boxes and dirty and contaminated items were observed in the medication storage room and on the crash cart and medication cart. These failures had the potential for cross-contamination, infection, ineffective resident medication absorption and false wound and lab culture results for 31 residents. During an observation and interview, with the Director of Nursing, on 8/10/2026 at 12:15 PM, the medication storage room ambient room temperature log was observed to be documented twice daily. The temperature log document did not contain minimum and maximum temperature ranges. The Director of Nursing stated she did not know what the ambient room temperature of the medication room should have been. She stated the risk was medications and supplies stored in the room had the potential to be defective if not stored in the correct environment. During an interview on 8/10/2026 at 3:56 AM, Licensed Nurse 1 stated she would document the medication room temperature on the temperature log. She stated she did not know what the temperature range should be. She stated she did not know when the temperature of the room was out of range. She stated the correct range was not listed on the temperature log document and staff would not know if the temperature in the room was out of range or not. During an observation and interview on 8/11/2026 at 10:33 AM, the Director of Nursing observed in the medication storage room, three 16-ounce bottles of medication disposal solution sitting behind the hand hygiene sink on the counter. All three bottles appeared to have grey particulate matter that resembled dust on the horizontal surfaces of the bottle top, One of the three bottles had brownish, sticky solution coming from the lid and dripped down the side surface. The solution appeared to be pool around the base of the bottle and was so sticky it prevented the Director of Nursing from being able to pick it up. It was observed to have dried to the countertop. The Director of Nursing stated the bottle being stuck prevented the countertop from being properly disinfected. The top shelf of the wire storage rack was observed to have a corrugated cardboard storage bin that had a line of what appeared to be liquid damage surrounding the entire outside and inside of the bin. Seven bottles of over-the-counter medications were observed in the bin and the Director of Nursing stated, The risk of storing medications in the damaged bin is the potential for cross contamination and infection. A drawer to the right of the medication refrigerator under the countertop was observed to have four expired culture tubes dated 8/2024. She stated the culture tubes should not be in there. A metal shoehorn with a black handle, not labeled with a resident name, was observed in the hand-washing sink with one edge in the contaminated sink and the other end leaned against the faucet handle. The Director of Nursing stated she did not know if it was clean or dirty and she did not know why it was in the sink. She stated it was contaminated. An observation of the freezer compartment in the resident food refrigerator indicated a two ice packs without resident names stored with four other re-useable resident ice packs. The Director of Nursing stated the ice packs were supposed to be disinfected before being placed in the freezer and the two ice packs that did not have surfaces that could be disinfected would be considered contaminated and should not have been stored in the freezer. An observation in the medication room indicated there were no disinfectant wipes or waterless hand sanitizer solution available in the medication storage room. The Director of Nursing agreed that if the disinfectant wipes and hand sanitizer were available in the room, the staff would be more likely to use them appropriately on surfaces and to clean the medication storage room. She stated the nursing staff assigned to the night shift was responsible for cleaning and organizing the medication storage room and that it did not appear that they were doing it thoroughly. During the observation, record review and interview with the Director of Nursing, the surface of the crash cart (A cart that contained supplies, suction pump and equipment required by policy and procedure for resident emergency situations, to be used by staff during resident emergency situations), located at the nursing station, was wiped with a white disinfectant wipe. The wipe was rubbed on the horizontal surfaces of the top and frame on the bottom, and the suction pump on the top, and was observed to have a substantial amount of grey detritus (Waste, debris, or loose fragments left behind after something is broken down, worn away, or destroyed). The Director of Nursing stated the night shift nurses were supposed to check the cart. She observed a log book document titled NOC (Night) shift Daily Duties, dated August 2026, and it did not indicate the expectation that the night nurses were supposed to dust the crash carts. A document titled Crash cart log, dated August 2026, did not indicated responsibility to dust or clean the crash cart or the equipment stored on it. The Director of Nurses stated all the nurses were responsible for cleaning, dusting and checking the medication carts, but she stated it was unclear who was responsible for the emergency crash cart. During an observation and interview on 8/11/26, at 11:30 AM, at medication cart #1, The Infection Preventionist wiped a white disinfectant wipe across all horizontal surfaces including the medication preparation surface and the frame, and the wipe was observed to have a large amount of grey detritus that appeared to be dust and greasy substances smudged on the wipe. She stated it did not appear to have been dusted or cleaned. She stated the medication cart surfaces and interior were supposed to be cleaned every shift by the licensed nurses. An observation of the drawers inside the cart that contained resident medications, supplements, blood testing equipment and supplies, indicated one loose medication (Losartin Potassium 25 mg tab)(A medication used to treat high blood pressure). She stated she did not know which resident it was intended for, or why it was not in the correct resident location. She stated it should not be there. During the observation and interview, the Infection Preventionist wiped a white disposable disinfectant cloth across the bottom of a resident medication storage drawer and grey matter that appeared to be dust, greasy dried liquid and chunks of dried white substance was observed on the wipe. The Infection Preventionist stated it did not appear the medication cart had been disinfected or cleaned. She stated the risk to residents was cross contamination and infection. She stated, according to the Centers for Disease Control (CDC) standards and recommendation, the medication room and the medication carts should be cleaned, disinfected and maintained in a sanitary manner or risk cross contamination and resident infection. During an interview on 8/12/26, Unlicensed Staff 2 stated she always felt rushed when she cleaned the medication room. She stated the licensed nurses have to let her in and stand there and wait for her to finish disinfection and cleaning of the room. She stated she would have done a better job if she had more time. During an interview on 8/12/26 at 12:37 AM, Licensed Nurse 3 stated all the nurses were supposed to clean and dust the medication carts, and the night nurses were supposed to take care of the crash cart and the medication storage room. She stated she did not know which surfaces on the ice packs could be disinfected or not. She stated she did not know what the manufacturer's instructions for use (MIFU) was and how the manufacturer recommended cleaning the surfaces of ice packs to prevent cross contamination. Review of a document titled Emergency Crash Cart Check Policy, revised 1/1/2026, indicated Equipment is clean and functional. Review of a facility Policy and Procedure, not dated or approved, titled Equipment and Supplies for Medication Storage and Administration, indicated Equipment and supplies support infection prevention, medication accuracy, and resident safety and are maintained in accordance with applicable standards of practice and regulatory expectations. Medication preparation and storage environments are designed to ensure security, cleanliness, appropriate environmental conditions . The facility ensures that equipment supplies necessary for medication storage and administration are a. Readily available b. Clean and in good working condition. The facility maintains temperature monitoring and processes for medication storage areas and takes action when reading fall outside acceptable ranges. Review of the Manufacturer's Instructions for Use (MIFU) for the (Company Name) ESwab culture tube indicated, STORAGE: Store the BD Swab devices at 2-30 C. If the product is stored at a different temperature, it would not maintain the stated specifications. PRODUCT DETERIORATION The content of the unopened and undamaged units is guaranteed to be sterile.BD BBL CultureSwab Sterile Swabs should not be used if (1) there is evidence of damage or contamination to the product, (2) the expiration date has passed .Review of a document titled Code of Federal Regulations (CFr) Title 21 S 205.50 Minimum requirements for the storage and handling of prescription drugs and for the establishment and maintenance of prescription drug distribution records. (c) Storage. All prescription drugs shall be stored at appropriate temperatures and under appropriate conditions in accordance with requirements, if any, in the labeling of such drugs, or with requirements in the current edition of an official compendium, such as the United States Pharmacopeia/National Formulary (USP/NF). (1) If no storage requirements are established for a prescription drug, the drug may be held at controlled room temperature, as defined in an official compendium, to help ensure that its identity, strength, quality, and purity are not adversely affected.

Based on interviews and record review, the facility failed to ensure the safety for five of five sampled residents (Resident 1, 16, 28, 31, and 40) when they did not assess the fall risk for Resident 31 and Resident 40 upon admission and when they did not complete post-fall evaluations for Residents 1,16, 28, 31, and 40 to prevent future falls.These failures limited the facility's ability to recognize hazards resulting in increased risk of future falls for Residents 1, 16, 28, 31, and 40.A review of Resident 1's admission record indicated she was admitted in 3/22 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and repeated falls.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/30/26 indicated Resident 1 had severe cognitive impairment, dependence in all Activities of Daily Living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and a history of repeated falls. The MDS documented Resident 1 was at high risk for falls.A review of Resident 1's Fall Risk Assessment, dated 6/30/26, confirmed Resident 1's fall risk status.A review of Resident 1's care plan, initiated 3/23/22, indicated Resident 1 was at risk for falls related to confusion, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, disorientation, unsteadiness on feet, muscle weakness, and wandering.A review of Resident 1's incident report titled 12/9/25 Fall Event, dated 12/9/25, indicated Resident 1 was found on the floor at approximately 8:15 a.m., with a large bump on the back of the head.A review of Resident 1's incident report titled 5/2/26 Unwitnessed Fall, dated 5/2/26, indicated Resident 1 was found on the floor at 1:55 p.m. displaying pain in the right leg.There was no documentation of the required post fall evaluation for Resident 1 following her 12/9/25 and 5/2/26 fall.A review of Resident 16's admission record indicated he was admitted in 8/25 with diagnoses including chronic diastolic (congestive) heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (CKD - a kidney disorder which prevents the kidneys from filtering the blood the way it should and causing waste to build up in the body and make a person feel sick), and retention of urine (when the bladder can't empty all the way, or sometimes can't empty at all).A review of Resident 16's MDS, dated [DATE], indicated Resident 16 had moderate cognitive impairment, dependence in transfers, and a history of falls.A review of Resident 16's Fall Risk Evaluation, dated 7/16/26, indicated Resident 16 was at high risk for falls.Resident 16's care plan, initiated 7/2/25, indicated Resident 16 was at risk for falls related to confusion, deconditioning, gait/balance problems, and incontinence.A review of Resident 16's incident report titled 7/1/26 Assisted Fall During Transfer, dated 7/1/26 at 9:30 p.m., indicated Resident 16 experienced an assisted fall during transfer from wheelchair to bed.A review of Resident 16's incident report titled 7/13/26 Unwitnessed Fall, dated 7/13/26 at 8:35 p.m., indicated Resident 16 was found on the floor next to the bed and wheelchair. Resident 16 later reported hitting his head during the fall. Continued neuro checks were ordered, and Resident 16 refused transfer to the hospital.There was no documentation of the required post fall evaluation for Resident 16 after the 7/1/26 and 7/13/26 falls.A review of Resident 28's admission record indicated he was admitted on 7/26 with diagnoses including acute respiratory failure (a condition when the lungs suddenly can't get enough oxygen into the body or can't get carbon dioxide out), muscle weakness, unsteadiness on feet, and need for assistance with personal care. There was no documented evidence that a fall risk evaluation was done at admission.A review of Resident 28's MDS, dated [DATE], indicated Resident 28 had moderate cognitive impairment and dependence in transfers and mobility.A review of Resident 28's Fall Risk Assessment, completed on admission, indicated Resident 28 was at high risk for falls.Resident 28's care plan, initiated 7/31/26, indicated Resident 28 was at risk for falls related to deconditioning, incontinence, and psychoactive drug use.A review of Resident 28's incident report titled 8/6/26 Unwitnessed Fall, dated 8/6/26 at 2:00 p.m., indicated Resident 28 slid out of the wheelchair while attempting to pick up a glass of milk from the floor. There was no documentation of the required post fall evaluation after the 8/6/26 fall.A review of Resident 31's admission record indicated he was admitted on 7/26 with diagnoses including malignant neoplasm of bladder (bladder cancer), hypertension (HTN -high blood pressure), and visual hallucinations.A review of Resident 31's MDS, dated [DATE], indicated Resident 31 had severe cognitive impairment and dependence in transfers and mobility.A review of Resident 31's care plan, initiated 7/11/26, indicated Resident 31 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and psychoactive drug use.A review of Resident 31's incident report titled 7/12/26 Unwitnessed Fall, dated 7/12/26 at 9:45 a.m., indicated Resident 31 was found lying on the floor at the foot of the bed.A review of Resident 31's incident report titled 7/26/26 Assisted Fall During Therapy, dated 7/26/26 at 10:23 a.m., indicated Resident 31 experienced an assisted fall during therapy. A 1 cm by 1 cm skin tear was noted on the right elbow.There was no documentation of the required the post fall evaluation for Resident 31 after the 7/12/26 and 7/26/26 fall.A review of Resident 40's admission record indicated he was admitted in 6/26 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), pneumonia (an infection/inflammation in the lungs), and acute and chronic respiratory failure. There was no documented evidence that a fall risk evaluation was done at admission.A review of Resident 40's MDS, dated [DATE], indicated Resident 40 had moderate cognitive impairment and dependence in transfers and mobility.A review of Resident 40's care plan referenced general fall prevention strategies; however, individualized fall risk factors were not identified due to the absence of an admission fall risk assessment.A review of Resident 40's incident report titled 6/26/26 Unwitnessed Fall, dated 6/26/26 at 10:44 p.m., indicated Resident 40 tripped over nasal cannula tubing while attempting to use the urinal. There was no documentation of the required post fall evaluation for Resident 40 after he fell on 6/26/26.A review of Resident 40's incident report titled 7/4/26 Unwitnessed Fall With Skin Tears, dated 7/4/26 at 3:37 a.m., indicated Resident 40 fell after attempting to close the window and had to be treated for multiple skin tears.During an interview on 8/12/26 at 3:14 p.m. with Licensed Nurse 3 (LN3), LN3 stated the facility uses a post fall assessment/evaluation tool, which is the required response after every fall.During an interview on 8/12/26 at 3:26 p.m. with the Director of Nursing (DON), the DON stated, Fall risk evaluations should be done at admission, and confirmed the fall risk evaluation was not completed for Resident 31 upon admission. The DON also stated each fall requires an incident report by adding a risk in the facility's electronic risk management system to document the fall, and do all of our notes, what our interventions are, etc. The DON stated the risk management system should trigger the post-fall evaluations automatically and confirmed that the required post-fall evaluations have not been completed because the evaluations were not being triggered since the facility's conversions to their new electronic medical record system on 6/1/26.During an interview on 8/13/26 at 11:49 a.m. with the MDS Coordinator (MDSC), the MDSC stated all new admissions receive a fall risk evaluation either the day of or the day after admission to determine the resident's level of fall risk classification. The MDSC confirmed the fall risk evaluation was not completed for Resident 31 and Resident 40 upon admission.A review of the facility's policy and procedure (P&P) titled, Fall Management, revised/reviewed 1/26, the P&P stipulated .Residents will be assessed for fall risk.The licensed nurse will complete a fall risk assessment upon admission, quarterly, with a significant change of condition, and following a fall.Complete an incident report and post-fall assessment/investigation.A review of the facility's P&P titled, admission Assessment Policy, revised/reviewed 1/26, the P&P stipulated, The facility will complete a comprehensive nursing assessment for each resident upon admission or readmission to identify immediate care needs, risks, medical conditions, functional abilities, and safety concerns. A licensed nurse will complete and document an admission assessment of the resident's overall clinical condition, including vital signs, cognition, pain, skin, mobility/fall risk.

Based on observation, interview, and record review the facility failed to implement an effective infection prevention and control program when: 1. One staff did not wear appropriate personal protective equipment (PPE) during a dressing change for a resident on enhanced barrier precautions (EBP) and touched her walkie with a gloved hand after touching the resident's bare skin; and 2. The Infection Preventionist was not able to identify the organism grown from a wound culture from an infected wound and the organism was not documented in the facility's infection surveillance tracker for one of seven residents sampled for infection control (Resident 7). These failures had the potential to spread multi-drug-resistant organisms (germs that resist three or more classes of antimicrobial drugs, making common infections hard to treat, raising risks of long illness and death) to vulnerable residents, causing infections. During an observation on 8/12/26 at 11:30 a.m., Licensed Nurse (LN) 4 prepared to change the dressing on Resident 20's wound with assistance from certified nursing assistant (CNA) 5. LN 4 gathered wound care supplies from a cart in the hallway. A sign posted outside the door indicated, Enhanced Barrier Precautions. LN 4 washed her hands, donned a gown and gloves and entered Resident 20's room. CNA 5, at Resident 20's bedside, was wearing gloves and asked LN 4 if she needed to wear a gown. LN 4 stated, No, you're just turning him. CNA 5 pulled down Resident 20's shorts and pushed his brief down to his thighs then turned Resident 20 on his left side, placing her her gloved hands on his bare skin to steady him. During the dressing change, CNA 5 received a call on her walkie clipped to the neckline of her scrub top. CNA 5 let go of Resident 20's hip with her gloved hand and touched the walkie to respond to the call. During an interview on 8/13/26 at 11:14 a.m., Infection Preventionist (IP) 6 stated that if a resident was on enhanced barrier precautions, the CNA assisting the nurse should wear a gown during a dressing change. IP 6 stated the risk was that if that resident was infected and the CNA went to another resident, she might contaminate the other resident with that organism. IP 6 stated walkies should not be handled with gloved hands during care, and must be sanitized before, during, and after use. Review of Resident 20's physician order, dated 7/29/26, indicated, Enhanced Barrier Precautions related to Right Buttock Wound. Review of facility policy Enhanced Barrier Precaution, last reviewed/revised 1/1/26, indicated, It is the policy of the community to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use . h. Wound care: any skin opening requiring a dressing. A review of Resident 7's admission record indicated Resident 7 was initially admitted in 4/26 and re-admitted in 7/2026 with the primary diagnosis of Infection and inflammatory reaction due to internal fixation device of her left tibia (surgical site infection and inflammation due to medical hardware placed during surgery in left knee and upper lower leg). A review of Resident 7's Care Plan indicated Resident 7 was placed on Enhanced Barrier Precautions (EBP- infection control guidelines used in nursing homes to stop the spread of dangerous germs) on 5/20/26, revised 7/10/26, related to left knee surgery wound and IV (Intravenous-through a vein) Vancomycin (a powerful antibiotic used to treat serious bacterial infections) and Ceftazidime (antibiotic used to treat severe bacterial infections). A review of Resident 7's Acute care hospital report, date of service 07/2/26, indicated Resident 7 had an ORIF (open reduction internal fixation- surgical repair of a broken bone) of her left tibia (lower leg bone) three months ago and her healing was complicated by wound dehiscence (opening) that had progressed over the past week with hardware exposed and drainage. Resident 7 presented to the hospital on 7/1/26 for an I&D (incision and drainage- cleaning out the wound) of the infected wound. The wound was cultured (a medical test used to find harmful bacteria or other germs causing an infection in a sore or injury) to determine the source of the infection. A review of Resident 7's Acute Care hospital report, date of service 07/4/26, indicated the culture results showed the wound grew Pseudomonas aeruginosa (a multidrug-resistant organism (MDRO), it is a major cause of hospital-acquired infections because it easily resists many common antibiotics) and Coryne striatum ( infection usually occurs when the bacteria enter the body through medical devices, or in people who are very sick, have weak immune systems, or have stayed in the hospital for a long time) and IV Vancomycin and Ceftazidime had been ordered. A review of Resident 7's Physician order summary indicated Resident 7 continued to receive IV Vancomycin last ordered 8/12/26. During a concurrent interview and record review on 8/13/26 at 12:00 p.m. with the Infection Preventionist 6 (IP 6) in her office, the IP 6 most recent infectious disease tracking report for 7/26 was reviewed. IP 6 confirmed, organism unknown was documented for Resident 7's left knee surgical wound. The IP 6 stated she did not have culture results from the facility or from the hospital. IP 6 stated she should know what organisms were being targeted by antibiotic treatments. IP 6 stated she did not know what organism Resident 7 had been receiving Vancomycin for and that she could not confirm what organisms were present in the facility related to Resident 7's infection. A review of a facility policy titled, Antibiotic Stewardship, Surveillance, revised 04/22, indicated, Infection prevention begins with ongoing active infection surveillance to identify infections that are causing, or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/ symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease or event followed by dissemination of that information to those who can improve the outcomes. The policy further indicated, Monitoring the implementation of the program, its effectiveness, the condition of any resident with an infection, and the resolution of the infection, are considered an integral part of the facility surveillance. All residents are monitored for the risk of infection and the presence of actual infections. Facility infection control reports identify the types and severity of the infection. The reports are used to identify trends and patterns. In addition to monitoring processes and outcomes the facility collects data about infections. The infection preventionist reviews data on a regular basis including culture results or other diagnostic test results consistent with potential infections.

Based on interview and record review, the facility failed to develop a complete baseline care plan for one of 13 sampled residents (Resident 20) when Resident 20's baseline care plan did not include interventions to promote the healing of wounds found on admission. This failure had the potential to cause Resident 20's wounds to worsen when there was no written plan in place with interventions to promote healing and prevent the wounds from worsening. During an interview on 8/10/26 at 11:39 a.m., Resident 20 stated he came from the local acute care hospital with a wound on his bottom. Resident 20 stated he thought it was likely from using a bed pan at the hospital. Resident 20 stated the nurses here told him about it and took a picture when he was admitted here, but he did not know it was there until they told him. Resident 20 stated they were not treating it or putting any dressings on it at the hospital. Review of Resident 20's electronic medical record revealed Resident 20 was admitted on [DATE] with multiple diagnoses including a right femur fracture (broken bone in the upper leg). Review of Resident 20's admission skin assessment, dated 7/20/26, indicated open areas of skin on his left and right buttocks, measuring 1 cm (centimeters) by 0.8 cm on the left, and 3 cm by 3.8 cm on the right. Review of of Resident 20's wound physician progress note, dated 7/27/26, indicated the wound on Resident 20's right buttock was a Stage III pressure injury (a full-thickness skin wound caused by prolonged pressure where damage extends through the outer and middle skin layers directly into the underlying fatty tissue) measuring 10.5 cm by 7.3 cm. Review of the certified nursing assistants' documentation of care for Resident 20 indicated documentation of turning and repositioning Resident 20 began on 7/28/26 and getting him out of bed for two hours in the morning and afternoon began on 7/28/26. Review of Resident 20's registered dietitian consult note dated 7/30/26 indicated recommendations to increase protein intake to promote wound healing. Review of Resident 20's baseline care plan dated 7/21/26 indicated Resident 20's skin had open area to left and right buttocks with no interventions documented to address how to care for the wounds or promote healing. During a record review and concurrent interview on 8/12/26 at 4:13 p.m., Transition Care Manager (TCM) verified it was part of her duties to develop the baseline care plan for new admissions. TCM stated the purpose of the baseline care plan was to outline the residents' goals while they were at the facility and to give an overview of the care the facility was to provide to them. TCM reviewed Resident 20's baseline care plan and verified she had noted the wounds on his buttocks but had not added any interventions to the care plan. When queried, TCM stated she was not sure of the rules for including interventions on the baseline care plans with the new management company because she was limited on what she could type. TCM stated normally she would put interventions on the last page where there was a summary but she currently was not able to type in there. TCM stated interventions on the baseline care plan were important for prevention of worsening of the wounds. TCM stated the potential outcome to the resident if the plan of care lacked interventions could be worsening of the wounds. During an interview on 8/13/26 at 8:09 a.m., Director of Nursing stated there should be interventions on the baseline plan of care. Review of facility policy and procedure Baseline Care Plan, last reviewed/revised 1/31/23, indicated, The community will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Interventions shall be initiated that address the resident's current needs including: Any health and safety concerns to prevent decline or injury, such as . pressure injury risk. Any special needs such as for . wound care.

Based on interview and record review the facility failed to ensure the accuracy of one out of 13 sampled resident's (Resident 12), documented clinical condition and medical record when Licensed Nurse 3 (LN 3) did not document her assessment of Resident 12 for reported stroke and seizure-like symptoms in the medical record, and did not notify Resident 12's physician. This failure omitted potentially significant events from Resident 12's medical record and clinical picture and could have informed Resident 12's interdisciplinary team's treatment decisions, continuity, and coordination of care.A review of Resident 12's admission record indicated Resident 12 was admitted in 3/26 with the diagnoses of Multiple Sclerosis (a long-lasting disease of the brain and spinal cord) and Epilepsy with complex partial seizures (a type of seizure that starts in one specific area of the brain and causes a temporary loss or alteration of consciousness).A review of Resident 12's Minimum Data Set (MDS-a resident assessment tool), dated 6/24/26 indicated Resident 12 had a BIMS (Brief Interview for Mental Status- a 0-to-15-point test that checks thinking, memory, and orientation in nursing homes and long-term care, 0-7 for severe cognitive impairment, 8-12 for moderate cognitive impairment, 13-15 cognitively intact) score of 13 with no cognitive impairment.During an interview on 8/10/26 at 11:20 a.m. with Resident 12 in her room, Resident 12 stated approximately one week ago two Certified Nursing Assistants (CNA's) observed Resident 12 acting strange, staring off into space, her speech was slow and altered and Resident 12 cursed which was out of character. Resident 12 stated the two CNAs reported her symptoms to LN 3 and LN 3 had not notified her physician. Resident 12 stated her Neurologist ( a medical doctor who diagnoses and treats disorders of the brain, spinal cord, and nerves) told Resident 12 any change in her condition needs to be reported right away and Resident 12 did not think her facility physician or her Neurologist had been notified by LN 3.A review of Resident 12's Neurology Progress Notes, dated 8/6/26, indicated Resident 12 had notified her Neurologist of a spell Resident 12 had two weeks ago when CNA's noticed she was staring and not responding as usual. Resident 12 recalled being asked if she was ok and she had responded rudely which was out of character.During an interview on 8/12/26 at 10:40 a.m. with Resident 12, she reported one of the facility staff members who had observed her symptoms and notified LN 3 was Certified Nursing Assistant 7 (CNA 7).During a telephone interview on 08/12/26 at 2:32 p.m. with CNA 7, CNA 7 stated Resident 12 had complex care needs and CNA 7 in addition to another CNA caring for Resident 12 both felt Resident 12's speech had been slow and slurred and Resident 12 seemed different. CNA 7 stated this was reported to LN 3 and LN 3 and another nurse came into the room and assessed Resident 12.During an interview on 8/12/26 at 11:45 a.m. with LN 3 at the nurses' station, LN 3 stated she remembered the event and recalled it had occurred one to two weeks ago. LN 3 stated two CNA's approached LN 3 and told her Resident 12 had slurred and slow speech and was cursing which was not like Resident 12. LN 3 stated she and another registry nurse had assessed Resident 12 and done a Neuro check (a fast, bedside assessment used by health workers to monitor a patient's brain function, track changes in condition, and spot early signs of brain injury or stroke ) and felt Resident 12 presented at her baseline. LN 3 confirmed Resident 12 had frequent medication changes during that time. LN 3 stated she had not reported the event to providers, and the assessment could not be found in the medical record because LN 3 had not documented the assessment. LN 3 stated she had not documented a progress note about the event either. LN 3 stated she could not provide any evidence of her assessment or its outcome. LN 3 stated the facility's policy was to document all assessments.During an interview on 8/12/26 at 3:50 p.m. with the Director of Nursing (DON) in her office, DON stated LN 3 not documenting her assessment of Resident 12 did not meet her expectation. DON stated the risk was Resident 12's clinical picture was not accurate, and Resident 12 was not a stable resident. DON stated LN 3 should have documented her assessment and who she notified so the Interdisciplinary team could address and monitor Resident 12. DON stated if symptoms were to happen again the team would think it was the first time and Resident 12's providers need to be aware of any changes.A review of a facility policy titled, Change in Condition, revised 1/1/26, indicated The licensed nurse evaluates the change of condition and determines the course of action based on standard of practice. The physician is notified, by phone (voice to voice), if the condition warrants immediate medical attention. If the condition does not warrant immediate medical intervention, licensed staff may notify the physician during regular business hours by phone or fax. A review of a facility policy titled, Nursing Documentation, revised 1/1/26, indicated The facility will maintain accurate, complete, timely, and resident-specific nursing documentation for each resident. Nursing documentation will reflect the resident's condition, care provided, response to interventions, changes in condition, medications and treatments, communication with providers and responsible parties, and other clinically significant events. Documentation will be completed in accordance with applicable federal and California requirements, professional standards of practice, and facility policies.

Based on interviews, and record reviews, the facility failed to ensure one out of 13 sampled resident's (Resident 6), received Trauma Informed Care when there was no trauma assessment completed on admission, no subsequent comprehensive trauma assessment, no trauma assessment was completed after Resident 6 informed staff of her history of trauma, and no trauma related triggers or symptoms were identified or care planned.This failure put Resident 6 at risk for re-traumatization, distress, and feeling unsafe.A review of Resident 6's admission record indicated Resident 6 was admitted in 06/2023 with the primary diagnosis of unspecified Dementia (brain-based cognitive decline, but tests have not yet identified the exact underlying cause) without behavioral disturbance and Osteoarthritis (a common form of joint disease causing bones to rub together, leading to pain, stiffness, and swelling in the hands, knees, hips, or spine).A review of Resident 6's Minimum Data Set (MDS-a resident assessment tool), dated 8/6/26, indicated Resident 6 had a BIMS (Brief Interview for Mental Status- a 0-to-15-point test that checks thinking, memory, and orientation in nursing homes and long-term care, 0-7 for severe cognitive impairment, 8-12 for moderate cognitive impairment, 13-15 cognitively intact) score of 15 with no cognitive impairment.During an interview on 8/10/26 at 10:22 a.m. with Resident 6 in her room, Resident 6 stated, I was burned badly when I was 11, my father was not a nice man, they had to do skin grafting all over. I am very scared when there are local fires.A review of all Social Services Progress Notes since admission for Resident 6 indicated no comprehensive trauma screening had been completed by social services.A review of Resident 6's Clinical admission Assessment, dated 03/20/23, indicated one screening question related to history of trauma and it was marked N/A (not applicable).A review of Resident 6's current Care Plan indicated there was no Trauma Informed Care Plan.During an interview on 8/12/26 at 3:00 p.m. with the SSD in her office, SSD stated trauma screening and assessment was not part of her admission assessment and she had not received any training on trauma. SSD stated she was not aware if Resident 6 had a history of trauma and this was not one of her regular job duties.During a concurrent interview and record review on 8/12/26 at 3:50 p.m. with the Director of Nursing (DON) in her office, DON stated she did not know if the facility had a trauma screening process. DON stated there was one question on admission, the DON was not aware of a more focused assessment and screening was not done periodically. DON stated Resident 6 had told the DON Resident 6's father had made her sleep in a trough and Resident 6 had been expressing feelings of not wanting to live. DON stated no trauma assessment was completed, and nothing was added to the Care Plan. DON stated she could provide a progress note from the interaction with Resident 6, dated 5/8/26, which indicated a discussion about suicidal ideation and activities, nothing is documented about trauma, trauma triggers, or services offered.A facility policy titled, Trauma Informed Care, revised 1/1/26, indicated, The facility will provide person- centered, culturally competent, trauma-informed care that promotes resident safety, dignity, choice, privacy, and respect. Residents with known or suspected trauma, PTSD, or trauma related symptoms will be assessed and have individualized interventions incorporated into their care plan to reduce the risk of re-traumatization. Trauma screening will be completed as part of the admission/comprehensive assessment process and reassessed when there is a significant change or new trauma-related concern.

Based on interview, and record review the facility failed to ensure one out of 13 sampled resident's (Resident 6), received appropriate social services to promote psychosocial and spiritual well-being when the Social Services Designee (SSD) failed to honor Resident 6's preferences and need for familiar, religious community, and repeated requests for transportation to her community church service in the local area 4.8 miles away were denied.This failure contributed to Resident 6's feelings of depression, loss of community, and frustration and undermined Resident 6's right to determine what spiritual and individual activities were important to her.A review of Resident 6's admission record indicated Resident 6 was admitted in 06/2023 with the primary diagnosis of unspecified Dementia (signs of brain-based cognitive decline, but tests have not yet identified the exact underlying cause) without behavioral disturbance and Osteoarthritis (a common form of joint disease causing bones to rub together, leading to pain, stiffness, and swelling in the hands, knees, hips, or spine).A review of Resident 6's Minimum Data Set (MDS-a resident assessment tool), dated 8/6/26, indicated Resident 6 had a BIMS (Brief Interview for Mental Status- a 0-to-15-point test that checks thinking, memory, and orientation in nursing homes and long-term care, 0-7 for severe cognitive impairment, 8-12 for moderate cognitive impairment, 13-15 cognitively intact) score of 15 with no cognitive impairment.During an interview on 8/10/26 at 10:22 a.m. with Resident 6 in her room, Resident 6 stated she had asked the SSD to help her with transportation because her only friend able to help could no longer handle Resident 6's wheelchair. Resident 6 stated the SSD told her it could not be arranged.During an interview on 8/11/26 at 1:39 p.m. Resident 6 stated she wanted to be able to attend her church's services but was told paratransit services could not take her in her wheelchair and Resident 6 would not be able to stay for the whole service if paratransit took her. Resident 6 stated she really would have liked to find a way to get there, there was nothing to do here at the facility and it was depressing, and she could only crochet so much. Resident 6 stated I refuse to work with the SSD anymore, I am done trying to get anywhere with her, it frustrates me.A review of Resident 6's current Care Plan indicated one activity of interest initiated on 9/19/24 and revised on 6/4/26, to crochet, and Resident 6 had not identified many areas of interest but should be invited when activities of interest were on the calendar. Care Plan further indicated there were no social services focus, goals, or interventions when the Care Plan was initiated on 6/13/23 and none were added when the Care Plan was revised on 5/18/26.A review of SSD Progress Notes indicated Resident 6 informed the SSD of her desire to attend her church's services on Sunday nights on 5/7/26.A review of a Progress Note authored by the Director of Nursing (DON), dated 5/8/26, indicated Resident 6 expressed she did not want to live anymore and felt old and tired and was tired of being in pain, but had no plan to hurt herself. The progress note further indicated the DON encouraged her to get involved in activities like crocheting.A review of Resident 6's most recent Physician Progress Note, dated 7/9/26, indicated Resident 6 voiced that she was done with life and wanted to die and requested transport to church and back on Sunday's. Resident 6's physician noted the request unfortunately did not work out.During an interview on 8/11/26 at 3:20 p.m. with the SSD in the lounge, the SSD stated she had arranged for paratransit, but they would not wheel Resident 6 in or out of the church and Resident 6 had no family or friends available to take her because Resident 6's friends were getting older and could not help any longer. SSD stated she felt Resident 6 was lonely, but the facility could not provide an escort and had not found anyone to take her. SSD stated, If we do it for one resident, we have to do it for all.During an interview on 8/12/26 at 3:00 p.m. with the SSD in her office, SSD stated Resident 6 had no family or friends to take her or go with her, and as far back as the SSD could remember this was how transport had been facilitated. SSD stated it was sad but that was the way it was. The SSD stated all residents have the right to attend community activities, not just the residents that have outside support, but the facility could not necessarily provide the help. The SSD stated she had not asked the Director of Nursing or the Administrator if they could assist in finding an escort for Resident 6.A review of a facility document titled, Admissions Coordinator/Social Services Designee Job Description, revised 2/20, indicated specific job responsibilities as follows, Throughout the course of stay in the Skilled Nursing Facility is in regular contact with the family about the resident's needs and progress. As necessary, referrals are made to outside agencies and resources and assistance in arranging transportation for necessary resident appointments. On an ongoing basis, develops and implements social care plans and resident assessments, including but not limited to, minimum data sheet requirements, psychotropic review, quarterly assessments, change of condition, or change in the plan of care. Interprets social, psychological and emotional needs of the resident to the physician and other healthcare team members.A review of a facility policy titled Resident Transportation Policy, revised 1/1/26, indicated The facility will ensure residents requiring transportation for medical appointments, treatments, diagnostic services, emergency care, hospital transfers, or other authorized services are transported safely and timely. Transportation will be appropriate to the resident's current clinical condition, mobility, cognitive status, safety needs, required medical equipment, and level of assistance.A review of a facility policy titled Resident Activities Program Policy, indicated The facility will provide a variety of meaningful activities based on resident needs and preferences. Activities may include, social and recreational activities, music and entertainment, exercise and movement, arts and crafts, games and cognitive activities, spiritual and religious programs, outdoor and community activities, cultural and holiday programs, dementia specific activities, individual and 1 to 1 activities.A review of a facility document titled, Facility Assessment, updated 1/21/26, indicated under Resident support/needs 2.1, Psycho/social/spiritual support, Support emotional and mental well-being, support helpful coping mechanisms, provide culturally competent care, learn about resident preferences and practices with regard to culture and religion and stay open to requests and preferences and work to support those as appropriate. Provide or support access to religious preferences, use or encourage prayer as desired by resident, provide opportunities for social activities/life enrichment (individual, small group, and community).

Based on interview and record review, the facility failed to provide adequate supervision needed to prevent accidents for one resident (Resident 196) of three sampled residents when Resident 196 was left on the toilet and the staff member left Resident 196's room. This failure resulted in Resident 196 sustaining a spinal cord compression (when pressure is applied to the spinal cord causing swelling and restricted blood flow to the nerves and spinal cord) and death. Findings: A review of Resident 196's admission record indicated he was admitted to the facility on [DATE] with medical diagnosis which included: acute on chronic combined systolic and diastolic heart failure (a sudden worsening of a pre-existing condition where the heart struggles to both effectively pump blood out and fill with blood properly), difficulty in walking, need for assistance with personal care, and muscle weakness (lack of muscle strength). A review of Resident 196's Fall Risk Evaluation dated 8/19/24 at 2:03 p.m. indicated within the previous six months of hospitalization notes Resident 196 had experienced an exacerbation (worsening of or an increase of symptoms) of congestive heart failure (CHF, a serious condition which occurs when the heart cannot pump enough blood throughout the body), generalized weakness, and poor exercise tolerance. This assessment also indicated the section titled Risk for Falls was not completed. A review of Resident 196's Brief Interview for Mental Status (BIMS, an assessment used to measure a person's thought process and word recall) Evaluation dated 8/23/24 at 3:10 p.m. indicated a moderate cognitive impairment which meant a person may need extra assistance with daily activities. A review of Resident 196's care plan initiated on 8/29/24 indicated, [Resident 196] is on diuretic [medication used to help the body get rid of excess fluid and salt] therapy .[related to] edema, HTN [hypertension], CHF .Interventions .Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness Q [every]- shift .Monitor/document/report PRN [as needed] adverse reactions to diuretic therapy: dizziness, postural hypotension [a condition that causes a sudden drop in blood pressure when you stand up after sitting or lying down], fatigue, and an increased risk for falls. A review of Resident 196's witnessed fall document dated 9/4/24 at 10:06 a.m. indicated, Resident has an assisted fall in the common shower room at around 9:40 am. As per CNA [Certified Nursing Assistant], resident suddenly felt weak on his knees while getting dressed and holding onto the transfer bar .Resident .stated that he felt weak .Predisposing Physiological Factors .Gait Imbalance [check marked] .Weakness/Fainted [check marked] . A review of Resident 196's care plan initiated on 9/6/24 indicated, 9/4/24 at 10:00 AM [had an] assisted fall .Goal .no injury .Interventions .CNA to make sure w/c [wheelchair] is close to him before standing in shower room .Bilateral AFO (Ankle Foot Orthotic) inserts to go into his shoes to aid in walking. A review of a change in condition evaluation dated 9/13/24 at 10:32 p.m., indicated, [At 10:30 p.m.] Resident [196] was ambulating with walker to reach for a blanket on the floor, resident states 'I reached too far and fell on my L [Left] side'. Resident was lying on L side with skin tear with mild bleeding noted on L hand measuring 3 cm [centimeters, a unit of measure]. A review of Resident 196's care plan initiated on 9/13/24 indicated, On 9/13/24 [Resident 196 had a fall] at [10:30 p.m.] .Goal .No further injury .Interventions .Transfer to ER [emergency room ] for evaluation. A review of Resident 196's un-witnessed fall document dated 9/16/24 at 9:55 p.m. indicated, Bathroom call light was activated, upon arrival [Resident 196] was seen on the floor in a sitting position. Resident Description: He was unable to wait for assistance, he tried to stand from the toilet when he slid to the floor .Predisposing Physiological Factors .Weakness/Fainted [check marked] A review of Resident 196's nursing care plan initiated on 9/17/24 indicated, On 9/16/24 [Resident 196 had a] fall [at 9:55 p.m.] .Goal .no injury .Interventions .Increase rounding at night [and] Post sign in room and bathroom to remind him to use call light. A review of Resident 196's MDS dated [DATE] indicated, .04. Supervision or touching assistance- Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently .[Score] 04 [for] .Toilet transfer: The ability to get on and off a toilet . A review of Resident 196's un-witnessed fall document dated 9/17/24 at 10 a.m. indicated, .Predisposing Physiological Factors .Weakness/Fainted/Syncope [a brief loss of consciousness that occurs due to a temporary drop in blood pressure] .Predisposing Situation .Ambulating without Assist [check marked] .At aprox [sic] 940 [a.m.] I answered call light and assisted [Resident 196] from bed to bathroom using FWW [front wheel walker]. After helping him sit on toilet I asked if he wanted me to stay with him or if he wanted a minute. He said he needed a few minutes and would use the light and call when he was done. I left and answered a call light in [another room] within a few minutes nurse said [Resident 196] was on the floor in the bathroom. I went to assist. Call light was not on When asked what happened He replied He did not know, He was trying to have a B.M. [bowel movement] and then was on the floor. We assisted him to the WC [wheelchair] with 3 people. Once in W/C 2 CNA and I were going to transfer to bed when he stated he was going to vomit. Nurse called. MD ordered to transfer to ER for evaluation .IDT [interdisciplinary team, a group of people with different areas of expertise who work together to achieve a common goal] review and recommended: If he return .move to a room closer to the nurses station. A review of a hospital discharge summary dated 9/17/24, indicated, .Hospitalist Discharge Summary and Death Certificate .Date of Admission: 9/17/2024 date of death : 9/19/24 .Immediate Cause of Death .Cervical cord compression .Underlying Cause leading to above: C1 and C2 vertebral fracture .Underlying Cause leading to above .Fall .Other significant conditions contributing to death but not resulting in the underlying cause given above .CHF .Principal Diagnosis: C1 and C2 vertebral fracture with cord compression .Secondary Diagnoses: Frequent falls. Status post fall . In an interview on 11/7/24 at 2:38 p.m., the DON confirmed supervision was not increased after Resident 196's fall on 9/4/24 because this fall was witnessed. The DON confirmed the only intervention in the care plan for prevention of falls initiated on 9/13/24 was to transfer Resident 196 to the ER for evaluation. The DON stated this was not a good intervention for prevention of falls. The DON verified supervision of Resident 196 was not increased after this fall. The DON stated Resident 196 was taken to the toilet by the Director of Staff Development (DSD) but did not remain in the toilet area with him because he had requested privacy, therefore, staff stood outside waiting for him to call them when he was done. The DSD was on vacation during this investigation and could not be interviewed. A review of the facility policy and procedure titled Fall Reduction and Management Program . dated 10/2023 indicated, .Every effort be made to reduce and/or prevent falls from occurring and/or minimize serious injury if a fall should happen .Fall Risk Evaluation .The Licensed Nurse will .Complete a fall assessment upon admission .Considerations of special needs may include .Residents with recurrent falls .Toileting supervision: Whether resident needs direct supervision in the bathroom or whether resident can use bathroom call light independently .staff can remain directly outside the bathroom if resident requests .General Staff .All staff will keep alert to residents' need for safety, and will be vigilant and intervene as needed in situations that could precipitate a fall .All direct care staff .will pay close attention to residents identified at risk for falls. 39621 41175 27532

Based on observation, interview, and record review, the facility failed to ensure staff used and understood the need for appropriate Personal Protective Equipment (PPE) for one resident (Resident 5) of five sampled residents for infection control, who had a medical status that required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). This failure had the potential to increase the risk of spread of MDROs and other infections among vulnerable residents, staff, and visitors. Findings: During an observation on 11/5/24 at 3:29 p.m., Resident 5 was calling for staff assistance to be transferred from her wheelchair to the toilet. Certified Nurse Assistants (CNA) L and CNA M donned gloves as they entered the room to help Resident 5. A sign posted on Resident 5's door indicated, ENHANCED BARRIER PRECAUTIONS .PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing . During a concurrent interview and observation of the signage posted in front of Resident 5's room on 11/5/24 at 3:33 p.m. with CNAs L and M, both staff confirmed they only wore gloves as they transferred Resident 5 to the toilet. CNA M stated gowns were only required when changing (linens and/or briefs) and during wound care, but not during transfers. CNA L stated she was unsure, but confirmed the sign stated gowns were also needed during resident transfers. CNA M looked at the sign and stated he was also unsure as that was what he was taught, and added he would ask the nurse again. During an interview outside Resident 5's room on 11/5/24 at 3:36 p.m. with the Director of Nursing (DON) and the Infection Preventionist (IP), the DON stated the facility followed Centers for Disease Control (CDC, the national public health agency for the United States) standards for infection control. Both staff confirmed Resident 5had the correct EBP signage on her door. The DON stated EBP was only required during Resident 5's wound care but not with other activities. The IP stated there was a list in the nursing station of the five residents currently on EBP, and staff were expected to refer to said list to confirm when to use both gloves and gowns for each resident. The DON stated the facility complied with the national guidelines as there was additional information from the CDC supporting their current practice. When a copy of this the additional information was requested, the DON stated she would consult with the facility's Regional Consultant. During an interview on 11/6/24 at 10:01 a.m., the DON stated after she reached out to Regional Consultant, she was able to confirm both gowns and gloves were required during all activities listed on the signage. The DON stated CNAs L and M should have worn gowns and gloves while they transferred Resident 5 to the toilet. The DON acknowledged the concern of not following the CDC standards, as the staff received information which contradicted the national guidelines. A review of the facility policy titled, Infection Control Precautions - Categories of Transmission Based Precautions, dated 4/2024, indicated, Standard Precautions shall be used when caring for residents at all time regardless of their suspected or confirmed infection control status .Enhanced Barrier Precautions (EBP, CDC July 12, 2022) expand the use of gown and gloves beyond the anticipated blood or body fluid exposures .These precautions are intended to used broadly across the facility for residents who meet the criteria .be in place for the duration of the resident's stay in the facility or until the resolution of the wound or device is removed that initially placed them at risk .

Based on observation, interviews, and record review, the facility failed to ensure safe storage and disposal of medications when loose units of unidentified pills and an expired bubble pack of narcotics were found in one medication cart. This failure put residents at risk of receiving expired medications that were potentially ineffective and unsafe for use and prevented prompt identification of possible loss and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled drugs. Findings: During an observation of Medication Cart 1 on 11/6/24 at 10:09 a.m., four units of loose pills (two white cut pills, one yellow round pill, and one white oval pill) were found among the cart's drawer bins. All four pills were unlabeled and unidentifiable. Further inspection of the cart's narcotic bin revealed a bubble pack affixed with a label that indicated, Oxycodone 5MG TAB . Exp: 11/01/24 . There were five pills left in the bubble pack. During a concurrent interview and observation of the cart on 11/6/24 at 10:28 a.m., Licensed Nurse O (LN O) stated the nurses on NOC (night) shift were expected to check the medication carts daily for any expired and/or unlabeled medications. LN O confirmed the presence of the loose pills and expired narcotics in the drawers and stated, They do not belong there. LN O stated the loose pills should have been identified during the cart checks and discarded, and the expired bubble pack of narcotics should have been removed and given to the Director of Nursing (DON) on 11/1/24 for disposal. LN O confirmed the resident whose name was affixed on the bubble pack was still in the facility and stated keeping an expired pack in the cart increased the risk of said resident to be given expired medications. During an interview on 11/8/24 at 9:30 a.m., the DON stated medication carts were checked by the night shift staff every night. The DON stated all medications were expected to be checked for labels and expiration dates. The DON stated loose pills were not identifiable and should have been removed from the cart. The DON stated staff were expected to discard expired medications, with expired narcotics brought to her for disposal. A review of the facility policy titled, Medication Administration: Disposition of Discontinued Medications, dated 6/2024, indicated, It is the policy of the Company to manage the disposition, destruction and disposal of discontinued and/or out-of-date medications in accordance with the Federal and State regulations and in a manner that ensures maximum safety for residents, nursing personnel and environment .Expired, deteriorated or unwanted controlled substances shall be destroyed by means that will assure protection against unauthorized possession or use .

Based on observation, interview and record review, the facility failed to ensure the shower room in hallway 400 of the facility was kept in good working condition when the water in one of the showers did not drain properly and broken tile with sharp edges was found in the shower room floor. These failures increased the potential for residents to experience falls when water pooled and abrasions on their feet. Findings: During an interview on 11/04/24 at 2:14 p.m., Resident 19 stated the water in the 400 hallway shower room did not drain well. Resident 19 showed the Surveyor the shower room she was referring to. During an observation on 11/04/24 between 2:37 p.m. and 2:42 p.m., in the 400 hallway shower room, the surveyor ran the water at full force for 5 minutes. After five minutes, the water created a pool on the shower floor. It took 5 minutes for the water to drain completely. During this observation the shower room floor had broken tile which created sharp edges capable of causing injuries to residents' feet. During a concurrent interview and observation with Maintenance Staff E on 11/4/24 at 2:48 p.m., he stated pooling water in this particular shower room was an ongoing problem because hair accumulated in the drain. Maintenance Staff E stated he had been notified the water was backing up and not draining well in this shower about a month ago. Maintenance Staff E stated he cleared the hair out of the drain once a week. Maintenance Staff E stated the tile had been broken in this shower room for about a year. The Maintenance Staff E stated it had not been fixed because they were unable to find the same color of tile. Maintenance Staff E was observed pulling approximately six large chunks of hair out of the drain with a metal wire. During an interview on 11/4/24 at 3:26 p.m., Certified Nurse Assistant F (CNA F) stated she had been working at the facility for about six months and had noticed the water always backed up in the 400 hallway shower room. During an interview on 11/6/24 at 3:37 p.m., Maintenance Lead G stated the 400 hallway shower room was checked every 3-4 weeks but only when there was a work order request submitted and usually they just removed the hair from the drain. Maintenance Lead G confirmed they did not perform regular checks on this shower, but instead waited for a call order to check it. Maintenance Lead G stated there was nothing they could do to prevent this shower from getting clogged because residents' hair kept falling out. Maintenance Lead G stated the reason the broken tile was not repaired was because the facility had plans to remodel it. Record review of work orders from 9/30/24 to 11/4/24 indicated no work order was requested or completed on the shower room located in the 400 hallway of the facility. Record review of the facility policy titled, Environmental Safety, last revised in February 2015, indicated, It is the policy of the Company to provide residents with a pleasant, homelike, clean and healthy environment that assures quality of life and enjoyment as well las meeting their physical, emotional and safety needs.

Based on observation, interview and record review, the facility failed to ensure one of twelve sampled residents (Resident 19) wore her hearing aids daily to be able to communicate effectively with staff. This finding had the potential for Resident 19 to experience difficulty communicating with others and have feelings of isolation and loss of control. Findings: Record review of Resident 19's Face Sheet indicated she was admitted to the facility on [DATE] with medical diagnoses including cerebral infarction (a process that reduces blood flow to the brain). Record review of a care plan for Resident 19 indicated, Hearing Ability: Adequate with a device .Hearing Appliances: Left and Right Hearing Aid. During a concurrent interview and observation on 11/4/24 at 2:24 p.m., Resident 19 stated she could not understand the speech of the person conducting the bible studies at the facility. Resident 19 stated her hearing aids were not working, and she did not know what was wrong with them. Resident 19 stated she needed to work on having them checked out. At the time of this interview, Resident 19 was not observed wearing hearing aids, and had difficulty hearing, and she asked the Surveyors to remove their masks when speaking to her because she could not hear well. During a second observation on 11/5/24 at 2:38 p.m., Resident 19 was observed in the hallway of the facility not wearing her hearing aids. During a third observation on 11/6/24 at 1:30 p.m., Resident 19 observed in the hallway of the facility not wearing her hearing aids. During a concurrent observation and interview on 11/7/24 at 3:45 p.m., Resident 19 was observed not wearing her hearing aids in the hallway of the facility. Certified Nurse Assistant I (CNA I) confirmed the observation and stated morning shift should have put them on. CNA I went to Resident 19's room, found the hearing aids, and checked them for functionality. Once he was able to turn them on, he put them in Resident 19's ears. Resident 19 immediately started to understand much better and answer the Surveyor's questions appropriately. During an interview on 11/8/24 at 10:02 a.m., CNA J stated she was Resident 19's CNA on 11/7/24 during the morning shift. CNA J stated she attempted to assist Resident 19 in putting in her hearing aids but Resident 19 refused. CNA J stated she immediately notified the assigned licensed nurse of Resident 19's refusal to wear her hearing aids. Record review of progress notes for Resident 19 from 11/4/24 to 11/7/24 at 1:04 p.m., did not indicate Resident 19 had refused to wear her hearing aids from 11/4/24 to 11/7/24. Record review of the facility policy titled Sensory Disabled-Care of, last revised in April of 2017, indicated, Special care will be taken to ensure that the person with disabilities will be provided with the equipment and attention needed to assure comfort, improved well-being and dignity .Hearing impaired individuals frequently have speech problems .While giving a.m. (morning) care, prepare the hearing aid for the resident if the resident is too ill, forgetful or confused to do it themselves.

Based on interview and record review, the facility failed to ensure that one of two sampled contracted employees (Employee B) was provided with annual abuse training. This had the potential to result in inability for Employee B to avoid, identify, and report abuse timely, which could have resulted in actual episodes of employee to resident abuse, and violation of the abuse reporting requirements in Skilled Nursing Facilities (SNFs). Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Right Femur (Thigh bone) and Dysphagia (Difficulty swallowing) according to the facility Face Sheet (Facility Demographic). Record review of a report titled, REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE, received by the DEPARTMENT on 5/25/23 indicated Resident 1 verbalized Employee B had grabbed his nipples, during a nutrition consult. The report also indicated Employee B did not work for the facility directly, he worked for a company that was contracted by the facility. During a phone interview on 5/31/23 at 1:00 p.m., Employee B denied having inappropriately touched Resident 1 and stated he was trying to clean up Resident 1 after he vomited on his clothing during a swallow evaluation. Employee B was asked for the date he received his last abuse training prior to the incident with Resident 1. Employee B stated his abuse training was in February of 2022, during his new hire orientation. Record review of a written statement signed by Employee B on 5/31/23, indicated, I COMPLETED INITIAL PATIENTS RIGHTS TRAINING UPON HIRING BY [Name of contracted company employing Employee B) IN FEBRUARY, 2022. Record review of a report e-mailed by Administrative Staff A on 6/08/23 at 11:27 a.m., indicated Employee B received his last training on sexual harassment, abuse, neglect and dignity on 3/10/22. During a phone interview with the Director of Staff Development (DSD) on 6/02/23 at 12:05 p.m., she was asked who was responsible for ensuring contracted individuals received their annual abuse training. The DSD stated she kept track of the facility's employee-required trainings, but not for contracted employees. The DSD stated not knowing the answer to this question. Record review of an email sent to Administrative Staff A by the Surveyor on 6/05/23 at 1:32 p.m., the Surveyor asked Administrative Staff A who was responsible for ensuring contracted staff received their annual abuse training. Administrative Staff A responded to this e-mail on 6/08/23 at 11:16 a.m., in which she indicated, [Name of contracted company employing Employee B] is responsible for maintaining compliance with required annual abuse trainings. Record review of the facility policy titled, Abuse and Incident Reporting-SNF California, last revised in May of 2023, indicated, It is the policy of the Company to protect the rights, safety and well-being of each resident (regardless of physical or mental condition), for whom we provide care and treatments against any and all forms of physical , verbal, sexual and metal abuse .Staff will receive education on physical, verbal, sexual and metal abuse .Training will occur at hire and orientation of new employees and annually thereafter.

Based on interview and record review, the facility failed to treat 3 of 5 residents (Resident 1, Resident 3, and Resident 4) with respect and dignity when Licensed Nurse W spoke in an unfriendly, angry, or hostile manner to Resident 1 and Resident 3 and ignored Resident 4's request. This failure resulted in Resident 1 feeling shamed, Resident 3 feeling anger directed at her and Resident 4 feeling ignored. Findings: A review of Resident 1's quarterly Minimum Data Set (MDS - This process provides a comprehensive assessment of each resident's functional capabilities) dated 2/13/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - tool used to screen and identify cognition) score of 11 which indicated he was moderately impaired. During an interview on 5/4/24, at 11:26 a.m., in Resident 1's room, the resident stated he sometimes felt Licensed Nurse W (LN W) was not in the mood while working. Resident 1 stated LN W would sometimes respond to him in an angry tone, her facial expression not encouraging interaction. Resident 1 described LN W as suplada (Tagalog term for women who are not very friendly, snobbish, or unapproachable) and would feel ashamed. Resident 1 thought it might be a joke to LN W, but it sounded rude to him. A review of Resident 3's Admission MDS dated [DATE], indicated she had a BIMS score of 14 and was cognitively intact. During an interview on 5/4/24, at 12:05 p.m., Resident 3 stated LN W was almost always rude and sounded like she did not like her job. Resident 3 stated LN W would answer in short one or two words and sounded hostile. Resident 3 was upset and stated that she told someone to not assign LN W to her. Resident 3 stated she felt like LN W had something against her and did not like her. Resident 3 stated when she spoke with LN W, LN W would stand by the door and seemed like she did not want to be near Resident 3. A review of Resident 4's quarterly MDS dated [DATE], indicated Resident 4 had a BIMS score of 14 which indicated he was cognitively intact. During an interview on 5/4/24, at 2:30 p.m., Resident 4 stated he knew LN W and stated he had called the nurses station one night to request to have his dinner tray removed from his room. LN W answered and had hung up the phone on him. Resident 4 stated later, in the hallway, he again requested to have his tray removed and LN W ignored him. A review of the facility ' s policy on Resident rights last reviewed on 2/2022 indicated, it is the policy of the Company to assure residents the right to a dignified existence, self-determination, and communication . A review of the copy of the Resident Bill of Rights provided each resident on admission to the facility indicated the rights of a patient under the California Code of Regulations Title 22, to be treated with consideration, respect and full recognition of dignity and individuality .

Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 1), copies of medical records pertaining to herself, within two working days. The medical records were delivered to the resident 14 days after she signed a written request for them. This failure had the potential to result in inability for the resident to advocate for her care, provide the records to other medical providers for continuity of care, and frustration for Resident 1. Findings: Record review of the facility Face Sheet (Facility Demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Fracture of Left Femur (Thigh bone) and Asthma (A disease that causes the airways of the lungs to swell and narrow, making it difficult to breathe). Record review of Resident 1 ' s MDS (Minimum Data Sheet-An assessment tool) dated 10/21/22 indicated her BIMS (Brief Interview of Mental Status-A cognition [ the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 15, which indicated her cognition was intact (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). During a phone interview on 2/27/23 at 9:35 a.m., Resident 1 stated she stayed at the facility for three weeks, while recovering from a fracture she suffered at home. Resident 1 stated she visited the facility in early February of 2023 to request her medical records and was asked to sign a release of information form. Resident 1 stated she wanted the results of the blood tests that were performed while she was living at the facility. Resident 1 stated she requested the records to be e-mailed to her, but the records she requested still had not been delivered. Record review of a facility document titled, REQUEST TO ACCESS HEALTH RECORDS, dated 2/14/23, indicated, I, [Resident 1] hereby make the following request with respect to health records in the possession of [Name of facility] for the period 10/7/23 to 10/22/23 .Receive an electric (Sic) copy of health records. This document had Resident 1 ' s signature on it. During a concurrent interview and record review with Medical Records Director (MRD) on 2/28/23 at 11:15 a.m., he confirmed Resident 1 came to the facility on [DATE] and signed a request for her medical records. MRD stated he sent Resident 1 ' s request to Corporate Risk Manager A, who in turn, sent the request to a facility attorney to provide the requested records to Resident 1. MRD stated he had been following up on the request with Corporate Risk Manager A, and provided the chain of e-mails, but explained he had not received a response to his last e-mail sent to the Corporate Risk Manager A on 2/24/23 at 1:12 p.m. MRD stated he was not aware that Resident 1 had received her records yet. During an interview with Administrator in Training (AIT) on 2/28/23 at 11:30 a.m., she stated Resident 1 still had not been provided with the records she requested on 2/14/23. AIT stated the medical records should have been provided to Resident 1 within 48 hours, and she did not know the reason it took longer. AIT attempted to contact Corporate Risk Manager A by phone, and found out she was on vacation until 3/13/23. Record review of an e-mail sent by AIT to the Surveyor on 2/28/23 at 5:26 p.m., indicated Resident 1 ' s requested medical records had just been e-mailed to her (14 days after Resident 1 signed a written request for her medical records). Record review of the facility policy titled, Clinical Record: Copying/Printing, dated 2023, indicated, It is the policy of the Company to make/print copies of the resident ' s clinical record when a valid request, written or verbal, has been received, and according to Medical Record Privacy and HIPAA (Health Insurance Portability and Accountability Act-A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) Guidelines .Upon written request from the resident or the resident ' s legal guardian .the Clinical Record Coordinator will respond to the request within 24 hours or two working days.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 188) from an air mattress that deflated, when the facility was aware that these air mattress types had a risk of deflating. This failure resulted in Resident 188 falling out of bed, and sustaining a right thigh bone fracture. Resident 188 was transferred to the hospital and passed away nine days later. Findings: Review of Resident 188's Admission Record indicated Resident 188 admitted to the facility in May 2021 with diagnoses including heart disease and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 188's Minimum Data Set (MDS, an assessment tool), dated 10/26/22, indicated Resident 188 had short and long-term memory problems, and her cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 188 required extensive assistance from two people for bed mobility (how a resident moves to and from a lying position, turns side to side, and positions their body while in bed). Review of a fall risk assessment for Resident 188, dated 10/28/22, indicated Resident 188 had a high risk for falls. Review of Resident 188's Fall Risk Care Plan, with a revision date of 12/8/22, indicated the following interventions: Assist Resident with ambulation and transfers, utilizing therapy recommendations . Determine Residents ability to transfer . Evaluate fall risk on admission and PRN [pro re nata, a Latin term to mean as needed] . If fall occurs, alert provider . If fall occurs, initiate frequent neuro [neurological, brain function] and bleeding evaluation per facility protocol . If Resident is a fall risk, initiate fall risk precautions. Review of a nursing progress note for Resident 188, dated 12/28/22, at 5:14 a.m., indicated, Resident found sitting on the floor in the corner of her room . The top half of her air mattress was deflated . Mattress was inflated, and resident was assisted back into bed . Resident unable to tell nurse what happened, just that she fell and needed help . Review of a nursing progress note for Resident 188, dated 12/28/22, at 5:50 a.m., indicated, . spoke to [family member] and informed her of fall and R [right] leg pain. She stated that she would like her [family member] sent out to make sure she did not break a bone. [Physician] was called, was given order to send out resident for further evaluation and xray per family request . paramedics arrived around 05:50 [a.m.] and transported resident to [name of hospital]. Review of Certified Nurse Assistant (CNA) 1's documentation of care provided to Resident 188 between 10 p.m. on 12/27/22 to 6 a.m. on 12/28/22 indicated the following: 1. Turning and repositioning at least every 2 hours: CNA 1 documented at 5:59 a.m. NA [Not Applicable] for 11:30 p.m., 1:30 a.m., 3:30 a.m., and 5:30 a.m.; 2. Bladder Elimination: Between 10 p.m. and 6 a.m., CNA 1 documented 1 [bladder incontinence] at 5:59 a.m.; and, 3. Bowel Elimination: Between 10 p.m. and 6 a.m., CNA 1 documented 1, M [bowel incontinence, bowel movement medium in size] at 5:59 a.m. Review of Resident 188's hospital xray report of her right pelvis, hip and knee, dated 12/28/22, indicated a right femoral (thigh) fracture. Review of a hospital document for Resident 188 titled, Discharge Summary and Death Certificate, dated 1/7/23, indicated Resident 188 passed away at the hospital on 1/7/23, at 10:25 a.m. The document indicated the immediate cause of death was due to the right thigh bone fracture. The document indicated underlying causes were sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death) from a urinary tract infection, atrial fibrillation (a rapid, irregular heart beat that can lead to blood clots in the heart.), and dementia. Review of a letter from the facility to The Department, dated 1/18/23, indicated, Investigation of fall: After further investigation, it was determined that the un-witnessed fall could potentially be related to the deflated air mattress. [Name of manufacturer] air mattress was in use by facility and tubing appeared to be unattached thus causing the air mattress to deflate. Tubing could have become unattached for the reason that the O rings were not in use. During and interview with Licensed Nurse (LN) D on 1/24/23, at 4 p.m., LN D stated Resident 188 was totally dependent on staff to move in bed. LN D stated she was Resident 188's nurse when the resident had her fall the morning of 12/28/22. LN D stated she found Resident 188 on the floor, at the head of the right side of her bed, leaning up against the wall. LN D stated she found the top half of Resident 188's air mattress completely deflated and the tube was not attached to the mattress. LN D stated the air mattress did not alarm when the tube detached from the mattress. LN D stated Resident 188 was not complaining of pain until she was placed back in her bed. During a concurrent observation and interview on 1/25/23., at 11:25 a.m., with the Director of Staff Development (DSD) and Resident 35 in the resident' s room, Resident 35 was observed sitting in a chair next to his bed. The bed had an air mattress with three tubes that were attached at the bottom of the mattress and to an electric pump at the foot board. The DSD stated the air mattress on Resident 35's bed was the same kind that was on Resident 188's bed. When asked if his mattress ever deflated, Resident 35 stated, once, while he was sitting in his chair next to the bed, the tube spontaneously popped away from the valve and the top half of his mattress deflated. Resident 35 stated he told maintenance and the maintenance man reattached the tube and re-inflated the bed. During an interview with the Director of Maintenance (DM) on 1/25/23, at 11:40 a.m., the DM stated he and his partner would set up the air mattresses on residents' beds. The DM stated they did not receive training from the manufacturer on the set up and functioning of the mattress, but found the air mattress self-explanatory. The DM stated the connection between the tubes and the mattress was secured by o-rings. The DM stated the o-rings would degrade over time from repeated exposure to heat, and would eventually disintegrate, which would make it easier for the tubes to detach from the mattresses. During an interview with CNA 1 on 1/25/23, at 11:50 a.m., CNA 1 stated she was Resident 188's CNA when the resident fell on [DATE]. CNA 1 stated she went into Resident 188's room at approximately 4 a.m. to turn the resident to her right side. CNA 1 stated the mattress was inflated. CNA 1 stated she returned to Resident 188's room at approximately 5 a.m. and found the resident on the floor to the right side of her bed, and the mattress was deflated. CNA 1 stated it took four staff members to lift Resident 188 back into bed. CNA 1 stated Resident 188 started complaining of pain once she was placed back in her bed. During a follow-up interview with the DM on 1/27/23, at 10:55 a.m., the DM stated the tubes would detach from the mattresses often. The DM stated he imagined staff would reattach the tubes to the mattresses independently and would not involve maintenance by submitting work orders. The DM stated tubes would likely detach when staff would touch them when tucking linen under mattresses, or when staff would move beds. The DM stated the staff was not trained to inspect the o-rings before re-attaching a tube. The DM stated he did not routinely inspect the air mattresses once they were on the residents' beds. The DM stated he would inspect the air mattress o-rings when he was responding to a work order submitted by staff. The DM stated he would replace o-rings from the mattresses that were in storage. The DM stated he and the Administrator tried several times to contact the manufacturer to order additional o-rings months before Resident 188's fall on 12/28/22. The DM stated the manufacturer did not reply back until after Resident 188's fall. During an interview with the Director of Nursing (DON) on 1/27/23, at 12 p.m., the DON stated she expected Licensed Nurses and Certified Nurse Assistants to check for the placement and functioning of air mattresses each shift. The DON stated she expected nursing staff to troubleshoot issues, but, if not able to fix an issue, she expected the staff to remove the air mattress and submit a maintenance work order. The DON stated she would not expect the nursing staff to know about o-rings. The DON stated the fall prevention interventions for a resident who was totally dependent on staff for bed mobility were increased rounding, frequent checks to anticipate their needs, and increase frequency of incontinence or toileting. Review of a facility policy and procedure titled, Fall Reduction and Management Program, revised date 2/21, indicated, It is the policy of this Facility that every effort be made to reduce and/or prevent falls from occurring and/or minimizing serious injury if a fall should happen.

Based on observation, interview and record review, the facility did not ensure outdated drugs and biologicals were disposed of properly, when: 1. Two bottles of expired house stock medications (Over-the-counter medications) were found in the facility's medication room stored with other active house stock medications. This had the potential to result in inadvertently administering expired medications to the residents of the facility, which could have caused them harm, or lack of medication therapy. 2. Three controlled medications (Substances regulated by Federal law) were found in the facility's medication carts for two residents that had been discharged more than one week prior to the observation (Resident 139 & Resident 26), stored with other controlled drugs. This had the potential to result in drug diversion among facility staff. 3. Several expired blood collection lab tubes and intravenous tubing (For administration of fluids and medications through a person's veins) were found in the facility medication room. This had the potential to result in inaccurate and contaminated lab readings, and infections to the residents on intravenous therapy using the expired tubing. Findings: 1. During a concurrent observation and interview with the Director of Nursing (DON) on 1/23/23 at 9:56 a.m., it was observed the facility had a special container for discarding expired and outdated medication. The DON stated outdated medications were supposed to be placed in that container for destruction. During a concurrent observation and interview on 1/23/23 at 10:44 a.m., two bottles of expired over-the-counter eye vitamins and supplements were observed stored with other active house stock medications. These bottles were unopen and had an expiration date of 12/2022. This was confirmed by the Resident Care Manager, who was present during the observation. 2. During an interview on 1/23/23 at 10:09 a.m., the Director of Staff Development (DSD) was asked how the facility discarded outdated controlled medications. The DSD stated Licensed Nurses were supposed to keep outdated controlled medications in the controlled medication cabinet inside the medication carts until they could give the medications to the DON for destruction since the DON was the only staff member with the key to the narcotic lock inside the medication room. The DSD stated the DON and Pharmacist destroyed controlled medications together. During a concurrent observation and interview on 1/23/23 at 11:03 a.m., twelve prefilled syringes, each containing 5 mg (Milligrams) of Morphine Sulfate (A controlled narcotic medication used to treat moderate to severe pain) for Resident 139 were found in the medication cart stored with other active controlled medications for other residents. In addition, seven tablets of Lorazepam (A controlled medication used to treat anxiety disorders) 0.5 mg were also found in the medication cart for Resident 139. Licensed Nurse B, who was assigned to this medication cart, stated Resident 139 was no longer at the facility. Licensed Nurse B stated floor nurses were supposed to let the DON know that Resident 139 still had medications in the medication cart. Licensed Nurse B stated she believed she had notified the DON already about these medications but would mention it again. Record review of a Discharge Note dated 12/29/22 at 7:27 p.m., indicated Resident 139 was discharged from the facility on 12/29/22. During a concurrent observation and interview on 1/23/23 at 2:44 p.m., seventeen tablets of Diazepam (A controlled medication used to treat anxiety disorders) 10 mg, and a bottle containing 26.5 ml (milliliters) of Morphine Sulfate (100 mg per 5 ml) were found in the controlled cabinet of another medication cart, prescribed for Resident 26. Licensed Nurse C, who was assigned to this medication cart, stated those medications belonged to Resident 26, who had passed away on 1/12/23. Licensed Nurse C stated the medications were supposed to stay in the medication cart until the pharmacist came to the facility to pick them up. When asked how the pharmacist would know to pick them up, if the medications did not indicate the resident (for whom they were prescribed) had passed away. Licensed Nurse C stated Licensed Nurses were supposed to notify the pharmacists verbally to pick up the outdated controlled medications. Licensed Nurse C stated the pharmacist came to the family about once per month. During an interview on 1/27/23 at 8:49 a.m., the Administrator in Training (AIT) stated Licensed Nurses were required to give the outdated controlled medications to the DON for her to place inside a locked cabinet inside the medication room, for future destruction with the pharmacist. 3. During a concurrent observation and interview on 1/23/23 at 10:21 a.m., with the DSD and DON present, several blood collection tubes for lab tests were found to have expired on 10/31/22. This was confirmed by the DSD. The DSD stated they were only used for STAT (immediate) lab draws as the laboratory they were contracted with, for regular lab draws, used their own supplies. These blood collection tubes were stored with other active blood collection tubes. In addition, a bag full of intravenous extension sets (Intravenous tubing) with an expiration date of 4/30/22 were also found in the medication room. The DSD stated the facility did provide intravenous (IV) therapy. During an interview on 1/27/23 at 8:49 a.m., the AIT stated Licensed Nurses were supposed to be checking the medication room to ensure they were discarding expired items. When asked if they had a system in place to ensure this was being done, the AIT stated she did not know. During an interview on 1/27/23 at 11:35 a.m., the AIT was asked to provide a policy on expired medical equipment such as IV tubing and blood collection tubes. The AIT stated she could only find a policy titled, Medical Device Reporting (Lock Out/Tag Out). This policy did not talk about disposition of expired IV tubing or blood collection tubes. Record review of the facility policy titled, Medication Administration: Disposition of Discontinued Medications last revised in February of 2021, indicated, Expired, deteriorated or unwanted controlled substances shall be destroyed by means that will assure protection against unauthorized possession or use .Discontinued medications include physician-ordered discontinued medications (prescription and/or over-the-counter (OTC), medications remaining in the facility after resident is discharged or deceased , expired medications and out-of-date house stock medications .All discontinued medications must be stored under lock and key and logged appropriately before destruction in facility or pharmacy .Give the discontinued medications to the person in charge of destroying the medications .Give the discontinued controlled medication or narcotic to Director of Nursing (DON).

Based on interview and record review, the facility failed to ensure an abuse allegation for one of six sampled residents (Resident 14) was reported to the required authorities within the appropriate timeframes established by the Federal regulations. This failure had the potential to result in financial abuse, frustration and emotional harm for Resident 14. Findings: Record review indicated Resident 14 was admitted to the facility on [DATE], with medical diagnoses including Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible), according to the facility's Face Sheet (Facility demographic). Record review of Resident 14's MDS (Minimum Data Set-A resident assessment tool) dated 12/16/22, indicated her BIMS (Brief Interview of Mental Status-A cognition assessment) was 13, which indicated her cognition was intact. Record review of a report sent by the facility's Administrator in Training (AIT) to the Department on 1/18/23 indicated, Resident [Resident 14] reported to a health service manager that daughter is taking her money and she is scared .Resident states that she does not have a good relationship with this daughter and would like to sue her daughter for her money back. During an interview on 1/23/23 at 11:11 a.m., Resident 14 was observed to be very upset, with tears rolling down her face. Resident 14 stated, I can't take this anymore. Resident 14 stated one of her daughters had taken all her money, her entire life's savings, without her consent. Resident 14 explained that her daughter had taken funds from her bank account. During an interview on 1/24/23 at 4:05 p.m., the AIT stated she was told by Resident 14 her daughter took away her personal phone and was taking money from her bank accounts. The AIT stated she spoke to the Activities Director about this issue, and found out the Activities Director was aware of this allegation already, but she had not reported this abuse allegation to the authorities because Resident 14 suffered from dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). During another interview on 1/24/23 at 4:30 p.m., the AIT stated she was initially notified by Resident 14 of this abuse allegation on 1/16/23, and on 1/17/23 she notified the Department. AIT stated she then also notified the long-term-care Ombudsman and the police department. Record review of an Activities Note documented by the Activities Director on 5/03/22 at 12:10 p.m., indicated, Yesterday morning and today [Resident 14] has come to me very upset, crying, reporting that her daughter has taken all her money and sold her house. She has expressed to me that she wants to file a police report. She was inconsolable. Eventually I was able to convince her that she doesn't have to worry about a bill here, that she is on MediCal (California Medicaid, a Federal and State program that helps with healthcare costs for some people with limited income and resources) and it pays for her stay. She came back all day long yesterday and again this morning stating the same issues: that her money was taken by her daughter and her house was sold without her consent. During an interview on 1/24/23 at 4:37 p.m., with the Director of Staff Development (DSD), and Administrator present, the Activities Director stated she had been working for the facility since 2018 and received abuse training every year. The Activities Director stated she was aware she was a mandated reporter (a person who, because of his or her profession, is legally required to report any suspicion of abuse or neglect to the relevant authorities.) The Activities Director confirmed writing the note on 5/03/22 at 12:10 p.m., in which Resident 14 discussed that her daughter was taking her money and she wanted to file a police report. The Activities Director stated she told the previous Director of Nursing, who no longer works for the facility, and the Social Services Director about Resident 14's allegation, and the consensus was that she had dementia and did not know what she was talking about. The Activities Director confirmed she did not report this allegation to required authorities and did not call the police for Resident 14 to file a police report. The DSD was asked if the facility needed abuse to be confirmed in order to report it to the required authorities, and she stated, No. The Administrator was asked if he was aware of this abuse allegation made by Resident 14 in May of 2022. The Administrator stated he was not. During an interview with the Social Services Director on 1/25/23 at 3:37 p.m., she stated the Activities Director may have mentioned in a meeting that Resident 14 stated somebody was taking her funds, but it was not until recently that she was made aware of the whole situation. During an interview on 1/27/23 at 8:46 a.m., the AIT stated all staff were mandated reporters, and they should immediately notify the healthcare team of abuse allegations made by residents, notify CDPH (California Department of Public Health), law enforcement, the long-term care Ombudsman and Adult Protective Services. Record review of a facility policy titled, Abuse and Incident Reporting-SNF (Skilled Nursing Facility) California last revised in January of 2020, indicated, The facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reporting (Sic) appropriately and timely in accordance with Federal and State requirement .Per the Elder Justice Act, if the reportable event does not result in serious bodily injury, the staff member shall report the suspicion no later than 24 hours after forming the suspicion .Mandated Reporter must notify the Ombudsman or local law enforcement IMMEDIATELY by telephone .Facility must notify the Department of Health and Ombudsman by submitting a written report SOC #341 (Name of report) within 2 working days.

Based on observation, interview and record review, the facility failed to post the required daily staffing information timely per the Federal regulations for Skilled Nursing Facilities. This had the potential to result in the inability for residents and visitors to determine if the facility was having staffing shortages, for advocacy purposes. Findings: During a concurrent observation and interview on 1/23/23 at 9:38 a.m., it was noted that the daily staffing information posted in the facility nursing station contained the daily posting from the day before, 1/22/23. There were no staffing postings for 1/23/23 with the current staffing information. Licensed Nurse A, who was present during the observation, confirmed the staffing posting was from yesterday. She stated the front desk clerk was supposed to bring the new one. During an interview on 1/26/23 at 1:39 p.m., Unit Manager D stated visitors were allowed in the facility typically at 9:00 a.m. but sometimes earlier. She stated the Unit Manager Assistant, was supposed to have posted the staffing information for 1/23/23 the night of 1/22/23 but she must have forgotten. She stated the staff member who usually did this was on medical leave at the present time. Record review of the facility policy titled, Postings-Required for SNF (Skilled Nursing Facility) last revised in January of 2023, indicated, It is the policy of the Company to post information according to state specific and federal guidelines for Skilled nursing .Information to be posted will include, but not be limited to, the following: 10. Daily staffing as required by State and Federal regulations .The facility will post the following staffing information on a daily basis: A. The facility name. B. The current date. C. The total number and actual hours worked of direct care staff per shift .The facility will post the nurse staffing data on a daily basis at the beginning of each shift.

Based on interview and record review, the facility failed to ensure interventions to help prevent exposure and spread of COVID-19 were implemented when: 1. A registry staff (Unlicensed Staff A) that tested positive for COVID-19, did not complete the COVID-19 screening tool prior to starting her shift on two occasions, and; 2. The facility did not notify a [CONDITION(S)] clinic and transportation agency that a resident of the facility (Resident 3) that used the services of these companies, that he had been exposed to COVID-19. These failures could have contributed to exposure of COVID-19 to the residents of the facility, resulting in two residents (Resident 1 and Resident 2) contracting the virus. These failures also had the potential to result in spread of COVID-19 in the community. Findings: 1. The DEPARTMENT received an e-mail from Health Care Manager B on 4/30/21 at 2:53 p.m., indicating a registry staff they had used for several days had tested positive for COVID-19. During an onsite visit on 5/04/21 at 9:00 a.m., Health Care Manager B stated that on 4/30/21 they received notification that a registry Certified Nursing Assistant (Unlicensed Staff A) had tested positive for COVID-19 during a test performed on 4/28/21. According to Health Care Manager B, Unlicensed Staff A had worked the night shift on 4/26/21 and 4/27/21 at the facility. Health Care Manager B stated Unlicensed Staff A was also scheduled to work the night shift of 4/28/21 but called off, and was tested for COVID-19 that same day, which resulted in the positive test. Health Care Manager B stated Unlicensed Staff A had told her she had not received the COVID-19 vaccine, but the reasons were unknown. Health Care Manager B stated not knowing the last time Unlicensed Staff A was tested for COVID-19, prior to her positive test on 4/28/21. During an interview with Health Care Manager B on 5/04/21 at 9:15 a.m., she stated that immediately after they were notified Unlicensed Staff A had tested positive for COVID-19, they conducted contact tracing, and tested all residents Unlicensed Staff A had contact with, for COVID-19. Health Care Manager B stated two residents (Resident 1 and Resident 2) tested positive for COVID-19 after they were assigned to Unlicensed Staff A the nights of 4/26/21 and 4/27/21. Test reports for Resident 1 and Resident 2 indicated they both tested positive for COVID-19 on 4/30/21. During an interview with Health Care Manager B on 4/04/21 at 11:05 a.m., she stated Unlicensed Staff A had not completed the screening tools (Facility forms inquiring for COVID-19 symptoms, which included a temperature check) during her shifts on 4/26/21 and 4/27/21. Health Care Manager B stated the facility's Administrative Assistant and herself reviewed the screening tools and document titled, COVID-19 ENTRY TO CARE CENTER LOG, to ensure Unlicensed Staff A had completed her COVID-19 screening prior to her shifts, and could not find evidence she completed it. The facility document titled, COVID-19 ENTRY TO CARE CENTER LOG, for 4/26/21 and 4/27/21 had an area to write the first and last name of the person completing the screening tool, and the date. The name of Unlicensed Staff A was not present for 4/26/21 or 4/27/21, which indicated she had not completed the screening tools. During an interview with Health Care Manager on 5/06/21 at 11:07 a.m., she was asked about the facility's process to ensure night shift staff completed their COVID-19 screening tools. Health Care Manager stated they collected the screening tools and scanned them into the records but did not cross check them to ensure all night shift staff had completed them. The facility policy titled, Screening for COVID-19, last revised in August of 2020 indicated, It is the policy of the Company to conduct screening for COVID-19 as a means of detection and prevention of introducing COVID-19 into the community .Circumstance Requiring Screening .3. Staff Screening Tool Upon arrival for every shift-Prior to beginning work. 2. During an interview on 5/04/21 at 10:38 a.m., Health Care Manager B stated the facility had one resident (Resident 3) that left the facility three times per week for [CONDITION(S)] appointments. Health Care Manager B was asked if this resident had direct contact with Unlicensed Staff A, who tested positive for COVID-19 on 4/28/21, the nights of 4/26/21 or 4/27/21 for night shift. Health Care Manager B reviewed some facility documents, and confirmed Resident 3 had contact with Unlicensed Staff A during those nights, but stated Resident 3 had been tested for COVID-19 after this contact and tested negative. A nursing note dated 4/30/21 at 7:18 p.m., indicated, Resident [Resident 3] was administered a Covid 19 nasal swab PCR (Polymerase Chain Reaction-Type of COVID-19 test) test due to possible exposure to positive exposure(sic-repeated statement) to staff member. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Transportation: [Name of transportation agency]. During an interview with the DON (Director of Nursing) on 5/04/21 at 10:45 a.m., she was asked if Resident 3 had attended his [CONDITION(S)] appointments for the week of 5/03/21. The DON stated Resident 3 went to [CONDITION(S)] on 5/03/21. The DON was asked if the facility had informed the [CONDITION(S)] clinic or transportation agency of Resident 3's recent possible exposure to COVID-19. The DON stated they did not. During an interview on 5/04/21 at 11:25 a.m., Health Care Manager B was asked if the facility had a policy for communicating possible COVID-19 exposures with other medical facilities or transportation agencies. Health Care Manager B stated the facility did not have a policy on that subject. The CDC (Centers for Disease Control and Prevention-National public health agency of the United States) article titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (Severe acute respiratory syndrome coronavirus 2 of the [NAME] Betacoronavirus) Spread in Nursing Homes updated on 3/29/21 indicated, For residents going to medical appointments, regular communication between the medical facility and the nursing home (in both directions) is essential to help identify residents with potential exposures or symptoms of COVID-19 before they enter the facility so that proper precautions can be implemented.

Based on observation, interview and record review facility staff failed to promote care in a manner to enhance dignity and respect for 1 of 4 residents (Resident 1), when Certified Nursing Assistant (CNA) A continued to provide incontinent (inability to control bladder) care after Resident 1 told him to stop and stated CNA A was raping her. This failure resulted in Resident 1 being exposed to continued fear and anxiety, when staff did not respond to Resident 1's cry for help. CNA A returned to Resident 1's room later that evening which frightened Resident 1and which Resident 1 stated made her feel helpless and fear for her safety. Findings: During an interview on 11/2/16 at 8:30 a.m., with the Administrator and Licensed Nurse (LN) B, the Administrator stated Resident 1 had reported to visiting family on 11/1/16, that Certified Nursing Assistant (CNA) A had raped her during the night on 10/31/16. The Administrator stated CNA A had stated, during the facility internal interview, Resident 1 said stop, you're raping me. The Administrator stated CNA A continued to change the incontinent brief (designed for adult incontinent use) and did not stop and should have when Resident 1 said stop. LN B stated, during an interview with CNA A, CNA A indicated he was just doing his job, that he had to finish changing her. LN B stated, even though Resident 1 clearly told CNA A to stop he did not, and CNA A did not report it to staff on the evening shift (3 p.m. to 11 p.m.). LN B stated upon return from the emergency room with Resident 1 the police officer and LN B asked Resident 1 if she felt safe and Resident 1 indicated she felt safe but had a bad experience. During an observation and concurrent interview on 11/2/16 at 10:05 a.m., Resident 1 was in bed with Family Member 2 at the bedside. Resident 1 stated on 10/31/16, during the night, while she was asleep, CNA A came into the room and ripped the blanket off her and got on top of her and held down her arms. Resident 1 sated she tried to fight him off by hitting CNA A and cried out for help, but no one responded, and stated her roommate was asleep with her hearing aides out so she could not hear and didn't respond. Resident 1 stated she felt helpless, frightened and that CNA A returned later that night and tried to apologize. She stated she was so frightened and just wanted him away from her. Resident 1 stated she still did not feel safe and it was a horrible experience, felt so helpless, and it will take a very long time to recover from this. Family Member 2 stated Resident 1 had relayed the same story to her and the social service person who had just finished interviewing Resident 1. Family Member 2 stated even after staff assured Resident 1 that CNA A was not there and only female caregivers would take care of her, Resident 1 continued to state she was afraid and felt helpless. Family Member 2 stated, its such a shame, she is on hospice (a program of medical and emotional care for the terminally ill). Family Member 2 also stated Resident 1 kept commenting that it would take a very long time to get over this horrible experience. During a record review on 11/2/16 at 9:30 a.m., the Emergency Department Report, dated 11/1/16, indicated physician's [DIAGNOSES REDACTED].Based on the patients presentation to the ER (emergency room ) today, the general diagnostic impression is reported assault. At this time I see no obvious life-threatening injuries . From the emergency department standpoint, the patient is safe for discharge and the rest of the evaluation will be left up to the evaluating officer . During an interview on 11/2/16 at 11 a.m., Social Service (SS) C stated Resident 1 had been interviewed about the rape allegation earlier that morning. SS C stated Resident 1 stated CNA A came into the room in the middle of the night while she was sleeping and reported he raped me. When SS C asked Resident 1 what happened Resident 1 stated he ripped the cover (blanket) off her and got on top of her. When asked how he got on top of her, SS C stated Resident 1 stated he just did, when asked what CNA A was doing Resident 1 told SS C that she was hitting him and he tried to penetrate her and got off her when she kept hitting him. SS C stated that Resident 1 told her that CNA A returned with a handful of Kleenex with poop on them and he changed her diaper. When SS C asked Resident 1 if she was afraid SS C stated Resident 1 stated yes, but not really now. During a record review, on 11/3/16 at 11:25 a.m., CNA A's documented statement, dated 10/31/16, indicated: .I told her I need to change you or can I just check if your (sic) dry so that I don't have to change you, then while I'm doing care she said to me you are rapping (sic) me, and I told (Resident 1) I'm just helping you to get change and put pad on her bottom and I'm just doing my job. I did not report this to anybody because I was busy and their (sic) still have a patient to help get on bed so I'm rushing and I did not think about it to report. During an interview on 1/9/17 at 2:40 p.m., Police Officer D stated the police determined that alleged rape of Resident 1 was unfounded, and that CNA A did not stop when Resident 1 told him to stop. Resident 1's annual History and Physical, dated 4/21/16, indicated Resident 1 was enrolled in hospice care for Stage 4 [MEDICAL CONDITION]. The annual Minimum Data Set (MDS, a resident assessment and evaluation tool), dated 9/12/16, indicated the Brief Interview of Mental Status (BIMS) score of 14 (score of 13-15 indicates cognitively intact). A Care Plan entitled Psychosocial Well-Being dated 11/2/16, indicated the problem of psychosocial well-being is impaired related to emotional distress and included interventions of provide emotional support, only female caregivers, and Social Services to provide support if feelings of emotional distress.

Based on staff interview, clinical record review, and facility document review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accident when: 1) The facility failed to ensure adequate supervision to prevent falls for one of 14 sampled residents (Resident 9) with a history of multiple falls, when staff left the resident unattended in the restroom. This failure resulted in Resident 9 sustaining a fall with a hip fracture. 2) Staff did not follow the facility Fall Protocol when they failed to complete a post fall evaluation for two of 14 sampled residents (Resident 3, 8) after a fall and staff did not update the Fall Risk Care Plan for one of 14 sampled residents (Resident 3) after a fall which placed residents at risk for further falls and potential for injury. 3) Silver Cream used for polishing jewelry was located on the shelf beside the sink in a shared bathroom where one of the roommates with a [DIAGNOSES REDACTED]. 4) The patio had uneven cement walking paths and drop off points of 2 to 6 inches from the cement paths to the actual ground surrounding the path which created a fall hazard and potential for injury. Findings: Review of Resident 9's facesheet (a patient summary sheet which includes contact details, and a brief medical history), indicated Resident 9 was admitted on [DATE], for rehabilitation care with multiple [DIAGNOSES REDACTED]. During an interview on [DATE] at 1:13 p.m., Licensed Staff T stated Resident 9 used the recliner with tab alarm (features a pull string that attaches magnetically with garment clip to the resident. When the resident attempts to rise out of the chair the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver) and pad alarm (a quick alert pressure-sensing safety alarm placed on the resident's bed, wheelchair seat or recliner which alerts when the resident attempts to rise out of the chair or bed). Review of Resident 9's MDS (Minimum Data Set, an assessment tool) admission assessment, dated [DATE], the functional status indicated Resident 9 required limited assistance with bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene. Review of Nurses Notes, dated [DATE] at 1:25 a.m., indicated Resident 9 had a fall from the recliner and incurred a scalp laceration requiring treatment at the emergency room and three staples to close the head wound. New interventions added to the Short Term Care Plan were to encourage the resident to always call for assistance for transfers, ambulation, and tab alarm in geri-chair (or geriatric chair - a positioning chair, designed to have multiple reclining and upright positions to maximize comfort). A post fall evaluation, dated [DATE], of Resident 9's functional status indicated the resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with transfers and limited assistance with contact guard assist with ambulation. Assistive devices used by the resident included walker and wheelchair. During an interview on [DATE] at 9:55 a.m., Rehab Director V, when asked to differentiate between stand by assist and contact guard assist, stated with contact guard assist, the resident was a little more declined, and the caregiver has a hand on the patient, but not helping. Review of Nurses Notes, dated [DATE] at 8:30 a.m., Resident 9 had a second fall in his room and was found sitting on the floor with a skin tear on his left hand. New interventions added to the short term care plan were for continuous frequent visual check and offer for assist, tab/pad alarm on, non-skid pad placed in the geri chair recliner, continue reminding resident to always call for assistance and call light within reach at all times. A post fall evaluation, dated [DATE], of Resident 9's functional status indicated the resident now required one person assist (physical assist) for bed mobility and transfers and required front wheel walker with contact guard assist for ambulation. The post fall evaluation requiring one person assist for bed mobility and transfers and contact guard assist with ambulation was not indicated in the care plan. A Nurses Notes, dated [DATE] at 4:45 a.m., indicated Resident 9 had a fall in the bathroom requiring transfer to the acute hospital on [DATE] at 5:20 a.m. The Nurses Notes indicated Resident 9 was inside the bathroom with the CNA (certified nurse assistant) helping the resident back in his recliner. The Nurses Notes documented the Resident was standing with his walker, had no signs of distress, no shortness of breath and was stable. The CNA went outside the resident's room to get a blood pressure machine and heard a sound, like the resident fell . The CNA rushed inside the bathroom and noted the resident on the floor lying on his right side and the right forehead with a bleeding wound. "The Resident could not move his right lower extremity and complained of severe pain." Review of a signed statement, dated [DATE], Unlicensed Staff U documented he assisted Resident 9 in the bathroom and informed him he (CNA) would be checking his (resident's) vital signs and the resident said "OK." Unlicensed Staff U documented he quickly left to get the vital signs machine when he heard the resident yell and a thud. Review of the acute care hospital discharge summary dated [DATE], indicated the resident was admitted on [DATE], status [REDACTED]. The resident had multiple diagnoses, was kept on comfort care, and died [DATE]. Review of the Event Investigation Summary, dated [DATE], Management Licensed Staff AF documented Resident 9 continued to require one person assist / supervision with his ADL's (activities of daily living). Management Licensed Staff AF documented it was an avoidable accident, had staff not left the resident to get the BP (blood pressure) cuff. During an interview on [DATE] at 3:30 p.m., Management Licensed Staff AF stated it was an avoidable accident, as the CNA left the resident to get the BP machine. 2. Record review on [DATE] at 10 a.m., indicated Resident 3 was admitted to the facility on [DATE], for aftercare for a pelvic fracture identified after Resident 3 had five falls prior to admission. A Fall Risk Care Plan was initiated on [DATE]. Nurses notes, dated [DATE], indicated staff witnessed Resident 3 sliding from the wheelchair to the floor. A post fall assessment was not present in the medical record. This fall was not included on the Fall Risk care plan. During an interview on [DATE] at 9 a.m., Licensed Nurse (LN) N stated she had witnessed this fall and had reported it to Management Licensed Nurse B. After discussion, they determined the fall occurred shortly after Resident 3 received a pain medication and the plan was to change the pain medication to Tylenol. LN N stated the fall incident report had been completed. During an interview on [DATE] at 11:25 p.m., Management Licensed Nurse (LN) B stated the incident report for Resident 3 was in the office, but the post fall evaluation could not be located for Resident 3. Management LN B stated a post fall assessment was required after each resident fall and the Fall Risk Care Plan should have been updated. During an interview on [DATE] at 11 a.m., Management LN B stated after researching, it was determined the post fall assessment for Resident 3 had not been done. Record review on [DATE] at 9 a.m. indicated Resident 8 had a Fall Risk Care Plan which included a fall on [DATE] as "fall from bed." Nurses notes, dated [DATE], indicated at 7:15 p.m., Resident 8 was found on the floor beside the bed on the floor mat. A post fall assessment was not present in the medical record. During an interview on [DATE] at 4:15 a.m., Management LN B stated there had been an incident report for Resident 8's fall but the post fall evaluation could not be located and thought the note might have been lost. Facility document review on [DATE] at 4:50 p.m., of the policy and procedure titled: Fall Reduction and Management Program, dated revised [DATE] indicated: "Definition of a Fall: A sudden unanticipated change in body position coming to rest on the ground or onto the next lower surface (e.g. onto a bed, chair, or bedside mat) that may or may not result in a physical injury. This definition includes an assisted lowering to the floor.... Procedure: I. Fall Risk Evaluation...2. Complete a fall risk evaluation using the approved tool on a resident once a fall has occurred in the facility, when there is a subsequent fall, quarterly, change of condition and as needed...II. Care Planning and Implementation: Based on resident fall evaluation, an individualized care plan with the goal to prevent falls or minimize serious injury if a fall occurs will be developed, implemented, monitored and modified as needed. Licensed Nurse and/or Interdisciplinary Team will: 1. Develop an individualized care plan that addresses the risk factors identified, formulate goals that promote resident safety and (prevention/reduction of falls and minimize serious injury if all fall occurs. 3. Implement the care plan...4. Review, evaluate, revise or modify the care plan on a quarterly basis and as needed..." 3. During the initial tour of the facility on [DATE] at 9:15 a.m., a container labeled Silver Cream was located on the bathroom shelf beside the sink. This room was occupied by two residents and included Resident 8. Record review on [DATE] at 9 a.m., indicated Resident 8 had a history of [REDACTED]. During an observation on [DATE] at 10:30 a.m., the silver cream was in the medicine cabinet in the bathroom in the room where Resident 8 resided. During an interview on [DATE] at 10:40 a.m., when asked about the silver cream in the bathroom, LN Q stated she was not aware it was in the bathroom and stated Resident 8's roommate probably had it as that resident made silver jewelry. LN Q concurred the silver cream should not be within the reach of Resident 8 due to the dementia and this represented a potential hazard. Review of the facility policy: Environmental safety, dated [DATE], indicated all chemicals that could be considered toxic if ingested would be removed from resident rooms or placed in a locked drawers that will be inaccessible to a wandering resident. 4. During an observation on [DATE], at 12:30 p.m., a resident and family were outside on the patio having lunch. During an observation on [DATE], at 10 a.m., there were six areas of the patio where the cement was not level with the ground surface. The pathway to the activity room had the largest discrepancy. The cement was approximately six to eight inches higher than the ground. During an interview on [DATE], at 9:30 a.m., with Maintenance Supervisor R and Maintenance Director S, the potential hazard to residents was demonstrated. Maintenance Director acknowledged the hazard and stated it would be an easy fix with rock or bark fill in to make the grounds level. Maintenance Supervisor stated they could probably have someone out to fill this area in by the weekend. During an observation and concurrent interview on [DATE] at 10:15 a.m., with Administrator A, he stated the facility had plans to re-construct the patio area. Stating that this was to be done very soon. When work orders were requested to confirm his statement, he stated "No, it's not that far along. This will be done after April, in the next budget period." The facility policy and procedure titled, "Environmental Safety" dated [DATE], indicated: "It is the policy of the Company to provide residents with a pleasant, homelike, clean and healthy environment that assures quality of life and enjoyment as well as meeting their physical, emotional and safety needs...Staff will be inserviced on monitoring for potential safety hazards, appropriate reporting and prevention." The facility policy and procedure titled "Accident Prevention" dated [DATE], indicated: ..."All reasonable precautions will be taken by the facility to protect a resident from possible injury from dangerous conditions, falling, wandering, other agitated residents or staff and staffing negligence...The facility shall take all reasonable precautions to protect a resident from dangerous conditions relating to renovations, construction or repair sites."