Every finding on record at Veterans Home Of California - Barstow

Based on observation, interview, and record review, the facility failed to ensure that staff followed infection prevention and control practices when Custodian 1 did not use appropriate personal protective equipment (PPE) while performing environmental cleaning in a room under Enhanced Barrier Precautions (EBP).This failure had the potential to result in the spread of infection putting both residents and staff at risk.Findings:During a concurrent observation and interview on 4/19/26 at 12:02 PM with Certified Nursing Assistant (CNA) in Resident 6 and Resident 25's room, two EBP signs were observed posted by the room's entrance. CNA stated Resident 25 was on EBP for his wound on the left leg and Resident 6 was on EBP for his chronic suprapubic catheter.During an observation on 4/22/26 at 9:38 AM in Resident 6 and Resident 25's room, where two EBP signs were posted, Custodian 1 was observed not wearing gloves and gown while sweeping the floor, touching the beds, curtains, and dresser.During a concurrent observation and interview on 4/22/26 at 9:40 AM with the Hospital General Service Administrator (HGSA) and Custodian 1 in Resident 6 and Resident 25's room, where two EBP signs were posted, Custodian 1 was observed cleaning without any PPE. HGSA stated custodians need to wear a gown and a pair of gloves when cleaning and disinfecting rooms with EBP. Custodian 1 stated she knew the EBP signs were posted and that she should have worn PPE prior to performing her cleaning tasks.During an interview on 4/22/26 at 10:12 AM with the Infection Preventionist Registered Nurse (IPRN), IPRN stated custodians were expected to wear PPE before entering the room of any resident under EBP for cleaning and disinfecting.During a review of the facility policy and procedure (P&P) titled, Enhanced Barrier Precautions (EBP) Policy (All Homes), dated 12/30/2025, the P&P indicated, High-Contact (Environmental Services) EVS activities for which staff should use gown and gloves while cleaning and disinfecting the environment around residents on EBP: . *Cleaning and disinfecting high-touch surfaces such as bed rails, remote controls, bedside tables or stands on or near the resident's space .

Based on interview and record review, the facility failed to document non-pharmacological interventions for five of five sampled residents (Residents 1, 21, 24, 25, and 31) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents to receive unnecessary psychotropic medications which can lead to side effects, such as sedation and falls. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Alprazolam (generic for Xanax, a medication for anxiety) 0.5 milligrams (mg) OD (orally disintegrating, dissolves in the mouth), take one tablet by mouth and allow to dissolve daily for anxiety, manifested by mood changes, irritability, negative thoughts. Monitor for behavior and side effects every shift, dated 2/13/25; b. Bupropion (generic for Wellbutrin XL, extended release, a medication for depression) 150 mg, take one tablet by mouth daily for depression disorder m/b (manifested by) verbalization of hopelessness and sadness. Monitor for behaviors and side effects every shift, dated 12/10/24; and c. Olanzapine (generic for Zyprexa, a medication to treat psychiatric conditions) 5 mg, take one tablet by mouth daily at bedtime for schizophrenia (a psychiatric condition) m/b hallucinations and delusions. Monitor side effects and behaviors every shift, dated 12/10/24. A review of Resident 1's medical records included March 2025 Behavior Monitoring Records (BMR) for alprazolam, bupropion, and olanzapine. The following behaviors were documented for alprazolam: one episode of irritability on 3/3/2025 and one episode of mood changes on 3/3/25. The following behaviors were documented for bupropion: one episode of sadness on 3/20/25. The following behaviors were documented for olanzapine: one episode of delusions on 3/30/25. The medical record also included a blank form, Resident 1's March 2025 Non-Pharmacological Intervention (NPI) Flow Sheet for Psychotropic Medication (NPI Flow Sheet). A review of Resident 1's medical records included a care plan for depression, created 7/13/24. The depression care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. The care plan interventions, updated 7/13/24, also indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. A review of Resident 1's medical records included a care plan for schizophrenia, created 7/13/24. The schizophrenia care plan intervention, updated 7/13/24, indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with the Director of Nursing (DON) 1, Resident 1's March 2025 BMRs and March 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 1 in March 2025 as required. 2. A review of Resident 24's medical records indicated the following physician's orders: a. Fluoxetine (generic for Prozac, a medication for depression) 20 mg, take one capsule by mouth daily for depressive disorder, dated 10/15/24; and b. Olanzapine 5 mg, take one tablet by mouth daily for depressive disorder with anxiety, dated 10/15/24. A review of Resident 24's medical records included March 2025 BMR for fluoxetine and olanzapine. The following behaviors were documented for fluoxetine: one episode of anxiousness on 3/12/25 and 3/26/25. The following behaviors were documented for olanzapine: one episode of anxiousness on 3/12/25. The medical record also included a blank form, Resident 24's March 2025 NPI Flow Sheet. A review of Resident 24's medical records included a care plan for mood disorder manifested by anxiousness, created 8/25/24. The anxiousness care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. A review of Resident 24's medical records included a care plan for depressive disorder, created 8/25/2024. The depression care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 24's March 2025 BMRs and March 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 24 in March 2025 as required. 3. A review of Resident 25's medical records indicated the following physician's orders: a. Escitalopram (generic for Celexa, a medication for depression) 10 mg, take one tablet by mouth daily for depression m/b verbalizations of sadness, dated 5/30/24; b. Lorazepam (generic for Ativan, a medication for anxiety) 0.5 mg, take one tablet by mouth daily for anxiety disorder, m/b agitation and irritability, dated 1/28/25; and c. Quetiapine (generic for Seroquel, a medication for psychiatric conditions) 50 mg, take one tablet by mouth daily at bedtime for depressive disorder with psychosis m/b hallucinations and angry outbursts, dated 5/30/24. A review of Resident 25's medical records included March 2025 BMR for escitalopram, lorazepam, and quetiapine. The following behaviors were documented for lorazepam: two episodes of agitation on 3/25/25, and one episode of irritability on 3/3/25, 3/28/25, and 3/30/25. The following behaviors were documented for quetiapine: one episode of angry outbursts on 3/25/25. The medical record also included a blank form, Resident 25's March 2025 NPI Flow Sheet. A review of Resident 25's medical records included a care plan for anxiety disorder, created 4/18/24. The anxiety care plan intervention, updated 2/6/25, indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. The care plan interventions, updated 4/18/24, also indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 25's March 2025 BMRs and March 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 25 in March 2025 as required. 51705 4. A review of Resident 31's medical records indicated the following physician's orders: a. Divalproex sodium (generic for Depakote, a medication used to treat various psychiatric and neurological conditions) 250 mg DR (delayed release) tablet. Take one tablet by mouth every 12 hours for bipolar disorder m/b mood swings. Monitor behaviors and side effects . dated 10/8/24; and b. Olanzapine 5 mg tablet. Take one tablet by mouth every morning for schizophrenia m/b auditory hallucinations/hearing voices. Monitor for behaviors and side effects every shift dated 10/8/24. A review of Resident 31's medical records included February 2025 Behavior Monitoring Records (BMR) for divalproex sodium, mirtazapine, and olanzapine. The following behaviors were documented for divalproex sodium: one episode of mood swings on 2/1/25, 2/16/25 and 2/19/25. The following behavior was documented for olanzapine: one episode of auditory hallucinations on 2/27/25. The medical record also included a blank form, Resident 31's February 2025 NPI Flow Sheet. A review of Resident 31's medical records included a care plan for bipolar, updated 3/7/25. The bipolar disorder care plan intervention indicated Provide Non-Drug Interventions and document on non medication intervention sheet, when resident behavior occurs. A review of Resident 31's medical records included a care plan for schizophrenia updated 3/7/25. The schizophrenia care plan intervention indicated Use Non-Drug Interventions or Approaches to Address Behaviors in Addition to Ordered Medications. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 31's February 2025 BMRs and February 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 31 in February 2025 as required. 5. A review of Resident 21's medical records indicated the following physician's order: risperidone (generic for Risperdal, a medication to treat psychiatric conditions) 1 mg tablet. Take one tablet by mouth every morning and one tablet by mouth every evening for schizoaffective disorder m/b angry outburst and believing people are out to get him, monitor behaviors and side effects every shift dated 1/7/2025. A review of Resident 21's medical records included February 2025 BMR for risperidone. The following behaviors were documented for risperidone: two episodes of angry outbursts on 2/27/25 and two episodes on 2/28/25. The medical record also included a blank form, Resident 21's February NPI Flow Sheet. During an interview on 5/1/2025 at 8:56 AM with the Supervising Registered Nurse (SRN) 1, SRN 1 stated NPIs are documented whenever a resident is exhibiting a behavior. During a concurrent interview and record review on 5/1/25 at 2:57 p.m. with DON 1, Resident 21's February 2025 BMRs and February 2025 NPI Flow Sheet were reviewed. DON 1 acknowledged the medical record indicated no NPI were provided to Resident 21 in February 2025 as required. During an interview on 5/1/2025 at 3:05 PM, DON 1 stated there should be an entry on the NPI Flow Sheet whenever there is an episode of behaviors. DON 1 stated non pharmacologic interventions are important to reduce the unnecessary use of medications. DON 1 stated unnecessary use of psychotropic medications have the risk of side effects of the medications, such as groggy in the morning and falls with injury. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Management, last reviewed by the facility on 11/12/2024, the P&P indicated, Resident's care plan will include behavioral interventions implemented in an attempt to decrease the target behaviors.

Based on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and 31) were free of unnecessary medications when blood pressure (BP) and blood sugar (BS) hold parameters were not followed with the administration of medications. This failure had the potential for unnecessary medications for Residents 1 and 31, which can lead to side effects such as low blood pressure and low blood sugar. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Hold diabetes medications if BS is less than 110 at 6:00 a.m., dated 12/10/24; b. Check BS twice a day at 6:00 a.m. and 5:00 p.m., dated 7/12/24; and c. Januvia (brand name for sitagliptin, a medication for diabetes) 100 milligrams (mg), take one tablet by mouth daily at 6:00 a.m. for diabetes, dated 12/10/24. A review of Resident 1's January 2025 Medication Administration Record (MAR) indicated Resident 1's BS was less than 110 at 6:00 a.m. on the following dates: - 1/25/25 BS 107 - 1/28/25 BS 90 The January 2025 MAR indicated Resident 1 received a Januvia dose on both dates. A review of Resident 1's February 2025 MAR indicated Resident 1's BS was less than 110 at 6:00 a.m. on the following dates: - 2/13/25 BS 86 - 2/15/25 BS 90 The February 2025 MAR indicated Resident 1 received a Januvia dose on both dates. A review of Resident 1's March 2025 MAR indicated Resident 1's BS was less than 110 at 6:00 a.m on the following dates: - 3/11/25 BS 76 - 3/22/25 BS 95 - 3/26/25 BS 83 - 3/27/25 BS 100 The March 2025 MAR indicated Resident 1 received a Januvia dose on the above four dates. A review of Resident 1's April 2025 MAR indicated Resident 1's BS was less than 110 at 6:00 a.m on the following dates: - 4/21/25 BS 78 - 4/29/25 BS 90 The April 2025 MAR indicated Resident 1 received a Januvia dose on both dates. During a concurrent interview and record review on 5/1/25 at 10:02 a.m. with the Director of Staff Development (DSD) 1, Resident 1's physician orders and MAR were reviewed. DSD 1 stated the physician's orders to hold diabetes medication for BS less than 110 at 6:00 a.m. meant Januvia was supposed to be held on those days. DSD 1 stated if the physician's orders to hold diabetes medications are not followed, there is a risk of blood sugar dropping too low which can cause the resident to fall. During a concurrent interview and record review on 5/1/25 at 2:47 p.m. with the Director of Nursing (DON) 1, Resident 1's January, February, March, and April 2025 MARs and physician's orders were reviewed. DON 1 stated the physician's orders indicated to hold Januvia for 6:00 a.m. blood sugar reading less than 110. DON 1 acknowledged the resident incorrectly received Januvia on two dates in January 2025, two dates in February 2025, four dates in March 2025, and two dates in April 2025 (total 10 doses) when the medication was supposed to be held. DON 1 verified the physician's orders were not followed. 51705 2. During a review of Resident 31's Physician Orders on 4/30/25 at 9:11 a.m., the physician's orders indicated Resident 31 had three active orders for blood pressure medications: a. Amlodipine (generic for Norvasc, a medication for high blood pressure) 5 milligram (mg, a unit of measure) tablet. Take one tablet by mouth daily, hold for SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110, dated 9/10/24. b. Chlorthalidone (generic for Thalitone, a medication for high blood pressure) 25 mg tablet. Take one tablet by mouth every morning for hypertension (blood pressure), hold if SBP less than 110 or if DBP (diastolic blood pressure, the bottom number in a blood pressure reading) less than 50, dated 9/10/24. c. Metoprolol succinate (generic for Toprol XL, a medication for high blood pressure) 50 mg ER (extended release). Take one tablet by mouth every evening. Hold if SBP less than 110, DBP less than 50 or HR (heart rate) less than 50, ordered 9/10/24. The holding parameters were updated to hold if SBP less than 105, HR less than 50 on 2/7/25. During an interview on 5/1/25 at 8:56 a.m., with Supervising Registered Nurse (SRN) 1, SRN 1 stated nurses administer blood pressure medications upon receiving physician orders and ensuring it meets the prescribed parameters. SRN 1 stated the process for documenting held medications is for nurses to initial the MAR, circle their initials and write the reason why it was held (not given) on the back of the MAR. A review of Resident 31's January 2025 MAR indicated Resident 31's SBP was less than 110, but Resident 31 received a metoprolol succinate dose on the following date: - 1/31/25 at 5 p.m., blood pressure 100/50 A review of Resident 31's February 2025 MAR indicated Resident 31's SBP was less than 110, but Resident 31 received a metoprolol succinate dose on the following date: - 2/5/25 at 5 p.m., blood pressure 105/54 A review of Resident 31's April 2025 MAR indicated Resident 31's SBP was less than 110, but Resident 31 received a dose of amlodipine and chlorthalidone on the following date: - 4/16/25 at 8 a.m., blood pressure 109/57 A concurrent interview and record review was conducted on 5/1/25 at 11:38 a.m., with the Director of Staff Development (DSD) 1 of Resident 31's February 2025 MAR. Resident 31's blood pressure was documented as 105/54 on 2/5/25 at 5 p.m. An initial without a circle was observed on the MAR for 2/5/25 for the metoprolol succinate dose. DSD 1 stated, If I don't see [initials] circled, I'd have to assume [the medication] was given. DSD stated the 2/5/25 metoprolol succinate dose was not held. A concurrent interview and record review was conducted on 5/1/25 at 2:38 p.m., with the Director of Nursing (DON) 1 of Resident 31's January through April 2025 MARs. DON 1 stated the metoprolol succinate was given on 1/31/25, but should have been held because the SBP was less than 110. Resident 31's February MAR indicated that Resident 31's blood pressure was 105/54 on 2/5/25 at 5 p.m. DON 1 stated that the 2/5/25 metoprolol succinate dose should've been held. Resident 31's blood pressure on 4/16/25 at 8 a.m., was documented as 109/57 on Resident 31's April 2025 MAR. DON 1 stated the amlodipine and chlorthalidone doses were not held because no circle. A drug literature review of amlodipine on Daily Med (an electronic drug information source) updated 12/15/08, indicated amlodipine side effects include, but are not limited to edema (swelling), flushing (increased blood flow to the surface of the skin) and palpitations (feeling one's own heartbeat, which may feel like its racing or pounding). A drug literature review of chlorthalidone on Daily Med updated 10/9/24, indicated chlorthalidone side effects include, but are not limited to dizziness, muscle weakness, nausea, vomiting, orthostatic hypotension (a drop in blood pressure upon standing from a seated or lying position). A drug literature review of metoprolol succinate on Daily Med updated 2/14/25, indicated metoprolol succinate side effects include, but are not limited to dizziness, bradycardia (slow heart rate), tiredness and hypotension. A review of the facility's policy and procedures (P&P) titled, Administering Medications, last reviewed by the facility on 2/1/25, indicated: .Medications must be administered in accordance with the orders . and .if a drug is withheld .the individual administering the medication will ensure their initials are circled on the MAR and the reason why the medication was not administered will be documented in the space provided .

Based on interview and record review, the facility failed to ensure the accurate provision of medication for one out of five sampled residents (Resident 1) when Resident 1 did not receive hypoglycemia (low blood sugar) medication as ordered by the prescriber. This failure had the potential for Resident 1 to experience symptoms of hypoglycemia, including confusion and dizziness. Findings: 1. A review of Resident 1's medical records indicated the following physician's orders: a. Check BS twice a day at 6:00 a.m. and 5:00 p.m., dated 7/12/24; and b. Glutose 15 gel (brand name for glucose (sugar) 15 grams, a medication to treat low blood sugar) by mouth as needed for blood sugar (BS) less than 80, dated 12/10/24. A review of Resident 1's January through April 2025 Medication Administration Records (MAR) indicated Resident 1's BS was less than 80 on the following dates and times: - 1/3/25 at 6:00 a.m. BS 70 - 3/11/25 at 6:00 a.m. BS 76 - 4/21/25 at 6:00 a.m. BS 78 The January through April 2025 MARs indicated Resident 1 did not receive Glutose 15 as ordered on any of the above dates. During a concurrent interview and record review on 5/1/25 at 2:47 p.m. with the Director of Nursing (DON) 1, Resident 1's January, February, March, and April 2025 MARs and physician's orders were reviewed. DON 1 stated Resident 1 was supposed to receive Glutose 15 on 1/3/25, 3/11/25, and 4/21/25 because Resident 1's blood sugar was less than 80. DON 1 verified the physician's orders were not followed. A review of the facility's policy and procedure titled, Administering Medications, reviewed 2/1/25, indicated, .Medications must be administered in accordance with the orders .

Based on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when two boxes of eye drops were found in a bin labeled and full of ear drops in one of one sampled medication rooms. This failure had the potential for residents to receive the wrong medication, which could result in the residents experiencing negative health outcomes. Findings: During a concurrent observation and interview on 4/28/25 at 11:56 a.m., with the Director of Staff Development (DSD) 1, a tour of the Skilled Nursing Facility (SNF) unit medication room was conducted. Eight boxes of ear drops were observed in a black bin labeled, EAR DROPS. Two boxes of eye drops (one box of Refresh and one box of Visine, both used to treat dry eyes) were also stored in the same bin. DSD acknowledged two eye drops were in the ear drop bin. During a concurrent interview and record review on 5/1/25 at 2:27 p.m., with the Director of Nursing (DON) 1, the facility's policy and procedure (P&P) titled, Storage of Medications, last reviewed by the facility on 5/31/24 was reviewed. The P&P indicated, .Medication Storage Requirements .Eye medications are kept separate from ear medications . DON 1 acknowledged eye drops and ear drops should be stored separately from each other.

Based on interview and record review, the facility failed to implement their policy for Theft and Loss Reporting and Investigation for one of three sampled residents (Resident 1), when the Report of Suspected Dependent Adult-Elder Abuse (Form SOC 341) for Resident 1 was not completed and sent to the ombudsman. This failure had the potential to result in an inadequate investigation of the loss of Resident 1's property. Findings: On 1/6/25 at 10:30 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a resident loss of one hundred dollars and a fifty dollar gift card. Resident 1, an [AGE] year-old male admitted on [DATE], with diagnoses of Hypertension, and Emphysema. During an interview on 1/6/25 at 10:50 a.m. with the Health and Safety officer (HS 1), HS 1 stated the incident was reported on 12-29-24 by the CNA (CNA 1) for Resident 1. CNA 1 verified the resident had one hundred dollars and a fifty dollar gift card in his wallet and the money and gift cards were now missing. The resident can access the nightstand lockbox by himself. The resident cannot remember what happened to the money or gift card because of memory issues. Form SOC 341 (Report of Suspected Dependent Adult-Elder Abuse) was not completed. During an interview on 1/7/25 at 10:20 a.m. with the Ombudsman (Omb1), Omb1 stated the facility did not submit a SOC 341 (Report of Suspected Dependent Adult-Elder Abuse) regarding Resident 1's loss of property. During a review of the facility's policy and procedure titled, Theft and Loss Reporting and Investigation, dated 12/17/2024, indicated Theft or losses $100 or greater will be reported by Security to 1. Highway Patrol, 2. California Department of Public Health, 3. Ombudsman for Skilled Nursing Facility Residents (Form SOC 341).

Based on observation, interview, and record review, the facility failed to ensure that food was stored in a safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe. 2. The kitchen freezer contained foods that were not dated and labeled. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During a concurrent observation and interview on 6/4/2024 at 9:02 a.m. with Food Manager (FM) in the kitchen, there was a spatula (kitchen utensil used to mix ingredients) with cracks on the right lower side and a yellow dried substance on the top edges. FM confirmed the spatula was not safe to be used due to the risk of food contamination and food-borne illnesses. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services-Sanitation (All Homes), dated 11/5/2023, the P&P indicated, All utensils, counters, shelves, and equipment will be kept clean and maintained in good repair (i.e. free from breaks, corrosion, open seams, cracks, and chipped areas). 2. During a concurrent observation and interview on 6/5/2024 at 9:05 a.m. with Food Service Technician (FST) 1 in the Skilled Nursing kitchenette's freezer, six out of six popsicles were not dated and labeled. FST 1 stated, I don't know why it was not labeled. It was usually inside the box with date on it and needs to be labeled to prevent food-born illnesses. During a concurrent observation and interview on 6/5/2024 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1 in the Skilled Nursing kitchenette's freezer, a meatball package was opened, not dated, and not labeled. LVN 1 stated, This one does not have a label and date. It is not supposed to be like this, or the resident can get sick. During an interview on 6/5/2024 at 11:30 a.m. with the Director of Dietetics (DOD), DOD stated the expectation was for staff to label and date all foods to prevent food-borne illnesses. DOD further stated the date was important to ensure the residents consumed a safe food product. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services-Leftover and Extra Food, dated 11/5/2023, the P&P indicated, Labeling, dating, and monitoring refrigerated food, including but not limited to, leftovers, so it is used by its used-by date or frozen were applicable or discarded.

Based on observation, interview, and record review, the facility failed to ensure a safe and comfortable working environment for staff when the water temperature of the kitchen's hand washing station was 156.1 degrees Fahrenheit (unit used to measure temperature). This failure had the potential for staff burning their hands and poor handwashing practices, leading to a potential spread of infection. Findings: During a concurrent observation and interview on 6/4/2024 at 11:06 a.m. with the Director of Dietetics (DOD) and the Food Manager (FM) in the kitchen, the Surveyor checked the water temperature at the hand washing station using a thermometer (a device that measures temperature), and the water temperature registered at 156.1 degrees Fahrenheit. DOD and FM confirmed the water temperature was too hot and had the potential for staff to burn their hands. DOD stated the hot water has always been out of range, and there was no work order to fix it. FM stated the hand washing water temperature should be 120 degrees Fahrenheit, but there was no work order. During a review of the facility's policy and procedure (P&P) titled, Plumbing and Water Supply Maintenance, dated 2/9/2024, the P&P indicated, If water temperature exceeds 120 degrees Fahrenheit during normal business hours, a work order is submitted. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, dated 1/18/2023, Section 5-202.12, titled, Handwashing Sink, Installation, indicated, An inadequate flow or temperature of water may lead to poor handwashing practices by food employees. A mixing valve or combination faucet is needed to provide properly tempered water for handwashing. The International Plumbing Code (IPC) states that tempered water is having a temperature range between 29.4 C (85 F) and 43 C (110 F).

Based on observation and interview , the facility failed to ensure a safe, clean, and comfortable environment, when the wheelchair of one of 15 sampled residents (Resident 29) was not found in good working condition with a torn, cracked, and frayed armrest. This failure had the potential to violate Resident 29's rights to a safe, clean, and comfortable environment. Findings: During a concurrent observation and interview on 6/5/2024 at 8:42 a.m. with Resident 29, Resident 29 was observed sitting in their wheelchair. The wheelchair had a large tear on the right armrest with the cushion exposed. In addition, the armrest had a large worn area consisting of multiple rough raised cracks and the edges were frayed with white lining showing through the black armrest cover. Resident 29 stated that the armrest was torn when they received the wheelchair from the facility. Resident 29 further stated that the worn armrest bothered them, was not comfortable, and did not look nice. During an interview on 6/5/2024 at 3:20 p.m. with Lead Registered Nurse (LRN), the LRN stated the armrest was torn, and Resident 29 needed a new wheelchair. The facility was unable to provide a policy and procedure related to maintaining residents' wheelchair in good working condition during the survey.

Based on observation, interview and record review, the facility failed to date an opened bottle of Polyethylene Glycol (medication to treat constipation) for unsampled Resident 30. This failure had the potential for Resident 30 to receive expired and less than optimal medications. Findings: During a review of Resident 30's Face Sheet (resident demographics), the Face Sheet indicated Resident 30 was admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language and problem-solving abilities that are severe enough to interfere with daily life) and chronic pain. During a review of Resident 30's Quarterly Minimum Data Sheet (MDS, standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 30 had a severe cognitive impairment. During a concurrent medication storage observation and interview on [DATE] at 10:11 a.m. with Licensed Vocational Nurse (LVN) 3, the medication cart for the 600 POD had an opened bottle of Polyethylene Glycol for Resident 30 which was not labeled with the open date. LVN 3 confirmed the bottle was not labeled with the open date. LVN 3 stated she gave the Polyethylene Glycol to Resident 30 on [DATE]. During a review of Resident 30's Medication Administration Record (MAR, a record of all medications administered to a resident), dated [DATE], the MAR indicated the medication was administered. During an interview on [DATE] at 10:53 a.m. with the Director of Nursing (DON), the DON stated the nurse should date the medication (Polyethylene Glycol) when it was opened. The DON stated any licensed staff who administered medication was responsible for checking the medication cart to make sure all opened medications were labeled with an open date. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated [DATE], the P&P indicated, When opening a multi-dose container, the date opened will be recorded on the container.

Based on interview and record review, the facility failed to ensure the Medication Administration Record (MAR, a record of all medications administered to a resident) was accurately documented on 6/2/2024 for two of 15 sampled residents (Residents 19 and 48) when: 1. For Resident 19, a licensed nurse did not document that medications were administered for the 8 a.m. dose on 6/2/2024. 2. For Resident 48, a licensed nurse did not document that medications were administered for 10 a.m. dose on 6/2/2024. These failures had the potential to result in inaccurate medication administration including underdosing or overdosing Residents 19 and Resident 48. Findings: 1. During a review of Resident 19's Face Sheet (resident demographics), the Face Sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses of high blood pressure and urinary incontinence. During a review of Resident 19's MAR, dated June 2024, the MAR indicated, on 6/2/24, for the 8 a.m. administration time, there were no staff initials in the box to reflect medications were administered for the following medications: a. Amlodipine (treatment for high blood pressure) b. Aspirin (treatment to prevent blood clots) c. Coenzyme Q10 (treatment for high cholesterol) d. Docusate Sodium (treatment for constipation) e. Eliquis (treatment to prevent blood clots) f. Finasteride (treatment to decrease size of the prostate) g. Gabapentin (treatment for nerve pain) h. Glucosamine/Chondroitin (treatment to slow the breakdown of cartilage in the joints) i. Mag Oxide (treatment for magnesium deficiency) j. Metamucil Powder (treatment for constipation) k. Metoprolol succinate tablet (treatment for high blood pressure) l. Oyster Shell (treatment for bone health) m. Sertraline (treatment for depression) n. Vitamin D-3 (treatment for Vitamin D deficiency) During an interview on 6/5/2024 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I forgot to sign the medications for [Resident 19] that were given on 6/2/2024. During an interview on 6/6/2024 at 10:57 a.m. with the Director of Nursing (DON), the DON stated, The expectation is for the nurse to prepare the medication, pass to the resident, and sign the MAR. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/18/2024, the P&P indicated, Documentation of Medication Administration .As required or indicated for a medication, the individual administering the medication will record in the Resident's medical record .The signature and title of the person administering the drug. 2. During a review of Resident 48's Face Sheet (resident demographics), the Face Sheet indicated Resident 48 was admitted to the facility on [DATE] with diagnoses of hypertensive heart disease (long term high blood pressure that causes changes to the heart) and type 2 diabetes mellitus (disease in which blood glucose levels are higher than normal). During a review of Resident 48's MAR, dated June 2024, the MAR indicated, on 6/2/24, for the 10 a.m. administration time, there were no staff initials in the box to reflect medications were administered for the following medications: a. Amlodipine (treatment for high blood pressure) b. Docusate Sodium (treatment for constipation) c. Furosemide (treatment for fluid retention) d. Glipizide (treatment for type 2 diabetes mellitus) e. Propranolol (treatment for high blood pressure) During an interview on 6/5/2024 at 2:05 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I forgot to sign for medications for [Resident 48] that were given on 6/2/2024. During an interview on 6/6/2024 at 10:57 a.m. with the Director of Nursing (DON), the DON stated, The expectation is for the nurse to prepare the medication, pass to the resident, and sign the MAR. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/18/2024, the P&P indicated, Documentation of Medication Administration .As required or indicated for a medication, the individual administering the medication will record in the Resident's medical record .The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to maintain the kitchen dishwasher in a safe operating condition. This failure had the potential to result in safety concerns. Findings: During a concurrent observation and interview on 6/4/2024 at 9:00 a.m. with Food Service Technician (FST) 2 in the kitchen, the dishwasher was spraying water resulting in a pool of water on the floor. FST 2 stated the spraying started when the machine was turned on. During an interview on 6/5/2024 at 8:40 a.m. with Chief Plant Operations (CPO), CPO stated the dishwasher machine was spraying water because it was missing the multi-flap curtains. During an interview on 6/5/2024 at 8:50 a.m. with the Food Manager (FM), FM stated the expectation was to prevent the water spraying out of the dishwasher machine, due to infection control and safety issues. During a review of the dishwasher's manual, [undated], the manual indicated, Multi-flap curtains are used throughout the dishwasher to keep moisture inside and reduce the potential of hot water injury. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services-Equipment (All Homes), dated 11/5/2023, the P&P indicated, Equipment will be provided and maintained in good working order. All equipment will be operated and maintained according to the manufacturer's specifications for cleaning and sanitizing and safe operating condition.

Based on interview and record review, the facility failed to properly electronically transmit the Minimum Data Set (MDS, a resident assessment and care-screening tool) to the Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES), for eight out of 17 sampled residents (Residents 8, 13, 14, 36, 43, 50, 56, and 58). This failure had the potential to result in inadequate monitoring of the residents' progress and lack of resident-specific information being provided to CMS for payment and quality measure monitoring. Findings: During an investigation of a triggered task related to Assessment Completed Late, the MDS coordinator was asked to provide CMS submission reports of Residents 8, 13, 14, 36, 43, 50, 56, and 58. A review of the iQIES Report MDS 3.0 Final Validation Reports for Residents 8, 13, 14, 36, 43, 50, 56, and 58 indicated a warning message, Assessment Completed Late: an Omnibus Budget Reconciliation Act (OBRA) assessment (comprehensive or quarterly) was due every quarter, unless the resident is no longer in the facility. A prior record within 92 days of the submitted record could not be found. During a concurrent record review and interview on 7/13/23 at 8:25 a.m. with the MDS Coordinator, the MDS Coordinator reviewed the transmission data for Residents 8, 13, 14, 36, 43, 50, 56, and 58 in the computer. The MDS Coordinator confirmed the MDSs were submitted timely. However, upon submitting the MDS to IQIES database, she received a warning message indicating failure of transmission for those residents, meaning that the residents' assessments did not synchronize with the iQIES database. The MDS Coordinator stated the transmission system was new and she hoped it will work in the future. The MDS Coordinator stated synchronization with iQIES was always a problem. During a follow-up interview on 7/13/23 at 9:42 a.m. with the MDS Coordinator, when asked what to do when CMS sends a warning message indicating that the MDS transmission was submitted late, the MDS Coordinator stated she should have contacted CMS for a ratification. Review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI), MDS 3.0, version 1.17.11, under the section for Validation Edits, indicated the Internet iQIES provides validation edits to monitor the timeliness and accuracy of MDS record submissions. If the transmission of the MDS's records did not meet the edit requirements, the system will provide error and warning messages on the provider's Final Validation Report. Each time a user accesses the iQIES and transmits an MDS file, the iQIES performs three types of validation including Warnings which flags missing or questionable data such as timing errors. The provider must evaluate each warning to identify necessary corrective actions.

The facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities, for three out of 17 sampled residents (Residents 63, 48, and 17): 1. For Resident 63, the facility failed to notify the physician to obtain an optometrist (eye doctor) referral to replace or fix his broken prescription glasses and his backup (second pair of glasses). This failure had the potential for Resident 63 not being able to see things clearly, read, or watch television. 2. For Resident 48, the facility failed to process an audiology (hearing doctor) consult. This failure had the potential for a decrease in his quality of life when Resident 48 was in need of hearing aids. 3. For Resident 17, the facility failed to reschedule a missed audiology appointment. This failure had the potential for Resident 17 not to attain his highest practicable physical, mental and psychosocial well-being. Findings: 1. During a review of the admission face sheet record, indicated Resident 63 was admitted to the facility on [DATE]. During a review of Resident 63's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date 5/31/23, indicated the resident had a Brief Interview for Mental Status (BIMS), score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident 63 had moderate limited vision, and used corrective lenses (glasses). During a review of Resident 63's care plan to address Visual Problems related to macular degeneration (vision impairment resulting from deterioration of the central part of retina), the approaches included to schedule eye checks as needed. During an observation and interview with Resident 63 on 7/10/23 at 3:33 p.m., Resident 63 inquired about getting a new pair of glasses. Resident 63 was wearing a pair of spare glasses, the spare glasses were broken and unrepaired with (missing nose pads, a safety pin was holding the missing screws to keep the hinge together, and no temple protection, adhesive tape was applied around the frame). Resident 63 stated his prescription glasses and lenses were accidentally broken, two weeks ago. Resident 63 stated he gave the glasses to the nurses, who informed him they would either make an appointment with an optometrist, or send the glasses to be fixed. The resident reported the accident occurred at least two weeks ago; however, as of the current date, no action had been taken to repair or replace the broken glasses. During an interview with RN 1 on 7/10/23 at 10 a.m., RN 1 stated Resident 63's broken glasses were kept in a plastic bag at the nurses' station. An observation of the broken prescription glasses indicated the lens were entirely cracked and fragmented, and the frame was broken in multiple places, no parts of the glass were intact. RN 1 stated they forgot to request a referral for an optometrist consultation, or to send the glasses for repair. There was no documented evidence a follow up had occurred over a two week period. During an interview with RN 2 on 7/13/23 at 10:09 a.m., when asked for the facility's Policy & Procedures related to vision appointments and follow ups, RN 2 stated there was no policy in place. RN 2 stated they typically ask for a referral from the physician, schedule appointments, and provide transportation for the residents. 29492 2. During a review of Resident 48's medical record, it indicated he was admitted to the facility on [DATE] with diagnoses which included Chronic A-fib (atrial fibrillation- an irregular heart rate that can cause decreased blood flow), legal blindness and that Resident 48 was hard of hearing. During a review of physician's order dated 7/1/23 at 10:20 a.m., indicated LLVA [[NAME] Veterans Administration] Audiology; Annual hearing test and to obtain new hearing aids .Schedule resident to LLVA audiology . During an interview on 7/12/23 at 11:47 a.m, with Office Technician (OT) 1, she was unable to locate where Resident 48's audiology referral was processed. OT 1 stated, she was the person to input the information and stated, I don't see it, I will put it in now. During an interview on 7/12/23 at 2:01 p.m., with Resident 48 and with the assistance of Certified Nursing Assistant (CNA) 2, CNA 2 had to speak loud to ask Resident 48 if he had hearing aids in his possession. Resident 48 stated he did not. CNA 2 stated she had not seen him with hearing aids, and stated he was hard of hearing. During a review of the policy and procedure titled, Physician Orders and Progress Notes, dated 10/24/22, it indicated, .All orders, written by a person lawfully authorized to prescribe, will be carried out unless contraindicated. 34448 3. During a review of Resident 17's face sheet (demographics), the face sheet indicated Resident 17 had been readmitted to the facility on [DATE], with diagnoses that included hearing loss. During a concurrent observation and interview on 7/10/23 at 11:23 a.m. in Resident 17's room, Resident 17 was observed lying in bed watching television. Resident 17 stated to talk louder because he was hard of hearing in both ears. Resident 17 was questioned if he had hearing aids that he could wear. Resident 17 stated he had hearing aids that did not work. Resident 17 stated the staff, Know but don't care. During a concurrent observation and interview on 7/12/23 at 8:18 a.m. in Resident 17's room, Resident 17 was observed lying in bed without wearing hearing aids. Resident 17 stated his hearing aids were in a box and, I would show them to you if I knew where they were. During a review of Resident 17's Progress Note, dated 5/23/23, the Progress Note indicated, Resident 17 had completed an audiology appointment on 8/5/22. During the appointment, Partially occluding cerumen (earwax) was removed, and the tubing was replaced on Resident 17's hearing aids. The Progress Note further indicated, RTC (return to center) 4-5 months for tubing replacement. During a review of Resident 17's care plan titled, Communication Deficit R/T (related to) Moderate Hearing Problem, dated 10/30/22, the care plan indicated, Resident referred to (name of facility) to check hearing aids evaluate if new ones are needed. During a concurrent interview and record review on 7/12/23 at 8:39 a.m. with Registered Nurse (RN) 1, RN 1 stated there was not an audiology progress note in Resident 17's clinical record dated 8/5/22. In addition, RN 1 stated he did not know if Resident 17 wore hearing aids. During a concurrent interview and record review on 7/12/23 at 2:02 p.m. with the Nurse Instructor (NI), Resident 17's Past Clinic Visits, were reviewed. The Past Clinic Visits, indicated Resident 17 had completed an audiology appointment on 8/5/22, and was a NO-SHOW for the 12/7/22 audiology appointment. NI stated there had not been follow up to reschedule the missed 12/7/22 appointment. The facility was unable to provide a policy and procedure for rescheduling missed appointments.

Based on observation, interview and record review, the facility failed to ensure Resident 55's Minimum Data Set (MDS, a resident assessment and care-screening tool) accurately reflected the resident's status regarding an indwelling catheter (a flexible plastic tube (a catheter) inserted into the bladder, to provide continuous urinary drainage). This failure had the potential to result in inadequate monitoring of the resident's care and support needs. Findings: During a review of Resident 55's face sheet (demographics) indicated, Resident 55 was admitted to the facility on [DATE] with a diagnosis of obstructive uropathy (which occurs when urine cannot drain through the urinary tract). During a concurrent observation and interview on 7/11/23 at 9:32 a.m. with Resident 55 in his room, he was observed lying on his bed and did not have an indwelling catheter. Resident 55 stated he had a catheter for about a year but no longer had one. During a review of Resident 55's Physician Orders, dated 3/23/23 at 10:30 a.m. the Physician Orders indicated to discontinue Foley Catheter (indwelling catheter) per Urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) status post Urolift (procedure that lifts enlarged prostate tissue, so it no longer blocks the flow of urine). During a concurrent interview and record review on 7/13/23 at 9 a.m. with the MDS Coordinator, Resident 55's MDS-Version 3.0 Resident Assessment and Care Screening Nursing Home Quarterly (NQ) Item Set, dated 5/3/23 was reviewed. The MDS, under section H for Bladder and Bowel, indicated Resident 55 had an indwelling catheter. The MDS Coordinator stated that the Bladder and Bowel section which included the indwelling catheter was missed. During a review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI), MDS 3.0, version 1.17.11, Section 2.1 Introduction to the Requirements for the RAI, indicated the RAI process is the basis for the accurate assessment of each resident.

Based on observation, interview and record review, the facility failed to implement Resident 6's care plan (detailed plan for a resident which includes specific interventions) when a floor mat was not used when Resident 6 was in her bed. This failure had the potential for injury for Resident 6. Findings: During a review of Resident 6's Falls: Morse Fall Scale dated 7/5/23, the scale indicated she had a history of falling and was at a high risk for falls. Resident 6's Plan of Care dated 6/17/23, indicated to prevent falls Place floor mat next to bed when using low bed. During an observation on 7/12/23 at 9:55 a.m. of Resident 6's room and in the presence of Certified Nursing Assistant (CNA) 1, there was no floor mat in her room. CNA 1 stated, I don't think she has it [mat] because she transfers herself and we help her. She is very vocal too, and will shake her head and say [NAME]. CNA 1 further stated, The wheelchair would get in the way. During an observation on 7/12/23 at 10 a.m. with Registered Nurse (RN) 1, he confirmed there was no floor mat in Resident 6's room, and stated, If she [Resident 6] requested to take it [mat] away we should have removed it from the care plan. This is an oversight. During a review of the facility policy and procedure titled, Comprehensive SNF [skilled nursing facility] /ICF [intermediate care facility] Care Plans (All Homes), dated 7/10/23, it indicated, An individualized plan of care designed to ensure a systematic and compreshensive approach for meeting a Resident's specific needs. It further indicated the care planning process includes, 4. Implementation: Delivery of actual nursing care, nursing activities, putting approaches or solutions to work.

Based on interview and record review, the facility failed to ensure Resident 39's clinical record was maintained in accordance with accepted professional standards and practices, when the hospice (a program providing compassionate comfort care for people facing a terminal illness with a prognosis of six months or less) agency care plan was not contained in the clinical record. This failure resulted in the hospice agency care plan not being available for review by all health care providers, and the potential to adversely affect coordination of care. Findings: During a review of Resident 39's face sheet (demographics), the face sheet indicated Resident 39 had returned from the acute care hospital on 5/2/23. Resident 39's admitting diagnoses upon readmission to the facilty included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and acute and chronic respiratory failure. During a review of Resident 39's physician's (MD) orders, dated 5/3/23, the MD orders indicated Resident 39 was admitted to hospice agency. During a concurrent interview and record review on 7/11/23 at 9:59 a.m. with Registered Nurse (RN) 1, Resident 39's hospice care plan was reviewed. RN 1 stated the facility had developed Resident 39's hospice care plan. RN 1 was unable to locate a care plan developed by the hospice agency. RN 1 stated, We have our own care plan for him and the hospice agency usually follows it. I think they're following our care plan. During a concurrent interview and record review on 7/11/23 at 2:54 p.m. with Nurse Instructor (NI), NI stated facility staff developed a hospice care plan, and the hospice agency developed their own care plan. NI reviewed Resident 39's clinical record and stated she did not know why the hospice agency's care plan was not in the clinical record. NI stated, It's not in the chart. We need to make sure it's in the chart. That's how we coordinate care. During a review of the facility's policy and procedure (P&P) titled, Medical Records, dated 6/19/23, the P&P indicated, . 3. Medical records will be current and kept in detail consistent with good medical and professional practice based on the service provided to each Resident. 4. All current clinical information pertaining to the Resident will be centralized in the medical record .

Based on observation, interview and record review, the facility failed to provide a safe environment, when the hot water temperature of a hand washing sink registered above 165 degrees. This failure had the potential for the facility residents to burn their hands. Findings: During the initial kitchen tour on 7/10/23 at 10:43 a.m., a hand washing sink (with foot pedals) was observed directly behind the resident serving area (a cafeteria style service area used for resident meals). The sink appeared approximately 10 feet from the resident serving area. Near the resident serving area and directly in front of the sink, was a movable rack with chips on it, in which the residents could get their own chips/snacks. Next to the resident serving area a red line was painted on the floor which indicated, Employees Only. However, there were no physical barriers between the resident serving area and the hand wash sink. A sign posted above the sink indicated, Caution Water Temperature Exceeds 120 Degrees. On 7/10/23 at 10:44 a.m., when Surveyor accessed the water it was immediately very hot to touch. During a concurrent observation and interview on 7/10/23 at 11:35 a.m., the temperature of the hand washing sink was checked, using the facility's thermometer in the presence of the Food Service Manager (FSM) and the Registered Dietician (RD). The hot water of the sink registered 165.4 degrees Fahrenheit, and had steam coming from the running water. The FSM confirmed the water was hot. During a concurrent observation and interview on 7/12/23 at 3:24 p.m. with the Food Service Technician (FST), she stated in the evening around 6 p.m. they have a single chain they put across one of the two entrances to the food service area to block the residents from entering after hours where the handwashing sink was located. The FST stated the other entrance was Open all night, but I've never seen them go back there. During a review of the policy and procedure (P&P) titled, Plumbing and Water Supply Maintenance, dated 2/9/2023, the P&P indicated under the section titled Hot Water, .Hot water temperature controls will be maintained to automatically regulate temperature of hot water delivered .to attain a hot water temperature between 105 degrees and 120 degrees Fahrenheit during normal business hours, a work order is submitted. Plant Operations staff will be dispatched to the area for corrective action.

Based on interview and record review, the facility failed to report to California Department of Public Health (CDPH) Resident 1 ' s allegation of misappropriation of property within 24 hours. The facility did not report Resident 1 ' s allegation of misappropriation of property to CDPH until 6/23/2022 (5 days later). This failure delayed CDPH ' s investigation, and had the potential for misappropriation of Resident 1 ' s funds by the facility. Findings: On 7/13/2022 at 9:50 AM, an unannounced onsite visit was conducted to investigate an allegation of misappropriation of property. Resident 1 reported to staff that he witnessed a Certified Nursing Assistant (CNA 1) taking $120.00 from his wallet on 6/19/2022. A review of Resident 1 ' s Resident Property Loss Report, dated 6/21/2022, indicated the facility ' s investigation of Resident 1 ' s misappropriation of property started on 6/21/2022. During an interview with Resident 1 on 7/13/2022 at 11:22 AM, Resident 1 stated he witnessed CNA 1 holding his wallet and taking his money. Resident 1 stated he reported the incident to Licensed Vocational Nurse 1 (LVN 1) on 6/19/2022. During an interview with LVN 1 on 7/17/2022 at 1:15 PM, LVN 1 stated Resident 1 gave him a hand written note about his missing money on 6/19/2022. LVN 1 also stated he sent an email message about the incident to the Staff Services Manager (SSM 1) and Supervising Registered Nurse (SRN 1) on 6/19/2022. During an interview with SSM 1 on 7/13/2022 at 10:35 AM, SSM 1 stated LVN 1 reported the incident via email message on 6/19/2022, and he confirmed the facility started investigating the incident on 6/21/2022. During an interview with the Administrator (Administrator 1) on 7/17/2022 at 1:41 PM, Administrator 1 stated Resident 1 ' s allegation of misappropriation of property on 6/19/2022, was not submitted to CDPH within 24 hours.

Based on observation, interview and record review, the facility failed to follow its policy and procedure when: 1. One of 17 sampled residents (Resident 14) was observed in the designated smoking area with oxygen in use via a nasal cannula (device that has two prongs and delivers oxygen directly into the nostrils) and a portable oxygen tank set at eight liters per minute. 2. Routine resident rounds were not completed for 11 unsampled residents (Resident's 13, 56, 52, 26, 53, 58, 2, 23, 67, 29, 11) on two consecutive dates and times in the 700 unit. These failures did not promote a safe environment and had the potential to compromise the well-being of the residents. Findings: 1. A review of Resident 14's history and physical report dated 4/22/22, indicated he was admitted on [DATE] with diagnoses of [CONDITION(S)] ([CONDITION(S)]-damage to tissues in the lungs making it hard to breathe) and hypoxemia (low level of oxygen in the blood). An observation was conducted of the designated smoking area on 8/2/22 at 8:55 AM. There was a sign posted, No oxygen beyond this point. Resident 14 was observed in the designated smoking area with oxygen in use via a nasal cannula and a portable oxygen tank set at eight liters per minute. There was no staff in the designated smoking area. During an interview on 8/2/22 at 9:06 AM with the Certified Nurse Assistant (CNA 1), CNA 1 confirmed, Resident 14 was in the designated smoking area, with oxygen, a portable oxygen tank and no staff was present. CNA 1 stated, Resident 14 should not be in the smoking patio because he is on oxygen, and this is a safety concern. CNA 1 further stated, Resident 14 was forgetful, had dementia (memory loss and judgment) and needed constant re-direction. CNA 1 stated, resident rounds are done every two hours and as needed. During an interview on 8/3/22 at 7:13 AM with the Licensed Vocational Nurse (LVN 1), LVN 1 stated, residents on oxygen and with oxygen tanks are not allowed in the designated smoking areas because this is a safety hazard and they can blow up. A review of the facility's policy and procedure titled, Routine Resident Checks, reviewed 5/10/22, indicated, The facility promotes the safety and well-being of residents by providing routine resident rounds / checks. Nursing staff check on the well-being of each assigned resident. A review of the facility's policy and procedure titled, Safe Smoking & Tobacco Use, reviewed 7/8/22, indicated, Smoking is prohibited in the following area where oxygen is in use. 2. A review of the hourly checks form indicated the following: *8/1/22 at 2 PM, the hourly rounds were not completed by staff for the following residents, Resident's 13, 56, 52, 26, 53 and 58. *8/2/22 at 5 PM and 6 PM, the hourly rounds were not completed by staff for the following residents, Resident's 2, 23, 67, 29 and 11. During an interview on 8/3/22 at 7:13 AM with the Licensed Vocational Nurse (LVN 1), LVN 1 stated, the licensed nurse is responsible for verifying resident rounds are completed and the round sheets are collected at the end of shift by the licensed nurse. During an interview on 8/4/22 at 9:09 AM with the Certified Nurse Assistant (CNA 2), CNA 2 confirmed, she was assigned to resident rooms, 1002A through 1004B on 8/2/22. CNA 2 confirmed, she didn't complete the hourly rounds for her assigned resident rooms at 5 PM and 6 PM, because she couldn't find the rounds sheet. During an interview on 8/4/22 at 9:25 AM with the Certified Nurse Assistant (CNA 3), CNA 3 confirmed, she was assigned to resident rooms, 1010A through 1012B on 8/1/22. CNA 3 confirmed, she didn't complete the hourly rounds for her assigned resident rooms at 2 PM, because she got busy with another resident and forgot to check on these residents. CNA 3 stated, the hourly rounds should have been done on these residents. CNA 3 further stated, it was her mistake. A review of the facility's policy and procedure titled, Routine Resident Checks, reviewed 5/10/22, indicated, The facility promotes the safety and well-being of residents by providing routine resident rounds / checks. The facility protocol for routine resident checks are hourly during the day/pm shifts, 7 am-11 pm. The Licensed Nurse shall ensure rounds are being done. Upon completion of the round the nursing assistant will initial the round form to designate the resident check has been completed. The Registered Nurse or other designated licensed nurse will observe that all scheduled rounds are conducted and all documentation on the logs are consistent with the rounds made by staff.

Based on observation, interview and medical record review, the facility failed to provide adequate supervision for 1 of 3 sampled Residents (Resident 1) by not performing resident rounds on (MONTH) 21, 2019. The surveillance video showed that on (MONTH) 21, 2019 at 1:39 AM, Resident 1 exited the POD 1000 (Unit name) through the unlocked back door wearing only pajama pants. This failure had resulted in Resident 1 stayed outside of the facility in the freezing cold temperatures for approximately 6 hours. Resident 1's dead body was discovered by an off duty custodian, laying on the snow covered ground, with bruises on his hands and arms at the bottom of the 43 foot hill near the military tank on (MONTH) 21, 2019 at 7:30 AM. Findings: An observation of the location where Resident 1's body was found was conducted on (MONTH) 21, 2019, at approximately 7:30 AM. The distance from the facility exit door to POD 1000 and to the location where Resident 1's body was found, approximately 40 feet from a steep embankment. There was a military tank parked on the grounds. The ground was noted to be uneven, covered with ice and rocks. On (MONTH) 22, 2019, at 12:40 PM, an interview was conducted with the Skilled Nursing Facility Administrator (SNFA). The SNFA stated on (MONTH) 21, 2019 at 7:30 AM, he heard the announcement of a man down outside, near the military tank at the entrance to the facility compound. The SNFA went outside and saw a body of a man laying outside on the ground near the military tank only wearing pajama pants. The SNFA stated the body's hands and arms were bruised. The SNFA stated the body was first discovered by an off duty custodian. The body was identified as Resident 1. Review of Resident 1's medical record indicated a [AGE] year old male, was admitted to the facility in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. Review of the interdisciplinary team meeting note dated (MONTH) 13, (YEAR), indicated Resident 1 was able to ambulate independently, using a front wheeled walker, without any difficulty. Resident 1 had memory impairment. The Morse fall scale assessment tool indicated Resident 1 had impaired mobility, weakness gait, walked short steps and at times would shuffle. On (MONTH) 22, 2019, at 1:15 PM, an interview was conducted with the off-duty custodian. She stated that she found Resident 1's body lying on the ground outside of the facility, near the military tank on (MONTH) 21, 2019 at 7:30 AM. The Custodian stated that it had snowed the day before the incident. She stated that day as she drove around the facility she saw the body on the ground by the military tank and pulled over. She went for help immediately after realizing what she saw. Review of the SNF POD 1000 surveillance video of the night of (MONTH) 20, 2019 to (MONTH) 21, 2019 was conducted with the Health and Safety Officer (HSO). On the video surveillance at time stamp 1:39 AM, Resident 1 was shown walking out of his room independently without using a front wheeled walker. Resident 1 was exiting the POD 1000 through the unlocked and unalarmed back door wearing only pajama pants. No staff were visible on the video recording when Resident 1 left the facility through the unlocked and unalarmed door. Review of the weather forecast for the facility's local area indicated that the nighttime temperatures for (MONTH) 20-21, 2019 ranged from 28.9 to 30.9 degrees Fahrenheit. It indicated the temperature was extremely cold for any person, especially an elderly person. A review of the facility document titled, Hourly Checks: Making Rounds-Anticipating Needs, dated, (MONTH) 20, 2019, indicated, Potty: Check on the needs for the resident's trip to the restroom to avoid falls and other unsafe conditions. Position: Make sure residents are comfortable and assessing the risk of pressure ulcers. Pain: Asking residents to describe their level on a scale 1-10. Possessions: Making sure the items residents need are within reach, such as water, tissues, TV remote control. Staff are to make rounds at designated times and initial boxes . Licensed nurse to verify rounds are done. The boxes for hours 2300 (11 PM), 0100 (1 AM), 0300 (3 AM), and 0500 (5 AM) were all signed with the same initials indicating the rounding checks had been completed by CNA 1. On (MONTH) 26, 2019 at 10:06 AM, a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated, That day (February 20, 2019) I got there late because it was cold and raining. The patient (Resident 1) is very independent and very alert and will ask for help if he needs anything. He (Resident 1) and his roommate usually sleep all night. I checked on them and got them settled for the night. He (Resident 1) doesn't like to be bothered in the night, so I didn't need to check on him. I didn't see him (Resident 1) after 1 AM (February 21, 2019). On (MONTH) 22, 2019, at 1:30 PM, an interview was conducted with the Supervising Registered Nurse (SRN). The SRN confirmed CNA 1 and LVN 1 were on duty in the 700-unit POD 1000 (Resident 1's room location) on the night of (MONTH) 20, 2019. The SRN stated staff conducted rounds to check on the residents every two hours on the night shift and every hour on day shift. The SRN stated during the rounds, staff ensure the residents were clean, comfortable and safe. The SRN stated staff must document when the rounding are performed. The rounding document dated (MONTH) 20, 2019 to (MONTH) 21, 2019 was reviewed with the SRN. The hours in question was completed by CNA 1 indicating the rounds were performed on Resident 1 on (MONTH) 21, 2019 from 1 AM through 5 AM. The SRN admitted the rounding document inaccurately reflected CNA's checks as the surveillance video recording indicated Resident 1 was seen leaving the POD 1000 on (MONTH) 21, 2019 at 1:39 AM, and had not returned to the facility. A review of the facility policy titled, Routine Resident Checks dated (MONTH) 2007, indicated, Staff shall make routine resident checks to help maintain resident safety and well-being. Resident Checks, Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any changes in the resident's condition, identify weather the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc . A telephone interview was conducted with Licensed Vocational Nurse (LVN) 1 on (MONTH) 4, 2019, at 7:30 PM. LVN 1 stated he was the licensed nurse on duty in the POD 1000 the night of (MONTH) 20-21, 2019. LVN 1 stated he did not do a physical verification on Resident 1 when the resident rounds was performed by CNA 1 from 1 AM through 5 AM on (MONTH) 21, 2019. On (MONTH) 21, 2019, a review of the official Coroner Investigation report indicated Resident 1's cause of death as , Hypothermia with [MEDICATION NAME] force injury of the head and neck.

Based on interview and record review, the facility failed to: 1.Ensure medications were administered to Resident 16 as ordered by the physician and without errors, and; 2. Ensure licensed nurses followed medication administration policy and procedures to prevent medication errors from occurring. As a result, significant medication errors occurred causing Resident 16 to be hospitalized for [REDACTED]. enough water and other fluids to carry out its normal functions), hypoxemia (an abnormally low level of oxygen in the blood), and acute on [MEDICAL CONDITION]. Acute-on-[MEDICAL CONDITION] also known as acute kidney injury defined as rapidly progressive impairment of renal function that results in fluid and electrolyte derangement and retention of normally excreted substances in the blood. The medication error impacted his overall physical well-being and creating a significant decline in functional status. Resident 16 subsequently had a fall related to his general weakness, instability, and declined in functional abilities from the recent hospitalization . Findings: A concurrent interview was conducted with the Director of Nurses (DON) and Standards Compliance Coordinator (SCC) on 2/27/14 at 10 a.m. The DON stated the facility had a medication error involving LVN 1 and Resident 16. The DON stated LVN 1 gave Resident 16 medications intended for Resident 25. The DON stated Resident 16 received both, his morning meds along with Resident 25's 8 a.m. medications. The DON stated Resident 16 experience a decline in condition and had to be sent out to the hospital as a result of the medication error. The Standards Compliance Coordinator stated the medication error occurred on 7/17/13, and it involved a registry nurse (LVN 1). The Standards Compliance Coordinator stated LVN 1 admitted to not following procedures for identifying the residents prior to giving the medications. The facility's policy and procedure titled, "Administering Medications," dated December 2012, was reviewed on 2/27/14. The policy indicated, "The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with another facility personnel..." A closed record review was conducted for Resident 16 on 2/26/14. Resident 16 was an [AGE] year-old male admitted to the facility on [DATE]. Resident 16's [DIAGNOSES REDACTED]. The Physician orders [REDACTED]. ( a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion ), [MEDICATION NAME] 10 meq tablet ( a medication used to prevent and correct potasium deficiency), [MEDICATION NAME] DR 20 mg ( a medication used to treat heartburn and symptoms of [MEDICAL CONDITION] reflux disease), [MEDICATION NAME] 5 mg ( a diabetes medicine that helps control blood sugar levels), [MEDICATION NAME] HCL 500 mg ( a diabetes medicine that helps control blood sugar levels), [MEDICATION NAME] 60 mg ( a [MEDICAL CONDITION] hormone replacement medication), and Vitamin D 1,000 unit tablet ( a medication used to reduce elevated [MEDICAL CONDITION] hormone). The electronic Progress Notes indicated that on 7/17/13, a medication error occurred during the 8 a.m. medication pass when Resident 16 was given medications that had been prescribed to another resident (Resident 25). Resident 16 received his 8 a.m. medications along with Resident 25's 8 a.m. medication. Resident 16 received ten additional medications in error that had not been prescribed to him by the physician. The medications given in error included: 1.[MEDICATION NAME] 40 mg ([MEDICATION NAME] is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion). Resident 16 had already received [MEDICATION NAME] 20 mg as ordered by his physician and with the additional 40 mg given in error, for a total of Flurosemide 60 mg. 2. Aspirin 81 mg (Aspirin is part of a group of medications called nonsteroidal anti-[MEDICAL CONDITION] drug - NSAIDS. A [MEDICATION NAME] that works by reducing substances in the body that cause pain, fever, and inflammation, used to treat pain, and reduce fever or inflammation, and sometimes given to treat or prevent [MEDICAL CONDITIONS], and chest pain). 3. [MEDICATION NAME] 180 mg (a calcium channel blockers, which works by relaxing the muscles of your heart and blood vessels, used to treat hypertension (high blood pressure), [MEDICAL CONDITION] (chest pain), and certain heart rhythm disorders). 4.[MEDICATION NAME] 5 mg (an oral diabetes medicine that helps control blood sugar levels. This medication helps your pancreas produce insulin). Resident 16 had already received [MEDICATION NAME] 5 mg as ordered by his physician and with the additional 5 mg given in error, for a total of [MEDICATION NAME] mg. 5.[MEDICATION NAME] 100 mg (reduces the production of uric acid in your body). 6.[MEDICATION NAME] ER 600 mg (is an [MEDICATION NAME] that helps loosen congestion in your chest and throat, making it easier to cough out through your mouth by thinning mucus (phlegm) in the lungs and making it less sticky). 7. [MEDICATION NAME] 50 mg (is a beta-blocker that affects the heart and circulation (blood flow through arteries and veins). 8. [MEDICATION NAME] 30 mg (a group of drugs called [MEDICATION NAME], which dilates (widens) blood, making it easier for blood to flow through and easier for the heart to pump). 9. [MEDICATION NAME] 325 mg (a type of iron). 10.[MEDICATION NAME] Sodium 250 mg (a stool softener). The Progress Notes dated 7/17/13 at 11:21 a.m., indicated, "Med error by assigned nurse." The progress notes further indicated that the physician had been notified and orders were given to continue vital signs every 30 minutes for 24 hours, and to send resident to emergency department if there was a significant change in mental status and in vital signs if systolic below 98, diastolic below 55, pulse below 50. Progress Notes indicated first set of vitals taken at 10 a.m. were: blood pressure 132/60, pulse 73, and at 10:45 a.m. blood pressure was 118/58 and Pulse 75. The following vitals were recorded on the Medication Administration Record (MAR) for 7/17/13: Blood pressure and pulse 11:30 a.m. 108/55 P 69 12 p.m. 110/55 P 67 12:30 p.m. 106/53 P 59 1 p.m. 110/54 P 60 2 p.m. 104/63 P 56 3 p.m. 116/56 P 61 3:30 p.m. 111/54 P 56 4 p.m. 112/54 P 55 5 p.m. 135/88 P 55 6 p.m. 104/51 P 51 7 p.m. 79/40 P 43 7:30 p.m. 85/46 P 53 8 p.m. 89/45 P 45 8:30 p.m. 110/53 P 44 9 p.m. 147/60 P 44 10 p.m. 114/55 P 46 11 p.m. 114/55 P 48 12 a.m. 101/55 P 33 At 7 p.m., Resident 16's blood pressure was 79/40 and pulse 43. Resident 16 was not taken to the hospital for treatment for [REDACTED]. Progress Notes, dated 7/18/13 indicated Resident 16 was sent to the hospital at 1 a.m. for evaluation and treatment due to [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (low heart rate), and irregular pulse. The hospital records were reviewed on 2/26/14. Resident 16 was hospitalized for [REDACTED]. Arterial blood gas levels, taken on 7/18/13, indicated Resident 16 was experiencing hypoxemia - (Po2) partial oxygen level was low at 78 (normal 80-100 millimeter of mercury (mmhg) ). The hospital History and Physical indicated Resident 16 had, "Acute on [MEDICAL CONDITION]." The hospital Physician Discharge Orders, dated 7/20/13 at 1 p.m. indicated Resident 16 was treated for [REDACTED]. Acute-on-[MEDICAL CONDITION] also known as acute kidney injury defined as rapidly progressive impairment of renal function that results in fluid and electrolyte derangement and retention of normally excreted substances in the blood. According to Best Practice Journal 46 (2012): 10-15. Print, "Acute-on-[MEDICAL CONDITION]: prevention, diagnosis, management and referral in primary care." "It is also being recognized that even small impairments to renal function, changes too small to be recognized as organ failure, have a significant effect on patient morbidity and mortality...A reduction in blood flow to the kidney is the most common cause of acute kidney injury...Acute kidney injury should be considered a medical emergency..." Progress Notes dated 7/20/13 at 10:10 p.m., indicated Resident 16 was readmitted to the facility at 7:40 p.m. The progress notes indicated, "He is very weak and is unable to stand on his own. He needs total assistance for care. He was admitted with pull-ups on and wanted them taken off. This writer instructed him that we wanted to leave them on for a few days to see how he is doing...He needed to have the paramedic assist him in turning to sit on the recliner. He was unable to get out of the recliner on his own. When taken to the bathroom, he was unable to transfer from w/c (wheelchair) to toilet on his own. When he had to stand up for his body assessment, he was very weak and not able to hold on to the handrail...He cannot dress himself, unable to hold his arm up to put his shirt on..." The electronic Progress Notes dated 7/21/13 at 6:10 a.m., indicated, "Resident needed two of us to get him to a sitting position. He was unstable on his feet as the CNA assisted him to turn and sit on his w/c...still very unsteady on his feet..." The electronic Progress Notes dated 7/22/13 at 10:46 a.m., indicated, "...is total care at the moment..." Electronic Progress Notes dated 7/23/13 at 9:27 a.m., indicated Resident 16 continues to be very unsteady on his feet and remained at risk for falls. Resident was placed on one to one assist as he fell on [DATE] at 2:40 a.m. Resident 16 sustained a laceration to mid posterior side of his head. Resident 16's MDS, with assessment reference date of 4/23/13 and signed by the MDSC/RN on 5/1/13 certifying the assessment was accurate, was reviewed. Section G (Functional Status) of the MDS indicated Resident 16 was independent on all activities of daily living. The MDS indicated Resident 16 was independent and required no help or physical assistance from staff for bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, and bathing. The MDS, dated [DATE], indicated under ADL-Functional status, "Resident with recent hospitalization and has had generalized weakness impacting his functional abilities and balance." The MDS, dated [DATE], indicated under Indicators for Fall Risk, "Resident with acute illness resulting in his instability impacting his increase risk for falls...Resident has balance issues with standing up, transferring, turning around and walking. He had incident and is on 1:1 CNA for fall. Resident with generalized weakness post-acute care and was started on ABT (antibiotic) for a UTI (urinary tract infection), all these factors impacting his balance issues." On 3/3/14, a review of documents and interviews conducted during an Entity Reported Incident investigation by California Department of Public Health on 7/22/13 was done. An interview with LVN 1 on 7/22/13, at 11 a.m. The LVN stated she went straight to work on the floor after she received her assignment by the RN. The LVN stated she was never given the facility's med pass policy and procedure and was not aware of the facility's medication pass procedure prior to the incident. LVN 1 stated Resident 16 was in the same room as Resident 25. LVN 1 stated she was told by the RN to give Resident 25 his medication. LVN 1 stated she thought Resident 16 was Resident 25 and she gave Resident 16 medications intended for Resident 25. LVN 1 stated she did not ask Resident 16 what his name was and did not check the resident's name badge. The LVN further stated pictures of the residents were supposed to be part of the resident's MAR (Medication Administration Record), but there was no picture of Resident 25 in the MAR, and Resident 16 did not have a name badge on. LVN 1 stated as a registry nurse she was not given access to the computerized MAR being used by the facility nurses. RN 1 had already given Resident 16 his 8 a.m. medications and it was documented on the computerized MAR, but LVN 1 did not have access to that. LVN 1 stated she realized she gave medications to the wrong patient around 10 a.m., when Resident 16 walked by the medication cart and RN 1 identified Resident 16. LVN 1 stated she immediately reported the medication error to RN 1 and took Resident 16's vitals.