Every finding on record at Veterans Home Of California - Redding

Based on observation, interview, and record review the facility failed to store and label pasteurized eggs in accordance with professional standards for food service safety, and facility policy, when an unlabeled tray containing 18 pasteurized eggs was found in the walk-in refrigerator outside of its marked container.This failure had the potential to expose medically fragile residents to food contamination, increasing the risk of foodborne illness for all 39 residents who eat meals prepared in the kitchen.During an observation on 4/20/26 at 2:20 p.m. in the Main Kitchen's walk-in refrigerator a tray containing 18 pasteurized eggs was observed left outside of its marked container. The tray did not have a label indicating the received-on date or the use by date.During an interview on 4/20/26 at 2:31 p.m. with Stock Clerk (SC) 1, SC1 was unable to identify a used by date labeled on the tray of eggs.During an interview on 4/20/26 at 2:34 p.m. with [NAME] (C) 1, C1 was unable to identify a used by date labeled on the tray of eggs.During an interview on 4/23/26 at 3:11 p.m. with the Food Services Manager (FSM), the FSM stated that the tray of eggs should have been stored in the original container. The FSM further stated that if stored outside of original container, then the tray of eggs should have been relabeled using the details from the original container.During a review of the facility's policy and procedures (P&P) titled, Food & Nutrition Services- Leftover and Extra Food, dated 4/13/26, 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 where applicable or discarded The P&P further indicated, Foods stored in refrigerators, freezers and dry storage will have food item name and expiration date on label.

Based on observation, interview, and record review the facility failed to maintain proper grooming by ensuring fingernail care for one of twelve sampled residents (Resident 7), in accordance with the facility policy titled, Activities of Daily Living.This failure had the potential to increase the risk of infection for Resident 7.During a review of Resident 7's admission Record, dated 12/16/25, the admission Record, indicated Resident 7 was admitted to the facility with diagnoses of osteoarthritis (breakdown of cartilage) and tremor (involuntary shaking).During a concurrent observation and interview on 4/20/26 at 2:31 p.m. with Resident 7, in the facility hallway, Resident 7 was seated in his wheelchair with his fingernails exposed. Resident 7's fingernails were long. Resident 7 stated he wanted his nails trimmed and staff did not consistently perform nail trimming.During a concurrent observation and interview on 4/20/26 at 4:13 p.m., with Certified Nursing Assistant (CNA) 1, in the facility hallway, Resident 7 was seated in his wheelchair with his fingernails exposed. CNA 1 confirmed Resident 7's fingernails were long and that they should have been trimmed.During an interview on 4/22/26 at 3:16 p.m. with the Director of Nursing (DON), the DON stated licensed nurses should provide hygiene care, including nail trimming, to reduce the risk of skin injury.During a review of the facility policy and procedure titled, Activities of Daily Living dated 1/26/26. The policy indicated, nursing staff must assist the resident with activities of daily living, including maintaining proper grooming and providing finger and toenail care.

Based on observation, interview, and record review, the facility failed to ensure expired medication was not available for use when two vials of Lidocaine HCL (used to rapidly numb specific body areas for medical procedures by blocking nerve pain signals) were stored in the emergency kit beyond their expiration date.This failure had the potential to place residents at risk of receiving expired medication, which may lead to harmful side effects or reduced effectiveness.During a concurrent observation and interview on [DATE] at 9:10 a.m. with the Director of Nursing (DON) inside the medication room, the emergency kit contained two vials of Lidocaine HCL which had an expiration date of 3/2026. The DON confirmed the medication vials were expired. The DON stated that pharmacy and nursing staff should check the emergency kit for expired medication.During an interview on [DATE] at 10:24 a.m. with the DON, the DON stated, medication should not be expired for resident safety and for drug efficacy.During a review of the facility's policy and procedure (P&P) titled, Emergency Drug Kit, dated [DATE], the P&P indicated, 1. The pharmacist checking the Emergency Drug kit will also indicate the earliest expiration date and the name of that item on the outside of the container. 2. It is the responsibility of the contract production pharmacy to cycle out the e-kits prior to the expiration date listed on the exterior of the kit.

Based on observation, interview, and record review the facility failed to maintain an effective infection control program when one of twelve sampled residents (Resident 20) indwelling catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the floor.This failure had the potential to cause cross contamination and increase the risk of infection for Resident 20.During a concurrent observation and interview on 4/20/26 at 5:55 p.m., with Registered Nurse (RN) 1 in the facility hallway, Resident 20 was observed seated in a wheelchair self-propelling in the hallway. A urinary catheter drainage bag was secured to the lower portion of the wheelchair however, the catheter tubing was touching the floor. RN 1 confirmed the observation and stated the tubing should not be in contact with the floor due to infection control concerns.During a review of Resident 20's admission Orders (AR) dated 12/2/25, the AR indicated, Resident 20 required a indwelling catheter for a diagnosis of bladder outlet obstruction (blockage at the base of the bladder).During an interview on 4/22/26 at 11:08 a.m. with Infection Preventionist (IP), IP stated indwelling catheter tubing must not contact the floor to reduce infection risk.During a review of the facility policy and procedure titled, Guidelines for Use of a Urinary Catheter, dated 7/21/25, the policy indicated, catheter care is provided routinely to residents with Foley catheters in accordance with recognized standards.During a review of the facility In-Service Lesson Plan titled, Urinary Catheter Care, the basics dated 2/5/24, the In-service indicated, indwelling catheters should be secured to a wheelchair with tubing and bag kept off the floor, ensuring no contact or dragging during mobility.

Based on observation, interview, and record review, the facility failed to reassess fall risk factors and update the care plan interventions for 1 of 3 sampled residents (Resident 2), who was identified as being at high risk for falls. This failure resulted in Resident 2's unwitnessed fall, transfer to the acute care hospital for evaluation and treatment, and subsequent admission due to several broken ribs and a broken right collarbone on 8/3/25 (refer to Intake 2581256).Findings: During a concurrent observation and interview on 8/20/25 at 11:35 AM with Resident 2 in his room, Resident 2 was observed with multiple purplish black discolorations on the right side of his trunk, right side of his head/face, and some small, scattered purplish black discoloration on his right arm. Resident 2 was alert and oriented to person, place, and time. However, Resident 2 got short of breath easily and was drowsy during the interview. Resident 2 stated he did not recall what happened on 8/3/25 when he fell and sustained his injuries. During an interview on 8/19/25 at 11:45 AM with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Resident 2 was independent with his activities of daily living but was considered a high fall risk. CNA 1 stated Resident 2 was on frequent rounding checks for a little bit until it was discontinued. CNA 1 stated frequent rounding was checking on the residents every 15 to 30 minutes sometimes hourly depending on the resident's need and noting what was seen, addressing the 4Ps (pain, potty [bathroom needs], positioning, and possessions [or proximity of personal items]), and ensuring alarms were in place and working. During a review of Resident 2's face sheet, the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a progressive respiratory disease, causing shortness of breath), heart failure, and progressive joint disease resulting in joint pain. Resident 2 had a history of falls. During a review of Resident 2's Case Manager's Note, dated 7/3/25, the note indicated his Brief Interview for Mental Status (BIMS) score was 13/15 (intact cognition). The note also indicated Resident 2 fell on 5/30/25, prior to his admission to the facility and he used a four-wheel walker to ambulate. During a review of Resident 2's Interdisciplinary Progress Note - Nursing, dated 8/3/25 at 10:30 PM, the note indicated Resident 2 had an unwitnessed fall while toileting and was found on the floor with his four-wheel walker behind him on 8/3/25 at 8:30 PM. During a review of Resident 2's Interdisciplinary Progress Note - Nursing, dated 8/4/25 at 4:10 AM, the note indicated Resident 2 was admitted to the acute care hospital with several broken ribs and broken right collarbone on 8/3/25. During a review of Resident 2's Interdisciplinary Resident Fall Investigation and Intervention, the notes indicated Resident 2 had unwitnessed falls on the following dates: a. 7/25/25 at 3:28 PM - due to inability to gauge sleepiness and exhaustion and retire to bedb. 7/26/25 at 1:20 AM - due to impaired balance and overestimated ability. During a review of Resident 2's Fall Risk Assessment Forms (total score of 10 or above represents HIGH RISK), indicated Resident 2 scores were as follows:a. 6/24/25 (on admission), scored 16. b. 7/25/25 (post-fall), scored 15. c. 7/26/25 (post-fall), scored 18. During a review of Resident 2's Interdisciplinary Progress Note - Nursing, dated 8/4/25 at 8 AM, the note indicated a late entry for 7/28/25 when Resident 2's daughter requested the alarms (SMART alarms [devices that use sensors to detect when a patient or resident gets out of bed or a chair, alerting a caregiver wirelessly to help prevent a fall]) to be removed because the alarms were Keeping him awake and exhausted. The note also indicated that both the resident and his daughter appeared relieved after the alarms were removed. During a concurrent interview and record review on 8/20/25 at 2:08 PM with the Director of Nursing (DON), Resident 2's Fall Prevention Care Plan initiated on 6/24/25 was reviewed. The care plan was updated after each fall with the following interventions: a. Frequent rounding was initiated on 7/25/25 for one week (end date 8/1/25). b. Initiate SMART alarms on 7/26/25 and were discontinued on 7/28/25. c. Frequent rounding for two weeks was initiated on 8/3/25 (date of most current fall- after Resident 2 fell).The DON stated Resident 2's frequent rounding that was initiated on 7/25/25 concluded on 8/1/25. The DON also stated the nurses should have reassessed Resident 2 risk factors and updated the care plan to continue frequent rounding indefinitely since Resident 2 and his family refused the use of alarms on 7/28/25. The DON was unable to provide documented evidence to show there were fall prevention interventions implemented after the frequent rounding intervention was discontinued on 8/1/25, two days prior to Resident 2's unwitnessed fall with significant injuries on 8/3/25. In addition, the DON was unable to provide a policy and procedure (P&P) for the frequent rounding checks intervention. During a review of the P&P titled, Fall Risk Assessment and Prevention Program, dated 3/20/23, the P&P indicated, A Registered Nurse (RN), will complete the fall risk assessment on all Residents . 3. After each fall . II. Result/Scores . B. Based upon the Fall Risk Assessment, if the Resident is assessed as a high risk, the Supervising Registered Nurse (SRN) or designee will: 1. Develop and implement a plan of care for falls based upon the identified risks. 2. Communicate the plan of care to direct care staff via verbal or written instruction.

Based on interview and record review, the facility failed to ensure the pain medication was administered as prescribed for Resident 1. This failure had the potential to result in uncontrolled pain management and adverse outcomes for Resident 1 (refer to Intake 2573274).Findings: During a review of Resident 1's face sheet, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included heart failure, metastatic (the spread of cancer cells from the place where they first formed to another part of the body) prostate cancer, and muscle weakness. During a review of the facility's policy and procedure titled, Medication Administration, General Guidelines (SNF), dated 4/21/25, the P&P indicated, Medications are administered only by nursing . 1. As Ordered: Medications are administered in accordance with and with orders of the prescriber. During a concurrent interview and record review on 8/20/25 at 10:23 AM with the LVN 1, the physician order for Oxycodone (narcotic pain medication usually prescribed for severe pain) 5 milligrams (mg) immediate release was reviewed. The physician order indicated, Take one tablet by mouth every 4 hours, as needed for lower back pain. LVN 1 stated she did not administer the Oxycodone as prescribed and she should have called the physician to obtain a medication order for Resident 1's generalized pain. During a concurrent interview and record review on 8/20/25 at 10:32 AM with the Director of Nursing (DON), Resident 1's Medication Record, dated July 2025, was reviewed. The Medication Record indicated the pain medication Oxycodone 5 mg immediate release was administered on 10 occasions by multiple nurses for the incorrect indication as follows: 1. 7/16/25 at 3:35 PM - Increased generalized pain2. 7/18/25 at 3 PM - Body pain 3. 7/25/25 at 7 PM - Generalized pain 4. 7/26/25 at 7 AM - Generalized/facial/neck 5. 7/26/25 at 12 PM - Neck pain6. 7/26/25 at 9 PM - Neck pain 7. 7/27/25 at 4:40 AM - Face and Neck pain 8. 7/28/25 at 7 AM - Face Pain9. 7/29/25 at 1 PM - Face and Neck pain 10. 7/31/25 at 8 AM - Neck pain The DON stated the nurses should have obtained a physician order for Resident 1's general pain. During an interview on 8/20/25 at 1:40 PM with Medical Doctor 1 (MD 1), MD 1 stated the nurses can administer Resident 1's pain medication Oxycodone 5 mg immediate release as needed for other pain indications even though the indication on his physician order stated for lower back pain. During an interview on 8/20/25 at 1:46 PM with Pharmacist 1 (Pharm 1), Pharm 1 stated it was okay for nurses to administer Resident 1's pain medication Oxycodone 5 mg immediate release as needed for other pain reasons other than the indication stated on the physician's order.

Based on observations, dietary and leadership staff interview and departmental document review the facility failed to ensure food handling practices were consistently carried out in accordance with food safety standards when: 1. There were lapses in cooldown monitoring of foods associated with foodborne illness and 2. One staff member was chewing gum during food production activities. These failures had the potential to result in foodborne illness and cross-contamination for the facility's residents. Findings: 1. Potentially Hazardous Foods (PHFs) are those foods capable of supporting bacterial growth associated with foodborne illness. Protein based foods such as meat, beans and canned tuna are considered PHFs and require time/temperature control for food safety during periods of preparation, storage and distribution (US Department of Agriculture [USDA], Food Code, 2022). Cooked foods requiring time/temperature control for safety food shall be cooled: within 2 hours from 135 F (degrees Fahrenheit) to 70 F and within a total of 6 hours from 135 F to 41 F or less. Food shall be cooled within 4 hours to 41 F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna (USDA Food Code, 2022). During initial tour observation of the main production kitchen on 04/07/25 beginning at 08:20 a.m., there were multiple pans of frozen entree foods in Freezer #B. The following foods included, but not limited to, Macaroni and Cheese, dated 2/13/2025 and cooked corned beef, dated 3/15/2025. It was also noted in Refrigerator #A there was approximately one-half gallon of prepared tuna salad, dated 4/6/25. In a concurrent interview the Food Manager (FM) indicated that some of the frozen items were over production and would be used at a later time as a meal substitute. The FM also stated there were various food production methods for the skilled nursing facility (SNF) kitchen. He stated depending on the item and dietary department staffing food items may be prepared in the main kitchen and then transported to the SNF kitchen for distribution, while others may be prepared in the SNF kitchen. During a food production observation on 04/08/25 at 09:20 a.m., the surveyor asked [NAME] (C) 1 to describe the process for preparing tuna salad. C1 indicted the tuna and mayonnaise were stored at room temperatures in the dry storage area. C1, indicated if there was mayonnaise in the refrigerator it would be used first. C1 described the process of mixing the ingredients then placing the finished product in the refrigerator. C1 indicated there was no temperature monitoring during the food storage period, rather temperatures were taken shortly prior to using the tuna. In a concurrent confirming interview with the FM he acknowledged the facility did not monitor food temperatures for items prepared from ingredients at ambient (room) temperature. The surveyor asked C1 to describe the process when there was an overproduction of an item that was intended to be saved for later use. C1 indicated the item would be taken from the hot line and moved to either the refrigerator or freezer and if it did not cool down fast enough, they would utilize the blast chiller (an appliance to quickly cool foods to a low temperature). C1 and the surveyor proceeded to Freezer #B where dietary staff were storing previously cooked items. The following cooked items were present: macaroni and cheese, dated 2/13/25; vegetarian meatloaf, dated 3/16/25 and lentil loaf, dated 3/15/25. Concurrent review of the departmental document titled, Cool Down Log, dated 2/10/25 through 4/7/25 revealed none of the observed items in the freezer were monitored during the cooldown process. In a concurrent interview FM acknowledged there was currently no system to monitor cooldown temperatures for foods prepared from room temperature ingredients. The undated, facility policy titled, Food & Nutrition Services-Leftover and Extra Food (All Homes) guided staff on the process of properly cooling foods, however, did not include guidance for documenting the process. It was also noted the policy did not address the necessity to monitor the cooldown of PHFs from room temperature ingredients. 2. During general food production observations on 4/7/25 beginning at 10:55 a.m., it was noted Food Service Worker (FSW) was preparing mechanically altered items for the noon meal. FSW was consistently moving her mouth in a chewing motion, resembling the motion of chewing gum. During an general conversation with FSW the surveyor noted a white item in her mouth resembling gum. The surveyor asked if she had gum in her mouth to which she stated, I Do. The undated, departmental policy titled, Food & Nutrition-Staff Operations and Training (All Homes) indicated, .Eating/Drinking/Tobacco/Gum in Work Areas . 3. Employees must not chew gum .in kitchen or serving areas .

Based on observation, interview, and record review, the facility failed to ensure that internal and external medications were stored separately for 2 of 2 medication storage areas observed. This failure had the potential to cause cross-contamination and medication administration errors. Findings: On 04/07/25, at approximately 3:20 p.m., during a tour of the medication storage areas located in the Clamath and [NAME] nursing stations, it was observed that internal-use medications were stored directly adjacent to external-use products without appropriate separation. Specifically, oral medications such as [NAME] & Thrive Loperamide tablets, Glucosamine Sulfate 500 mg capsules, and Calcium Citrate tablets were stored next to external-use items including Fleet Saline Enema, GenTeal Tears Lubricant Eye Drops, Refresh Plus Eye Drops, and Major Ear Drops (Carbamide Peroxide 6.5%). No physical barrier, labeled bin, or designated shelving was in place to distinguish internally administered medications from those intended for external use. During an interview conducted on 04/07/25 at 3:30 p.m. the time of the observation with the facility's Quality Assessment Nurse, he acknowledged the improper storage practice, stating, I didn't know internal and external medications were being stored together, but it looks like we've been doing it that way for a while. This acknowledgment confirmed the storage practice had likely been ongoing and unrecognized by facility staff. The facility's policy, titled Storage of Medications, outlines specific expectations regarding medication segregation. Section 6, subsection B of the policy clearly states, Internally administered medications are kept separate from externally used medications such as lotions, creams, ointments or suppositories. Despite this policy, the observation on 04/07/25 revealed that oral medications, including anti-diarrheals and dietary supplements, were intermixed with external-use medications, such as eye drops and enemas, with no form of separation in place.

2. During a review of the Face Sheet, for Resident 9, the Face Sheet, indicated, Resident 9 was admitted to the facility on [DATE], with diagnoses which included depression (feeling sadness) and alzheimer's disease (memory loss). The physician's order, dated 07/29/24, indicated Resident 9 should receive Aripiprazole (Abilify) 2 milligrams (mg) by mouth at bedtime for the treatment of depression. This medication was classified as an antipsychotic and requires monitoring to assess both its effectiveness in managing the targeted condition and the presence of any side effects or adverse reactions. Upon review of the behavior monitoring and side effect tracking tool for Resident 9, the documentation showed that only side effect monitoring was being conducted, such as assessments for drowsiness, dizziness, or extrapyramidal symptoms. There was no documentation of behavioral monitoring, including identification of target behaviors, baseline symptoms, or ongoing evaluations of whether the medication was effective in addressing the resident's depression. In an interview on 04/09/25 at 10 a.m., the Quality Assurance Nurse confirmed that behavioral monitoring had been overlooked and stated, It should have been filled out, but was missed. Based on observation, interview, and record review, the facility failed to ensure two of 17 sampled residents (Resident 9 and Resident 19) were free of unnecessary psychotropic medications (drugs that affect brain function, mood, thoughts, or behaviors) when: 1. Staff did not implement non-pharmacological interventions (treatments that do not involve medication prior to administering psychotropic medications) for Resident 19. 2. Staff failed to implement behavioral monitoring related to the use of psychotropic medications for Resident 9. These failures had the potential to result in unecessary drug administration for Residents 9 and 19. Findings: 1. During a review of the Face Sheet for Resident 19, the Face Sheet indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During an interview on 4/9/25 at 8:28 a.m., with Resident 19, Resident 19 stated he notified staff that he was not sleeping well because he experienced jerking episodes throughout the night which had been keeping him awake. Resident 19 stated the physician ordered a sleeping pill. During a review of Resident 19's record on 4/9/25 at 8:35 a.m., the record indicated: On 2/2/24, the physician ordered Melatonin (a supplement used to regulate sleep cycle) at bedtime as needed. On 3/24/25, the physician ordered Temazepam (psychotropic medication-sleeping pill) for insomnia (trouble sleeping) at bedtime as needed. There was no documentation of any non-pharmacological interventions. On 3/24/25, a Nursing Care Plan was developed for Insomnia. Interventions included, Administer Temazepam. There were no non-pharmacological interventions planned to address the resident's insomnia. On 4/1/25, the physician ordered Trazodone (psychotropic medication-sleeping pill) for insomnia at bedtime as needed. There was no documentation of any non-pharmacological interventions. During a concurrent interview and record review on 4/9/25 at 3:16 p.m.,with License Vocational Nurse (LVN) 2, Resident 19's April 2024, Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 19 received Trazodone on 4/1/25, 4/4/25, 4/5/25, 4/6/25, and 4/7/25. There was no documentation which indicated non-pharmacological interventions were attempted prior to administering Trazodone on each date. The MAR further indicated Resident 19 did not receive Melatonin between the dates of 4/1/25 through 4/9/25. LVN 2 stated she did not offer Resident 19 Melatonin prior to administering Trazodone. LVN 2 confirmed there was no documentation in the record which indicated non-pharmacological interventions were attempted prior to administering Trazodone. During a concurrent interview and record review on 4/10/25 at 8:20 a.m., with Director of Nursing (DON), DON stated prior to starting a psychotropic medication, non-pharmacological interventions should have been attempted and documented in the resident's record. Resident 19's March and April 2025 MAR were reviewed with the DON, the DON confirmed there were no non-pharmacological interventions documented prior to administering the psychotropic medications to Resident 19. DON confirmed there was no documentation to show Resident 19 was offered Melatonin to help him sleep in March or April 2025. DON stated Melatonin and non-pharmacological interventions should have been attempted prior to administering psychotropic medication. During a review of the facilities policy and procedure (P&P) titled, Psychotropic Drug Management, SNF, last reviewed 10/21/24, P&P indicated, Resident's care plan will include behavioral interventions implemented in an attempt to decrease the target behaviors . Non-pharmacological, or behavior interventions were attempted, but failed to resolve the cause of the behaviors .

Based on observation, interview, and record review, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, three medication errors were observed out of twenty-eight opportunities, resulting in an error rate of 10%, and involved two separate insulin administrations and one nasal spray medication for Resident 3. These deviations from proper technique posed a risk for suboptimal therapeutic outcomes. The failure to adhere to manufacturers' instructions for insulin and nasal spray administration not only violates professional standards of practice but also increases the risk of therapeutic failure and resident harm. Findings: 1. According to the manufacture's insert instructions for insulin (#1), the dose button must be held in and the needle kept in the skin for at least five seconds to ensure full dose delivery. Similarly, manufacture's insert instructions for insulin (#2) once the dose button was pressed, the needle should remain under the skin for six seconds. Failing to follow these steps may result in an incomplete dose being delivered. During a review of the Face Sheet for Resident 3, the Face Sheet, indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) and muscle weakness. On 4/7/25 at 8 a.m., during medication administration observations, Licensed Vocational Nurse (LVN) 1 was seen administering insulin #1 and insulin #2 to Resident 3. In both instances, the nurse inserted the insulin pen needle and immediately withdrew it after pressing the dose button, without holding the needle in the subcutaneous tissue for the duration specified in each manufacturer's instructions for use. During an interview on 4/7/25 at 8 a.m., at the time of observation, the LVN 1 acknowledged the error and stated, I forgot about holding that insulin needle in the patient as required by the manufacturer. She confirmed that she routinely removed the pen immediately after pressing the dose button and was not consistently following the manufacturer's holding time guidance. 2. According to standard manufacturer's instructions for most Saline Nasal Spray-intranasal sprays, the nasal passages should be cleared (individual should blow their nose) prior to administration to ensure the medication contacts the mucosa effectively. On 4/7/25 at 8 a.m., during medication administration observations, LVN 1 administered a nasal spray to a Resident 3 without instructing the resident to blow their nose beforehand. When interviewed, the LVN 1 stated, I just didn't know that you were supposed to blow the nose for the nasal spray.

Based on observation, leadership interview and dietary department document review the facility failed to ensure sufficient staff were employed as evidenced by the lack of a full-time qualified position to supervise and manage the day-to-day operations of the skilled nursing dietetic services. Failure to ensure sufficiently qualified staff may result in dietetic services that are inconsistent with professional standards of practice placing 35 residents at risk for potential food related medical complications. Findings: Per California Code of Regulations, Title 22, Chapter 3, dietetic services is defined as the provision of safe, satisfying and nutritionally adequate food for patients with appropriate staff, space, equipment and supplies. Additionally, California Health and Safety Code, 1265.4 describes the staff qualifications for the day-to-day management of dietetic services in a skilled nursing facility. The Health and Safety Code describes, in the absence of a full-time Registered Dietitian with supervisory responsibilities for dietetic services, the licensed facility shall employ a full-time qualified dietary services supervisor. There are 7 recognized pathways, all of which are based on a variety of educational experiences. During the initial tour of the main kitchen on 4/7/25, beginning at 8:20 a.m. the surveyor was introduced to the Food Manager (FM). In a concurrent interview, the FM indicated he was responsible for the day-to-day management of both the skilled nursing kitchen, as well as a separately licensed residential care facility for the elderly (RCFE). The FM indicated primary food production activities occurred in the RCFE kitchen with some menu items also produced in the skilled nursing facility (SNF) kitchen. The FM acknowledged his position was not dedicated as full-time to the SNF, rather had foodservice responsibilities for multiple levels of care. The surveyor was also introduced to the Dietetics Assistant Director (DAD), a Registered Dietitian. The DAD indicated her position was responsible for supervisory oversight of the Registered Dietitians as well as the Food Service Managers for both the RCFE, as well as the SNF. The DAD position also included the responsibility of all departmental administrative functions such as staffing and budget. In an interview and concurrent document review on 04/08/25 at 1:30 p.m., with the DAD the organizational chart for the veterans home was reviewed. The DAD indicated the Director of Dietetics position, as well as a food service supervisor (FSS) II position was currently vacant. The DAD indicated that within the current organizational structure there is no position designated to be the full-time qualified Food Service Director dedicated to the skilled nursing facility. The DAD confirmed all of the dietetic services leadership positions within the home are split between the RCFE and the SNF. The DAD acknowledged her position was not dedicated solely to the SNF. The surveyor also reviewed the responsibilities of the Registered Dietitian (RD) within the SNF. The DAD indicated one of the RD positions was dedicated to the SNF, however the position did not include day to day management of dietetic services for the SNF, rather the focus was clinical nutrition care. In an interview on 04/09/25 at 10:15 a.m., the Assistant Administrator (AA) 1 for the home indicated the process for vacancies was to post a position, which was done by Human Resources (HR) in Sacramento. The applications were then forwarded to the departmental supervisor for screening and selection of candidates to interview. The screening then goes back to Sacramento HR for final review who will determine the final candidates eligible for interview. Concurrent review of the Minimum qualifications for the FSS II revealed one of the qualification pathways would be consistent with the regulatory requirements, however there were others that were based solely on experience. The AA 1 indicated he can move positions within an organizational structure at the local level, however position duties would be more difficult to modify and would need to be taken through HR channels. The AA 1 indicated to his knowledge the home had not attempted to make modifications to position descriptions and/or position minimum qualifications. The AA 1 indicated a RD used to be responsible for the day-to-day supervision of the SNF kitchen, however she returned to a clinical nutrition role. Additionally, the AA 1 indicated the home had approved the FM to receive the necessary training as outlined in the California Health and Safety Code. In an interview 04/09/25 at 11:40 a.m., the Registered Dietitian (RD) 1, RD 1 stated she alternates working in the SNF and in the RCFE. The RD 1 stated she does a monthly kitchen inspection at the SNF, completes weekly test trays and helps in the kitchen if they are short staffed. RD 1 indicated she did a monthly sanitation inspection which includes elements such as an evaluation of labeling/dating, food temperatures, observation of staff for hand hygiene and clean up after trayline and temperature testing for food storage. RD 1 acknowledged she does not have supervisory responsibilities for the day-to-day operation of the SNF dietetic services. In an interview on 04/09/25 at 1:10 p.m., the FM stated while he started the coursework to become Certified Dietary Manager, but he has not completed it. Review of the position description for the DAD indicated this position was responsible for assisting in the management of the home's Registered Dietitians and Food and Nutrition operations. The position description for the Food Manager indicated under the direction of Director of Dietetics the position plans, directs and coordinates food service activities. The position description of the Registered Dietitian indicated under the direction of the Director of Dietetics this position completes nutrition assessments and provides medical nutrition therapy. Review of undated, facility policy titled Food & Nutrition Services-Staff Operations and Training (All Homes) documented .Staffing Standards .A. Skilled Nursing (SNF) .2. If a dietitian is not employed full-time, a full-time Food & Nutrition Services supervisor will be employed to be responsible for the operation of the food service .

Based on observation, interview, and record review, the facility failed to ensure a complete and accurate medical record when consent for the use of psychotropic medication (drugs that affect brain function, mood, thoughts, or behaviors) was not documented in the medical record for one of 12 sampled residents (Resident 19). This failure had the potential for Resident 19 to receive psychotropic medication that the resident did not consent to leading to unwarranted side effects. Findings: During a review of the Face Sheet, for Resident 19, the Face Sheet, indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included heart failure (the heart can't pump enough blood to meet the body's needs), unspecified atrial fibrillation (heart condition which causes an irregular heartbeat). During a concurrent interview and review of Resident 19's record on 4/8/25 at 2:53 p.m., with the Director of Nursing (DON), the following physician's orders were reviewed: On 3/24/25, the physician ordered Temazepam (psychotropic medication used to aid sleep). On 4/1/25, the physician ordered Trazodone (psychotropic medication used to aid sleep). There was no documentation which indicated Resident 19 consented to receive the psychotropic medications. DON stated the ordering physician was responsible discussing the treatment with Resident 19 and for obtaining signed written consent from the resident. DON stated it was important to have written consent in the resident's chart so the medication nurse could verify that Resident 19 consented to receive the psychotropic medication prior to administration of the medication. During an interview on 4/8/25 at 3:37 p.m., with Registered Nurse (RN), RN stated the physician should obtain the Resident's signature on the consent for psychotropic medication form and nursing staff should verify the consent form was signed prior to administering psychotropic medication. RN stated psychotropic medication should not be administered without the resident's consent documented in the record. During a review of Resident 19's Medication Administration Record (MAR), the MAR indicated Resident 19 received Temazepam on 3/24/25, 3/26/25 through 3/31/25, and Trazodone on 4/1/25, 4/4/25 through 4/7/25. During a review of the facility's policy and procedure (P&P) titled, Informed Consent (All Homes), dated 2/28/25, indicated, Written information must include in the written psychotherapeutic drug informed consent . Informed consent will be filed in the Residents' health record . Psychotropic medication therapy informed consent forms will be used by the prescriber to document informed consent for new psychotropic medication orders . The licensed nurse will verify that the Resident's health record contains the documentation that the Resident or resident representative has given informed consent to the proposed treatment or psychotropic drug prior to initiating treatment

Based on observation, interview, and record review, the facility failed to respect 1 of 3 sampled residents (Resident 1) right to personal privacy when Resident 1's bank account statement was opened and viewed by facility staff. This failure resulted in unauthorized access to Resident 1's personal privacy. Findings: During a concurrent observation and interview with Resident 1 on 9/17/2024 at 9:25 AM in the day hall of the facility, Resident 1 was oriented to person and place. Resident 1 stated her son and daughter took care of her finances. During a review of Resident 1's Face Sheet, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain.) Furthermore, Resident 1's Face Sheet indicated the Resident 1's Son had the Durable Power of Attorney. During a review of Resident 1's durable power of attorney, dated 3/1/2023 showed Resident 1's Son's name. During an interview with the Standards and Compliance Coordinator (SCC) on 9/18/2024 at 8:20 AM in the facility's conference room, the SCC stated that the Memory Care staff was authorized to open mail for residents. During an interview with the Medical Social Worker (MSW) on 9/18/2024 at 8:45 AM in the facility's conference room, the MSW stated that she opened and viewed Resident 1's June 2024, Bank Account Statement. MSW stated Resident 1's Son had given his consent to open Resident 1's mail via telephone. The MSW was unable to provide documented evidence to indicate telephone consent was received from Resident 1's Son. During a telephone interview with Resident 1's Son on 9/18/2024 at 11 AM, he denied providing consent to open Resident 1's mail. The facility's policy and procedure titled Mail, Involvement With, Social Services dated 10/20/2023, indicated: The resident or legal representative may request mail assistance on a regular basis. This is especially indicated when a resident is in a coma, physically unable to open the mail, severely demented, blind or paralyzed. Under such circumstances, the mail may be forwarded to their representative or brought to the resident unopened. Mail may only be opened for the member at his or her request. If a resident has a conservator, power or attorney, payee, or other representative, the social worker may forward relevant mail to that representative.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions in the food service department when: 1. Equipment was not replaced when considered unsafe, 2. Foods were found uncovered in the storage area, 3. Foods were not labeled appropriately, 4. Unsafe food was not discarded. These failures had the potential to expose residents to food contamination and foodborne illnesses (sickness by consuming contaminated food or drinks) for a population of forty-one residents who consume food from the kitchen. Findings: 1. During a concurrent observation and interview on [DATE] at 8:21 a.m. with the Dietetics Assistant Director (DAD) in the main kitchen, a can opener was found with metal chipped off the cutting tip. DAD confirmed, the missing metal part of the can opener and acknowledged the metal was likely flaking into the canned food during use. During a concurrent observation and interview on [DATE] at 8:31 a.m. with the Food Manager (FM) in the main kitchen, four out of twelve cutting boards were discolored with deep scratches. FM confirmed, the four cutting boards were overworn and stated bacteria growth could occur in the deep scratches. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Sanitation (All Homes), dated [DATE], 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). During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].12, titled, Cutting Surfaces, dated [DATE], indicated, Surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 2. During a concurrent observation and interview on [DATE] at 8:28 a.m. with the Food Manager (FM) in the main kitchen, frozen burritos were found in the reach in freezer that were uncovered with ice build-up resembling freezer burn (frozen foods damaged). Also seen in this freezer were three chicken breasts and three vegetable patties in uncovered steam table pans that had ice covering the visible surfaces. FM stated, It should be covered. During an observation on [DATE] at 8:30 a.m. in the main kitchen, a bag of pork was left open to the air in the walk-in freezer. A steam table pan containing vegetarian chicken and two large pans of uncooked ravioli were uncovered in the walk-in freezer. During an interview on [DATE] at 2:30 p.m. with the Dietetics Assistant Director (DAD), DAD stated items are to be covered during storage to prevent cross contamination as well as to maintain food quality. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section ,d+[DATE].11, titled Packaged and Unpackaged Food - Separation, Packaging, and Segregation, dated [DATE], indicated, FOOD shall be protected from cross contamination by: . storing the food in packages, covered containers, or wrapping. 3. During a concurrent observation and interview on [DATE] at 8:28 a.m. with the Food Manager (FM) in the main kitchen, a large plastic container of black pepper and a large plastic container of whole bay leaves had black labeling on top of the black surface. FM confirmed, staff would not be able to visualize the use-by date on these items. During an observation on [DATE] at 10:29 a.m., in the reach-in freezer for the satellite (Skilled Nursing) kitchen, eight out of nine ice cream bowls did not have a label. During an interview on [DATE] at 2:35 p.m. with the Dietetics Assistant Director (DAD), DAD stated staff were expected to label food items with a used-by date. DAD further stated, staff were expected to check the use-by date in order to ensure food products were served before they became unsafe to eat. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services - Leftover and Extra Food, dated [DATE], 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. 4. During a concurrent observation and interview on [DATE] at 8:28 a.m. with the Food Manager (FM) in the main kitchen, two apple juice boxes were labeled with an opened date of [DATE] and a received date of [DATE]. FM stated they seemed to be mismarked which could be confusing to staff regarding the products safety. One apple juice box was shown with a manufacturer expiration date of [DATE]. FM confirmed, the apple juice box was expired and discarded it. During a review of the facility's policy and procedure (P&P) titled, Food & Nutrition Services - Food Storage Procedure Guidelines (All Homes), dated [DATE], the P&P indicated, A. Expiration dates printed by the manufacturer apply until the product is opened. B. Once opened, use the manufacturer's stated time limits.

Based on observation, interview, and record review the facility failed to ensure that two out of eight dumpsters were covered for the main and the satellite kitchens. This failure had the potential to attract pests, rodents and spreading bacteria and leading to food contamination for a population of forty-one residents. Findings: During a concurrent observation and interview on 4/22/24 at 9:05 a.m., with the Assistant Administrator (Admin 2), one out of four trash dumpsters for the main kitchen was not covered, exposing trash. Admin 2 confirmed, it should be closed and proceeded to close the two lids. During an observation on 4/23/24 at 10:56 a.m., in the satellite kitchen, one out of four trash dumpsters was not covered, exposing trash. During an interview on 4/24/24 at 2:30 p.m., with the Dietetics Assistant Director (DAD), DAD stated, trash dumpsters need to be closed at all times when not in use, because it can attract rodents or pests to the facility. During a review of the facility's policy and procedure (P&P) titled, Waste Management Program, dated 12/12/23, the P&P indicated, Movable bins, when used for storing or transporting solid wastes from the premises, will have tightfitting covers and be closed when not being loaded.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of four sampled residents (Resident 21 and 26) when: 1. A non-crushable medication, pantoprazole (medication to reduce acid production in the stomach), was crushed and administered to Resident 26 despite manufacturer's guidelines not to crush medication due to delayed release. 2. A non-crushable medication, finasteride (medication to treat enlarged prostate), was crushed and administered to Resident 26 despite facility's guidelines regarding handling of finasteride. 3. Resident 21 was not instructed to rinse his mouth after being administered fluticasone furoate (nasal spray used to treat sneezing, itchy or runny nose), umeclidinium (medication used for chronic obstructive pulmonary disease), and vilanterol inhalation powder (a combination of inhaled medications to treat breathing issues) despite manufacturer guidelines to rinse mouth after use to prevent hoarseness and oropharyngeal candidiasis (fungal infection in mouth). These failures resulted in three identified errors out of 27 opportunities for medication administration medications; the facility's medication error rate was 11.11%. Findings: 1. During a review of Resident 26's Face Sheet (demographic), the Face Sheet indicated Resident 26 was admitted on [DATE] with diagnoses of gastroesophageal reflux disease (GERD, disease that causes heartburn), dysphagia (condition that causes swallowing difficulty), and benign prostatic hyperplasia (BPH, condition that causes urination difficulty). During an observation on 4/23/24 at 7:34 a.m. in [NAME] Unit, Licensed Vocational Nurse (LVN 1) was observed crushing pantoprazole, mixing it in applesauce, and administering it to Resident 26. The packaging for the pantoprazole pills was labeled, Do Not Crush. During an interview on 4/23/24 at 9:55 a.m. with LVN 1, LVN 1 stated she was following the physician's order to crush crushable medications. LVN 1 stated that she did not see the Do Not Crush label on the medication blister pack. LVN 1 stated delayed release pantoprazole table was not a crushable medication. During a record review of Resident 26's Physician's Orders, dated 10/18/23, the orders indicated, May crush all crushable medications. During an interview on 4/24/24 at 2:21 p.m. with the Director of Nursing (DON), the DON stated the pantoprazole should not have been crushed. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, General Guidelines, dated 4/15/24, the P&P indicated, Altering the form of a medication, including crushing, requires a physician order . long acting or enteric coated dosage forms should not generally be crushed; an alternative form should be sought. During a review of the Prescribing Information (PI) for Pantoprazole, dated May 2012, the PI indicated, Patients should be cautioned that Protonix (pantoprazole) Delayed-Release Tablets and Protonix For Delayed-Release Oral Suspension should not be split, chewed, or crushed. 2. During a review of Resident 26's Face Sheet (demographic), the Face Sheet indicated Resident 26 was admitted on [DATE] with diagnoses of gastroesophageal reflux disease (GERD, disease that causes heartburn), dysphagia (condition that causes swallowing difficulty), and benign prostatic hyperplasia (BPH, condition that causes urination difficulty). During an observation on 4/23/24 at 7:34 a.m. in [NAME] Unit, Licensed Vocational Nurse (LVN 1) was observed crushing finasteride, mixing it in applesauce, and administering it to Resident 26. The packaging for the finasteride pills was labeled, Caution Special Handling. During an interview on 4/23/24 at 9:55 a.m. with LVN 1, LVN 1 stated she was following the physician's order to crush medications. LVN 1 stated that she did not see the Caution Special Handling label on the medication blister pack and was unaware of what that label meant. During an interview on 4/24/24 at 2:21 p.m. with the Director of Nursing (DON), the DON stated the finasteride should not have been crushed. During a record review of Resident 26's Physician's Orders, dated 10/18/23, the orders indicated, May crush all crushable medications. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, General Guidelines, dated 4/15/24, the P&P indicated, Altering the form of a medication, including crushing, requires a physician order. During a review of the facility provided document titled, NIOSH (National Institute for Occupational Safety and Health) Hazard Drugs, provided 4/23/24, the document indicated, These drugs require special handling. Use caution when handling these drugs by wearing gloves and do not cut/crush. The document indicated finasteride as one of the drugs that required special handling. 3. During a review of Resident 21's Face Sheet (demographic), the Face Sheet indicated Resident 21 was admitted on [DATE] with diagnosis of mild cognitive impairment. During an observation on 4/23/24 at 8:04 a.m. in Klamath Unit, Registered Nurse (RN 3) was observed administering fluticasone furoate, umeclidinium, and vilanterol inhalation powder with an inhaler to Resident 21 without instructing Resident 21 to rinse his mouth afterwards. The packaging for the inhaled medication included instructions that stated, Rinse your mouth after use. During an interview on 4/23/24 at 10:31 a.m. with RN 3, RN 3 stated Resident 21 did not rinse his mouth after inhaling fluticasone furoate, umeclidinium, and vilanterol inhalation powder, was not advised to rinse his mouth after use, and did not have history of refusing to rinse his mouth after inhaling the medication. RN 3 stated Resident 21 should have rinsed his mouth after receiving a dose of his oral inhaler. During an interview on 4/23/24 at 12:07 p.m. with the Director of Nursing (DON), the DON stated the licensed staff administering fluticasone furoate, umeclidinium, and vilanterol inhalation powder should have coached Resident 21 how to use the inhaler disk, including instructing Resident 21 to rinse and spit after use. During a review of a published study titled, Influence of Mouth Washing Procedures on the Removal of Drug Residues Following Inhalation of Corticosteroids, dated 6/12/06, the study indicated, Mouth washing after inhalation of corticosteroids is effective for prevention of local adverse effects such as hoarseness and oropharyngeal candidiasis. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, General Guidelines, dated 4/15/24, the P&P indicated, Medications are administered by legally authorized persons as prescribed in accordance with good nursing principles and practices. During a review of the Full Prescribing Information (PI) for Trelegy Ellipta (fluticasone furoate, umeclidinium, and vilanterol inhalation powder), dated January 2019, the PI indicated, Advise the patient to rinse his/her mouth with water without swallowing following inhalation to help reduce the risk of oropharyngeal candidiasis (fungal infection in the mouth).

Based on observation, interview and record review, the facility failed to implement the plan of care for two of 12 sampled residents (Resident 18 and Resident 25) when: 1. For Resident 18, the care plan intervention Call don't fall signs were not posted, and assistive devices were not within reach. 2. For Resident 25, the care plan intervention Call don't fall signs were not posted, and discontinued assistive devices with signage were present in room. These failures had the potential to result in subsequent falls and serious injuries for Residents 18 and 25. Findings: 1a. During a review of Resident 18's Face Sheet (demographics), the Face Sheet (demographics) indicated Resident 18 was admitted to the facility on [DATE], with diagnoses of left below the knee amputation, right transmetatarsal amputation (surgery to remove part of the foot) and has had frequent falls since admission. During a review of Resident 18's Quarterly MDS, dated [DATE], indicated Resident 18 was able to stand from a sitting position in a chair, wheelchair, or on the side of the bed, as well as transfer to and from a bed to a chair or wheelchair with assistance to set-up or clean-up. Review of Resident 18's BIMS score, indicated Resident 18's cognition was intact. During a review of Resident 18's Care Plan Weekly Summary, dated 4/20/24, Resident 18's Mobility plan of care included, left below knee amputee with prosthesis and able to self-propel manual wheelchair. During an observation on 4/24/24 at 11:02 a.m. in Resident 18's room, Resident 18 was lying in bed while Resident 18's wheelchair was observed across the room and the left prosthetic leg was observed in the bathroom, both not within reach. During a concurrent observation and interview on 4/24/24 at 11:04 a.m. with Quality Assurance Registered Nurse (QARN) in Resident 18's room, QARN stated, I do not know who put his prosthetic in the bathroom or the wheelchair across the room, but both need to be next to him. During an interview on 4/25/24 at 9:31 a.m. with Occupational Therapist (OT), OT stated, Resident is independent for donning and doffing of prosthetic and transfers. OT stated the prosthetic leg and wheelchair should be next to him. 1b. During a review of Resident 18's Fall Care Plan, dated 3/23/24, the Fall Care Plan indicated, Resident 18's interventions included displaying the Call don't fall signs. During an observation on 4/24/24 at 10:02 a.m., in Resident 18's room, there were no Call don't fall signs posted. During a concurrent observation and interview on 4/24/24 at 11:00 a.m., with Quality Assurance Registered Nurse (QARN) in Resident 18's room, QARN stated, I do not see any call don't fall signs posted, there should be three. 2a. During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills and the ability to carry out simple tasks) and other abnormalities of gait and mobility, and ataxic gait (impairment of the ability to coordinate the movements required for normal walking). During a review of Resident 25's Physical Therapy Evaluation, dated 2/13/24, the Physical Therapy Evaluation indicated, .Poor standing balance, fall risk . Gait: Unable . unsafe to ambulate . During a review of Resident 25's Significant Change Care Area Assessment (CAA), dated 3/4/24, the Significant Change CAA indicated, .Falls-CAAs triggered secondary to occasional falls with minor injuries . increased fall risk . for using four-wheel walker (FWW) . During observation on 4/24/24 at 10:22 a.m., in Resident 25's room, there was a sign posted, (Resident name) PLEASE USE YOUR WALKER and a walker was placed to the right side of the signage. During a concurrent interview and record review on 4/25/24 at 9:29 a.m., with Assistant Director of Nursing (ADON), Resident 25's Mobility Plan of Care, dated 4/9/24 was reviewed. The Mobility Plan of Care indicated, . Use of manual wheelchair . The ADON stated walker and signage should have been removed from Resident 25's room. During an interview on 4/25/24 at 9:34 a.m., with Physical Therapist II (PT II), PT II stated, He only uses wheelchair with one person assistance; the walker was discontinued. 2b. During an observation on 4/24/24 at 10:22 a.m., in Resident 25's room, there were no Call don't fall signs posted. During a review of Resident 25's Fall Care Plan, dated 4/9/24, the Fall Care Plan indicated, Resident 25's interventions included displaying of Call don't fall signs. During a concurrent observation and interview on 4/24/24 at 10:55 a.m., with Quality Assurance Registered Nurse (QARN) in Resident 25's room, QARN stated, I do not see any call don't fall signs, and there should be three. QARN stated that the signage was bright yellow with the words Call don't fall. During a review of the facility's policy and procedure (P&P) titled, Care Plans-SNF [skilled nursing facility]/ICF [intermediate care facility] (All Homes), dated 2/13/24, the P&P indicated, . the facility must develop and implement a comprehensive person-centered care plan for each resident . the interdisciplinary team (IDT) will develop and implement comprehensive care plan within 7 days. During a review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment and Prevention Program, dated 10/16/23, the P&P indicated, .the Interdisciplinary Team will develop an individualized plan . to prevent falls to maintain a safe environment for residents . transfer/activity parameters per PT/OT recommendations.

Based on observation, interview, and record review, the facility failed to ensure safe monitoring of pharmaceutical medical supplies when four expired filter needles (a needle designed to remove particles, like glass, that might contaminate medication) were found in the injectable Emergency Drug Kit (E-Kit, small supply of medications for emergency situations). This failure had the potential to result in expired and ineffective medical supplies being used for residents and had the potential to result in contaminated medications being injected into residents. Findings: During an observation on 4/22/24 at 10:29 a.m. in the Klamath Unit medication room, there was a sealed orange box labeled, Klamath E-kit. On the exterior of the E-kit, there was a list of contents, including filter needles, and the date for the earliest upcoming expiration date. The kit contained four filter needles, labeled lot #7025483 (code that identifies one batch of a product that is made at the same time) which did not have any expiration date. During an interview on 4/22/24 at 11:39 a.m. with the Pharmacy Technician (PT), PT stated some filter needles simply did not have any expiration date, but the most recent expiration date was posted on the lid of the E-kit for staff to know when to alert the main pharmacy to replace expired medications and supplies. During an interview on 4/23/24 at 12:06 p.m. with the Director of Nursing (DON), the DON stated she was unsure why there were no expiration dates on the filter needles. During a concurrent observation and interview on 4/24/24 at 9:55 a.m. with Registered Nurse (RN 2) in the Klamath Unit medication room, four filter needles in the emergency injectable medications kit did not have an expiration date. RN 2 stated the filter needles may be used for certain medications stored in the kit, but unable to identify which ones. RN 2 stated he could not find an expiration date for the filter needles. During an interview on 4/24/24 at 10:04 a.m. with PT, PT stated she was able to confirm that the product did not have an expiration date and never will expire by calling the pharmacy. During an interview on 4/24/24 at 11:15 a.m. with the filter needles [brand name] Manufacturer Representative (MR), the MR stated the filter needles associated with lot number #7025483 were produced in January 25, 2017, had a shelf life (time period during which an item may be stored and remain suitable for use) of 1825 days, and expired on January 24, 2022. The MR further stated all their medical supplies have an expiration date. During an interview on 4/24/24 at 2:21 p.m. with the DON, the DON stated the filter needles without expiration date should have been investigated for an expiration date and discarded. During a review of a published study titled, Maximizing patient safety: filter needle use with glass ampules, dated January 2005, the study indicated, Particle contamination of medications obtained from glass ampules can pose serious hazards to patients. Particle contamination may be reduced by using a filter needle when obtaining medication from glass ampules prior to administration. During a review of the facility's policy and procedure (P&P) titled, Emergency Drug Kit, dated 11/27/23, the P&P indicated, The contents are changed as needed depending on the SNF needs and reviewed by the pharmacy services committee. The pharmacist checking the Emergency Drug Kit will also indicate the earliest expiration date and the name of that item on the outside of the container. It is the responsibility of the contract production pharmacy to cycle out the E-kits prior to the expiration date listed on the exterior of the kit.

Based on interview and record review, the facility failed to protect Resident 1 from verbal abuse when CNA 1 (certified nurse ' s assistant 1) called Resident 1, you d**k, after Resident 1 punched CNA 1 on the chest. This failure resulted in verbal abuse to Resident 1. Findings: During an interview on 12/22/23 at 7:00 p.m. with CNA 3, CNA 3 stated, CNA 1 was assigned to Resident 1 ' s room. CNA 3 continued, CNA 2 and CNA 3 heard a call light ring, and they went to check who was calling. CNA 3 added they saw the light was from Resident 1 ' s room, and she started to walk to Resident 1 ' s room when CNA 2 joined. CNA 3 stated that as she was approaching Resident 1 ' s room, she heard a commotion in the room, so she listened at the door. CNA 3 added, she heard Resident 1 fussing and fighting, then she heard CNA 1 yell, F***ing D**k, to which CNA 2 told CNA 3 that was inappropriate. CNA 3 stated CNA 1 went to get linen for Resident 1 ' s room and CNA 2 and CNA 3 asked CNA 1 to leave the room. CNA 3 added she and CNA 3 took over care for Resident 1 and CNA 1 stayed outside the door. CNA 3 stated, she reported the incident to Charge Nurse 1, who notified SRN 1 (Supervising Registered Nurse 1). During a subsequent interview on 12/29/23 at 6:20 p.m. with CNA 3, CNA 3 stated, I miss interpreted my words. (CNA 1) did not use the F word. (CNA 1) just said ' you d**k ' to (Resident 1). During an interview on 12/22/23 at 7:30 p.m. with CNA 2, CNA 2 stated Resident 1 was on the memory care unit. CNA 2 added, she and CNA 3 heard a call light ring and checked to see whose call light it was. CNA 2 continued, she saw that it was for Resident 1, who could be combative and refused care. CNA 2 stated, I understand when a Resident becomes combative and refuses care, we are supposed to stop our care and come back in 5-10 minutes. CNA 2 stated, CNA 1 had pushed the call light for help and Charge Nurse 1 asked for CNA 2 to help CNA 1. CNA 2 stated that she arrived at Resident 1 ' s room prior to CNA 3 and Resident 1 was being combative. CNA 2 continued, she was trying to help Resident 1 in his bed when Resident 1 punched CNA 1 on the chest, and CNA 1 responded, stop that you dick. CNA 2 added, CNA 3 entered the room and kicked CNA 1 out of the room. During a record review of the MDS (Minimum Data Set) for Resident 1, dated 8/21/23, the record showed a BIMS (Brief Interview for Mental Status) score of 3 in a range of 0-15. A higher BIMS score indicated a intact cognitive response and a lower BIMS score suggested cognitive impairment. During a review of the Behavior Care Plan for Resident 1, the plan documented under the problem list, physical aggression towards others on 8/28/23 and striking out at staff on 11/18/23. The plan showed the interventions of provide redirection as indicated on 8/25/22, redirect and keep distance on 12/12/22, and avoid confrontation, monitor mood on 11/18/23. During a review of the Physicians Assessment, for Resident 1 dated 9/14/23, the assessment showed under A/P (assessment-plan), 1. Lewy Body Dementia (disease associated with abnormal deposits of a protein called alpha-synuclein in the brain).

Based on interview and record review, the facility failed to report an alleged abuse incident to law enforcement officials when Resident 1 reported a sexual assault incident in the Skilled Nursing Facility. This failure did not allow for law enforcement officials to conduct an investigation. Findings: During an interview on 9/13/23 at 11:22 p.m. with Standards Compliance 1 (SC 1), SC 1 stated when referring to the section of the policy titled, Will report to in accordance with State law, SC 1 stated We reported to the Ombudsman (resident advocate) and CDPH (California Department of Public Health) Licensing (oversight and monitoring agency for California skilled nursing facilities). SC 1 added, If we found an assault had occurred, we would have reported it to California Highway Patrol (CHP). SC 1 said, Our CHP doesn't want everything reported to them, only the financial and serious injuries. SC 1 stated after Social Worker 1 (SW 1) and SC 1 spoke to the Resident 1, SC 1 stated, We determined he wanted to shower himself. He does not want males to shower him. SC 1 added, The more Resident 1 talked about the assault, the assault became less intense, and he wanted to be given choices so he could make his own decisions. SC 1 stated, Resident 1 did not want male staff to assist him with showers, he preferred female staff only. SC 1 added, Resident 1 reported to the doctor, his mind was all befuddled because Resident 1 did not remember seeing the doctor yesterday. During an interview on 9/13/23 at 1:20 p.m. with California Highway Patrol officer 1 (CHP 1), CHP 1 stated, We encourage them (facility) to report even if it (the crime) is farfetched for their facility. That (the crime) is for us (CHP) to determine, not the facility. The facility handles the administration duties and we (CHP) handle the investigations. During a review of the facility's policy and procedure titled, Elder Abuse, Prevention and Reporting, last reviewed 6/8/23, the policy indicated under reporting, The home administrator or designee will report to officials in accordance with State law, including to the State Agency and Adult Protective Services where state law provides for jurisdiction in long-term facilities. The policy continued, All alleged violations will be reported immediately, but no later than two hours-if the alleged violation involves abuse or results in serious bodily injury. The policy added, Reporting the results of all investigations to the Administrator or his or her designated representative and to other officials, in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified, appropriate action must be taken.

Based on observation, interview and record review the facility failed to provide competent emergency basic life support immediately when one out of three residents (Resident 1) was experiencing a Foreign Body Airway Obstruction (FBAO), a choking episode. Nine out of nine facility staff members, including Certified Nurse Assistants (CNA 1, CNA 2), Licensed Vocational Nurses (LVN 1, LVN 2), Registered Nurse (RN 1), Quality Assurance Director (QAD), Supervising Registered Nurse (SRN), Charge RN (CRN) and Recreation/Activities staff (RA 1), failed to respond as trained with the basic emergency life support intervention. The staff failed to implement the [MEDICATION(S)] Maneuver (a procedure to dislodge an obstruction from a person's windpipe) in a timely fashion while Resident 1 was alert and responsive on [DATE]. The [MEDICATION(S)] Maneuver was delayed and not performed as trained, to Resident 1 during his emergency choking episode. This failure worsened the outcome of the FBAO, contributing to the death of Resident 1. Findings: During a review of Resident 1's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Within the doctor's orders, the diet had a few changes while Resident 1 resided at this facility. On [DATE] a magic cup (a fortified supplement) was ordered once daily. His fluids were changed to nectar thick liquids on [DATE] at 11:45 AM. On [DATE], the magic cup was increased to three times daily. On [DATE], an order to add butter and gravy to foods as appropriate (for weight gain) was made. During a record review of Resident 1's Resident Care Plan (Speech Therapy), dated [DATE], it indicated that PEG tube feedings (direct feeding into the stomach via a tube inserted through the abdominal wall) and N/G tube feedings (nasogastric tube feeding into the stomach via a tube in the nose) were both refused. The record indicated Resident 1 had severe dysphagia and moderate-severe dysarthria (difficult or unclear articulation of speech that is otherwise linguistically normal), and mild to moderate cognitive/linguistic deficits (relationship between language and the mind). This document also indicated, alteration in nutrition due to swallowing difficulty, and his inability to eat independently. In his care plan, it was written on [DATE] that the facility would provide assistance as indicated. Resident 1 was being assisted with eating his meal when he choked. During a review of Resident 1's medical record, the Minimum Data Set (MDS-an assessment tool) dated [DATE], described Resident 1 as a [AGE] year-old male, admitted on [DATE] to the facility. Resident 1's diagnoses, as listed in the MDS's Care Area Assessment (CAA), included secondary progressive [CONDITION(S)] (MS - a genetic disease indicated by progressive weakness and loss of muscle mass), end stage, with oral pharyngeal dysphagia (difficulty swallowing). Section K of the MDS, the Swallowing and Nutritional Assessment, indicated that Resident 1 had shown no signs or symptoms of a possible swallowing disorder since his admission, or within 7 days of the assessment. A record review of his weight was completed with the document titled, Weekly/Monthly Weight log, which showed Resident 1's admission weight was 108.4 pounds on [DATE] and he measured 5 feet 9.5 inches tall. Three months later, on [DATE] his weight had increased to 122.2 pounds. A record review of the document titled, Informed Consent Against Medical Advice to Follow Prescribed Modified Diet, was performed. This document indicated he was ordered an NPO (nothing by mouth) diet due to his medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with CNA 1 on [DATE] at 8:15 AM, CNA 1 stated on [DATE], while being assisted with eating his lunch meal in bed, Resident 1 began to choke. He was alert and responsive at the time. He raised his arms to his chest and hit the button to set off his personal alarm which sent alarms to the nursing station. CNA 1 noted his choking and she pushed the resident alarm on the wall near the bed followed by a Code Blue alarm (an alarm to notify other staff members a life threatening emergency was occurring and signaled the location at the nursing station), both of which sent alarms to the nursing station. Review of an Incident Report, dated [DATE] at 12:00 PM, corroborated this description. CNA 1 ran out in the hall to get assistance and quickly returned back into Resident 1's room. During an interview with CNA 1 on [DATE] at 11:30 AM, she clarified that while feeding Resident 1 his lunch, the head of the bed was elevated to approximately a 45-degree angle. Resident 1 threw up immediately when he started to choke. CNA 1 was in the room for ,d+[DATE] minutes after the nurses (LVN 1 and SRN 1) came in. She did not witness them attempting to perform the [MEDICATION(S)] Maneuver (sudden strong thrusts applied to the abdomen between the [NAME] and rib cage to dislodge an obstruction from a person's windpipe) during that time. She stated Resident 1 was fully conscious while she was with him. CNA 1 stated she never attempted to clear Resident 1's airway. She stated she went to get the assistance of someone with more medical knowledge. On [DATE], at 9:05 AM, during observation of a facility video recording showing Resident 1's room from the hallway at the facility, recorded on [DATE] with a time stamp of [DATE] at 12:17 PM, CNA 1 exited and quickly returned back into the room. A recap of a video timeline titled, Camera 365 (Unit) Resident 80 - Review (undated), presented at the time of viewing, showed she then exited the room again at 12:18 PM. RN 1 and LVN 1 ran in at 12:18 PM, and CNA 1 brought an emergency cart at 12:19 PM. LVN 1 and LVN 2 entered the room with more equipment (the second crash cart) at 12:20 PM. RA 1 entered the room at 12:22 PM. SRN and CRN responded to room subsequently. This time stamp varied from the time mentioned in interviews and the timeline presented by the QAD. During an interview with RN 1 on [DATE] at 1:40 PM, RN 1 stated she heard a CNA call out for assistance, He needs help. He choked! He choked! RN 1 stated, I yelled to (QAD) to get the crash cart. When I arrived in the room he was unresponsive and the head of the bed was up. I tapped on his chest trying to get a cough. I went to the other side of the bed and lowered the bed. I made a sweeping motion in his mouth. When asked if this was a blind sweep of his mouth, she answered, Yes it was. I didn't do CPR (Cardiopulmonary Resuscitation). He was a no code . The suction machine finally came in. It clogged up with saliva quickly. A second suction machine arrived with (SRN and the CRN). I clued her in on what I had just done When asked if there was someone taking notes, RN 1 responded, I don't know if anyone was taking notes. She then stated, I put my finger down his throat to check for a gag reflex. There was none. Then I pulled the tongue forward. Someone mentioned the [MEDICATION(S)] (Maneuver), but I didn't think it was appropriate as he was non-responsive, RN 1 continued, The head of bed was elevated. (SRN) did the [MEDICATION(S)] Maneuver and then (CRN). They stood on the bedrails and reached around his chest in a sitting position. During a document review of a student instruction manual, utilized by the facility to train staff, titled, Basic Life Support by the American Safety and Health Institute, 2015 Guidelines, the manual indicated, It is not recommended to use blind finger sweeps to check for foreign objects in the airway. During a review of the clinical record for Resident 1, the IPN (interdisciplinary progress notes) dated [DATE] at 1520 (3:20 PM), a late entry for SRN indicated that, At approx. (sic) 1220 (PM), CNA staff (CNA 1) requested SRN assistance for emergent clinical situation. CNA (CNA 1) reported while assisting Res (Resident 1) with lunch meal he experienced an episode of possible aspiration [the accidental ingestion of a fluid or solid into the trachea (windpipe) or lungs]. Emergency / Code Blue initiated @ (at) 12:19 (PM). Unit licensed (RN [1] and LVN [1]) staff responded to bedside with emergency cart & suction. SRN & RN from neighboring unit arrived with additional suction as requested. Upon entry to room @ approx. (approximately) 12:21 (PM), Res (Resident 1) was observed to appear cyanotic (bluish tone due to lack of oxygen). RN (RN 1) had implemented use of bag mask for ventilation (a medical device to assist with giving breaths) with O2 (oxygen) and was attempting to perform oral suction with use of [MEDICATION(S)] (an oral suctioning tool). No visible secretions captured in canister. Per staff report resident had + (positive) episode of emesis (vomiting) of food partials (sic) @ start of event. RN (RN 1) was observed evaluating for possible lodged food particles & completed finger sweep. Suction (machine) exchanged and efforts continued. Apical pulse (lower portion of the heart where beats are best heard) auscultated (listened to), present. MD contacted via phone by LVN staff @ approx. 12:21 (PM), notified of situation and EMS (Emergency Medical Services) contacted to assist with additional interventions, as POLST (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Current pulse present. Res (Resident 1) was assisted by clinical staff LVN/RN/SRN in position to perform [MEDICATION(S)] Maneuver. ,d+[DATE] thrusts were completed. Initial thrusts expelled audible tone, otherwise unsuccessful @ restoring air exchange. RN (RN 1) exchanged with SRN and performed additional ,d+[DATE] thrusts. Res (sic) did not demonstrate respirations, carotid (large artery on the side of the neck used to check for sign of life) pulse absent.[Per undated unsigned facility provided time-line the [MEDICATION(S)] was not performed until 12:,d+[DATE]:22 where clinical staff performed the [MEDICATION(S)] maneuver twice.] Nsg. (nursing) continued attempts of suction. EMS arrived @ bedside @ 12:30 (PM), reviewed POLST were provided SBAR (Situation, Background, Assessment and Recommendations) report, attempted suction, ambulance arrived at 12:36 (PM). Again, reviewed POLST, SBAR and completed evaluation. Res (sic) without S/S (signs/symptoms) of life - time of death pronounced by EMS (EMS's name) as 12:37 (PM) . A document review of the patient's Physicians Order for Life Sustaining Treatment (POLST), dated [DATE] was completed. This document indicated Resident 1 chose to be a DNR (do not attempt resuscitation) in section A. Resident 1 chose to select in Section B, Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally, avoid intensive care. Resident 1 selected in section C, No artificial means of nutrition, including feeding tubes. Section D included information on his end of life preferences and a physician signature indicating Resident 1's verbal agreement with the POLST. During an interview with the Director of Staff Development (DSD) on [DATE] at 1:20 PM, the DSD stated she was the only Basic Life Support instructor in house at this time. Staff could choose which company they trained with as long as it complied with the American Heart Association's standards. The DSD stated they used American Safety and Health Institute for their training at the facility. She explained that once the airway was obstructed there would be a lack of sound, inability to exchange air and the inability to cough. She continued, It is then the rescuer acts quickly to do immediate and repetitive abdominal thrusts with their arms around their victim. This process should continue until the foreign body is removed or the patient goes unconscious. She continued, if the patient was unresponsive, they would change interventions to the CPR (cardiopulmonary resuscitation) process as this could expel a foreign object. The DSD said staff would do this even if the patient was a DNR as this was a choking emergency. When asked if this skill was practiced during her class, she responded, No. We review anatomy of the lungs and diaphragm (the muscle used in breathing) and there is a very graphic film they watch. We have them locate the landmark of where to do the thrusts and have them gently push in and up on themselves. It is too intense of an intervention to practice on one another. A review of the student training book titled, Basic Life Support BLS for Healthcare Providers and Professional Rescuers, by American Safety & Health Institute 2015 Guidelines was completed. The book indicated, A forceful thrust beneath the ribs and up into the diaphragm can pressurize the air in the chest and pop an obstruction out of the airway. Compression of the chest over the breastbone can also create enough pressure to expel an object A person without any air exchange requires your help to survive. Repeated abdominal thrusts, given by standing behind someone and wrapping your arms around him or her have shown to be extremely effective in relieving a severe foreign-body obstruction. The student book indicated the responder is to continue with the [MEDICATION(S)] maneuver until the person can breathe normally or if the person becomes unresponsive, they are then to lower the patient to the floor and begin CPR, starting with compressions . This is to continue until another BLS provider takes over, the person shows signs of life or you are too exhausted to continue. A record review of the facility staff's trainings verified completion of the Basic Life Support classes were completed by RA 1, CNA 1, CNA 2, LVN 1, LVN 2, RN 1, SRN, CRN, and QAD. These staff were all current in their BLS training. One professional was a certified instructor of BLS. During record review of a document presented by the QAD, an undated and unsigned timeline had been created from various documentation entries, recollections, and the video of the hallway outside of Resident 1's room. This document indicated the interventions to clear the airway began at 12:08 PM. It also indicated that the [MEDICATION(S)] Maneuver was not performed until 12:20 to 12:22 PM. The IPN note dated [DATE] at 1520 (3:20 PM) indicated staff provided 2 sequences of ,d+[DATE] thrusts several minutes following his loss of consciousness, approximately ,d+[DATE] minutes after the choking event began per timeline presented by the QAD. The times varied on the video recording, in interview statements, in progress notes, and within the document presented by the QAD making it difficult to verify the actual times of the events. During a search of the internet at MedlinePlus National Institutes of Health/ U.S. National Library of Medicine at https://medlineplus.gov/ency/article/ 9.htm, this site indicated, A choking person's airway may be blocked so that not enough oxygen reaches the lungs. Without oxygen, brain damage can occur in as little as 4 to 6 minutes. Rapid first aid for choking can save a person's life. A record review of the Patient Care Report (PCR, the emergency response report) from the emergency call center, from [DATE], indicated the emergency call came in at 12:27 PM. Emergency Medical Services (EMS) arrived on scene at 12:35 PM. Time of death was called at 12:37 PM. Call Type was listed as [CONDITION(S)] / Death. Disposition was listed as, Patient Dead at Scene - No Resuscitation Attempted. The Narrative indicated, . Pt was noted to be pulseless and apneic (cessation of breathing) for approx. (approximately) x 20 minutes prior to EMS arrival with no CPR initiated . Review of Resident 1's death certificate listed the cause of death as aspiration on [DATE] at 12:37 (PM). Physician's Certification portion was signed on [DATE].

Based on interview and record review, the facility failed to prevent 1 of 3 sampled residents from neglect when licensed staff (RN 3) failed to assess a resident (Resident A) during a change of condition (change in health status), failed to offer medication for nausea and vomiting, and failed to provide wound care. Unlicensed staff notified RN 3 that the Resident A was not feeling well and complained of symptoms that could have been cardiac related. The assigned licensed staff nurse (RN 3) failed to assess Resident A following notification of the change of condition and Resident A was subsequently discovered deceased during change of the shift. Findings: On [DATE], an investigation was initiated regarding a complaint that Certified Nursing Assistants (CNA 5, CNA 6) had notified a registered nurse (RN 3) that Resident A needed attention. The resident was described as displaying symptoms, which could have been related to his known cardiac condition. The complainant reported that although RN 3 was notified, RN 3 did not assess the resident, have another RN assess the resident, did not provide wound care as ordered, or provide any other interventions. Resident A was found by staff deceased in his room at 6:35 a.m. on [DATE]. Resident A's medical record was reviewed on [DATE]. The (MONTH) (YEAR) Treatment-Wound Administration record for Resident A, dated [DATE] through [DATE] indicated the resident had four wounds, one skin tear above the left knee, one on the back of the left hand, a right wrist skin tear, and left gluteal fold (between leg and buttock) wound. Wound care treatment orders showed treatments were to be performed daily on the night (N[NAME]) shift. Further review of Resident A's medical record on [DATE], included the History and Physical (H&P), dated [DATE]. The H&P indicated Resident A, age 81, had primary [DIAGNOSES REDACTED]. Resident A's mental and behavioral status was documented as alert and agreeable. On [DATE] at 2:30 p.m., when asked about the night of [DATE], CNA 8 stated a supervising registered nurse (SRN) had been working on the staff schedule for the [DATE] night shift. CNA 8 was taking Resident A's blood pressure when Resident A overheard the SRN mention that for the [DATE] night shift, RN 3 was to be assigned to care for Resident A. Resident A specifically told the SRN he did not want RN 3 to take care of him. During interview with a supervising registered nurse (SRN 1), on [DATE] at 9:00 a.m., SRN 1 stated that although he had not worked the night of the event, he was aware Resident A and RN 3 had a relationship with conflict. SRN 1 characterized Resident A as having been very alert and an advocate for other residents at the facility. According to SRN 1, Resident A had asked for a change of nurses ,[DATE] weeks previously, not wanting RN 3 to provide care to him. SRN 1 had looked into making the change and informed Resident A that he would try to accommodate the resident's request. SRN 1 stated to accommodate the request, a resource nurse (a nurse available to assist with assessments, treatments and administration of medications) could do that resident's dressing changes or give his medications. SRN 1 stated during the [DATE] night shift, RN 3 should have traded assignments with a resource nurse to accommodate Resident A's request not to be cared for by RN3. During interview with CNA 6, on [DATE], at 1:50 p.m., CNA 6 indicated she worked the [DATE] night shift (from 10 p.m. to 6:30 a.m.) and helped CNA 5 during the shift, assisting with the call lights and covering her for breaks that night. CNA 6 stated Resident A, complained of dry heaves, nausea, and did not feel well. CNA 6 stated Resident A was not the same, with slow movements and speech. CNA 6 notified RN 3 several times during that night shift, that Resident A wanted medications for nausea. RN 3 stated, outside of Resident A's room, He doesn't like my face; I can't go into that room. RN 3 did not go into the room per CNA 6. According to CNA 6, this event occurred around 4:00 a.m. or 5:00 a.m., toward the end of the shift. During an interview on [DATE] at 10:00 a.m., CNA 5 stated she worked the [DATE] night (N[NAME]) shift, as the direct care provider for Resident A. Resident A put on the call light and informed her that he wanted the head of the bed up and had dry heaves. CNA 5 reported to RN 3 between ,[DATE] a.m., that Resident A looked sick and had dry heaves while she was getting a basin for the resident. CNA 5 stated she had not observed RN 3 check on Resident A and CNA 5 did not witness any refusal of care by the resident. During an interview with RN 3 on [DATE] at 2:36 p.m., RN 3 stated she was notified of Resident A's condition at 1:00 a.m. and checked on him at that time. Resident A was watching TV, and refused wound care treatment. RN 3 stated Resident A did not like her. RN 3 stated she was off the clock when patient was found dead. Review of Resident A's Medication Administration Record [REDACTED]. (milligrams) - take 1 tab by mouth every 6 hours as needed. There was no documentation on the MAR indicated [REDACTED]. During an interview with RN 4, on [DATE], at 3:28 p.m., RN 4 stated when she arrived to work on the a.m. shift, [DATE], Resident A was found unresponsive by a CNA on day shift. There was no report from RN 3 regarding Resident A's change of condition, complaints or status, nothing mentioned during the change of shift report. The patient expired at 6:35 a.m. on [DATE]. During an interview with RN 7, on [DATE] at 10:10 a.m., RN 7 stated she had been a resource nurse on the [DATE] N[NAME] shift. She indicated she worked the N[NAME] shift on [DATE] on another unit, which was next to the unit where RN 3 was assigned. RN 7 stated she was aware of the relationship between Resident A and RN 3. The RN stated a resource nurse could work both units. If there was friction between the patient and the RN 3, RN 7 could have provided care to Resident A. RN 7 stated that RN 3 did not ask RN 7 to give Resident A's medication or provide wound care treatment to the resident that night. On [DATE], record review showed no written evidence that wound care had been provided on the [DATE] N[NAME] shift. The Treatment-Wound Administration record for Resident A, dated [DATE] through [DATE] indicated the resident had four wounds with wound care treatment orders to be performed on the N[NAME] shift. On the record where a signature would have indicated the treatment had been done, instead there was RN 3's signature circled, indicating the treatment was not performed. On the back of the wound care record, RN 3 documented, All tx's (treatments) for N[NAME]'S done by resource nurse. The resource nurse, during the [DATE], 10:10 a.m. interview, stated she did not provide wound care to Resident A and had not been asked to. The medical record included a Gastric Care Plan, dated [DATE]. Within the plan were instructions to notify a physician if the resident had signs/symptoms of GI distress. No record of physician notification was in the record. Review of the vital signs record for Resident A for [DATE] or [DATE], indicated that there were no vital signs done for Resident A. Review of the facility policy and procedure titled, Notification of Physician, Resident, and Representative, dated [DATE], stated licensed staff of the Skilled Nursing Facility (SNF) must notify the resident, physician, and representative of significant or changes in the condition in the residents' condition. During medical record review, the Interdisciplinary Progress notes for Resident A, showed no documentation for [DATE] N[NAME] shift on that resident until after he was found deceased . During an interview at 11:30 a.m. on [DATE], the Director of Nursing (DON) stated wound care was usually done on N[NAME] shift. The DON stated if a resident had a request the facility was unable to accommodate, it should investigate the problem, and switch with another staff person to provide care for a resident if it was a staff-client conflict. She stated she knew of the relationship with Resident A and RN 3. The DON said the standard policy, if there was a change in condition of a resident, if reported, was that an assessment should be done, a physician called if needed, and vital signs should be reported to oncoming nurses. During an interview with the Skilled Nursing Facility administrator, on [DATE], at 3:10 p.m., the administrator stated when there was a conflict between staff and residents, the procedure was to provide conflict resolution, assess the situation and resolve the issues. A resource nurse would provide care if a patient refused treatment from the main nurse. The Certificate of Death for Resident A was reviewed on [DATE]. The indicated time of death was [DATE] at 6:35 a.m. The immediate cause of death was [MEDICAL CONDITION] and [MEDICAL CONDITION] Cardiovascular Disease.

AMENDED 2567-3/29/17 Based on interviews, record review and facility document review, the facility failed to ensure one of three residents (Resident 1) remained free of accidents as possible, when facility policy was not followed and the resident fell out of his wheelchair breaking his arm and the resident's plan of care failed to identify use of the wheelchair and associated risk for the resident. This failure resulted in actual harm to Resident 1 who sustained a fractured right arm. Findings: The facility reported incident indicated that on 6/29/16 at 11:05 a.m., Resident 1, while being pushed in his wheelchair, by a volunteer, fell out of the wheelchair and sustained a broken arm. The facility incident report indicated while Resident 1 was being pushed over yellow safety bumps on a sidewalk ramp, the wheelchair stumbled, and the jarring caused the resident to fall out of the wheelchair. The volunteer yelled for help and two passersby picked up the resident and transferred him back to the wheelchair. The volunteer stated she heard a pop during the lift. The volunteer had separated from the group and brought the resident to a distant restaurant across the mall parking lot at the resident's request. After the fall the volunteer pushed the resident back across the mall parking lot to the mall where the remainder of the group was gathered. The resident was asked if he wanted to go to the hospital or return to the facility. The resident stated he preferred to return to the facility. After an assessment by the nurse practitioner at the facility, the resident was transferred to a community hospital where he was diagnosed and treated for [REDACTED]. The record indicated that Resident 1 was wheelchair bound due to severe Parkinson's disease. The Minimum Data Set (MDS) quarterly assessment dated [DATE] indicated Resident 1 had limitation of both upper extremities, was not able to walk and required extensive assistance by another person to weight bear, transfer and move about in a wheelchair. A wheelchair was identified as the assistive device used. During an interview, on 1/30/17 at 1:30 p.m., the Administrator and Director of Nursing (DON) stated that the resident did not have footrests in place on this outing. The resident was not wearing a safety belt during the outing although the Administrator and DON stated there had not been a reason to assess the need for one. During an interview, on 1/30/17 at 3 p.m., the Recreation Therapist (R.T.) stated that nursing staff only accompany residents during an outing if residents will be eating. The R.T. stated that the volunteer did not notify her that she and Resident 1 were leaving the mall, which she should have done. The volunteer should not have left the mall alone with Resident 1. Regarding the resident's fall out of the wheelchair, the R.T. stated that the resident was would jump when startled. She could imagine him being jostled out of the wheelchair when going over those yellow bumps. During an interview, on 2/7/17 at 3:15 p.m., the volunteer accompanying Resident 1 stated she verbally prepared the resident before going over the bumps. The volunteer stated the resident tended to lean forward in the wheelchair and with the bumping he fell to the ground. She stated she yelled for help. The resident was very uncomfortable as it was a hot day and the resident was on the pavement. Two passersby lifted the resident back into the wheelchair. The volunteer stated she heard a pop when the resident was transferred back to the wheelchair. The volunteer then pushed the resident back across the parking lot to the mall. The resident reported to the Recreation Therapist he thought he broke his arm. The Recreation Therapist contacted the facility. The resident did not have footrests on the wheelchair for the outing. Regarding the lack of footrests, the volunteer stated that she could not put footrests on the wheelchair, only nursing. The resident's plan of care updated 6/25/16 for Activities of Daily Living and for the problem of Potential for Fall and/or injury failed to identify the resident's use of a wheelchair. The care plan did not indicate the resident had the tendency to lean forward when in the wheelchair. Review of facility policy titled: Therapeutic Activities, Community Outing (SNF) under the section staffing 6. Nursing staff will provide assistance with Resident transfers, toileting, and provide escort services as indicated to ensure the care and safety of the attending Residents. Review of wheelchair procedures from the facility's Volunteer Services Handbook revised May 2016, indicated the following section: IMPORTANT! THIS IS A NO LIFTING FACILITY. If a resident falls do not help them up ask them to lie still and go to the nearest staff and ask them to page the nurse. If you are with another volunteer or if someone is walking by ask them to go to security for you and stay with the resident. Medical personnel must evaluate each fall. The handbook under the section wheelchair procedures also indicated After a resident is seated, put foot pedals down . Another document titled: Wheelchair Assist indicated to make sure the resident's feet are on the footrests to prevent dragging and possible injury.