Every finding on record at Waterman Canyon Post Acute

Based on interview and record review, the facility failed to honor one of three sampled residents' (Resident 1) right to participate in the development and implementation of his or her plan of care when Resident 1's request for a care plan meeting was not addressed and scheduled by the facility in a timely manner.This failure had the potential to cause Resident 1 not to receive the needed care and services to meet their care planning goals.Findings:During a review of Resident 1's face sheet, it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (severe or complete paralysis of one side of body), and hypertension (high blood pressure).A review of Resident 1's Quarterly Minimum Data Set (MDS-assessment/evaluation of health status and functional needs of residents), dated January 21, 2026, under Section C, Cognitive Pattern, it indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14. (A BIMS score of 13 to 15 means cognitively intact.)During a review of Resident 1's Interdisciplinary Team (IDT) Care Conference (also known as Care Plan Meeting) Summary, dated January 21, 2026, it indicated the IDT discussed Resident 1's admission diagnosis, admission medication list, psychosocial assessment, physical therapy and discharge planning with Resident 1.During an interview with Resident 1, on February 10, 2026, at 11:44 AM, Resident 1 stated she needed clarification with her discharge planning, so she requested another care plan meeting from the Social Service Director (SSD) last January 28, 2026. Resident 1 further stated she has not yet received any update regarding her request. During an interview on February 10, 2026, at 1:28 AM, with the Social Service Director (SSD), the SSD stated she had still not scheduled Resident 1's care plan meeting even though Resident 1 had requested it two weeks ago.During an interview on February 10, 2026, at 1:28 AM, with the Assistant Director of Nursing (ADON), the ADON stated the IDT member mistakenly forgot to schedule Resident 1's requested care plan meeting. The ADON further stated it should be scheduled.During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, revised March 2022, the policy and procedure indicated, The interdisciplinary team is responsible for the development of resident careplans. 1. Resident care plans are developed according to the timeframes and criteria established by 483.21.4. The resident, the resident family and/or the residents legal representative/guardian or surrogate are encouraged to participate I the development of and revisions to the residents care plan. 5. Care plan meetings are scheduled at the best time of the day for the resident and family.During a review of the facility's P&P titled Resident Participation - Assessment/Care Plans, revised February 2025, it indicated The resident's/representative's right to participate in the development and implementation of his or her plan of care includes the right to:. c. request meetings.During a review of the facility's P&P titled Resident Rights, revised December 2016, it indicated Employees shall treat all residents with kindness, respect, and dignity. be informed of, and participate in, his or her care planning and treatment.

Based on observation, interview, and record review , the facility failed to permit the return of one of four sampled residents (Resident 1) following the clearance provided by a psychiatrist for transfer back to the facility from hospitalization . This failure resulted in Resident 1's delayed transfer to a skilled nursing facility (SNF- a place for people recovering from a hospital stay to get medical care and rehabilitation.) possibly resulted in disruption of care, which may lead to emotional distress.A review of Resident 1's admission Record (a document containing clinical and demographic information data) indicated Resident 1 was initially admitted to the facility on [DATE] , with a diagnosis that included acute kidney failure ( kidneys suddenly stops working properly), liver dieses ( a condition that stops the liver from working properly), and peripheral vascular disease ( blood vessels outside the heart and brain narrowed, restricting blood flow).During an interview on September 23, 2025, at 12:34 PM, the Director of Nursing (DON) confirmed that Resident 1 has been transferred to the hospital and is currently not in the facility.During a concurrent observation and record review, September 23, 2025, at 12:38 PM, it was observed Resident 1 was not present at the facility and noted that his name was not included in the current list of residents at the facility.During a review of the facility progress notes, dated September 4, 2025, it was recorded that at 10:30 AM, Resident 1 displayed aggressive behavior toward other residents and staff. A 911 call was made, and law enforcement arrived at the facility. A 5150 psychiatric evaluation was subsequently ordered, resulting in the transfer of Resident 1 to the hospital at 3:02 PM, on September 4, 2025.During a review of an Order Summary, dated September 4, 2025, at 1:34 PM, the order indicated for a 7-day hold, covering the period from September 4, 2025, to September 11, 2025.During a review of Emergency Department, notes dated September 4, 2025, it was noted that Resident 1 arrived at ER via EMS on September 4, 2025, at 3:24 PM. It was indicated that Resident 1 requires admission to Medical/Surgical floor, and a psychiatric evaluation was required for safety and further management.During a review of Resident 1's hospital psychiatry consult dated September 5, 2025, the note stated, .Disposition back to [NAME] Canyon; patient [Resident 1] is declining any thoughts of self-harm or harm to others. Patient [Resident 1] is not endorsing auditory visual hallucinations; patient is not endorsing delusional thought process.During a review of Resident 1's Social Worker (SW) note dated September 6, 2025, the note stated, .SW received a call from CMA reporting [name of a staff] from [NAME] Canyon Post is reporting the patient is unable to return. @1048~This writer called [NAME] w/[NAME] Canyon Post reporting the patient is unable to DC back due to being picked up by PD on 9/4/2025 and being placed on a 5150 hold and being aggressive with another resident. The patient [Resident 1] has been a resident at [NAME] Canyon Post for 3 years.During a review of the Discharge Planning Progress Note, dated September 9, 2025,it has been noted that the anticipated discharge date for Resident 1 is scheduled for September 10, 2025. The discharge plan entails transfer to SNF. Additionally, the search for placement has been expanded to Riverside and San [NAME] county. The note stated, . Previous SNF not taking patient [Resident 1] back. Also, the note mentioned, .leadership talking with [NAME] and ombudsman being called.During an interview on September 23, 2025, at 3:00 PM with the DON, the director emphasized that not accepting the resident would violate their policy. But, accepting him would potentially endanger the safety of other residents, as he had potential to assault them. The DON stated, I didn't take him back, this is the first time we didn't follow our policy. During a concurrent interview and record review on September 23, 2025, at 3:10 PM, with the DON, the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated October 2022 was reviewed. The P&P indicated, .Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred. During a subsequent interview and record review on September 23, 2025, at 3:10 PM, with the DON, the facility's P&P titled Transfer or Discharge Notices, dated March 2025, was reviewed. The P&P indicated, . If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care). When the DON was asked if the facility's P&Ps were followed, the DON did not provide a direct answer.During a telephone interview on October 21, 2025, at 10:57 AM with the Marketing Coordinator (Coordinator) , she confirmed that the facility did not evaluate the resident at the hospital to determine if he was okay to return, she stated, Normally we do, but in this case, we did not. She also added, I was just following what my DON told me. The director informed me we cannot have him back. He [Resident 1]is throwing things at patients and is a danger to others. The coordinator explained that prior to her call to the hospital on September 6, 2025, the DON had informed her, We cannot have him back. He is throwing things at patients, and he is a danger to others.

Based on interview and record review, the facility failed to complete a safe transfer and discharge for 1 of 3 sampled residents (Resident 1 and 2) when: 1. Resident 1 history of dementia was transferred to a lower level of care Room and Board, and Ombudsman not included in discharge planning. 2. Resident 2 was transferred to another facility dementia unit without Conservator and Ombudsman included in discharge planning. This failure resulted in Residents 1 and 2 being transferred without capacity to understand and make decisions, not being informed of rights regarding transfer/discharge and the added protection of the Ombudsman (patient rights advocate who ensures residents are not inappropriately discharged ). Findings: 1. During a review of Resident 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: dementia (memory loss, forgetfulness) hypertension (high blood pressure), diabetes type II (body does not produce enough insulin, or resist insulin). During a review on April 29, 2025, Resident 1 ' s Medical Record reviewed are as follows: 1. History and Physical (H&P) dated September 21, 2021, Has the capacity to understand and make decisions. 2. [Name] Health Progress Note/History & Physical dated November 21, 2024: Behavioral Disturbances Associated with Dementia: The patient .exhibits verbal outburst and physical aggression, aligning with behavioral and psychological symptoms of dementia. Plan: Asses potential triggers for the aggressive behavior .(Facility cannot provide recent H&P if the resident has the capacity to understand and make decisions) 3. Notice of Proposed Transfer/Discharge Notification Date February 27, 2025: Social Worker notified (Niece) .Transfer to Room and Board (lower level care) .The transfer or discharge is appropriate because your health has improved .Resident unable to sign. 4. Discharge Summary February 27, 2025, at 1400 (no resident signature or family notification documented). 5. Social Services Note February 07, 2025, 16:05: Met with the family of resident to discuss possible discharge. Residents family thinking about taking patient back to [country name] .Resident is Alert and oriented with episodes of confusion and forgetfulness .The team will continue to monitor the resident for any behavioral changes and concerns. Resident has episodes of refusals of care and medication regimen. 6. Social Services Note February 27, 2025, 11:43: Resident will discharge today to lower level of care. Resident is Alert and Oriented, self-responsible and able to make all needs known .Residents family are not involved and would not like to have any responsibility with his care. Resident will discharge to a Room and Board with meds and Home Health. 7. readmitted from Hospital March 05, 2025. 8. Notice of Proposed Transfer/Discharge Notification Date March 06, 2025: Person notified: (niece). Transfer to [skilled nursing facility], The transfer/discharge is necessary for your welfare and your needs cannot be met in the facility .Resident unable to sign. 9. Discharge Summary March 06, 2025, at 0800 (no resident signature or family notification documented). 10. Social Service Note: March 06, 2025, 1714: Resident discharged to another SNF today at 9:00AM. Resident is Alert/Oriented self-responsible and able to make all his needs known .Resident is noted to be a little aggressive to staff member but calmed down after a few minutes. SW reached out to the resident niece and notified of discharge . 11. No Integrated Discharge Team (multi-disciplinary team) IDT meeting regarding transfer planning documentation provided. During an interview on April 29, 2025, with the Social Worker (SW), SW stated, Resident 1 had a lot of aggression and refusals. On February 07, 2025, the niece was involved in discharge planning, she wanted to help me, but no one wanted to be responsible for him .the resident was telling family he wanted to go back home. No one wanted to take over care of him. The administrator at the Room & Board came to assess resident. He seen the 1:1 due to residents ' aggression, the resident is very ambulatory, he does everything. He can be aggressive we don ' t want other residents to get hurt. At the time it was safe for Resident 1 to make his decision to transfer to room and board. We were worrying about the other patients. His roommates were not safe, we had a lot of room changes and nothing changed. This resident was alert with periods of confusion, and he is refusing care, it was beneficial to send out, we were thinking about other residents. He had aggression and Room & Board they called 911, sent to [acute hospital], then he came back here, we readmitted him. We felt our residents were in danger, he was throwing things, we looked at other Skilled Nursing Facilities, we told the SNF about his aggression. It felt in conversation he understands everything with the interpreter in Spanish. We did involve the family in discharge planning, when the family washed their hands of him to make his decisions. For him at that time he did need the ombudsman to be involved. During an interview on April 29, 2025, with the Director of Nursing (DON), DON stated, Resident 1 Family did not disagree to the transfers. We did not force him; he was interviewed by the Room & Board. He is self-responsible, he makes his own decisions. When there is a problem with the residents and us the facility we call the Ombudsman. We tried calling the Ombudsman many times, in general they tell you they are the advocate of residents, so whatever the resident decides. I fell it was safe for him, there was not so many people at the Room and Board and the SNF, is a smaller facility. He gets triggered right away, this is not a quiet place and we have to protect the other residents. They came here, the admin from the admitting SNF to assess him as well they said we will take him and accepted the challenge. The second time it was a safe transfer, I have not gotten a call from them regarding any problems with him. He does have the capacity and makes his own decisions. The niece was informed. We felt he didn ' t like the residents here and no compatibility. We had him on 1:1, even with the 1:1 he hit another resident. There was an accepting Room & Board, the day after that they took him they sent him out due to altered mental status. He was very aggressive. He was sent to acute hospital, we accepted him back from the hospital and we kept looking for placements. He was transferred to SNF, he ' s probably doing good because we have not had a call from them since he was transferred there. 2. During a review of Resident 2 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with contact Responsible Party Public Guardian: Conservator [contact information]. Diagnoses to include: schizoaffective disorder (combination of symptoms, mood disorder, depressive, delusions, hallucinations), cognitive communication deficit (difficulties that arise from impaired cognitive functions), chronic obstructive pulmonary disease (block airflow, hard to breathe). During a review on April 29, 2025, Resident 2 ' s Medical Record reviewed are as follows: 1. Facesheet: Resident 2 has assigned Conservator since admission June 09, 2023. 2. History and Physical dated September 01, 2024: Has the Capacity to understand and make decisions. Brief Interview for Mental Status= 07 out of 15. 3. Social Service Note dated February 24, 2025, at 0844: This writer reached out to conservator and left a voice message to let her know that the patients wandering is now a risk for elopement at the facility and that IDT would like to transfer her to another Skilled Nursing Facility SNF to better monitor her of her wandering and her own safety. Social Worker (SW) is awaiting response at this time. 4. Discharge Summary: discharge date and time February 27, 2025, at 1900 to SNF, self-responsible, Reason: Resident 2 is at risk for elopement due to her wandering. (SW) reached out to the conservator and left a voice message to let them know that it will be safer for her to transition to another facility who can monitor her wandering episodes. 5. Physician Order February 27, 2025, May discharge to another SNF [name post acute]. (No reason for transfer documented) During an interview on May 13, 2025, with the Social Worker (SW), SW stated, Resident 2 had a conservator since admission, having a conservator is because resident cannot make own medical decisions. We include in care conferences, not all will attend the meetings, but we let them know about them. When we would call the conservator, we would always talk to the front desk person. They will only call us for court hearings, that ' s the only time we will hear back from them. The transfer was for safety reasons. The conservator was called but we left a voice message, then we had the (IDT) to makes the decisions for the resident. We did not involve the Ombudsman in the discharge planning, we sent the notification after the day Resident 2 was discharged . The resident knew the transfer was for the dementia unit, I know it was for a lock dementia unit and she knew she would benefit there. I have not heard back from the conservator .the other facility will be reaching out to her, I ' m assuming they already have it. The SNF was a smaller one and will monitor her behavior. I never heard back from conservator. During an interview on May 13, 2025, with the Director of Nursing (DON), DON stated, For Resident 2, the conservator usually they will not respond. The conservator makes the decisions for the residents. I cannot wait because of safety of patient very dangerous is she goes outside she will assault the other residents. We called the conservator for D/C planning, no response. We made the decision in the IDT meeting, because she is conserved this is why we did not call the ombudsman. We in IDT meeting made the decision for the resident. The resident was made aware of where she was going by those who interviewed her from other facility, the Administrator and (DON) they came to assess her. The priority is safety of resident, we notified the ombudsman after, it was safety issue I was afraid of. During a review of the facility ' s policy and procedure titled, Transfer or Discharge revised March 2025, the policy and procedure indicated, Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. During a review of the facility ' s policy and procedure titled, Attending Physician Responsibilities revised August 2014, the policy and procedure indicated, Providing Appropriate, Timely medical Orders and Documentation .4. The physician will provide documentation required to explain medical decisions and to help the facility comply with its legal and regulatory requirement. During a review of the facility ' s policy and procedure titled, Care Planning-Interdisciplinary Team revised March 2022, the policy and procedure indicated, The interdisciplinary team is responsible for the development of resident care plans. 4. The resident, the resident ' s family and or the resident ' s legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident ' s care plan. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. When a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken. 4. Documentation from the Care planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: c. That the resident and/or representative (sponsor) participate in a predischarge orientation program.

Based on interview, record review, and facility document and policy review, the facility failed to report an allegation of resident-to-resident abuse involving 2 (Resident #29 and Resident #83) of 2 sampled residents reviewed for abuse to the state survey agency within two hours. Findings included: A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 04/2021, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). The policy specified, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknow source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy further specified, 3. 'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #29's Admission Record revealed the facility admitted the resident on 12/19/2024. According to the Admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy, abnormality of gait and mobility, adult failure to thrive, dehydration, weakness, atherosclerotic heart disease, alcohol abuse, acute on chronic diastolic congestive heart failure, cand essential hypertension. Resident #29's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit any physical or verbal behavioral symptoms directed towards others during the seven-day assessment look-back period. Resident #29's Care Plan Report included a focus area, initiated 12/24/2024 and revised 01/01/2025, that indicated the resident had cognitive loss, impaired decision-making skills ,and forgetfulness and needed verbal reminders. Resident #83's Admission Record revealed the facility admitted the resident on 04/09/2024. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar type; Parkinsonism; delusional disorders; hallucinations; major depressive disorder; insomnia; and muscle wasting and atrophy. Resident #83's quarterly MDS, with an ARD of 01/08/2025, revealed the resident had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not exhibit any physical or verbal behavioral symptoms directed towards others during the seven-day assessment look-back period. Resident #83's Care Plan Report included a focus area, initiated 04/18/2024, that indicated the resident was at risk for decreased psychosocial well-being and adjustment issues; emotional distress and ineffective coping skills; poor impulse control; adverse effects on function, mental, physical, social, or spiritual well-being related to feeling down, depressed, or hopeless and little interest or pleasure in doing things. Resident #83's Progress Notes revealed a Nurse's Note, dated 03/16/2025 at 10:22 PM and electronically signed by Registered Nurse (RN) #5, that indicated Resident #83 was seen in their room holding scissors by a licensed vocational nurse (LVN). The note indicated that when the RN interviewed Resident #83, the resident reported they were sleeping in their bed when they got awoken by Resident #29 shaking their bed. The note further indicated Resident #83 reported Resident #29 punched them on the right thigh. Per the note, Resident #83 stated they then hit Resident #29 on the right side of the head. Per the note, staff moved Resident #83 to another room, the Director of Nursing (DON) was notified, and 911 was called. A Report of Suspected Dependent Adult/Elder Abuse, dated 03/17/2025, revealed the Assistant Director of Nursing (ADON) reported the incident involving Resident #29 and Resident #83 to the state survey agency as an allegation of physical abuse. The report indicated staff heard a commotion coming from Resident #29 and Resident #83's room and upon staff's arrival to the room, the residents were engaged in a verbal confrontation. Per the report, Resident #83 reported that Resident #29 woke them up by shaking their bed, and then, Resident #29 hit Resident #83. Resident #83 stated they then responded by hitting Resident #29. The report indicated Resident #29 reported that Resident #83 hit them first. A Transmission Verification Report, dated 03/17/2025, revealed the facility submitted the initial Report of Suspected Dependent Adult/Elder Abuse to the state survey agency on 03/17/2025 at 10:58, which was not within the required two-hour timeframe. During an interview on 03/21/2025 at 1:52 PM, the ADON stated the incident involving Resident #29 and Resident #83 was reported to him the evening of 03/16/2025. In contrast to the facility's policy, the ADON then stated that for incidents without a major injury, the facility reported them to the state agency within 24 hours. The ADON stated if an incident did result in major injury, they would report it within two hours.

Based on interview, observation, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 112, 114, 116, 202, 404, and 406. Findings included: A policy titled, Bedrooms, revised May 2018, revealed, All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. The policy revealed, 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. (Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in accordance with special needs of the resident and will not adversely affect the resident's health and safety.) On 03/17/2025 at 9:25 AM, the Director of Nursing (DON) stated the facility had some resident rooms that measured less than the required square footage. On 03/19/2025 at 3:15 PM, the Maintenance Director was observed while measuring Rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 112, 114, 116, 202, 404, and 406. Each room had closets, nightstands, wheelchairs, bathrooms, and resident beds, which were not observed to block the bathroom or closet doors. Residents could freely move around the rooms, and privacy curtains were in use. Room measurements were as follows: - Rooms 101, 102, 103, 104, 105, 106, and 107 had three residents each and measured 75.19 sq ft per resident. - room [ROOM NUMBER] had three residents and measured 74.54 sq ft per resident. - room [ROOM NUMBER] had three residents and measured 74.863 sq ft per resident. - rooms [ROOM NUMBER] had three residents each and measured 71.29 sq ft per resident. - room [ROOM NUMBER] had three residents and measured 73.04 sq ft per resident. - room [ROOM NUMBER] had two residents and measured 73.48 sq ft per resident. - room [ROOM NUMBER] had two residents and measured 78 sq ft per resident. On 03/19/2025 at 3:45 PM, the Maintenance Director stated the room measurements did not provide each resident 80 square feet as per regulation. On 03/20/2025 at 8:37 AM, Certified Nursing Assistant (CNA) #1 stated room [ROOM NUMBER] and room [ROOM NUMBER] seemed a little small at times, but noted the rooms were workable. On 03/20/2025 at 8:44 AM, CNA #2 stated the rooms were comfortable to take care of the residents. On 03/20/2025 at 8:50 AM, CNA #3 stated the space in the rooms was acceptable. She stated the staff were able to move the side tables, and moving the tables helped staff get around easier. On 03/20/2025 at 9:04 AM, the DON stated there were no issues related to the room sizes being brought to the attention of her or staff. She stated the facility conducted what the facility called angel rounds, and the angel rounds had room size concerns addressed on a sheet from which staff conducted the angel rounds. She stated if residents needed more storage they were able to use a storage area to store extra items.

Based on observation, interview and record review the facility staff failed to assist with activity of daily living (ADL) for 2 of 3 sampled Residents (Resident 1 and 3). This failure led to Resident 1 experiencing Moisture-Associated Skin Damage (MASD), characterized by skin inflammation and erosion due to extended exposure to moisture sources such as urine or stool. These failures posed a significant risk to the psychosocial well-being, health, and safety of both clinically compromised Residents 1 and 3. Findings: A review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Tear of Lateral Meniscus (an injury to one of the bands of rubbery cartilage that act as shock absorbers for the knee) A review of the SBAR (change of condition report) dated February 25, 2025, revealed a change in skin color or condition, specifically noting moisture-associated skin damage (MASD) on the left buttock, which extends to the right buttock. During an interview on March 6, 2025, at 12:03 PM, with Resident 1, Resident 1 reported that the staff did not change her diaper last night until this morning. She mentioned that when she activated her call light, the staff entered the room only to turn it off without inquiring about her needs, indicating that this occurs frequently during the night. She also noted that she did not have any bed sores upon her admission to the facility, but she now has developed a bed sore on her buttock. During an interview on March 6, 2025, at 1:04 PM, with the Certified Nursing Assistant (CNA 1), CNA 1 indicated that staff are required to change the resident's diaper every two hours or as necessary. He also mentioned that he would respond to the call light promptly upon noticing it. Additionally, the call light should be positioned within easy reach. During an interview on March 6, 2025, at 1:25 PM, with the Wound Care Nurse (WCN 1), the WCN 1 stated during the admission assessment of Resident 1, MASD was observed beneath the left breast, but there is no record indicating that MASD was present on the resident's buttocks. During a telephone interview and record review on March 11, 2025, at 10:05 AM, with the Assistant Director of Nursing (ADON 1). The Plan of Care (POC) record for Resident 1 was reviewed. ADON 1 confirmed that on March 3, 4, and 5 of 2025, Resident 1 was given a diaper change only three times over a 24-hour period. ADON 1 indicated that it is possible Resident 1 may be experiencing Moisture-Associated Skin Damage (MASD) due to the lack of care provided. A review of the facility policy and procedure (P&P) titled, Pressure Ulcer/Injury Risk assessment dated [DATE], indicated, .5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate . A review of Resident 3 Face Sheet (contain resident demographic), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE], with a diagnosis that included muscle wasting and atrophy (the thinning or loss of muscle tissue and mass). During an interview on March 6, 2025, at 12:35 PM, with Resident 2. Resident 2 expressed a desire to turn on her television. It was observed that the call light was secured beneath her bed padding. When inquired whether she could activate her call light, the resident indicated that she was unaware of its location. Upon being informed that the call light was situated under her padding and asked if she could reach it, the resident attempted to do so but was unable to succeed. During an interview on March 6, 2025, at 12:38 PM, with the CNA (CNA 2), CNA 2 indicated that the call light should not be positioned beneath the padding; rather, it ought to be secured to the resident's blanket or placed within the resident's reach. She explained that while attempting to tidy the bed in a hurry, she inadvertently placed the call light under the padding. She acknowledged her mistake, stating, my bad, it should not be placed there. A review of the facility P&P titled, Answering Call Light dated October 2010, indicated, .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with respect and dignity when a Certified Nursing Assistant (CNA 1) used profanity (language that is rude, offensive, or vulgar, often involving swear words, or disrespectful terms) with Resident 3 during an activity program on November 12, 2024. This failure compromised Resident 3 ' s dignity and violated his right to respect, which had the potential for Resident 3 to experience psychosocial harm (mental harm and suffering). Findings: A review of Resident 3's Admission Record (a document containing clinical and demographic data), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (group of lung conditions that causes breathing difficulties) and hypertension (blood pressure that is higher than normal) A review of Resident 3 ' s for titled History and Physical dated August 12, 2024, indicated . This resident [Resident 3] has the capacity to understand and make decisions . During concurrent observation and interview on November 22, 2024, at 3:00 PM, with Resident 3, Resident 3 was sitting in his wheelchair and participating in the activity program. Resident 3 stated that he recalled attending an activity program in the Gallery Room on November 12, 2024, around 9:30 AM. Resident 3 stated that during the program, residents, and activity staff, including CNA 1, engaged in a conversation. Resident 3 further stated that he heard CNA 1 tell him, F**k [f word is swearing words to curse someone] off, Resident 3. When he tried to clarify what CNA 1 had said, she repeated the same phrase. Furthermore, Resident 3 stated When she said my name, I knew the F word was directed at me, and she should not have said it. I haven ' t seen her since then. During a concurrent record review and interview on November 22, 2024, at 3:35 PM, with the Human Resources (HR), a facility document titled California Notice of Change in Relationship of CNA 1 indicated Name: CNA 1 . Your employment status has changed for the reason checked below: . discharged effective 11/14/2024 [November 14, 2024] . Involuntary - Violation of company policy . The HR stated the facility has terminated CNA 1 ' s employment. During a subsequent record review and interview on November 22, 2024, at 3:45 PM with the HR, a facility document titled Walk Away Policy and Procedure, signed by CNA 1 on May 1, 2024, indicated . that any staff member who becomes frustrated when assisting a resident must walk away from the situation, absent of an emergency and request assistance so as to prevent a resident from being subject to inappropriate conduct which includes, but is not limited to, verbal, mental, sexual, or physical abuse, . The HR stated that CNA 1 should have walked away but did not do so. During a follow up observation and interview with Resident 3, on December 31, 2024, at 10:35 AM, Resident 3 was sitting up on his bed. Resident 3 stated he felt upset when CNA 1 used the F word at him. He further stated, I feel relieved I did not see her [CNA 1] around anymore. During a phone interview on January 3, 2025, at 10:35 PM, with Activity Assistant (AA ), she stated that on November 12, 2024, around 9:30 AM, during an activity program, a resident was transferred to the hospital, leaving the wheelchair in the Gallery Room. She then asked CNA 1 to return the wheelchair to the resident's room. As she went out to retrieve the wheelchair, she overheard CNA 1 say, F**k off, [Resident 3's first name]. When Resident 3 attempted to clarify what CNA 1 had said, CNA 1 repeated the same phrase. The AA further stated that she told CNA 1 the behavior was unacceptable and reported the incident to the Assistance Director of Nursing (ADON), who sent CNA 1 home that day. Furthermore, the AA stated that CNA 1 should have simply walked away if she was frustrated or upset, but she did not. During an interview and concurrent record review, December 31, 2024, at 10:45 AM, with the ADON, the ADON reviewed the facility's policy and procedure titled, Resident Rights revised December 2016, indicated .Policy Statement. Employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to : . b. be treated with respect, kindness, and dignity; . The ADON stated the policy and procedure was not followed. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with respect and dignity when a Certified Nursing Assistant (CNA 1) used profanity (language that is rude, offensive, or vulgar, often involving swear words, or disrespectful terms) with Resident 3 during an activity program on November 12, 2024. This failure compromised Resident 3's dignity and violated his right to respect, which had the potential for Resident 3 to experience psychosocial harm (mental harm and suffering). Findings: A review of Resident 3's Admission Record (a document containing clinical and demographic data), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease (group of lung conditions that causes breathing difficulties) and hypertension (blood pressure that is higher than normal) A review of Resident 3's for titled History and Physical dated August 12, 2024, indicated . This resident [Resident 3] has the capacity to understand and make decisions . During concurrent observation and interview on November 22, 2024, at 3:00 PM, with Resident 3, Resident 3 was sitting in his wheelchair and participating in the activity program. Resident 3 stated that he recalled attending an activity program in the Gallery Room on November 12, 2024, around 9:30 AM. Resident 3 stated that during the program, residents, and activity staff, including CNA 1, engaged in a conversation. Resident 3 further stated that he heard CNA 1 tell him, F**k [f word is swearing words to curse someone] off, Resident 3. When he tried to clarify what CNA 1 had said, she repeated the same phrase. Furthermore, Resident 3 stated When she said my name, I knew the F word was directed at me, and she should not have said it. I haven't seen her since then. During a concurrent record review and interview on November 22, 2024, at 3:35 PM, with the Human Resources (HR), a facility document titled California Notice of Change in Relationship of CNA 1 indicated Name: CNA 1 . Your employment status has changed for the reason checked below: . discharged effective 11/14/2024 [November 14, 2024] . Involuntary - Violation of company policy . The HR stated the facility has terminated CNA 1's employment. During a subsequent record review and interview on November 22, 2024, at 3:45 PM with the HR, a facility document titled Walk Away Policy and Procedure, signed by CNA 1 on May 1, 2024, indicated . that any staff member who becomes frustrated when assisting a resident must walk away from the situation, absent of an emergency and request assistance so as to prevent a resident from being subject to inappropriate conduct which includes, but is not limited to, verbal, mental, sexual, or physical abuse, . The HR stated that CNA 1 should have walked away but did not do so. During a follow up observation and interview with Resident 3, on December 31, 2024, at 10:35 AM, Resident 3 was sitting up on his bed. Resident 3 stated he felt upset when CNA 1 used the F word at him. He further stated, I feel relieved I did not see her [CNA 1] around anymore. During a phone interview on January 3, 2025, at 10:35 PM, with Activity Assistant (AA ), she stated that on November 12, 2024, around 9:30 AM, during an activity program, a resident was transferred to the hospital, leaving the wheelchair in the Gallery Room. She then asked CNA 1 to return the wheelchair to the resident's room. As she went out to retrieve the wheelchair, she overheard CNA 1 say, F**k off, [Resident 3's first name]. When Resident 3 attempted to clarify what CNA 1 had said, CNA 1 repeated the same phrase. The AA further stated that she told CNA 1 the behavior was unacceptable and reported the incident to the Assistance Director of Nursing (ADON), who sent CNA 1 home that day. Furthermore, the AA stated that CNA 1 should have simply walked away if she was frustrated or upset, but she did not. During an interview and concurrent record review, December 31, 2024, at 10:45 AM, with the ADON, the ADON reviewed the facility's policy and procedure titled, Resident Rights revised December 2016, indicated .Policy Statement. Employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to : . b. be treated with respect, kindness, and dignity; . The ADON stated the policy and procedure was not followed.

Based on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accident during shower for one of three sampled residents (Resident 3), when Resident 3 was left in the shower unsupervised. This failure resulted in Resident 3 to receive multiple blisters to his lower body area. Findings : A review of Resident 3's clinical record titled, Admission Record (contains medical and demographic information) indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included paraplegia (impairment in motor or sensory function of the lower extremities) and muscle weakness (lack of strength in the muscles). During a review of Resident 3's History and Physical (H&P) dated September 23, 2023, the H&P indicated . This resident [Resident 3 ] has the capacity to understand and make decisions . During a review of Resident 3's Minimum Data Set (MDS- a computerized assessment instrument), Section GG Functional Abilities and Goals (Coding: Safety and Quality of Performance - If helper assistance is required because patient's/resident's performance is unsafe or of poor quality, score according to amount of assistance provided), dated March 7, 2024, the MDS indicated Resident 3 required, [coded] 03 for showering/bathing self, meaning partial or moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half). During a review of Resident 3's care plan, revised on March 8, 2024, it indicated, at risk for ADL [Activity of Daily Living]/mobility decline and requires assistance related to . non ambulatory, paralysis, paraplegia . During a review of Resident 3's clinical record titled eINTERACT SBAR [Situation-Background-Assessment-Recommendation - communication tool of summary for change of condition] dated March 10, 2024, it indicated . During wound care , WCN [Wound Care Nurse] notice patient has new wounds . to the left leg, scrotum, and penis with close/open blisters. Pt [Resident 3] is at risk for developing new wounds r/t [related to] poor circulation . During a review of Resident 3's physician order sheet, dated March 10, 2024, it indicated, a treatment order of . close blister to left leg .close blister to scrotum .apply to penis topically [specific area] for open blister . During a review of Resident 3's clinical record titled IDT note [Interdisciplinary Team - a group of healthcare professionals from different disciplines working towards a common goal for a resident) dated March 12, 2024, it indicated Resident asked the CNA [Certified Nurse Assistant 1] to wheel him to the shower room. Resident prefers to take a shower privately and he wants only set up help. CNA turned on the shower to middle area. Then Resident asked for the shower head so he can take shower by himself. CNA left resident during shower. CNA came back to check if he is done and wheeled resident back to his own room. During treatment . noted Also a blister on mid upper thigh Resident had multiple scar tissues on sacrum and perineal areas upon admission. Per Treatment Nurse, the areas where tissues were peeled off were pink and no bleeding noted. But due to peeled off areas were open; they were at high risk for complications . During concurrent observation and interview with Resident 3, on March 26, 2024, at 1:00 PM, Resident 3 sitting down in the wheelchair at the facility outside patio. Resident 3 stated I think I let the running shower head rest on my lap too long while washing my upper body not realizing the water might have been too hot for my skin, I can't feel anything from waist down. During further interview with Resident 3, on March 26, 2024, at 1:10 PM, Resident 3 stated CNA 1 was not with him throughout the shower. CNA 1 told him that he would come back to check on him and that he needed to attend to other patients. Resident 3 further stated CNA 1 was in and out the shower room approximately three times, each time being gone for 8-10 minutes. Resident 3 expressed he would feel safer and more comfortable if CNA 1 stayed with him throughout the shower. During an interview with the Treatment Nurse (TN), on April 19, 2024, at 11:25 AM, the TN stated that on March 10, 2024, during treatment, she discovered new blisters to left leg, scrotum, and penis area. She further stated that when she asked Resident 3 about it, he informed her that he had left the shower head running for too long yesterday (March 9, 2024). The TN then contacted the doctor to report the issue and obtain a treatment order. During an interview with Assistance Director of Nursing (ADON), on April 19, 2024, at 2:50 PM, the ADON stated CNA 1 should have stayed with Resident 3 throughout his shower to supervise for safety. During a follow up telephone interview, with CNA 1 on April 19, 2024, at 3:45 PM, CNA 1 stated that on March 9, 2024, Resident 3 was assigned to him for the first time. CNA 1 stated he wheeled Resident 3 to the shower room and adjusted the water temperature to be approximately between cold and hot, before leaving Resident 3 inside the shower room. CNA 1 further stated that he was unsure about the facility's practice, but he informed Resident 3 before leaving the shower room that he would be outside that he needed to attend to other patients and would check on him if he needed assistance or had finish his shower. During a review of the facility' s policy and procedure (P&P) titled, Activity of Daily Living (ADL's), Supporting revised March 2018, the P&P indicated Policy Statement. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . During a concurrent interview and record review with on April 19, 2024, at 4:00 PM, with ADON, the facility's P&P titled, Bath, Shower/Tub revised March 2024, was reviewed, the P&P indicated, Purpose. The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines. 1. Be sure that the bath area is at a comfortable temperature for the resident. 2. Residents who require assistance with ADL's: a. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower 3. Use the emergency call signal for assistance, if needed . The ADON stated the facility did not follow the policy.

Based on observation, interview, and record review, the facility failed to properly collect and document for one of 3 sampled residents (Resident 1) a 24-hour urinalysis specimen. This failure contributed to a clinically compromised Resident 1 not completing a physician ordered laboratory test. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: malignant poorly differentiated neuroendocrine tumors (highly aggressive cancer of pancreas), secondary malignant neoplasm of bone (bone cancer), spinal stenosis (narrowing inside the bones of the spine), palliative care (medical care focuses on providing relief from pain and other symptoms of serious illness). During a concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nurses (ADON), reviewed and verified the following: 1. Nurse Note dated February 11, 2024, at 08:50, Note Text states, Resident 1 sister called to collect 24-hour urine to resident start 5am Sunday until 5am Monday and she will pick up the urine collection 24 hours and will bring it to [acute hospital]. Placed a call [doctor] for order of Foley catheter (used to drain urine from the bladder by way of urethra) for insertion to collect 24-hour urine collections since the resident is confused not able to express needs and cannot follow command. Obtained new order to insert foley catheter for urine 24-hour urine collection carried out and noted. Foley catheter, insert used F14(size of catheter) catheter aseptically no urine obtained yet since the resident just had urinated diaper fully soaked with urine. Foley Catheter in a basin with ice. Will continue to monitor. 2. No Documentation in electronic medical record of a date, time start, end time, and no assessment of urine collection (color, quantity, etc.) for a 24-hour urine collection ordered February 11, 2024. 3. No laboratory results for the 24- hour urine collection ordered from February 11, 2024. During an interview on March 19, 2024, with the Case Manager (CM), CM stated, Resident 1 did go out to Oncology, he came back with order for Endocrinology. I don ' t see an order from his consults an order for UA 24-hour collection. If the family would have told us about any 24-hour urine collection we would call to get an order, the family doesn ' t usually know the details, so we call and document in the system. I was not made aware of the Nurse progress note from February 11, 2024. This nurse (RN1) should have notified us on this 24-hour urine collection order. During an interview on March 19, 2024, with the Social Service (SS), SS stated, R1 sister called on February 13, 2024, about the urine sample, she said she brought the Urine Container and gave it to the nurse and the facility lost it. I told her over the phone I forward it to Assistant Director of Nursing (ADON) and he will look into it. During an interview on March 19, 2024, with the Assistant Director of Nursing (ADON), ADON stated, There were no orders from his February 08, 2024, from Oncology, he came back with No orders to collect urine. The sister came in and told the nurse about the collection. There a note from the Registered Nurse (RN1) about called our doctor and got order for foley catheter and urine collection. In the note there is nothing about a collection container, just the 24-hour urine collection order, but the order time don ' t coincide with the collection times. We would not have sent out the foley bag as the collection container, it would be placed in our container. If we had the order for a 24-hour urine collection, we contact the other doctor or facility if they have a container, or question how they want this collected. We do not take containers from family stating that urine needs to be collected, we need to follow up with who is ordering the test. During a review of the facility ' s policy and procedure titled, 24-hour Urine Specimen revised October 2010, the policy and procedure indicated: The purpose of this procedure is to collect a 24-hour urine specimen for laboratory analysis .Preparation 1. Verify that there is a physician's order for this procedure .Equipment and Supplies 9. 24-Hour Urine Specimen container and tag .Steps in the Procedure 11.Observe the urine for color, sediments, blood, odor, etc. 15.Save all the urine during the 24-hour period . Documentation: The following information should be recorded in the resident's medical record: 1.The date and time that the specimen was collected.2.The name and title of the individual(s) who performed the procedure.3.The character, clarity and color of urine.4.All assessment data obtained during the procedure.5.The date and time the 24-hour period began and ended.6.The time each specimen was collected.7.The date and time the specimen was sent to the lab.8.How the resident tolerated the procedure.9.If the resident refused the procedure, the reason(s) why and the intervention taken.10.The signature and title of the person recording the data.

Based on interview and record review, the facility failed to report an unusual occurrence for one of 3 sampled residents (Resident 1) per there policy and procedure to the California Department of Public Health (CDPH) for a fall that resulted in right femur fracture. This failure has the potential to put (Resident 1) a clinically compromised resident health, safety, and well-being at risk. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis right dominant side following cerebral infarction (muscle weakness and paralysis due to disrupted blood flow to brain), Diabetes Type II (condition affecting how body processes sugar), muscle wasting and atrophy (decrease in size and muscle). During a concurrent interview and record review with the Assistant Director of Nursing (ADON) of Resident 1 ' s (R1) medical record are as follows: 1. Change of Condition (medical care record) dated January 12, 2024, at 11:38 states, Fall: During post-shower care, resident turned to adjust self and rolled off the bed and onto floor. Resident complained of pain to right thigh and noted with skin tear to left Forearm. Registered Nurse (RN) assessed, and resident assisted back into bed. Resident did not hit head, no Altered level of consciousness (ALOC). Order, send to hospital .STAT (urgent/rush) Xray Right femur/hip. 2. Progress Note (medical care record) dated January 13, 2024, at 00:44 states, All labs came back within normal limit and no fracture is seen on the femur and hip . 3. Progress Note dated January 15, 2024, at 1722 and 2040, states, Resident on charting r/t witnessed fall and Readmission from {hospital} . X-rays taken during shift. Pending results please follow up .Resident sent out to {hospital} related to Fracture of right femur. 4. Progress Note dated January 16, 2024, at 4:03, states, Resident came with diagnosis of fracture: femur distal, surgical procedure reduction and a splint on the Right leg. During an interview on February 22, 2024, with the (ADON), the ADON stated, The staff took Resident 1 to the shower on a shower bed, Resident ' s extremities are contracted. A CNA was on one side and the other CNA was reaching for shower blanket from the other side of shower bed, and because Resident 1 is contacted, Resident 1 tried adjusting himself on the shower bed, he was wet, and he fell off the shower bed. The two CNAs observed the fall, Resident 1 was sent to the hospital and came back. The return documents from hospital stated there was no fracture, but as we kept assessing him, we did another X ray and there was a fracture. We sent him out again, this time to a different hospital and he did come back with a fracture and a soft splint to right leg. It was not reported to state agency because we did not determine any abuse, it was not unusual occurrence, it was witnessed. We determined no neglect was at play. He did have a fracture, but we determined how he got it, so it was not an unusual occurrence for us to report. During an interview on February 29, 2024, with the Administrator (ADMIN), ADMIN stated, This was not reported, this resident had a fracture, but we were aware of how it happened. It was a known cause. It was not an unusual occurrence, so it did not fit the criteria to report. During a concurrent interview and record review with the ADON of the facility ' s policy and procedure titled, Unusual Occurrence Reporting revised December 2007, the policy and procedure indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.

Based on interview and record review the facility failed to follow their change of condition policy when one of three sampled residents, Resident 1 ' s daughter notified a license nurse of her Mothers (Resident 1 ' s) shortness of breath and stomach pains. This failure had placed a clinically compromised Residents (Resident 1) health and safety at risk by causing delay in treatment when no assessment, no documentation, and no physician notification, was done on a change in condition. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: hypertension (high blood pressure), hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side (paralysis to one side, partial weakness , conditions affection blood flow to the brain), gastrointestinal hemorrhage (bleeding in digestive tract), alcoholic cirrhosis with ascites (liver disease, cause fluid to accumulate in legs, abdomen). During a review concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. Careplan-1. Hernia to Mid abdomen (organ misplaced protruding), monitor for changes and report to MD. 2. Pain: at risk for pain or discomfort .Chronic Obstructive Pulmonary Disease (lung disease that block airflow), Colitis (inflammatory bowel), monitor .notify physician 3. Swelling to pubic area .4. Skin: Resident at risk for skin breakdown .observe/document/notify physician as needed .5.Refusal of care .Re-approach when refusing care to the extent possible. 2. No Change of Condition (COC) or Nurse Note on January 16, 2024, (when resident family member informed LVN1 of Shortness of Breath (SOB) and stomach pains). Nurse progress notes reviewed from admitted to January 20, 2024. 3. Nurse Progress Note dated January 20, 2024, at 12:30 .Doctor {name} informed of respiratory distress .oxygen Saturation 60% .called 911. During an interview with the License Vocational Nurse (LVN1) on January 23, 2024, at 10:48 AM, the (LVN1) stated, Resident 1 ' s family member did tell me about her breathing and her stomach pain, I believe it was one time she was here at bedside and again over the phone when I talked to her regarding a family member giving her food when she was on a puree diet. She told me that day I gave her a breathing treatment, I think it was January 16, 2024. When asked, did you do a (COC) for this resident regarding the stomach pains and you trying to assess her? LVN1 stated, no I did not, I should have documented the conversation with the family about the stomach pains and SOB. I did not document anything on this, only that I gave the breathing treatment. During an interview with the Assistant Director of Nursing (ADON) on January 23, 2024, the (ADON) stated, Based on the interview with LVN1, family did notify of resident change of condition, there should have been an assessment and COC documentation due to the stomach pains and call the doctor. During an interview with the Director of Nursing (DON) on January 23, 2024, at 12:06 PM, the (LVN1) stated, when asked, why was there no COC or documentation on January 16, 2024, when the family voiced concerns regarding SOB and stomach pains? States, Initiating the COC that is the independent function of a nurse responsibility, and she needs to report it. There was no report documented on the incident. I was not made aware. The nurse should have initiated a Change of Condition for this resident. During a review of the facility ' s policy and procedure titled, Change in a Resident ' s Condition of Status revised February 2021, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; 2. A significant change of condition is a major decline or improvement in the resident's status that: c. Ultimately is based on the judgment of the clinical staff. 3.Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 6.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to provide a safe and abuse free environment for one of three sampled resident (Resident 3) when Resident 3 was hit in the face by CNA 1 on November 26, 2023. This failure had the potential to cause emotional distress that could affect Resident 3's highest practicable level of psychosocial health and well- being. Findings: A review of Resident 3's Admission Record, (document containing clinical and demographic data), indicated Resident 3 was admitted to the facility on [DATE], with a diagnoses of acute pulmonary edema (a condition in which the fluid accumulates in the lungs, making it hard to breathe, hypertension(blood pressure that is higher than normal), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident 3's History and Physical, dated September 2, 2023, indicated Resident 3 .has fluctuating [continually change or shift back and forth] capacity to understand and make decisions . A review of State of California Form 341 (SOC 341-Report of Suspected Dependent Adult/Elder Abuse), completed on November 26, 2023, indicated .[Resident 3] claims staff member [CNA 1] slapped her in the face after providing assistance with her TV. Staff member immediately removed from the area and escorted off the premises. [Resident 3] was assessed and complained of headache and was provided PRN pain medication. Resident with slight swelling to left side of face. No redness or discoloration. Resident noted with calm demeanor, no visible distress observed . A review of a facility staff statement, dated November 26, 2023, written by CNA 2, indicated I [CNA 2] was outside on my break and I was talking to [name of receptionist] and CNA [name of CNA1] come outside and stated he has slapped the f**k [f word is swearing words to curse someone] out of the pt [Resident 3] . A review of facility staff statement dated November 26, 2023, written by CNA 3, indicated I [CNA 3] heard - loud noise. Seen [CNA 1] in my room [ROOM NUMBER] [assigned room to CNA 3, which was Resident 3 room] . He [CNA 3] stated he was helping me, and he slapped the sh**t [An exclamation or a very mild curse]out [Resident 3] for calling me a nigger [used as an insulting and contemptuous term for a black person]. During a record review of Resident 3's Interdisciplinary Progress Note, dated November 27, 2023, it indicated On 11/26/23 resident alleged that an employee slapped her in the face. Resident currently resting in bed without distress. Resident refused x-rays to face. No swelling noted at this time. Denied having any pain at this time. Observed in calm demeanor, without verbalization of fear or anxiety. Intervention(s) : >Employee was immediately escorted off the premises and placed on Administrative Suspension pending further investigation Resident assessed for injuries >MD (Medical Doctor) made aware, order received for facial x-rays >72-hour charting initiated >CP (Care Plan) updated. >SBPD (San [NAME] Police Department) notified . During a record review of a facility document titled California Notice of Changes in Relationship, dated November 27, 2023, indicated .Name [CNA1] . [check marked] discharge effective 11/27/2023 .Misconduct . A review of the facility's five-day summary, dated November 28, 2023, indicated .Outcome: An investigation was initiated, and staff members provided written documentation of an admission by employee [CNA 3] which confirmed the allegation. Employee was terminated on 11/27/28 and the employee was reported to the CDPH (California Department of Public Health). Investigative branch.72-hour monitoring continues, and the resident has not displayed any distress. No verbalization of fear or anxiety. No visible injuries observed, resident denies difficulty with movement of jaw. An all-staff in-service has been scheduled regarding Resident Abuse. Resident declines Psychologist follow up, but services remain available per resident request . During an interview with the Assistance Director of Nurses (ADON), on December 7, 2023, at 2:45 PM, the ADON stated they have substantiated the alleged physical abuse by CNA 1 against Resident 3. The ADON further stated the facility has terminated CNA 1. During an interview on December 7, 2023, at 4:05 PM, with Resident 3, Resident 3 stated her feelings was hurt when the incident happens, but she feels better since she does not see CNA 1 anymore after the incident. A review of facility's policy and procedure titled Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, indicated Policy Statement. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff .

Based on interview and record review the facility failed to follow their policy when one of three residents (Resident 1) was allowed to leave the facility and the appropriate agencies (police, ombudsman, and adult protective services) were not notified of this discharge. Resident 1 did not have the capacity to make her own decisions. This failure resulted in a unsafe discharge for a confused resident (Resident 1). Findings: A review of Residents 1's Admission Record (general demographics and medical information), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: Multiple sclerosis (disabling disease that affects the nervous system), traumatic brain injury (damage to the brain) and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures - loss of consciousness). The admission record indicated Resident 1 did not have a responsible person to notify in case of an emergency. Date of discharge: October 4, 2023. During a review of Resident 1's medical records, the Primary Care Physician's History and Physical (H&P), dated October 4, 2023, indicated This resident does NOT have the capacity to understand and make decisions. During a review of Resident 1's medical records, the Nurses Note written by Licensed Vocational Nurse 1, dated October 4, 2023, at 2:52 PM, indicated Resident 1 was discharged from the facility against medical advice (AMA). Medical Doctor is aware of discharge. Resident is alert and uses assistive device for walking. This document did not indicate the police, ombudsman or adult protective services were informed of this discharge. During an interview and concurrent record review of Resident 1's Medical Record with the Discharge Coordinator (DC 1) on October 10, 2023, at 2:22 PM, DC 1 stated Resident 1 was discharged AMA. LVN 1 wrote this note. LVN 1 did not call Adult Protective Services (APS), the ombudsman and the police department. Resident 1 left on October 4, 2023. The discharge should have been reported right away. DC 1 stated further, Resident 1 did not have the capacity to make decisions. LVN 1 should have called the police. During an interview and concurrent record review of Resident 1's Medical Record with the Supervising Registered Nurse (SRN) on October 10, 2023, at 2:50 PM, SRN 1 stated, Resident 1 did not have a responsible person (RP). The H&P says Resident 1 does not have the capacity to make decisions. LVN 1's note should have reflected the notification of the ombudsman, the police and APS. SRN 1 stated further, there aren't any notes from case management or the discharge planner about Resident 1's discharge against medical advice. During an interview and concurrent record review of Resident 1's Medical Record with Case management (CM) on October 10, 2023, at 3:03 PM CM stated, We would not let her go if she does not have the capacity. CM reviewed Resident 1's H&P then stated, Resident 1 should not have went AMA. During an interview and concurrent record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON) on October 10, 2023, at 3:19 PM, ADON stated, We should be notifying APS, ombudsman, and the rresponsible person if the resident has one and some family to let them know that the resident did leave against medical advice. For those that do not have the capacity to make decisions. We call the police, 911, and the ombudsman. ADON stated further, According to LVN 1's note, LVN 1 should have called the police dept, APS and the ombudsman should have been notified. The facility did not provide documentation that indicated the police, ombudsman or adult protective services were informed of Resident 1's discharge. During a review of Resident 1's medical records the document titled Discharge Against Medical Advice was dated October 4, 2023, at 2:23 PM, indicated This is to certify that Resident 1, a resident at (Facility) has been informed of the risk involved and has been advised against leaving the Center against the advice of the attending physician. In addition, the resident and all parties on her behalf do hereby release the attending physician and Center employees from all responsibility, and any ill effects, which may result from this action If resident is unable to consent the reason . state reason(s). This document was signed by a representative of the facility and the resident. This document did not indicate the reason why Resident 1 was allowed to sign out against medical advice or that a responsible person was informed of this discharge. During a review of the facility's policy and procedure titled Leaving Against Medical Advice/Without a Discharge Order undated, indicated Policy: 1. It is the policy of this facility to protect the rights of residents under the care and treatment of the facility. Although the resident has the ultimate right to leave the facility, the facility has a responsibility to provide oversight and protect the rights, health, and safety of each resident .5. In the event a resident does not have the capacity to make decisions, the facility will attempt to locate/contact the resident's family/responsible party/significant other to notify them of the resident's request to leave AMA. The facility will discuss the consequences of leaving against medical advice with the resident's family/responsible party/significant other and attempt to facilitate a safe exit from the facility by: Requesting address of person receiving the resident. Requesting contact information for the person facilitating the exit. Determining the relationship of the person arranging the exit and information will be documented in the resident's medical record. 6. For residents without capacity who do not have a responsible party and still wish to leave against medical advice, the facility will immediately: Notify the Local Authorities. Notify Adult Protective Services. Notify the Local Ombudsman's office with the route of notifications documented in the resident's medical record.

Based on interview, and record review, the facility failed to provide a safe environment with adequate monitoring and supervision for one of three sampled residents (Resident 1), that lead to resident 1 leaving the facility, and law enforcement being called. This failure resulted in elopement from facility with no documentation of who picked up resident and where resident went. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: diabetes mellitus type 2 (insulin resistant), Post Traumatic Stress Disorder (experiencing traumatic events), hypertension (high blood pressure) and dementia (impairment of memory, personality changes). During a review concurrent interview and record review of Resident 1's Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. History and Physical (from admitting hospital) dated May 22,2023 . patient becoming progressively more aggressive and violent over the past 2 weeks . 2. Nurse Notes dated May 26, 2023, at 11:11 indicates, Resident refusing treatment nurse skin assessment . 3. Nurse Note dated May 26,2026 at 13:48 indicates, Resident screaming and yelling, verbally and physically violent .3rd attempt of getting out of the facility was uncontrolled. Staff called 911, informed Responsible Party (RP) that Resident 1 left again, and no staff can control the Elopement. 4. Facility cannot provide documentation for a Transfer form or Nurse note of who (law enforcement or ambulance) and where Resident 1 was taken. During an interview on June 13, 2023, at 11:46 AM, with the License Vocational Nurse (LVN), LVN stated, Resident 1 came in May 25, 2023, on Noc shift. they told me he was trying to leave the facility, opening doors around the facility. He expressed he wanted to leave and around 1PM May 26, 2023, we were all watching him, he was very aggressive to staff, he was striking out. The DON called the (RP), I tried to calm him down because he was very violent. The DON called 911, I can't remember if it was the ambulance or the Police who picked him up, I didn't see. He was outside, he eloped. There was no transfer form completed, I don't know who picked him up or where he went. During an interview on June 13, 2023, at 11:59 AM, with the Assistant Director of Nursing (ADON), ADON stated, From what I was told, we called 911, the resident was walking out the gate, because of the aggressive behavior the staff could not control him, and he got out. If he ended up at the hospital, the police found him and reported it, I could assume they took him to the hospital. Usually with an elopement, we look for the resident, and if we see them trying to leave the facility, we try to get them back in. We call the Police and notify family. With this incident we should have called the local hospitals, looking for him. I can see what you are saying, there is no documentation of who picked up this resident or where he went. During an interview on June 13, 2023, at 1:16 PM, with the Administrator (Admin), (Admin) stated, I was made aware from the DON, they attempted with him, he said he was going home, he became aggressive with them, they were talking him back into the facility. The nurse called the Police, I don't think it was the ambulance they called, I think the Police picked him up. I was not made aware of an elopement. I know the Police was called; I don't know where he was taken, I can see there is no documentation of who picked up the resident nor where he went. Elopement protocol is, we conduct a search of the resident do an environment search call the police, local hospitals, family members and notify everyone we need to, and it should have been documented. During a review of the facility's policy and procedure titled, Elopements revised December 2007, the policy and procedure indicated, Staff shall investigate and report all cases of missing residents .2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner, b. Get help from other staff members in the immediate vicinity, if necessary .5. f. Document relevant information in the resident's medical record.

Based on observation, interview, and record review the facility failed to maintain a sanitary kitchen when: 1. The liners, inside the drawers and cabinets, were painted over, and was lifting and had a sticky residue underneath. 2. A green bucket, containing black water, and a sponge was stored in a cupboard under the sink. 3. There were black dirt, trash, and food residue on the floor, under the stove. There were yellow debris on the wall behind the stove. 4. There was an accumulation of leftover food in the gap between the floor and the stainless-steel island (isolated workstation/table in the kitchen area, away from the walls). 5. The liners on the closet drawers and drawers near dry storage were not smooth and not easy to clean. 6. The cabinets and drawers on the wall, near the dishwasher, had peeling linings. The drawers were sticky and not smooth and had debris. 7. The floor, under the ice machine, was raised and the bottom was black. There were three two-by-four (common lumber, measuring two inches [unit of measurement] in depth, and four inches in width, with varying length) wood logs piled under the ice machine. There were food scraps piled around the logs. 8. A yellow deposit had formed on the wall behind the ice machine. 9. There were yellow drips and splatters on all the wooden cabinets and cabinet fronts in the kitchen. 10. Three red ice chests were stored wet with the lid closed. 11. The dishwashing machine's data plate (manufacturer's recommendations for appropriate temperature and chemical concentration) was not affixed on the equipment. These failures had the potential for microorganism growth and pest attraction, and consequential food contamination for 158 residents of 158 residents receiving food from the kitchen. Findings: 1. During an observation on June 6, 2023, at 8:11 AM, in the kitchen, the liners, inside the drawers and cabinets, were painted over, and was lifting and had a sticky residue underneath. During an interview on June 6, 2023, at 9:30 AM, with the Dietary Services Supervisor 1 (DSS 1), the DSS 1 stated it was hard to clean the drawers because of uneven surfaces and the paper walls that were painted were coming off. The DSS 1 further stated, it should have been metal because wood was hard to clean. During an interview on June 8, 2023, at 1:30 PM with the Registered Dietitian (RD), the DSS 1, and the Dietary Services Supervisor 2 (DSS 2), the DSS 2 stated she suggested the wooden cabinets and drawers be replaced with stainless-steel. The RD stated it should be smooth and easily cleanable. 2. During an observation on June 6, 2023, at 8:15 AM, in the kitchen, a green bucket, containing black water, and a sponge was stored in a cupboard under the sink. During an interview on June 7, 2023, at 11:29 AM, with the DSS 1, the DSS 1 stated there should not have been any dirty water sitting under the sink in the cabinet. During an interview on June 8, 2023, at 1:40 PM, with the RD, the RD stated the water should be drained out. 3. During an observation on June 6, 2023, at 8:17 AM, in the kitchen, there were black dirt, trash, and food residue on the floor, under the stove. There were yellow debris on the wall, behind the stove. During an interview on June 8, 2023, at 1:45 PM, with the RD, the DSS 1, and the DSS 2, they stated their expectation was for the area to be kept clean. 4. During an observation on June 6, 2023, at 8:20 AM, in the kitchen, there was an accumulation of leftover food in the gap between the floor and the stainless-steel island. During an interview on June 8, 2023, at 1:45 PM, with the RD, the DSS 1, and the DSS 2, they stated their expectation was for the area to be kept clean. 5. During an observation on June 6, 2023, at 8:23 AM, in the kitchen, the liners on the closet drawers and drawers near dry storage were not smooth and not easy to clean. During an interview on June 8, 2023, at 2:15 PM, with the RD, the DSS 1, the DSS 2, the DSS 2 stated they were aware that the liners on the closet drawers were not smooth and not easy to clean. The wooden drawers and cabinets needed to be replaced with stainless-steel to have an even and smooth surface. 6. During an observation on June 6, 2023, at 8:35 AM, in the kitchen, the lining of the cabinets and drawers on the wall, near the dishwasher, had peelings. The drawers were sticky and not smooth on the surface and had debris. During an interview on June 8, 2023, at 2:18 PM, with the RD, the DSS 1, and the DSS 2, they stated their expectation was for the linings on the cabinets and drawers to not be peeling off and should be cleaned with a smooth surface. 7. During an observation on June 6, 2023, at 8:37 AM, in the kitchen, there were three two-by-four wood logs piled under the ice machine. There were food scraps piled around the logs. The floor, under the ice machine, was raised and the bottom was black. During an interview on June 8, 2023, at 2:20 PM, with the RD, the DSS 1, and the DSS 2, they stated their expectation was for area to be kept clean. 8. During an observation on June 6, 2023, at 8:39 AM, in the kitchen, there was a yellow deposit formed on the wall behind the stove. During an interview on June 8, 2023, at 2:30 PM, with the RD, the DSS 1, and the DSS 2, the DSS 1 stated it was hard area to clean. The DSS 2 stated her suggestion would be to change the old stove. 9. During an observation on June 6, 2023, at 8:40 AM, in the kitchen, the wall behind the ice machine had yellow-colored build up, and there were yellow-colored drips and splatters on all the wooden cabinets and cabinet fronts in the kitchen. During an interview on June 8, 2023, at 2:35 PM, with the RD, the DSS 1, and the DSS 2, they stated it should have been kept clean, and a stainless-steel surface would be easier to clean to ensure continued cleanliness. 10. During an observation on June 6, 2023, at 8:43 AM, three red ice chests were stored wet with the lid closed. During an interview on June 8, 2023, at 2:40 PM, with the RD, the DSS 1, and the DSS 2, the RD stated the ice chests should be air dried before storing. During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated, .11. All utensil, counters, shelves, and equipment shall be kept clean, maintained in good repair . During a review of the 2022 Food Code, U.S. (United States) Food and Drug Administration (FDA) (Food Code), dated 2022, the Food Code indicated, 4-602.13 Nonfood Contact surface. Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Nonfood-Contact Surface. the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 11. During an observation on June 6, 2023, at 8:45 AM, in the kitchen, the dishwashing machine's data plate was not affixed on the equipment. During an interview on June 8, 2023, at 2:43 PM, with the RD, the DSS 1, and the DSS 2, the DSS 1 stated she will obtain the data plate from the manufacturer and will affix it on the dishwashing machine. During a review of the facility's P&P titled, Dish Washing, dated 2018, the P&P indicated, .9. The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations. ***Please check your manufacturer's recommendations, which should be posted on your machine, and insert the temperature on the above posted line. This will allow the information to be handy if needed During a review of the 2022 Food Code, U.S. (United States) Food and Drug Administration (FDA) (Food Code), dated 2022, the Food Code indicated, 4-204.113, indicated, Warewashing (dishwashing) Machine, Data Plate Operating Specifications. A WAREWASHING machine shall be provided with an easily accessible and readable data plate affixed to the machine by the manufacturer that indicates the machine's design and operation specifications including the: (A) Temperatures required for washing, rinsing, and SANITIZING; (B) Pressure required for the fresh water SANITIZING rinse unless the machine is designed to use only a pumped SANITIZING rinse; and (C) Conveyor speed for conveyor machines or cycle time for stationary rack machines. The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing (dishwashing) machine has been tested , and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored.

45388 Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policies and procedures (P&P) when: 1. A Colistimethate (antibiotic medication- used to treat infection) IV (Intravenous- administers fluids, medications and nutrients directly into a person's vein) was not administered to Resident 94 on May 18, 2023 as prescribed by the physician. 2. Glucophage (medication used to lower sugar level) and Insulin Regular Human Injection (medication used to lower sugar level) was not administered to Resident 148 on June 4, 2023, as prescribed by the physician. 3. Resident 68 was administered Docusate Sodium (a stool softener) without being assessed for loose stools (as directed by the physician order). 4. There was no documentation of Resident 112's refusal of medication. 5. The facility did not ensure to maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) for Residents 55 and 18. 6. One of two treatment carts (a locked cart containing wound care supplies) was not clean and free from debris. These failures had the potential to adversely affect the health and safety of 159 highly susceptible residents residing the facility. Findings: 1. During a review of Resident 94's clinical record, the Admission Record (contains demographic and medical information), indicated Resident 94 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes (high sugar levels), history of infectious and parasitic disease (illness that is caused by an organism [living thing that can reproduce and adapt), resistance to multiple antibiotics, and immunodeficiency (body's decreased ability to fight infections or other diseases). During an observation, on June 6, 2023, at 11:38 AM, Resident 94 was lying in bed, sleeping. An IV (intravenously- administers fluids, medications and nutrients directly into a person's vein) pole, which was located at the right of his bed, had a IV medication bag hanging on it. It was labeled, RN (Registered Nurse) TO ACTIVATE/ MIX THEN INFUSE COLISTIMETHATE 150 MG IN NS [normal saline- sterile water] 100ML [milliliters- unit of measurement] IV- PIGGY BACK [shorter tubing that is attached to a longer tubing that administers fluids, medications, and nutrients directly into a vein] OVER 1 HOUR EVERY 12 HOURS FOR 7 DAYS. START 12 HOURS AFTER LOADING DOSE [large initial dose of medication]. The medication bag contained approximately 100 mL of fluid. There was an IV tubing attached to the IV medication bag with a label which indicated a start date of May 18, 2023, at 9:00 AM, (20 days ago) and a discard date of May 19, 2023 (19 days ago). During a concurrent observation and interview, with the Assistant Director of Nursing 1 (ADON 1), on June 6, 2023, at 11:44 AM, in Resident 94's room, the ADON 1 acknowledged the findings, and stated it looks like Resident 94's IV antibiotic medication was not administered. The ADON 1 further stated it should have been given. During a concurrent interview and record review, with the Registered Nurse 1 (RN 1), on June 7, 2023, at 7:45 AM, the RN 1 reviewed the picture of the Colistimethate antibiotic medication bag and the IV tubing label found at Resident 94's room and stated she was the one who labeled the IV tubing. The RN 1 stated it looked like the Colistimethate antibiotic medication was not administered to Resident 94 due to the bag appearing to have approximately 100 ML of fluid. During further interview and record review, with the RN 1, on June 7, 2023, at 7:48 AM, the RN 1 reviewed Resident 94's Medication Administration Review (MAR- record for what medication a resident has received) and stated Colistimethate was documented as administered to Resident 94 on May 18, 2023, at 9:00 AM and 21:00 PM [11:00 PM], and on May 19, 2023, at 9:00 AM. The RN 1 acknowledged the Colistimethate antibiotic medication should not have been documented as administered on all three dates. During a concurrent interview and record review, with the ADON 1, on June 9, 2023, at 7:44 AM, the ADON 1 reviewed the facility's policy and procedure (P&P) titled, Administering Medications, revised date of April 2019, which indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . The ADON 1 stated the P&P was not followed. 2. During a review of Resident 94's clinical record, the Admission Record indicated Resident 148 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes, peripheral vascular disease (narrowing or blockage of the blood vessels), and heart failure (heart does not pump enough blood the body needs). During a review of Resident 148's physician order, dated April 7, 2023, it indicated Resident 148 had an order for Glucophage Oral Tablet 500 mg [milligrams- unit of measurement]. Give 1 tablet by mouth two times a day for TYPE 2 DIABETES MELLITUS. Give with Breakfast and Dinner. During a review of Resident 148's physician order, dated April 6, 2023, indicated Resident 148 had an order for Insulin Regular Human Injection Solution 100 UNIT [unit of measurement] /ML (Insulin Regular (human)) Inject as per sliding scale [the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges]: if 151-200= 2 UNITS; 201-250= 4 UNITES; 251- 300= 6 UNITS; 301-350= 8 UNITS; 351-400= 10 UNITS; 401- 999= 12 UNITS; subcutaneously [beneath the skin] before meals and at bedtime for TYPE 2 DIABETES MELLITUS. During a concurrent interview and record review, with LVN 1, on June 9, 2023, at 7:29 AM, LVN 1 reviewed Resident 148's clinical record and stated she was unable to find documented evidence to indicate Resident 148 received Glucophage on June 4, 2023, at 6:45 AM, and Insulin Regular on June 4, 2023, at 6:30 AM. LVN 1 stated it looks like the medications were not administered. She further stated the consequences of the medication not being given could have affected Resident 148's blood sugar level. During a concurrent interview and record review, with the ADON 1, on June 9, 2023, at 7:43 AM, the ADON 1 reviewed the facility's P&P titled, Administering Medications, revised date of April 2019, which indicated, .4. Medications are administered in accordance with prescriber orders, including any required time frame .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) .21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . The ADON 1 stated the P&P was not followed. 47206 3. During a review of Resident 68's clinical records, the Admission Record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and chest pain. During a review of Residents 68's physician orders, dated May 20, 2020, it indicated an order for Docusate Sodium Capsule 100 mg Give 1 capsule by mouth one time a day for stool softener hold for loose stools. During a medication administration observation, on June 8, 2023, at 8 AM, with LVN 3, in Resident 68's room. LVN 3 was administered Docusate Sodium to Resident 68. LVN 3 did not assess Resident 68 for loose stool before administering the medication. During a concurrent interview on June 8, 2023, at 8:20 AM, with LVN 3, LVN 3 stated she should have asked if Resident 68 had loose stools prior to giving the stool softener. LVN 3 further stated she will follow the parameter of stool softener administration order from that point forward. During an interview with the ADON 1, on June 8, 2023, at 1:27 PM, the ADON 1 stated it was an expectation for licensed nurses to assess residents for loose stools prior to administering stool softener, to prevent the risk of dehydration which was very fatal to vulnerable residents at the nursing home. During a review of the facility's P&P titled, Policy Statement Administering Medications, dated April 2019, the P&P indicated, It is the policy that medications are administered in accordance with prescriber orders. 46917 4. During a review of Resident 112's clinical records, the Admission Record indicated Resident 112 was admitted to the facility on [DATE], with the diagnoses of muscle wasting and atrophy (thinning of muscle mass), chronic pulmonary edema (too much fluid in lungs), chronic obstructive pulmonary disease (damage to the airways of the lungs) and diabetes mellitus (disease elevated blood sugar levels). During a review of Resident 112's current Order Summary Report, it indicated Resident 112 had an order for Insulin lispro solution 100UNIT/ML [unit/milliliter-unit of measurement] inject as per sliding scale: if 151-200 = 1 unit; 201-250 = 2 units; 251-300 = 3units; 301-350 = 4units; 351-400 = 6 units; 401-450= 8units; NOTIFY MD [doctor] IF BLD [blood] SUGAR >400 [greater than] AND <70 [less than], subcutaneously [under skin] before meals and at bedtime for DIABETES MELLITUS. During an observation, on June 8, 2023, at 7:46 AM, with Licensed Psychiatric Technician (LPT 1), in Resident 112's room, LPT 1 checked Resident 112's blood sugar level (BS). The BS level obtained was 169. Resident 112 refused the insulin medication. During a concurrent interview and record review with the ADON 1, on June 9, 2023, at 11:43 AM, the ADON 1 reviewed Resident 112's clinical record and was unable to find documented evidence to indicate Resident 112 refused his insulin on June 8, 2023. The ADON 1 acknowledged the finding. During a concurrent interview and review, on June 9, 2023, at 11:45 AM, with the ADON 1, the ADON 1 reviewed the facility's P&P titled Requesting, Refusing and/or Discontinuing Care or Treatment dated February 2021, which indicated, . 8. Detailed information relating to the request, refusal, or discontinuation of treatment are documented in the resident's medical record . 9. Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following: . a. the date and time the care or treatment was attempted; . c. the resident's response and stated reason(s) for request, discontinuation, or refusal, . g. the date and time the practitioner was notified as well as the practitioner's response. The ADON 1 stated the policy was not followed for refusal. 43587 5.a. During a review of Resident 55's clinical records, the Admission Record, indicated Resident 55 was admitted on [DATE], with diagnoses which included hypertension (elevated blood pressure), neuralgia (nerve pain caused by inflammation, injury, or infection) and malaise (general feeling of discomfort). During a review of Resident 55's physician's order, dated February 22, 2018, it indicated, Morphine Sulfate ER (controlled medication used for pain) Tablet Extended Release 15 MG, give 1 Tablet by mouth every 12 hours for Pain Management . During a concurrent observation and interview with a LVN 2, on June 8, 2023, at 6:10 AM, LVN 2 inspected the bubble pack (a card that packages doses of medications within plastic bubbles organized by day and time of the day) containing Resident 55's Morphine Sulfate ER 15 MG tablets. The label on the bubble pack indicated it contained 60 quantities of one tablet upon receipt on May 27, 2023. The LVN 2 counted the contents of the bubble pack and stated there were 38 remaining tablets, and 22 tablets had been administered to Resident 55. A review of Resident 55's Controlled Drug Receipt/Record/Disposition Form (CDR - document used to record the administration or destruction of a controlled drug for tracking purposes) for Morphine Sulfate ER 15 MG tablet, indicated 21 tablets were administered to Resident 55 and accounted for on the record. (One tablet was unaccounted for). 5.b. During a review of Resident 18's clinical records, the Admission Record, indicated Resident 18 was admitted on [DATE], with diagnoses which included sepsis (a life-threatening complication of an infection), enterocolitis due to clostridium difficile (inflammation of the colon caused by C. Diff) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 18's physician's orders, dated May 17, 2023, indicated Resident 18 had an order to receive Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen - controlled medication used for pain) give 1 tablet by mouth every 6 hours for Moderate pain (4-6). During a concurrent observation and interview with LVN 2, on June 8, 2023, at 6:13 AM, LVN 2 inspected the bubble pack containing Resident 18's Norco tablets. The label on the bubble pack indicated it contained 60 quantities of one tablet upon receipt on May 29, 2023. LVN 2 counted the contents of the bubble pack and stated there were 39 remaining tablets, and 21 tablets had been administered to Resident 18. A review of Resident 18's CDR for Norco oral tablets 5-325 MG, indicated 19 tablets were administered to Resident 18 and accounted for on the record. (Two tablets were unaccounted for). During a follow up interview on June 8, 2023, at 6:15 AM, with LVN 2, LVN 2 stated the expectation was for the contents of the bubble pack to match its CDR to prevent drug diversion. During a concurrent interview and record review, on June 8, 2023, at 9:59 AM, with the ADON 1, the P&P titled, Controlled Substances, Revised November 2022, was reviewed. The P&P indicated, . Dispensing and Reconciling Controlled Substances . 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up . 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count . 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services or designee. The ADON 1 stated the policy was not followed. The ADON 1 further stated the expectation was for licensed nurses to reconcile controlled medications and inform him of any discrepancy because the potential for drug diversion. 47360 6. During a concurrent observation and interview on June 8, 2023, at 9:13 AM, with the Treatment Nurse (TN 1), at the 400 hallway, the TN 1 inspected the contents of the treatment cart M1-50 [name of the log on the treatment cart]. Inside the top drawer of the treatment cart, there were two plastic organizers that had crumbs. TN 1 acknowledged the finding and stated the treatment cart needed to be cleaned with the expectation that each container in the drawers be free from dirt and debris. During a review of the facility's P&P titled Storage of Medications, dated November 2020, it indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition, when: 1. Eight dish racks had cracks and chips. 2. One ice chest had a crack and hole in the bottom of the outer corner. These failures can lead to nests of pathogenic microorganisms, insects, and rodents, affecting 158 highly susceptible residents who receives food from the kitchen. Findings: During the tour of the kitchen, on June 6, 2023, at 8:57 AM, eight dish racks were observed to have cracks and chips. There was one ice chest, which had a crack and a hole, at the bottom of its outer corners. During an interview with the DSS 1, on June 7, 2023, at 11:29 AM, the DSS 1 acknowledged the findings and stated she expects the equipment to be kept in good working order without cracks and chips. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, .11. All utensil, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free form breaks, corrosions, open seam, cracks and chipped areas . During a review of the 2022 Food Code, U.S. (United States) Food and Drug Administration (FDA) (Food Code), dated 2022, the Food Code indicated, 4-201.11 Equipment and Utensils, Indicated, EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. Equipment and utensils must be designed and constructed to be durable and capable of retaining their original characteristics so that such items can continue to fulfill their intended purpose for the duration of their life expectancy and to maintain their easy cleanability. If they cannot maintain their original characteristics, they may become difficult to clean, allowing for the harborage of pathogenic microorganisms, insects, and rodents. Equipment and utensils must be designed and constructed so that parts do not break and end up in food as foreign objects or present injury hazards to consumers. A common example of presenting an injury hazard is the tendency for tines of poorly designed single service forks to break during use.

45388 Based on observation, interview, and record review, the facility failed to ensure the call systems were functional and accessible when: 1. The call systems for five out of ten resident showers (two in Shower room [ROOM NUMBER] [SR 3], two in Shower room [ROOM NUMBER] [SR 4], and one in Shower room [ROOM NUMBER] [SR 5]) were not accessible. 2. The call light indicator, above the door, did not turn on in room [ROOM NUMBER] (affecting Beds A, B, and C call lights). 3. For room [ROOM NUMBER] A, the call light cord (a cord connected to the wall and has a red button at the end to activate the corresponding call light in the hallway) was not functioning. 4. The call light indicator, above the door, did not turn on in room [ROOM NUMBER] (affecting Beds A, B, and C call lights). 5. The call light indicator, above the door, did not turn on in room [ROOM NUMBER] (affecting Bed B's call light). These failures had the potential to place 159 residents at risk of harm, as residents experiencing an emergency or needing assistance would not be able to call for help. Findings: 1. During a concurrent observation and interview, on June 7, 2023, at 11:28 AM, with the Regional Infection Prevention Nurse (RIPN) and the ADON 2, an inspection of the call lights at SR 4 was conducted. Two of the three call light cords (one measuring 21 inches [unit of measurement] long and 54 inches from the shower floor; the second one measuring 16 inches long and 60 inches from the shower floor) were not accessible to a resident lying on the floor. The ADON 2 stated a resident on the floor would not be able to reach the call light for the two showers. The ADON 2 further stated the expectation was that the call lights were accessible. During a concurrent observation and interview, on June 7, 2023, at 11:30 AM, with the ADON 2, an inspection of the call lights at SR 3 was conducted. Two of the three call light cords (one measuring 30 inches long and 43 inches from the shower floor; the second one measuring 24 inches long and 50 inches from the shower floor) in the shower were not accessible to a resident lying on the floor. The ADON 2 acknowledged the findings. During a concurrent observation and interview, on June 7, 2023, at 11:33 AM, with the ADON 2, an inspection of the call lights at SR 5 was conducted. One shower call light did not have a pull cord to activate the call system. The switch hub was located high above (47 inches from the floor) and not accessible to a resident lying on the floor). The ADON 2 acknowledged the findings. During a concurrent interview and record review, on June 7, 2023, at 12: 26 PM, with the RIPN and the ADON 2, a review of the facility's P&P, titled, Answering the Call Light, dated October 2010, indicated, .5. When the resident is in bed or confined to a chair to be sure the call light is within easy reach of the resident . and P&P titled, Bath, Shower, dated February 2018, indicated, .3. Use the emergency call signal for assistance, if needed . The RIPN and the ADON 2 stated the policy was not followed because the pull cords were too short and not within reach for the residents to use the emergency call signal for assistance. 2. During a concurrent observation and interview, June 7, 2023, at 9:05 AM, with Janitor 1 (J1), outside of room [ROOM NUMBER], the call lights for room [ROOM NUMBER] were inspected. room [ROOM NUMBER] A, 407 B, and 407 C's call lights were inoperable when pressed to activate, as no light indicator was visible over room [ROOM NUMBER]'s doorway to alert staff. J1 acknowledged the light did not turn on and stated the expectation is for the light to turn on if a resident presses the call light. During a concurrent observation and interview, on June 7, 2023, at 9:07 AM, with the Environmental Services Supervisor (ESS), outside of room [ROOM NUMBER], the ESS acknowledged there was no light indicator visible over room [ROOM NUMBER]'s doorway when the call light was pressed for 407 A, 407 B, and 407 C. The ESS stated it was important for the call lights to be working because that is one of the ways the residents communicate their needs with the staff. During a concurrent interview and record review, on June 7, 2023, at 10:06 AM, with the Assistant Director of Nursing (ADON 1), the ADON 1 stated the expectation of the call light were to be functional. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated October 2010, indicated, .7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the resident's call as soon as possible . The ADON 1 stated the policy was not followed. 43587 3. During an observation and interview with Resident 39, on June 7, 2023, at 8:09 AM, in Resident 39's room, Resident 39 was lying in bed, with the head of the bed elevated, eating breakfast. Resident 39 stated she needed a cup to pour her drink and pushed the red button at the end of the call light cord, to call for assistance. The call light indicator, above the door of room [ROOM NUMBER], did not turn on. During a concurrent observation and interview, on June 7, 2023, at 8:11 AM, with the Certified Nursing Assistant (CNA 4) in room [ROOM NUMBER], the CNA 4 inspected the call light for bed A, and it was inoperable. CNA 4 stated she was aware of the light not working for room [ROOM NUMBER]'s doorway but she did not notify the nurse supervisor. CNA 4 further stated the light on the doorway was expected to be on, when residents press the red button requesting assistance from the staff. During a concurrent observation and interview, on June 7, 2023, at 8:17 AM, with the Environmental Services Supervisor (ESS), outside of room [ROOM NUMBER], the ESS acknowledged there was no light indicator visible over room [ROOM NUMBER]'s doorway when the call light was pressed for 401 A. The ESS acknowledged the call light cord was not working and stated it was important for the call lights to be working properly because that is one of the ways the residents request assistance from the staff. The ESS further stated he was not aware of call light cord for room [ROOM NUMBER] A was not working. During a concurrent interview and record review, on June 7, 2023, at 10:19 AM, with the Assistant Director of Nursing (ADON 1), the ADON 1 reviewed the facility's P&P, titled, Answering the Call Light, dated October 2010, indicated, . 7. Report all defective call lights to the nurse supervisor promptly. The ADON 1 stated the policy was not followed and the call lights are expected to always work properly, for residents to request assistance. 46917 4. During an observation and interview on June 7, 2023, at 8:46 AM, with CNA 1, in room [ROOM NUMBER], the call lights for room [ROOM NUMBER] were inspected. room [ROOM NUMBER] A, 109 B, and 109 C's call lights were inoperable when pressed to activate, as no call light indicator was visible over room [ROOM NUMBER]'s doorway to alert staff of resident's needs. During an observation and interview on June 7, 2023, at 8:47AM, with Janitor 2, J2 verified that the call light indicator, outside room [ROOM NUMBER] did not turn on. The JS stated it should have been working. During an observation and interview on June 7, 2023, at 8:55AM with J2, J2 acknowledged the nursing station 1 panel indicated a call light on with no room number assigned to the light bulb. During interview and record review of facility document Maintenance Log Sheet and policy and procedure, Answering the Call Light, dated October 2010, with Assistant Director of Nursing 1 (ADON 1), the ADON 1 validated the maintenance log sheet had no descriptions of a non-functioning call light indicator for room [ROOM NUMBER]. ADON 1 verified that the policy was not followed for call light reporting. During record review of policy and procedure titled, Answering the Call Light, dated October 2010, the policy indicated .5. Report all defective call lights to the nurse supervisor promptly. 47360 5. During a concurrent observation and interview, on June 7, 2023, at 11:00 AM, with the Physical Therapist/Registered Nurse (PT/RN), outside of room [ROOM NUMBER], the call lights for room [ROOM NUMBER] were inspected. room [ROOM NUMBER] B's call lights was pressed to activate. There was no light indicator visible over room [ROOM NUMBER]'s doorway to alert the staff. PT/RN acknowledged that the light did not turn on, and stated the expectation was for the light to turn on if a resident presses the call light. During an interview on June 7, 2023, at 11:20 AM, with the Resident 24, Resident 24 stated, I do not know if they have ever come to my room after I pressed the call light. I have been here for two to three months and at first, I couldn't get out of bed, like I can now, but no one would come help when I needed help. During a review of the facility's policy and procedure titled Answering the Call Light: Level I, dated October 2010, the policy indicated, Report all defective call lights to the nurse supervisor promptly.

45388 Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment when: 1. There was water damage found in the ceiling in one of 57 resident rooms (Resident 26's room). 2. A report for a missing personal belonging was not addressed in accordance with the facility's policy for one of two residents (Resident 14) reviewed for personal belongings. These failures had the potential to negatively affect the mental and emotional well-being of Residents 26 and 14. Findings: 1. During a review of Resident 26's clinical records, the Admission Record (contains demographic and medical information), indicated Resident 26 was admitted on [DATE], with diagnoses which included pleural effusion (fluid between the layers of tissue that line the lungs and chest wall), chronic pulmonary edema (buildup of fluid in the lungs), and major depressive disorder (always feeling sad). During a concurrent observation and interview with Resident 26, on June 6, 2023, at 10:58 AM, in Resident 26's room, Resident 26 was lying in bed, watching television. The ceiling, above Resident 26's foot of the bed, had brown discoloration spots. Resident 26 stated the ceiling had been having some leaking issues for some time and the facility fixed it, but it happened again, and had been like that for a few weeks. Resident 26 stated, When it rains, the staff put down buckets and that is when it bothers me. During a concurrent observation and interview with the Environmental Service Supervisor (ESS), on June 6, 2023, at 11:04 AM, in Resident 26's room, the ESS acknowledged the ceiling had water damage. The ESS stated there have been some issues with leaking when it rains. The ESS further stated the ceiling was not supposed to be that way. During a concurrent interview and record review with the Assistant Director of Nursing 1 (ADON 1), on June 7, 2023, at 3:21 PM, the ADON 1 reviewed the facility's policy and procedure (P&P) titled, Homelike Environment, revised February 2021, which indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .4. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and homelike environment . The ADON 1 stated the policy was not followed because the ceiling's water damage was not safe due to the risk of more leaking and mold growth that could affect the resident's health. 47360 2. During a review of Resident 14's clinical records, the Admission Record indicated Resident 14 was admitted to the facility on [DATE], with diagnoses that included paraplegia (paralysis of legs and lower body), discitis (infection in the backbone) and left below the knee amputation (removal of left foot and ankle, below the knee). During a review of Resident 14's Personal Property Inventory Update, dated May 3, 2021, it indicated one black wheelchair, and one black back pad support was listed in Resident 14's personal belongings. During a concurrent observation and interview, on June 6, 2023, at 8:56 AM, with Resident 14, in her room, Resident 14 was lying in bed, waiting for her breakfast. Resident 14 stated, I have been eating in my bed for the past few months because the facility wheelchair hurts my back. Resident 14 further stated My personal wheelchair was gone after I returned from a hospitalization about three to four months ago. Resident 14 further stated I spoke with the CNAs (Certified Nurse Assistants), the nurses, and the therapists and they said they all looked for it, but they couldn't find it. During an interview, on June 8, 2023, at 9:13 AM, with Certified Nurse Assistant 5 (CNA 5), CNA 5 stated she does remember Resident 14 having her own wheelchair from home. CNA 5 further stated, Resident 14 always had it folded up next to her bed and it hasn't been seen in a few months. During an interview, on June 8, 2023, at 9:49 AM, with the Social Worker (SW 1), the SW 1 stated when a resident is placed on bed-hold (an empty bed the facility holds for an admitted resident when they leave the facility for a short period), it was the responsibility of the Social Services Department to go to the resident's room and collect all their belongings. The SW 1 further stated the belongings are stored and labeled. The SW 1 further stated, the resident's belongings are taken to a locked storage room, and once the resident returns, their belongings are given back. The SW 1 further stated, Resident 14's wheelchair and back pad were unfortunately misplaced. During a follow up interview and record review, with SW 1, on June 9, 2023, at 11:07 AM, the facility's P&P titled, [NAME] Canyon Post-Acute Theft & Loss policy Program, dated December 2013 was reviewed. The P&P indicated, the facility's process for the reporting of theft or loss of Residents' personal belongings. SW 1 stated the facility's P&P was not followed. She further stated the staff did not communicate to management or social workers that Resident 14's wheelchair and back pad were missing and lost. During a review of the facility's policy and procedure titled, Theft & Loss policy Program, dated December 2013, it indicated When a resident or anyone on behalf of a resident reports to a staff member that they are unable to locate personal belonging of a resident, staff, will conduct a prompt search . The staff member who discovers or is told by a Resident or anyone acting on behalf of a Resident that the Resident's property is missing shall report it to this Center's Administrator or his/her designee .

Based on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 89) reviewed for restraints (device used to prevent someone from doing something). This failure had the potential to cause inaccuracy in identifying Resident 89's care and support needs. Findings: During a review of Resident 89's clinical record, the Admission Record (contains demographic and clinical data) indicated Resident 89 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) and hypertension (blood pressure that is higher than normal). During a review of Resident 89's MDS Quarterly Assessment (an assessment for a resident that must be completed every 92 days following the previous assessment), dated April 19, 2023, under Section P titled Restrains and Alarm, it indicated Resident 89 had a trunk restraint (vest or waist restraints or belts used in a wheelchair cannot easily remove that either restricts freedom of movement or access to his or her body), which was being used when Resident 89 was in the chair or out of bed. During an observation, on June 6, 2023 at 10:41 AM, in Resident 89's room, Resident 89 was lying in bed. An inspection of his room was conducted, and there was no indication of any kind of restraint in his room. During a concurrent interview and record review, with the Minimum Data Set Nurse (MDS Nurse), on June 7, 2023, at 9:21 AM, the MDS Nurse reviewed Resident 89's clinical record and was not able to find any documentation that Resident 89 used any type of restraint. During further interview and record review on June 7, 2023, at 9:45 AM, with the MDS Nurse, the MDS Nurse reviewed Resident 89's Quarterly MDS assessment, dated April 19, 2023, and stated, It [Section P] was coded in error because Resident 89 did not have a restraint. During a concurrent interview and record review, on June 9, 2023, at 2:00 PM with MDS Nurse, the MDS Nurse reviewed the facility's policy and procedure titled, Certifying Accuracy of the Resident Assessment, revised November 2019, which indicated Policy statement .must sign and certify the accuracy of that portion assessment . The MDS Nurse stated the facility did not follow the policy. A review of the CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment), revised October 2019, indicated . P0100: Physical Restraints (cont.) Steps for Assessment 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period.

Based on observation, interview, and record review, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) when one (one) of three (3) sampled residents (Resident A) sustained fractures (broken bones) to both femurs (thigh bone, the longest and strongest bone within the human body). This failure had the potential for possible abuse to go uninvestigated and unreported. Findings: An unannounced visit was made to the facility on (MONTH) 30, (YEAR), to investigate a complaint of possible physical abuse for Resident A who sustained fractures to both legs. A review of Resident A's face sheet (contains demographic information and diagnoses) indicated that Resident A was admitted to the facility on (MONTH) 9, 2012, with [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. During a tour of the facility on (MONTH) 30, (YEAR) at 8:30 AM, it was observed that Resident A was not located in her room. A review of the facility census (a list of residents) indicated she was on a bed hold (a hold placed on the space while the resident is out to a hospital.) During an interview with a Certified Nursing Assistant (CNA 1) on (MONTH) 30, (YEAR), at 9:40 AM, she stated that she has taken care of Resident A since she was admitted to the facility. CNA 1 stated that she came back from her days off (January 25th and 26th) and was providing morning care to Resident A. CNA 1 stated, I pulled back Resident A's blanket and I noticed that her right leg was moving more than usual, I went to get the Charge Nurse / Licensed Vocational Nurse CN/LVN) to have her see the Resident. CNA 1 further stated, This was not right, Resident A was unable to move and her legs were stiff, she was paralyzed and had contractures. CNA 1 stated that she was able to transfer Resident 1 from the bed to the wheel chair without assistance, but that when she went to put her back in bed, she would always ask for assistance. CNA 1 confirmed that Resident A was a two person, manual assist. During an interview with the CN/LVN 1 on (MONTH) 30, (YEAR), at 10:10 AM, LVN 1 stated, on (MONTH) 27, (YEAR) at About 9:00 AM, CNA 1 came and told me there was something wrong with Resident A's leg, that it was moving more than it usually did. We both (CN/LVN 1 and CNA 1) went into the room and I saw that both of her legs looked wrong and both knees were pointing outward. LVN 1 further stated that she had never seen Resident A move her legs independently, that she was paralyzed on the right side of her body and that her limbs were contracted. LVN 1 contacted the Medical Doctor (MD), who gave an order for [REDACTED]. LVN 1 stated that she was not aware that Resident A had [MEDICAL CONDITION], she further stated that she was not sure how this happened but that, it seems that it could have been during a transfer. During a clinical record review for Resident A, a Change of Condition (C[NAME] - a report completed when there is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional areas that without intervention, may result in complications or death) dated (MONTH) 27, (YEAR), at 9:45 AM, was conducted. The document lists the C[NAME] was done due to changes in Resident A's bilateral lower extremities. It did not specify what the changes were. During a review of Resident A's nursing progress notes, dated (MONTH) 27, (YEAR), at 3:28 PM, indicated, Reported to me by CNA 1, that routinely cares for this patient (Resident A), that her bilateral lower extremities are unusually stiff and contracted and are now more flexible which is not normal for this resident. Informed Dr. (name of physician) of findings and he gave orders for [MEDICATION NAME] (a muscle relaxant) and bilateral (both sides of the body) x-rays to extremities ordered. X -ray done in house and x-ray tech (technician) noted what appeared to be a fracture in right lower extremity (radiology reports shows fracture to the right and left distal femur). Informed Dr. and he gave orders to send out to hospital for further evaluation, called ambulance for transport. Called X-ray Company to inquire about any previous x-rays for any contributing factors, report is in process of being read. A nursing progress note dated (MONTH) 28, (YEAR), at 8:11 AM, indicated Resident A was not observed with any active bruising to either leg. During a review of Resident A's progress notes and assessments, there was no documentation located that indicated that Resident A had any issues with transfers in the weeks prior to fractures. During a review of Resident A's Radiology Report, dated (MONTH) 27, (YEAR) at 11:10 PM, for x-ray results for the right and left knee, indicates No acute fracture or dislocation (of knee). The osseous (bone) structures appear intact. Joint space are narrowed. Soft tissue is unremarkable. Conclusion: No acute osseous abnormality. [MEDICAL CONDITION] changes. Limited single view. Consider full exam if clinically stable. [MEDICAL CONDITION] (lower third) femoral shaft partially visualized, recommend femur exam. A hand written, undated note on the Radiology Report by the facility physician indicated distal femur fracture most likely pathological FX (fracture), frail and bed ridden status. During a concurrent interview and record review with the Director of Nurses (DON) on (MONTH) 30, (YEAR), at 11:25 AM, she stated she had called the doctor and he stated that this was to be expected, that it was Resident A's diagnosis. The DON could not locate any documentation that confirmed a physician [DIAGNOSES REDACTED]. The DON indicated in the IDT note, she interviewed all CNA's who took care of Resident A. That both CNA's and nursing students (not employees of the facility) provided Resident A with baths and transfers in the days prior to the fracture. The DON stated the CNA's did not report anything unusual, and Resident A had no swelling, redness or open areas on her upper limbs. The DON further stated, after the fractures she watched all staff and there was no issues with how they transferred residents. The DON stated, with this type of diagnosis, [MEDICAL CONDITION] (the bones become brittle and fragile, typically a result of deficiency of calcium or Vitamin D) from loss of tissue, a person's legs can just break. The DON confirmed that Resident A was a two person manual transfer. A concurrent interview and record review of Resident A's Care Plans (CP - identifies a problem or diagnosis, with a goal and interventions) was conducted with the DON on (MONTH) 30, (YEAR), at 4:30 PM. A care plan entitled At risk for pathological fractures and further decline due to the DX (diagnosis) of [MEDICAL CONDITION] and DJD ([MEDICAL CONDITION] joint disease), indicated it was created on (MONTH) 2, (YEAR). The CP included only the problem and a goal; however, there were no interventions documented until (MONTH) 29, (YEAR), (two days after the fractures occurred). The CP was updated on (MONTH) 27, (YEAR) to include Actual pathological fractures of femur. The DON confirmed that there was no documented evidence to show that interventions were in place to prevent fractures in Resident A, prior to (MONTH) 29, (YEAR). A concurrent record review of the facility policy and procedure entitled, Abuse Investigation and Reporting dated Revised (MONTH) (YEAR),and interview was conducted with the DON on (MONTH) 30, (YEAR) at 11:40 AM. The policy indicated, All reports of resident abuse, neglect, exploitation, misappropriation of residents' property, mistreatment and /or injuries of unknown source (abuse) shall be promptly reported to the local state and federal agencies (as defined by current regulations). Under the section titled, Reporting .2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident's property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury . The DON stated that the facility did not report the fractures to the California of Department of Public Health, because Resident A had a [DIAGNOSES REDACTED]. The DON further confirmed that the resident was unable to move independently and that she was paralyzed on one side of her body and she had contractures in her limbs, and that is was unusual for a totally dependent, immobile resident to sustain two pathological fractures to the femur. A review of the Minimum Data Set (MDS, a mandated clinical comprehensive assessment of residents to include each resident's functional capabilities) was conducted. A quarterly assessment date of (MONTH) 11, (YEAR), shows in Section G (describes a resident's functional status), that Resident A needed extensive assistance and required a two plus persons assist for bed mobility and transfers between surfaces. In Section I - Active [DIAGNOSES REDACTED]. In subsection [MEDICAL CONDITION]: was answered No. A review of previous MDS annuals and quarterly assessments from (MONTH) 5, 2014, through (MONTH) 11, (YEAR), did not document Resident A had a [DIAGNOSES REDACTED]. During a review of Resident A's physician's orders, there was no indication that the resident received any medications related to a [DIAGNOSES REDACTED]. During a phone interview with Resident A's physician on (MONTH) 30, (YEAR), at 2:45 PM, he stated, That he felt that the fractures were pathological related to the resident's [DIAGNOSES REDACTED]. He stated that she once had an issue with calcium (a mineral, which is stored in the bones and teeth where it supports structure and function) so he stopped treatment, but as soon as she returns to the facility he will start Resident A on [MEDICATION NAME] (a calcium supplement) and vitamin D 3 (a vitamin supplement that helps the body absorb calcium.) The facility physician stated that Resident A was immobile and unable to move her lower body. He stated that the fractures could have occurred during changing, transfer or repositioning. During a phone interview with CNA 2 on (MONTH) 31, (YEAR), at 10:00 AM, CNA 2 stated that she was assigned to Resident A, on (MONTH) 25, (YEAR), and (MONTH) 27, (YEAR), on the night shift. CNA 2 stated that she had changed her and repositioned Resident A and she did not notice anything unusual with Resident A when she took care of her. CNA 2, stated that on the night shift she had never transferred the Resident out of bed, CNA 2 was unaware that Resident A had [MEDICAL CONDITION]. During a phone interview with LVN 4 on (MONTH) 31, (YEAR), at 10:30 AM, LVN 4 stated she was assigned to Resident A, on (MONTH) 25, (YEAR), on the PM shift. LVN 4 stated Resident A was a total care assist, who was unable to move and was contracted. LVN 4 stated that he was not told of issues with Resident A while she was on shift. LVN 4, stated that she did not know how it (the fractures to both femurs) happened, but stated that, It may have been when she was moved. During a phone interview with CNA 3 on (MONTH) 1, (YEAR), at 11:39 AM, CNA 3 stated she was assigned to Resident A, on (MONTH) 26, (YEAR) on the night shift. CNA 3 assisted with evening care for Resident A, but she did not get Resident A out of bed. She stated she heard something happened to Resident A after she came back from her days off. A review was conducted of the general acute care hospital (GACH) Emergency Documentation - MD note dated (MONTH) 27, (YEAR), at 6:38 PM, written by the attending physician. The note indicated the right leg was internally rotated and shortened, pressure ulcer to right foot, positive for crepitus (a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone) over the right and left femur, no obvious bruising or deformity. The radiology section of the note indicates, Interpretation: Distal femur FX (fracture) with displacement, and angular spiral FX. An additional note indicated Patient has bilateral femur fractures spiral in nature. This is consistent with abuse. Patient will need to be admitted to the hospital, consulate by Ortho (orthopedics- a physician specializing in diseases and injuries of the bones) and Adult Protective Service (APS) report to be filed against (Name of Facility). A review of the General Radiology (x-ray) report from the general acute care hospital (GACH) dated (MONTH) 27, (YEAR), at 5:24 PM, of the hip and pelvis, indicated, The view of the bony pelvis demonstrates diffuse [MEDICAL CONDITION] of the pelvis. A review of the General Radiology report from the GACH dated (MONTH) 27, (YEAR), at 6:02 PM of the right femur indicates, Views of the right femur demonstrate an oblique [MEDICAL CONDITION] third (3) of the femur. There is demonstration of lateral displacement of the shaft of the femur measuring 1.6 cm (centimeters). There is also demonstration of approximate 4.6 cm override of the fracture fragments demonstrated. Impression: [MEDICAL CONDITION] third of the right femur with displacement and overriding the fracture fragments. The radiology report did not demonstrate any [MEDICAL CONDITION] in the femur. A review of the General Radiology report from the GACH dated (MONTH) 27, (YEAR), at 7:05 PM of the left femur indicates, Views of the left femur demonstrate a [MEDICAL CONDITION] third (3) of the left femur. There is demonstration of approximate 10 cm override of the fracture fragments noted. There is also demonstration of lateral displacement of the shaft of the femur measuring 2.5 cm. In addition there are multiple fractures lines seen extending to the distal shaft of the femur as well. Impression: [MEDICAL CONDITION] third of the left femur with displacement and overriding the fracture fragments. The radiology reports of the left and right femur did not demonstrate any [MEDICAL CONDITION] in the femurs as it had in the x ray of the hip/pelvis. A review of the Orthopedic Consultation report from the GACH dated (MONTH) 27, (YEAR), at 8:12 PM indicated, on examination She (Resident A) has deformity of bilateral thighs. She has crepitus when she attempts to move her legs. Her skin on her legs is intact. The assessment portion of the document indicates, bilateral femoral shaft fractures in a patient (Resident A), who is post [MEDICAL CONDITION] (stroke), who is bedbound, nonverbal, cannot eat and is on percutaneous endoscopic gastronomy feedings (a tube in placed into the stomach in which nutrients and medication is given). The recommendation/treatment for [REDACTED]. She will not survive this if we do not operate on her. I will talk to the family tomorrow when they come in and if they want me to fix her I will. Her chance of dying with surgery is less than if we do not do surgery. If we do not do surgery of the bilateral femoral shaft fractures she will not survive. During a phone interview with the GACH Orthopedic Consultant ([NAME]) physician on (MONTH) 1, (YEAR), at 1:00 PM, the [NAME] physician stated, I can't say for sure how the patient's fractures may have occurred, but I know someone must have known when they happened, there would have been a very loud snap, in fact two. These are acute severe fractures. When I first saw her, when I touched her leg she expressed pain, her legs were deformed, were crepitus, someone must have noticed she was in pain and the legs were deformed. The [NAME] physician stated that it would have taken a lot of force to get spiral fractures (a fracture that encircles the shaft of the bone that is caused by a twisting force to the thigh). He further stated there would have been a very loud sound and feel, so whoever did this would have known it. You can get the x-rays and records if you would like a second opinion. I am very comfortable in saying that when this happened someone had to have known what they did. It is inconceivable that no one knows how or when it happened. During an interview with LVN 5 on (MONTH) 5, (YEAR), at 8:00 AM, LVN 5 stated that she had taken care of Resident A on (MONTH) 26, (YEAR) on the night shift. LVN 5 stated when she returned after her days off, she had heard Resident A had fractures of her legs. LVN 5 stated that she was not sure how it happened but maybe during transfer. During an interview with CNA 4 on (MONTH) 5, (YEAR), at 10:00 AM, CNA 4 stated he was assigned Resident A on (MONTH) 25, (YEAR), on the night shift. Resident A was a total assist and she could not move. CNA 4 stated that one person could get her out of bed, but that to put her back you needed two, he stated on the night shift he had not gotten Resident A out of bed. CNA 4 stated I don't know what happened.' During an interview with CNA 5 on (MONTH) 5, (YEAR), at 10:30 AM, CNA 5 stated he was assigned to Resident A on (MONTH) 26, (YEAR), on the PM shift. Resident A was a total assist. CNA 5 stated that when he got her out of bed that he could transfer her by himself, but that when she was transferred back to the bed that he always got help to transfer her. CNA 5 stated that Resident A was unable to move and had contractures, he did not notice anything unusual when I took care of her. An interview with LVN 3 was conducted on (MONTH) 5, (YEAR), at 10:50 AM. LVN 3 was assigned to Resident A on (MONTH) 25 and 26th, (YEAR). LVN 3 stated Resident A, is a two person assist, that she would get up and sit in the wheel chair. LVN 3 stated she was surprised when she heard that Resident A had two broken legs after she returned to work after her days off. I think I would look at her transfers. An interview was conducted with the DON with the Administrator (ADM) and Administrator in Training (AIT) on (MONTH) 5, (YEAR), at 12:00 PM. The DON stated, I went by what the physician said, the fractures were due to Resident A's [DIAGNOSES REDACTED]. She confirmed she had not seen a Resident with two pathological fractures of the legs prior to this incident. The DON confirmed that the facility failed to report the injuries to the California Department of Public Health. During a follow-up phone interview with Resident A's physician on (MONTH) 5, (YEAR), at 12:45 PM, the findings from the general acute care hospital related to Resident A sustaining two spiral fractures to both femurs was discussed. The physician stated, No one told me that she had a fall or an accident, he further stated that with this information he might look at the fractures differently. During a phone interview with Registered Nurse (RN 1) on (MONTH) 13, (YEAR), at 8:00 PM, RN 1 stated she has taken care of Resident A for a long time. Resident A was able to respond to her with nodding her head. RN 1 further stated, When she returned to work she had heard that the resident had two fractures, and the DON had discussed this with her. RN 1 stated that she had told the DON that the only way this type of fracture could have occurred given the area of the fracture was during a transfer with a Hoyer Lift (a device that allows a person to be lifted and transferred with a minimum of physical effort in a sling), the area of the fracture is the same place that the sling would be on the residents. During a follow-up phone interview with Resident A's physician on (MONTH) 22, (YEAR), at 12:15 PM regarding the radiology reports from the facility and the GACH. The physician stated that he did not remember seeing any radiology reports specific to [MEDICAL CONDITION] in the femurs, but that sometimes the reports will indicate the presence of it and at other times they do not. The physician stated That after learning what type of fractures that his resident sustained [REDACTED]. A review of the Discharge Summary from the Resident A's hospital stay dated (MONTH) 30, (YEAR), indicated The patient was admitted with [DIAGNOSES REDACTED]. Surgical evaluation by (physician name), the orthopedist, was done who felt that the patient has a terminal prognosis and requires extensive surgery which she may not withstand and after discussion with the patient's family, it was decided to pursue palliative (care is focused on providing relief from the symptoms and stress of a serious illness) and comfort care. The family agreed to hospice care and no surgical intervention.

Based on observation, interview, and record review, the facility failed to ensure resident food was stored, prepared, distributed and served under sanitary conditions when: 1. Roast beef and the beef juices taken from the refrigerator were found to have temperatures in the Danger Zone (the Danger Zone refers to temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms in foods that are cooked and cooled the day before and can cause foodborne illness). 2. The cupboards in the kitchen had brown, greasy stains, and contained wood shavings inside them and had rough surfaces and edges. 3. A blender cup was found stored and put away wet and dirty with food residual. 4. Twelve, eight ounce cans of Glucerna and Ensure were found stored under the sink near the water pipes. 5. The serving carts containing the resident's dining trays and silverware were found to be left in the hallway near the dining room uncovered and unattended. 6. The dishwashing staff did not know how to properly sanitize the tray cards. These failures had the potential to result in food borne illness in a highly susceptible population (persons who are more likely than other people in the general population to experience food borne illness because they are immunocompromised) of 154 residents. An Immediate Jeopardy situation was declared on March 15, 2016 at 1:51 PM, in the presence of the Administrator, Registered Dietician (RD), and Dietary Service Supervisor (DSS), the Director of Nursing (DON), and the Director of Staff Development (DSD) due to the facility's failure to ensure potentially hazardous foods (PHF) were cooled according to the cooling procedure. PHF held in the Danger Zone for more than six hours if cooked and cooled, may cause a foodborne illness outbreak if consumed. Findings: 1. During a tour of the kitchen on March 15, 2016 at 9:00 AM, Cook 1 was observed with a cart containing a large tray with seven cooked roasts resting on it. There was also a large stock pot. The stock pot was twelve inches in diameter and contained ten inches of beef juices from the cooked roasts. All of these items were removed from the refrigerator by Cook 1. During a concurrent interview with Cook 1, she stated the roasts had been cooked yesterday and were to be served today for lunch. The survey team checked the temperature of the roasts and identified the roasts had internal temperatures of 41.9 degrees F, 43.5 degrees F, 44.8 degrees F, 41.9 degrees F, 43.9 degrees F, 43.7 degrees F and 43.7 degrees F. The beef juices in the stock pot had a temperature of 54 degrees F. During a concurrent interview and record review on March 15, 2016 at 9:15 AM with the DSS, she stated, I checked the temperature of the roasts two hours after cooking and six hours after cooking. A record review of the facility's cooling log titled, Chill Control Log, dated March 14, 2016, showed a starting temperature of the roast at 156 degrees F. Two hours later the temperature was recorded at 70 degrees F and six hours later it was recorded at 40 degrees F. The DSS was unable to state why the temperatures of the roasts were higher than 40 degrees F. There was not a recording for the beef juices. The DSS stated, I did not check the temperature of the beef juices. We never check the temperature of the juices. During an interview on March 15, 2016 at 10:24 AM with the Registered Dietician (RD), she stated, I check the cooling logs at least every month and sometimes weekly. I do not check the temperature on items in the refrigerator, I only check the cooling logs. She stated, I also check the monthly inservices (education and training) that the dietary staff attends. Regarding the high temperatures of the roasts and beef juices, she said, I will speak to the DSS. The undated facility policy and procedure titled, Cooling Procedures showed, If the temperature after two hours of cooling is not 70 degrees F or less, return food to the heat and reheat to 165 degrees F for meat and hold for 15 seconds. If the food does not reach 70 degrees F or less again within 2 hours, discard the food item. After 70 degrees F or less in 2 hours, record the temperature in the log book and continue cooling for four more hours to reach 40 degrees F or less and record this final temperature in the log book. According to the 2013 Food and Drug Administration Food Code, Cooked time/temperature for safety food shall be cooled: within two hours from 135 degrees F to 70 degrees F and within a total of six hours from 135 degrees F to 41 degrees F or less. An Immediate Jeopardy situation was declared on March 15, 2016 at 1:51 PM, in the presence of the Administrator, Registered Dietician (RD), and Dietary Service Supervisor (DSS), the Director of Nursing (DON), and the Director of Staff Development (DSD) due to the facility's failure to ensure potentially hazardous foods (PHF) were cooled according to the cooling procedure. PHF held in the Danger Zone for more than six hours if cooked and cooled, may cause a foodborne illness outbreak if consumed. On March 16, 2016 at 1:01 PM, the Immediate Jeopardy was removed in the presence of the Administrator, the RD, the DSS, the DON, and the DSD when the facility's Corrective Action Plan was approved and the survey team confirmed implementation of the Corrective Action Plan, which included the following components: 1. Registered Dietician will re-educate all dietary staff on the cooling procedure policy and logs as enclosed. Dietary Staff will continuously receive follow up education regarding cooked and cool process on a weekly basis for 4 weeks then quarterly thereafter. 2. Revised cool down log for potentially hazardous foods will be implemented immediately. 3. Dietary Supervisor and/or Registered Dietician will monitor actual process of the cool down on a daily basis for 30 days to make sure that the deficient practice will not reoccur. The focus will be on all foods that are cooked and cooled. 4. Registered Dietician will randomly take the temperature of all cooked and cooled potentially hazardous foods on a weekly basis as part of the Quality Assurance process. 2. During an observation on March 14, 2016 at 8:30 AM, in the facility kitchen, the lower cupboards near the doorway had a dark, greasy residue. Also the lower cupboards near the sink contained wood shavings inside. The surface and edges were rough to the touch. During a concurrent interview with the DSS, she stated, The cupboards have wood shavings inside them. According to the 2013 Food and Drug Administration Food Code, Food shall be protected from contamination by storing the Food: In a clean dry location; where it is not exposed to splash dust, or other contamination. Mulituse food - contact surfaces shall be: (1) smooth. (2) Free of breaks, open seams, cracks, chips inclusions, pits and similar imperfections. 3. During an observation in the kitchen on March 14, 2016 at 8:40 AM, a blender cup was found stored wet with water and white food residue inside. The blender was covered in plastic and sitting on the counter. During a concurrent interview with the DSS, she stated, If it is covered in plastic, it is clean and ready to use. The blender is wet, dirty and should not be stored that way. A review of the undated facility policy and procedure titled, Cleaning, under Mixer/Blender showed, Removable parts are rinsed and washed in the dishwasher. Non-removable parts are damp wiped with a cleaning solution and rinsed with water. Allow to air dry. According to the 2013 Food and Drug Administration Food Code, Equipment and utensils shall be air-dried or used after adequate draining. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking or storing of wet items such as pans prevents them from drying and may allow an environment where microorganisms can grow. 4. During an observation in the kitchen on March 14, 2016 at 9:10 AM, twelve, eight ounce cans of Glucerna and Ensure were found stored under a sink near water pipes. During a concurrent interview with the DSS, she stated, I did not know it was there and I will ask about it. I do not know if it should be stored under the sink. According to the 2013 Food and Drug Administration Food Code, Food may not be stored: Under sewer lines that are not shielded to prevent potential drips; Under leaking water lines including leaking automatic fire sprinkler heads, or under lines on which water has condensed. 5. During a tray line observation on March 15, 2016 at 6:20 AM, the serving carts containing the resident's dining trays and silverware were found to be left in the hallway near the dining room. The carts were left uncovered and unattended until 6:45 AM when the breakfast meal was served. The hallway is an open area accessible to staff, residents and guests. During a concurrent interview with the DSS, she stated, We always have the trays in the hallway. We come right out to serve so yes, they are just there. We serve out on the floor (in the open hallway near the dining room). According to the 2013 Food and Drug Administration Food Code, Sanitized utensils shall be handled, displayed and dispensed so that contamination of food and lip-contact surfaces is prevented. 6. During an observation on March 15, 2016 with Dishwasher 1, at approximately 9:25 AM, she was unable to demonstrate how to properly sanitize the tray cards. Dishwasher 1 placed the tray cards in a bucket, added some quaternary sanitizer and then added warm water. The water and solution in the bucket did not completely cover the tray cards. She swished the cards around for ten seconds and then dumped out the solution and rinsed the cards with water on a rack. During a concurrent interview with Dishwasher 1, she stated, I do it this way because the plastic coating peels off of the tray cards when they are placed in the dishwasher. During a concurrent interview with the DSS, she stated, It is my understanding that the tray cards are being sanitized in the dishwasher every day.

Based on observation, interview, and record review, the facility failed to ensure stored refrigerated medications and vaccines were within a temperature range of 36 degrees Fahrenheit to 46 degrees Fahrenheit. This failure had the potential to allow for the administration of refrigerated medications and vaccines that had lost their potency and had the potential to adversely affect the health and safety for one of 24 sampled residents (Resident 22) and 11 of 18 unsampled residents (Residents F, G, H, I, J, L, M, N, O, P, Q). In the presence of the Administrator, Director of Nursing, Case Manager, Director of Medical Records, Director of Staff Development, and Minimum Data Set Nurse an Immediate Jeopardy was called on March 16, 2016 at 5:07 PM. Findings: During the medication storage inspection conducted on March 16, 2016 at 10:30 AM, the temperature of the medication refrigerator located on Nursing Station 2 was observed to be at 28 degrees Fahrenheit (F). The temperature was confirmed by LVN 1 and the refrigerator log was requested. During a review of the refrigerator log for Nursing Station 2, on March 16, 2016 at 10:30 AM, the log showed the temperature was out of range (36 degrees F to 46 degrees F) as follows: a. March 1, 2016, 34 degrees F. b. March 3, 2016, 34 degrees F. c. March 13, 2016, 34 degrees F. The last temperature documented on the refrigerator log was on March 15, 2016, which showed 38 degrees F. On March 16, 2016 at 10:45 AM, a request was made for the Licensed Vocational Nurse (LVN 1) to open the medication refrigerator and a calibrated thermometer was placed inside the refrigerator. At 10:57 AM the temperature of the refrigerator was rechecked with LVN 1 and the refrigerator thermometer temperature was observed to be 24 degrees F. The temperature on the calibrated thermometer was observed to be 24.8 degrees F. LVN 1 confirmed the temperatures observed on the thermometers. The medications, vaccines and TPN (Total Parenteral Nutrition, feeding a person intravenously) stored within the refrigerator were not maintained within the required 36 to 46 degrees F. The following medications and vaccinations were observed to be stored inside the medication refrigerator: a. Hep B Vaccine (vaccine used to prevent the Hepatitis B Virus, which can cause a serious disease that attacks the liver). b. Tetnus Toxoid DPT (a vaccine that is used to prevent contagious and potentially fatal diseases which include: [DIAGNOSES REDACTED]-a disease that affects the nose, throat and air passages which hinders breathing, pertussis -[DIAGNOSES REDACTED], spasms of uncontrollable coughing, and tetanus -a disease which causes profound and painful spasms of muscles, including locking of the jaw, and death). c. Lantus (a medication to treat diabetes {high blood sugar}). d. Aplisol (used as an aid to [DIAGNOSES REDACTED].}). e. Influenza vaccine (a flu vaccine). f. Infuvite (vitamins used for infusion to prevent vitamin deficiency). g. Vancomycin (an antibiotic medication). h. Clindamycin (an antibiotic medication), i. Amikacin (an antibiotic medication). j. Meropenem (an antibiotic medication). k. Zosyn (an antibiotic medication). l. Metronidazole (an antibiotic medication). m. Fluconazole (used to treat fungal infection). n. Cefazolin (an antibiotic medication). o. Humalog (medication used to treat diabetes). p. Humulin (medication used to treat diabetes). q. One E- kit (emergency kit) which contained: Lorazepam (medication to treat seizures and can relieve anxiety). Humulin N (a short-acting insulin used to treat diabetes). Humulin R, (a insulin that is slower to act and lasts longer to lower blood sugar). r. TPN. During an interview with the Director of Nursing (DON) on March 16, 2016 at 11:00 AM, the DON stated, The refrigerator should be 36 to 46 degrees inside. While interviewing the DON and the Maintenance Supervisor (MS) at 11:25 AM, on March 16, 2016, LVN 2 entered the DON's office and stated, I just checked the fridge temp (temperature) at 11:17 AM and the temp was 28 degrees F, I moved the knob to adjust the temp, it was set on snowflake setting. A review of the clinical record for Resident 22 indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 14, 2016, indicated Resident 22 was taking Amikacin (antibiotic used to treat infection) 300 milligram (mg, unit of measure), every 8 hours via an intravenous (IV, into the blood stream) for 10 days. The Amikacin medication was observed stored in the refrigerator at Nurse's Station 2. A review of the clinical record for Resident F indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 1, 2016, showed Resident F had an order for [REDACTED]. A review of the clinical record for Resident G indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 14, 2016, showed Resident G had an order for [REDACTED]. A review of the clinical record for Resident H indicated that the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the physician's orders dated February 24, 2016, showed Resident H had an order for [REDACTED]. A review of the clinical record for Resident I indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 9, 2016, showed Resident I had an order for [REDACTED]. A review of the clinical record for Resident J indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 15, 2016, showed Resident J had an order for [REDACTED]. A review of the clinical record for Resident L indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 14, 2016, showed Resident L had an order for [REDACTED]. Metronidazole (antibiotic) 500 mg every 6 hours via a PICC line. Zosyn (antibiotic) 3.375 gram every 6 hours via a PICC line for 7 days. All antibiotics were observed stored in the refrigerator at Nursing Station 2. A review of the clinical record for Resident N, indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's orders dated February 2, 2016, showed Resident N had an order for [REDACTED]. A review of the clinical record for Resident O, indicated that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 8, 2016, showed Resident O had an order for [REDACTED]. A review of the clinical record for Resident Q indicated that the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician's orders dated March 13, 2016, showed Resident Q had an order for [REDACTED]. A review of the clinical record for Resident M indicated that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the physician's orders dated March 15, 2016, showed an order for [REDACTED]. A record review of the Vaccine Education and Administration Record showed Resident M received a flu vaccination Lot # 01 on March 15, 2016, to Residents left arm. The Flu Vaccine was observed stored in the refrigerator at Nursing Station 2. During a clinical record review of Resident P who was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the physician's orders dated March 16, 2016, showed an order for [REDACTED]. A record review of the Vaccine Education and Administration Record showed Resident P received a pneumonia vaccination Lot# LO3K159 on March 16, 2016, Expires on April, 2017, to Residents Left deltoid (Shoulder area). The pneumonia vaccination was observed stored in the refrigerator at Nursing Station 2. A review of the refrigerator temperature log showed an entry dated March 16, 2016, with a notation Knob adjusted at 11:17 AM. At 11:49 AM documentation showed the temperature was 35 degrees F. During a telephone interview with Pharmacist 1 on March 16, 2016 at 3:21 PM, when discussing the out of range temperatures of the medication storage refrigerator at Nursing Station 2, the Pharmacist stated, All of the IV antibiotics except the clindamycin, and the vaccines and the TPN must be stored at the recommended temperature of 36 to 46 degrees Fahrenheit. If they are stored out of range they can lose potency. During a review of the facility policy, untitled and undated, under the section Temperature Control the policy reads, Drugs requiring refrigeration shall be stored in a refrigerator between 36 and 46 degrees Fahrenheit. A daily Medication Refrigerator Temperature Log will be kept to assure that the temperature is maintained . The facility provided an acceptable corrective action plan on March 16, 2016 at 6:30 PM. On March 17, 2016 at 3:59 PM, after interviews, observations and record reviews confirmed the implementation of the corrective action plan the Immediate Jeopardy was removed in the presence of the Administrator, Director of Nursing, and the Director of Staff Development. The corrective action plan included: 1) Upon notification from Health Facility Evaluators of the temperature noted under 36 degrees all the medications in the refrigerator were removed. 2) Medications were reordered. 3) All Licensed nurses will be in serviced beginning on March 16, 2016 and will continue until March 17, 2016 regarding medication refrigerator temperature control guidelines. 4) Effective immediately refrigerator temperature will be checked and logged on an hourly basis for 72 hours and then daily thereafter by the RN Supervisor. 5) DON will be notified if the temperature is below 36 degrees or above 46 degrees. 6) Upon notification of such problems DON will have Maintenance Supervisor check the thermostat control and the DON or designee will discard refrigerated medications and reorder from the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Resident 11 and 24) were free from accidents when: 1. a. Resident 11 sustained a laceration (a cut through the layers of skin extending into the tissue beneath the skin) on the right leg during an assisted transfer with a Hoyer Lift (Invacare portable patient lift), on March 15, 2015. 1. b. Resident 11 sustained an abrasion (a scraped area on the skin) to the left cheek, near the left eye, during an assisted transfer with a Hoyer Lift, on April 19, 2015. 2. Resident 24, had a fall while in a standard wheelchair which resulted in an abrasion on the right forehead and a clavicle (collarbone) fracture (a break in the bone). These failures resulted in Resident 11 and Resident 24 sustaining injuries and had the potential for the residents to not be able to attain their highest practicable physical, mental and psychosocial well being. Findings: 1. a. During an interview with Resident 11 on May 4, 2015 at 3:30 PM, when asked about safety in the facility, Resident 11 stated she was involved in two incidents during Hoyer lift transfers which resulted in injuries. Resident 11 stated on March 15, 2015, when the Certified Nurse Assistants (CNA 3 and CNA 5) were transferring Resident 11 from the bed to the wheelchair with the use of the Hoyer lift she sustained a laceration on the right leg with bleeding, which required an evaluation and treatment at the hospital emergency department and stitches (by surgical suturing of the skin). Resident 11 stated the other incident happened on April 2015 when the Certified Nurse Assistants (CNA 3, CNA 4 and another unrecalled CNA) were transferring Resident 11 from the bed to the wheelchair with the use of the Hoyer lift. The Hoyer lift tilted and as a result, the bar (where the Hoyer lift sling was attached to) hit Resident 11 on the area around the left eye. A review of the clinical record revealed Resident 11 was admitted on [DATE] with [DIAGNOSES REDACTED]. A history and physical examination [REDACTED]. A review of the physician orders revealed Resident 11 had been taking Coumadin (a blood thinning medication) for DVT. A review of the nurses' progress notes dated March 15, 2015, (no time indicated), revealed, Res (resident) was being hoyer lifted to wheel chair @ 11AM the foot rest leg bar lacerated lower leg L 8 (length measured = 8 centimeters) x W 1.7 (Width = 1.7 centimeters) D 0.3 (Depth = 0.3 centimeters). Res was than (then) transferd (transferred) back to bed, (with) legs slightly elevated, tx (treatment) nurse was able to cover laceration . Res was taken to (name of the hospital) ER (emergency room ). A review of the Situation-Background-Assessment-Recommendation (SBAR-a form used to document nurse progress notes and communication to the physician, nurse practitioner or physician assistant and the responsible party) dated March 15, 2015 at 11 AM, revealed, Assessment. Resident needs min (minimum) of 3 people (assistance) for Hoyer lift (transfer). Opened (right) lateral side of calf during placement into WC (wheelchair). A review of the nurses' progress notes dated March 15, 2015 at 5 PM, revealed, Resident 11 came back from the hospital secondary to laceration of (right ) lower leg; with a new physician order for [REDACTED]. The note indicated a pain medication was given to Resident 11 as ordered. A review of the nurses' progress notes dated March 16, 2015, (no time indicated), revealed, a reassessment was done on Resident 11's (right) lower leg laceration which measured 8 centimeters long with 11 stitches. A review of the care plan initiated on December 15, 2014, titled, Problem: Bleeding & Bruising related to the [DIAGNOSES REDACTED]. A review of the care plan for Resident 11, initiated on December 15, 2014, titled, Care Plan for Fall Risk, revealed, Problem: Actual or Potential risk for fall or injury related to fall due to: inability to bear weight, muscle weakness, difficulty in walking . (physical condition). Under approaches, revealed, .2. Minimize hazards in resident's environment, including: . anticipate needs and provide prompt and appropriate assistance. provision of appropriate staff supervision . An interview with CNA 3 was conducted in the presence of the Registered Nurse/ Charge Nurse (RN/CN) on May 5, 2015 at 1:50 PM. When asked to describe the incident involving Resident 11 on March 15, 2015, CNA 3 stated the incident happened during the transfer of Resident 11 from the bed to the wheelchair with the use of the Hoyer lift, by CNA 3 and CNA 5. CNA 3 stated, as Resident 11 was being lowered in the sling (carries the person while being transferred) onto the wheelchair, CNA 3 was standing behind Resident 11 and the wheelchair facing CNA 5, who was operating the lift (with the use of a control) as it descended. CNA 3 explained Resident 11's right leg was over a little too far on the right side (during the descent) and resulted in Resident 11's right leg hitting where the foot rest connected to the wheelchair, before Resident 11 sat on the wheelchair. CNA 3 stated she did not see exactly what happened because she was behind Resident 11. An interview with CNA 5 was conducted on May 6, 2015 at 2 PM. When asked to describe the incident involving Resident 11 on March 15, 2015, CNA 5 stated she was operating and controlling the lift. CNA 5 stated Resident 11 was too close to one side during the descent which caused an injury with bleeding to Resident 11's leg. CNA 5 stated Resident 11's wheelchair did not accommodate Resident 11's physical needs (needs a larger wheelchair) and normally, there should be someone (another staff) guiding Resident 11's leg during the transfer. CNA 5 stated since the incident on March 15, 2015, they started using 3 people to assist in Resident 11's Hoyer lift transfer to ensure safety. During an interview with CNA 3 on May 6, 2015 at 2:50 PM, CNA 3 stated since the incident on March 15, 2015, they started using 3 people to assist in Resident 11's Hoyer lift transfers for safety and to ensure the incident would not happen again. Review of the facility Policy and Procedure titled, Hoyer Lift, copyrite 3/93, provided by the facility, shows under Purpose, 1. To transfer a heavy resident. Under the section Procedure, the policy did not reflect the number of persons necessary to safely transfer a resident. During an interview on May 6, 2015 at 5 PM, the RN/CN stated based on her assessment and investigation of the incident, she felt they needed three people to assist Resident 11 during the Hoyer lift transfer (as she had indicated on the SBAR form dated March 15, 2015). 1. b. A review of the nurses' progress notes dated April 19, 2015 at 6:15 PM, revealed, .monitor for getting hit on (left) cheek by hoyer lift - area with slight redness no swelling has small abrasion near (Resident 11's) left eye. A review of the physician orders revealed Resident 11 had been taking Coumadin (a blood thinning medication) for DVT. Review of a Nursing Spectrum Drug Handbook, 2009, reflects the U.S. Food and Drug Administration has issued a black box warning for Coumadin, which reflects the drug may cause fatal bleeding. A review of the Situation-Background-Assessment-Recommendation (SBAR) form dated April 19, 2015 at 10:30, .Resident hoyer lift tilted & hurt (Resident 11) left cheek .Assessment:.Need a bigger hoyer lift to accommodate resident's (physical condition) . has small bump to left cheek its (it's) red, & c/o (complaint of) dull pain. A review of Resident 11's care plan initiated on December 15, 2014, titled, Problem: Bleeding & Bruising related to the [DIAGNOSES REDACTED]. A review of the care plan for Resident 11 initiated on December 15, 2014, titled, Care Plan for Fall Risk revealed, Problem: Actual or Potential risk for fall or injury related to fall due to: inability to bear weight, muscle weakness, difficulty in walking.(physical condition).Approaches.2. Minimize hazards in resident's environment, including: locking moveable equipment and furniture feet . anticipate needs and provide prompt and appropriate assistance.provision of appropriate staff supervision. An interview with CNA 3 and CNA 4 was conducted in the presence of the Registered Nurse/Charge Nurse (RN/CN) on May 5, 2015 at 1:50 PM, revealed CNA 3, CNA 4 and another unidentified CNA, assisted Resident 11 with a Hoyer lift transfer on April 19, 2015. CNA 4 stated she did not know if during the transfer of Resident 11, the base adjustment handle (a bar found next to the main column of the lift used to move the base legs of the hoyer lift further apart or bring them back together) clicked all the way (to indicate the base legs were locked at its widest position) to keep the Hoyer lift from tilting. This resulted in the Hoyer lift to tilt, causing the bar (where the hoyer lift sling was hooked) to hit Resident 11 on the left cheek (around the left eye). An inspection of the Hoyer lift used to transfer Resident 11 (during the March 15, 2015 and April 19, 2015 incidents) and a concurrent interview with CNA 4 was conducted on May 6, 2015 at 10:15 AM. CNA 4 demonstrated that shifting the base adjustment handle all the way to the farthest right until you hear it click, would open and lock the base legs to its widest position. She further demonstrated that if the base adjustment handle was not shifted to the farthest right, it would cause the base legs to be opened but not locked at its widest position. CNA 4 then proceeded to wheel the Hoyer lift against the wall and by doing so, the base legs hit the wall and closed by itself. CNA 4 stated during the incident on April 19, 2015, the base legs of the Hoyer lift closed by itself causing the lift to tilt to the side, and the bar where the sling was hooked on, hit Resident 11 on the left cheek close to the eye. CNA 4 stated the handle was not tight enough and they should have made sure the handle was locked all the way. CNA 4 stated she did not feel the Hoyer lift was safe enough to meet Resident 11's needs safely. CNA 4 stated she did not inform the Environmental Services Supervisor (ESS) of her concern about the Hoyer lift herself and was not sure if the ESS was ever informed. During an interview with ESS on May 6, 2015 at 11:50 AM, the ESS stated he has not received reports of any problems or issues regarding the Hoyer lift. A review of the manufacturer's manual revealed, OPERATION.WARNING .ONLY operate this lift with the legs in MAXIMUM OPEN POSITION and LOCKED in place. The base legs MUST be locked in the open position at all times for stability and patient safety when lifting and transferring a patient. 2. A review of the clinical record revealed Resident 24 was admitted on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the INITIAL HISTORY and PHYSICAL form dated May 13, 2014, revealed, Resident 24 had [DIAGNOSES REDACTED]. The physical examination revealed Resident 24 had a right shoulder deformity. A review of the nurses' progress notes dated November 27, 2014 at 2:30 PM, revealed, Resident sent out to (name of the hospital) secondary S/P (status [REDACTED]. Right forehead abrasion no active bleeding. Possible Right shoulder dislocation. There was no documentation of what or how the fall incident happened. A review of the nurses' progress notes dated November 27, 2014 at 5:50 PM, revealed, Resident returned (to the facility) with sling on the right arm. A review of the hospital's DISCHARGE INSTRUCTION SUMMARY, dated November 27, 2014, revealed under patient instructions, .Clavicle Fracture,.FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN FOR FURTHER EVALUATION AND TREATMENT. During an interview with the Registered Nurse/Charge Nurse (RN/CN) and a concurrent review of the clinical record on May 8, 2015 at 8:50 AM, the RN/CN was asked to describe the incident. The RN/CN stated she was called out to the patio where she found Resident 24 laying on the cement. RN/CN stated when Resident 24 was asked what happened, Resident 24 stated the standard wheelchair hit the bump resulting in Resident 24 falling forward. Resident 24, who already had a problem (general weakness) on the right arm, was not able to brace the right shoulder area during the fall. The RN/CN confirmed there was no documented evidence to show how the incident happened. During an interview on May 8, 2015 at 9:15 AM, when asked about the incident, Resident 24 spoke about having a fall incident from the wheelchair at home and did not recall other fall incidents while being at the facility. Resident 24 confirmed having had difficulty moving the right side. During an interview with the RN/CN and a concurrent review of the clinical record on May 8, 2015 at 11:45 AM, she stated at the time of the incident, Resident 24 was placed by the CNA (who was no longer employed by the facility), on a standard wheelchair because the motorized wheelchair was not running. The RN/CN confirmed there was no documentation to show Resident 24 was provided with education and training on the use of the standard wheelchair while the motorized wheelchair was unavailable, to address the safety needs of Resident 24. RN/CN stated, I see what we needed to do. When asked whose responsibility was it to provide education and training to Resident 24 on the use of the standard wheelchair, RN/CN stated it would be both by the nursing and the rehabilitation departments. During an interview with Occupational Therapy Director (OTR) on May 8, 2015, she confirmed there was no documented evidence to show Resident 24 received training or education on the use of the standard wheelchair while the motorized wheelchair was unavailable on November 27, 2014. The OTR stated there should have been communication and coordination of care between nursing and the rehabilitation departments. During an interview with the Director of Nurses on May 8, 2015 at 3:05 PM, when asked what the process was for the review of the incidents, the DON stated the incidents were discussed during the daily stand-up meetings (meetings to provide awareness of outstanding issues). The DON stated, We talk about the incidents verbally but we don't document effectively. The DON confirmed there was no documented evidence of an interdisciplinary review of the incidents for Resident 11 and Resident 24. When asked for the facility's policy and procedure on fall and incident management, the DON stated there was none specific to fall and incident management. The DON stated the facility followed the CHANGE OF CONDITIONS policy and procedure. A review of the facility's undated policy and procedure titled, CHANGE OF CONDITIONS, revealed, PURPOSE: To assure that appropriate care and documentation occurs when residents experience a change of condition.PROCEDURE: 1. Assess the resident's condition: limited movement, neurological checks for injuries such as falls, pain .4. Document what, where, symptoms, assessment, treatment, notifications .

Based on interview and record review, the facility failed to ensure for 2 of 3 sampled residents (Residents A and B), that the resident's bowel movements were being monitored, and that medications were being administered as needed to prevent the residents from developing constipation, fecal impaction (feces that is tightly wedged in an area of the intestines) and medical complications. The facility also failed to have a policy and procedure in place for the nursing staff to follow to ensure adequate maintenance of bowel movements and prevention of constipation for the residents. 1. For Resident A, this failure resulted in Resident A developing a perforated bowel (a forced hole in the intestines caused by excessive amounts of stool that causes the stool to leak into the abdominal cavity), and the need for emergency surgery to repair his bowels. Resident A subsequently expired due to medical complications [REDACTED]. 2. For Resident B this failure resulted in Resident B not having regular bowel movements, and had the potential to cause constipation, fecal impaction, and perforated bowel. Findings: An unannounced visit was made to the facility on [DATE] at 2:30 PM to investigate the complaint regarding quality of care. During a review of Resident A's clinical records reflected that Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident A was admitted to the facility to receive physical and occupational therapy to potentially return home to independent living. During a review of Resident A's physician's orders [REDACTED]. a. Order dated [DATE] for [MEDICATION NAME] (a stool softener) 100 milligrams (mg) 3 times per day by mouth. b. Order dated [DATE] for Milk of Magnesia 30 ml (milliliters) daily as needed for constipation if no bowel movement for 3 days. c. Order dated [DATE] for 2 [MEDICATION NAME] suppositories per rectum daily as needed for constipation if Milk of Magnesia ineffective. d. Order dated [DATE] to have Enema (introduction of a solution into the rectum and colon to stimulate a bowel movement) daily as needed for constipation. e. Order dated [DATE] to start [MEDICATION NAME] 30 ml orally every day as needed for constipation and discontinue Milk of Magnesia. f. Order dated [DATE] to discontinue prior [MEDICATION NAME] order and start [MEDICATION NAME] 250 mg orally twice per day for constipation. During a review of the daily medication administration records for Resident A from [DATE] through [DATE] reflected that Resident A received the [MEDICATION NAME] medication as ordered. Resident A received 1 dose of Milk of Magnesia on [DATE]. Resident A received a dose of [MEDICATION NAME] Suppository on [DATE] and again on [DATE]. Resident A did not receive any Enema or [MEDICATION NAME] medication during his stay at the facility. The DON verified the finding during the record review. Further review of Resident A's medications reflected a facility form titled "Controlled Drug Record" from [DATE] through [DATE] in which Resident A received a total of 27 tablets of [MEDICATION NAME] (a narcotic pain medication) ,[DATE] mg for pain. (A common side effect of [MEDICATION NAME] is constipation). A review of the Certified Nurses's Aide (CNA) daily flow sheets from [DATE] through [DATE] reflected the following documented bowel movements for Resident A: a. On [DATE] the letter "L" for large bowel movement was documented for the day (am) shift. b. On [DATE] the letter "L" for large was documented on the night shift. c. On [DATE] the letters "L" for large and "M" for medium were documented for the evening (pm) shift. d. On [DATE] the letter "L" for large was documented for the evening shift. e. On [DATE] the letter "O" for no bowel movement was initially recorded, then the letter "O" was crossed out and the letter "L" was written instead. Further review of the CNA daily flow sheets reflected that Resident A did not have a bowel movement from [DATE] to [DATE] (4 days), did not have a bowel movement from [DATE] to [DATE] (4 days), and did not have a bowel movement from [DATE], to [DATE] (4 days). The DON verified the finding during the record review. A review of the Minimum Data Set (a comprehensive nursing assessment reflecting a resident's overall functional status) dated [DATE] reflected that Resident A required extensive assistance for bed mobility, transferring, walking, hygiene and bathing. Resident A was dependent on staff for his toileting needs. A review of the facility's policy and procedure book did not reflect any policy and procedure for how the staff monitored resident's bowel movements or interventions to prevention residents from developing constipation and fecal impactions. During a review of Resident A's care plans reflected a care plan problem dated [DATE] titled "Risk for Constipation" Related To Narcotics (pain medication) And Immobility". The listed interventions on the care plan were to give Resident A medications as ordered, encourage fluids, reposition as needed, and notify the physician of any change of condition. A review of a second care plan dated [DATE] titled "Risk For Pain/Discomfort/Infection Secondary To Complaint of Constipation" reflected to monitor Resident A for constipation, abdominal distention, medicate as ordered, encourage fluids as tolerated, and document/notify the physician of any changes." During a review of the licensed nurse progress notes dated [DATE] at 7:30 PM, it reflected that Resident A's temperature was 99.9 degrees Fahrenheit (high) and his blood pressure was ,[DATE] (very high). Resident A was complaining of pain to his lower abdomen. Resident A was restless and agitated. The physician was called and Resident A was transferred to the acute hospital. A visit was made to the acute hospital on [DATE] at 1:30 PM to review Resident A's clinical records at the hospital. The records reflected that Resident A arrived at the emergency roiagnom on [DATE] (time unknown) with a [DIAGNOSES REDACTED]. Resident A received emergency surgery to repair his bowel. Resident A had expired on [DATE] at 4:43 AM. During a review of a hospital document titled: "emergency room Triage Assessment" (an initial nursing assessment done upon a patient's arrival to the emergency room ), dated [DATE] at 8:05 PM, it indicated that Resident A stated to the nurse that he had been having abdominal pain since 6:30 AM on [DATE] and his pain was at a 6 out of 10 pain scale (10 being the worst pain). Resident A also stated to the nurse that he had not had a bowel movement for the past 6 days while at the skilled nursing facility. During a review of the operative report for Resident A dated [DATE], it reflected that Resident A had a perforated cecum (a pouch that is considered to be the beginning of the large intestine which contains fecal material), and diffuse peritonitis. During a review of the hospital form titled "Hospitalist Medicine Progress Note", dated [DATE], it reflected that the physician documented in his progress note that Resident A stated to the physician that Resident A had been complaining of constipation and abdominal pain for 7 days at the skilled nursing facility where he came from. A second visit was made to the facility on [DATE] at 9:30 AM. During an interview with the Director of Nurses (DON) on [DATE] at 3:30 PM, she stated that the facility had no policy and procedure for monitoring a resident's bowel movements or for the prevention of constipation. The DON stated that the CNA records the bowel movements on the CNA daily flow sheets and informs the nurse when a resident has a bowel movement. The DON stated that if Resident A had no documented bowel movements in 4 days then Resident A should have been given all possible medications as ordered for constipation. The DON stated that the nurses should have been performing abdominal assessments on Resident A, and monitoring his bowel pattern due to Resident A's history of constipation and not having regular bowel movements. The DON further stated that Resident A should have not gone for 4 days in a row without having a bowel movement. The DON confirmed that no abdominal assessments were performed for Resident A during his stay at the facility and Resident A had no documented bowel movements from [DATE] to [DATE], from [DATE] to [DATE], and from [DATE] to [DATE]. The DON confirmed the CNA flow sheet documentation for Resident A's bowel movements while at the facility. The DON could not explain why the letter "O" was originally written on the CNA flow sheet to reflect Resident A had no bowel movement on [DATE], and then the letter "L" (large) was written in place of the "O". During a telephone interview with the licensed vocational nurse (LVN 1) on [DATE] at 2 PM, she stated that the CNA's are supposed to inform the nurses if a resident has not had a bowel movement for 3 days or complains of constipation. LVN 1 stated that it was a red flag if a resident had not had a bowel movement for 3 days, and that nurses would need to administer all ordered medications for constipation or call the physician if none were ordered. LVN 1 further stated that if Resident A had gone 4 days without a bowel movement then other bowel medications should have been tried. LVN 1 confirmed that the CNA flow sheets indicated that Resident A had gone 4 days without a bowel movement during 3 different time periods, and that Resident A did not receive all ordered medications as needed for constipation.

Based on interview and record review, the facility failed to ensure for 1 of 3 sampled residents (Resident A) that he did not develop a pressure ulcer while at the facility. The facility failed to ensure that Resident A received necessary care and treatment to promote healing of the pressure ulcer and prevent development of new pressure ulcers. The facility failed to ensure that Resident A's physician was notified of the increased size of the pressure ulcer and lack of healing progress. In addition, the facility failed to have a policy and procedure in place for assessing a resident's skin condition, preventing skin breakdown, and providing wound care treatment. These failures resulted in Resident A developing a pressure ulcer to his buttock/coccyx (area at the base of the spinal column) area, had the potential to delay wound healing, and had the potential to cause further development of pressure ulcers. Finding: An unannounced visit was made to the facility on [DATE], at 2:30 PM, to investigate a complaint regarding quality of care for Resident A. During a review of Resident A's clinical records, it reflected that Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident A's initial nursing assessment dated [DATE] at 6 PM, reflected that Resident A had a surgical incision to his left hip. Resident A had no other skin breakdown documented upon his admission to the facility. During a review of the nurse's notes dated June 6, 2013 at 1 PM, reflected that Resident A had developed an open area to his right buttock with darkened skin surrounding the open area. The physician was notified and a treatment order was obtained to cleanse the area with normal saline (water with a small amount of salt), pat dry, apply [MEDICATION NAME] dressing (a waterproof dressing used to treat pressure sores), and change dressing every 3 days and as needed. Further review of the nurses notes and physician's orders [REDACTED]. During review of Resident A's "Wound Care Evaluation Record" reflected that on June 6, 2013 the open area on his right buttock measured 1.5 centimeters (cm) in length by 1.2 cm in width, and 0.1 cm in depth with surrounding purple discolored tissue. On June 12, 2013 the wound was measured to be 5 cm in length by 3.5 cm in width, and unable to determine the depth due to suspected deep tissue injury (a pressure related injury to the tissue beneath the skin) with surrounding purple discolored tissue. On June 18, 2013, the wound was measured to be 6.5 cm in length by 5 centimeters in width, and unable to determine the depth due to suspected deep tissue injury with necrotic (dead) tissue. There was no staging of the wound documented. (Pressure ulcers are typically categorized in 4 progressive stages, stage 4 being the most severe involving full loss of skin, extending through muscle tissue and possibly exposing bone). During a review of Resident A's Minimum Data Set (a comprehensive assessment form completed by different medical staff which indicated the overall functional abilities of a resident), dated June 15, 2013 reflected that Resident A required extensive assistance from staff with physical mobility, hygiene, dressing, bathing, and dependent on staff for his toileting needs. During a review of Resident A's care plans, a care plan titled "Risk For Infection Secondary To Open Area To Right Buttocks", dated June 6, 2013, reflected the following nursing interventions: a. Monitor for signs and symptoms of infection. b. Keep area clean and dry. c. Treatment as ordered. d. Encourage resident out of bed daily. e. Reposition every 1 hour and as needed. f. Document and notify MD (physician) of any changes. Further review of the care plan did not reflect any new updates or new interventions initiated by the staff in an attempt to promote healing of Resident A's skin breakdown after the care plan was initiated on June 6, 2013. During an interview with the Director Of Nurses (DON) on June 21, 2013 at 4:45 PM, she stated that an air mattress was not ordered for Resident A until the day right before he was transferred to the hospital on June 19, 2013. Further review of the clinical records did not reflect any documented evidence that Resident A's physician was notified after June 6, 2013 that Resident A's wound had tripled in size within the first 6 days, and that the wound was not improving with the current treatment. A visit was made to the acute hospital on July 17, 2013 at 1:30 PM to review Resident A's clinical records. During a review of colored pictures dated June 20, 2013 at 5 AM reflected that Resident A's bilateral buttocks and coccyx area had extensive skin breakdown with several open areas. The skin had multiple areas that were discolored red, purple and black. A second visit was made to the facility on [DATE] at 9:30 AM. During an interview with the DON on August 7, 2013 at 3:30 PM, she stated that every time she walked passed Resident A's room, Resident A was lying in the same position on his bed. During an interview with licensed vocational nurse/treatment nurse (LVN 2) on August 7, 2013 at 3:40 PM, she stated that Resident A's pressure sore to his right buttock started out small as a stage 2 (open area of skin), and it changed very quickly. LVN 2 stated that Resident A's wound to his buttock area was suspected to be deep tissue injury because the skin was dark purple. (According to the National Pressure Ulcer Advisory Panel, 2002, the term "Deep Tissue Injury" is defined as "a pressure-related injury to subcutaneous tissues under intact skin. These [MEDICAL CONDITION] may herald the subsequent development of a stage 3 to 4 pressure ulcer even with optimal treatment"). LVN 2 stated that she did not take any pictures of the wound, and she did not order an air mattress for Resident A until the day before he discharged to the hospital on June 19, 2013. During a telephone interview with the Physical Therapist Assistant (PTA 1) on August 8, 2013 at 10:30 AM, she stated that Resident A required maximum assistance from staff for his physical mobility due to his non-weight bearing status from his left [MEDICAL CONDITION]. A third visit was made to the facility on [DATE] at 3 PM. During an interview with the DON on November 1, 2013 at 3 PM, she stated that the facility did not have a policy and procedure for skin care, wound care, or preventing the development of pressure ulcers. The DON stated that the nurses just followed whatever the physician's orders [REDACTED]. The DON stated that Resident A's wound progressed very rapidly and she did not know why Resident A's treatment order for wound care was not changed when his wound showed no healing progress and increased size after the first week. The DON acknowledged that Resident A's care plan reflected that Resident A needed to be turned every hour, and the DON stated there was no documented evidence that was being done. The DON stated that Resident A was a very large man who needed extensive assistance with his bed mobility. The DON further stated that Resident A should have been placed on an air mattress right away when the wound first developed and she could not explain why that was not done. During an interview with LVN 2 on November 1, 2013 a 4 PM, she stated that she did the wound care to Resident A's pressure sore every 3 days, and measured the wound every week. LVN 2 stated that she did not notify the physician of the wound measurements, or that the wound was rapidly increasing in size and not healing. LVN 2 stated she wanted to wait and see if the wound would eventually start healing so she did not request any new change in the wound care treatment orders from the physician. LVN 2 stated that she did not attempt to order an air mattress for Resident A until June 18, 2013, but the resident was discharged the following day to the hospital. LVN 2 could not explain why no new interventions were implemented to promote healing of Resident A's pressure sore.