Other·May 14, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of complaint #CA00621546. Representing the Department of Public Health: HFEN #29821. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F655 SS=D Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 05/24/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on interview, medical record and document review, the facility failed to develop a baseline plan of care which addressed the immediate safety needs for one of three residents (Resident 1). This failure may have contributed to a fall with major injury, including a hospital stay and need for intensive neurological care. Findings: Review of the 11/10/18 physician History and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Physical reflected 53 year-old Resident 1 was admitted with diagnoses including thrombocytopenia (decreased number of blood platelets which help the blood to clot; the condition can be associated with abnormal bleeding) and a recent "large...cerebellar hemorrhage" (bleeding into the cerebellum, the part of the brain that regulates motor movement including the coordination of balance) with brain surgery for clot removal and "a complex postoperative course" including neurological intensive care. Review of the 7:29 p.m., 11/19/18 nursing "Admission Observation" database and 1:18 a.m. and 4:08 a.m., 11/20/18 nursing progress notes reflected knowledge that Resident 1 had been admitted for recovery from a recent cerebellar stroke, that he had "bleeding problems," "weakness," "balance problems," "memory loss," and difficulty with vision, hearing and communication. On the evening of admission, at 8:29 p.m., 11/19/18, Resident 1 was assessed to be at high risk for falls. It was noted in the "Johns Hopkins Fall Risk Assessment Tool" that the resident required "assistance or supervision for...transfer..." and "[lacked]...understanding of [his] physical and cognitive limitations." In addition, the 12:29 p.m., 11/20/19 entry noted that Resident 1 was on falls precautions. In a 1:28 p.m., 2/8/19 interview, Unit Manager 1 (UM 1, one of two managers on Resident 1's nursing unit) confirmed the resident had been identified to be at risk for falls. Resident 1's 11/19/18 baseline care plan indicated, "Identified safety concerns...Fall risk" but no fall reduction strategies were identified. A 10:22 p.m., Resident 1's 11/20/18 nursing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE progress note read, "Confused, nonstop attempts to get out of bed, sitter [in-room safety attendant] placed at bedside, combative with brief [undergarment] change and cleaning, requires 4 staff members to safely change..." Presence of a sitter was also documented in nursing progress notes at 1:16 p.m. and 11:22 p.m. on 11/22/18, 2:19 a.m. on 11/24/18, 3:50 a.m. on 11/26/18 and 1:25 a.m. on 11/29/18. Medical record review reflected that fall prevention interventions were not added to Resident 1's baseline care plan until after he was found on the floor of his room at 7:05 a.m., 11/29/18. In an 8:32 a.m., 3/8/19 interview, UM 2 confirmed that fall prevention interventions were not added to Resident 1's care plan until the day of his fall. During an 8:01 a.m., 3/22/19 interview, the Director of Nursing Services acknowledged that fall prevention activities taken "never made it to the care plan." She indicated that the assignment of a safety attendant to a resident was an intervention that should be added to a care plan. Review of the facility's 10/31/17 "Baseline Care Plan" policy reflected, "The care plan includes, at a minimum...Address resident health and safety concerns to prevent decline or injury, such as...Fall risk...The care plan...includes interventions that address his/her current needs... The 12/23/14 "Interdisciplinary Team/Care Plan Process" policy stated, "A preliminary care plan is developed upon admission to assure that the resident's immediate care needs are met...The care plan is developed by an interdisciplinary team which includes...Licensed nurse who has FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE responsibility for the resident...Nursing assistants responsible for resident care...Therapists (speech, occupational, physical, etc.) as applicable....

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 05/24/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, medical record and document review, the facility failed to provide the direct observation and supervision, as identified by the facility, necessary to prevent an accident/injury for one of three residents (Resident 1). This failure to supervise Resident 1 resulted in a fall with major injury. Resident 1 developed bleeding into his head and required a subsequent eight-day general acute care hospital stay, including neurological intensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care, after the fall. Findings: Review of the 11/10/18 physician History and Physical reflected 53 year-old Resident 1 was admitted with diagnoses including thrombocytopenia (decreased number of blood platelets which help the blood to clot; the condition can be associated with abnormal bleeding) and a recent "large...cerebellar hemorrhage" (bleeding into the cerebellum, the part of the brain that regulates motor movement including the coordination of balance) with brain surgery for clot removal and "a complex postoperative course" including neurological intensive care. An 11/18/18 laboratory test result indicated Resident 1's platelet count was low at 98,000 platelets per microliter (mcL, a unit of measure; normal is 140,000-400,000 platelets per mcL per https://healthy.kaiserpermanente.org/healthwellness/health-encyclopedia/he.completeblood-count-cbc.hw4260? kpSearch=q692#hw4305). Review of the 7:29 p.m., 11/19/18 nursing "Admission Observation" database and 1:18 a.m. and 4:08 a.m., 11/20/18 nursing progress notes reflected knowledge that Resident 1 had been admitted for recovery from a recent cerebellar stroke, that he had "bleeding problems," "weakness," "balance problems," "memory loss," and difficulty with vision, hearing and communication. At 8:29 p.m., 11/19/18, Resident 1 was assessed to be at high risk for falls. It was noted in the "Johns Hopkins Fall Risk Assessment Tool" that the resident required "assistance or supervision for...transfer..." and "[lacked]...understanding of [his] physical and cognitive limitations." In addition, the 12:29 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE p.m., 11/20/18 entry noted that Resident 1 was on falls precautions. Resident 1's 11/19/18 baseline care plan indicated, "Identified safety concerns...Fall risk" but no fall reduction strategies were identified. A 10:22 p.m., Resident 1's 11/20/18 nursing progress note read, "Confused, nonstop attempts to get out of bed, sitter [in-room safety attendant] placed at bedside, combative with brief [undergarment] change and cleaning, requires 4 staff members to safely change..." Presence of a sitter was also documented in Resident 1's nursing progress notes at 1:16 p.m. and 11:22 p.m. on 11/22/18, 2:19 a.m. on 11/24/18, 3:50 a.m. on 11/26/18 and 1:25 a.m. on 11/29/18. The 12:28 p.m., 11/20/18 "Physical Therapy Initial Assessment" indicated Resident 1 had muscle weakness, diminished sensation in one arm and one leg, impaired coordination and needed assistance of two staff for safety when getting out of bed. The 11/30/18 "Physical Therapy Discharge Assessment" reflected that the resident had begun to take steps in a set of parallel bars but his standing balance and safety awareness remained "poor." Clinical document review of Resident 1's 3:53 p.m., 11/29/18 "Fall Event" record indicated the time of discovery to be 7:05 a.m., 11/29/19. In a 2:25 p.m., 2/8/19 interview, day shift Certified Nurse Assistant 1 (CNA 1) stated that on the morning of 11/29/18, she received report from night shift CNA 2 outside Resident 1's room while the resident slept. CNA 1 indicated that after report and before assuming care of Resident 1, she went "around the corner" to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE retrieve needed care supplies. When she returned "less than two minutes" later, she discovered Resident 1 lying prone (face down) on the floor next to his bed with a cut above one eye. CNA 1 stated the resident was a known fall risk who had attempted to get out of bed without assistance "numerous times;" she had served as Resident 1's sitter on day shift, 11/28/19 (the day prior) as well. When asked what she did if she needed to leave Resident 1's room, she indicated she "would ask someone to step in for her" so the resident was not left unattended. During a 1:28 p.m., 2/8/19 interview, UM 1 confirmed the resident had been identified to be at risk for falls. When asked why a sitter was not present at the time of Resident 1's fall, UM 1was unable to identify the reason, and further stated that she did not participate in any postfall analysis events. In a 2:59 p.m., 3/6/19 interview, Licensed Vocational Nurse 1 (LVN 1, the licensed nurse responsible for Resident 1's care on day shift, 11/29/18) described Resident 1 as "confused and restless" and added that "he needed a sitter because he was such a high fall risk." In a 9:29 a.m., 3/6/19 interview, Registered Nurse 1 (RN, the licensed nurse responsible for Resident 1's care the night of 11/28/18 to 11/29/18, stated that Resident 1 "should have had a sitter." RN 1 further stated that a resident for whom a sitter has been assigned should not be left alone. In a 6:18 a.m., 3/8/19 interview, CNA 2 stated there had been no discussion about his remaining in Resident 1's room while CNA 1 gathered supplies. CNA 2 indicated that while he had been the safety attendant the night of 11/28/18 to 11/29/18 for both Resident 1 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE his roommate, the residents did not have a caregiver in constant attendance between approximately 5:30 a.m. to 6:30 a.m. on 11/29. CNA 2 stated the facility provided an in-service which two of the four night shift CNAs on the unit needed to attend. While the two were in class, CNA 2 assisted the remaining CNA in caring for all the residents on the 40-bed unit. CNA 2 stated that during the time prior to 5:30 a.m., another caregiver replaced CNA 2 in the room whenever the CNA needed to leave, providing ongoing resident monitoring. During the 6:18 a.m., 3/8/19 interview, CNA 2 stated that both residents in the room needed to have a sitter because "either one could have gotten out of bed [unassisted]." In an 8:32 a.m., 3/8/19 interview, Unit Manager 2 (UM 2, one of two nursing managers of the unit on which Resident 1 resided) stated, "We tried to adjust the schedule to provide a 1:1 [safety attendant]...so someone could be in the room with him." In a 3:27 p.m., 3/7/19 interview, the DNS indicated it "...was reasonable that the CNA left..." Resident 1 unattended to gather supplies since the resident was sleeping at the time CNA 1 left. The DNS added it was "not an expectation that [safety attendants] would never leave the room." During the 8:01 a.m., 3/22/19 interview, the DNS stated that CNAs "can leave [the room] briefly or for breaks" [if it seems safe to do so]." The DNS stated she had not promised a safety attendant "24/7" and was unable to guarantee that the facility "could stop or prevent anything from happening." She indicated she'd told family only that staff "would do our best to assure he had more care and services [than he would have had without a safety attendant assigned]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555153 (X3) DATE SURVEY COMPLETED 05/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FAIR OAKS HEALTHCARE CENTER 11300 Fair Oaks Boulevard Fair Oaks, CA 95628 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During the 3/7/19 interview, the DNS stated that the facility did not have written guidelines for sitter care. In an 8:01 a.m., 3/22/19 interview, the Director of Nursing Services (DNS) indicated that on 11/20/19 or shortly thereafter, nursing leaders began to "redistribute assignments" on the unit "to place one CNA in the room. We would always have a sitter assigned." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MHJ311 Facility ID: CA030000071 If continuation sheet 10 of 10