Health inspection·September 21, 2019

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Potential for minimal harm Based on interviews and facility policy review, the facility failed to ensure mail was delivered to the residents on Saturday. This had the potential to affect any of the 65 residents of the facility, who received mail, at the time of the survey. Residents Affected - Many Findings: During an interview with six cognitive residents on 09/18/19 at 10 AM, three of the residents stated they attended Resident Council meetings regularly, and three stated they did not attend regularly; all six responded they did not receive mail on Saturdays, when asked by the surveyor. In an interview on 09/18/19 at 2:25 PM, the Receptionist stated, When I get the mail, I sort it and put the resident's mail into the resident's box for [Activity Director and Activity Aide names] to deliver. On 09/18/19 at 4:10 PM, the Receptionist responded to the question about how mail was delivered on Saturdays, stating, They usually hold it for us on Saturdays because they don't want to just leave it anywhere. At 4:15 PM, the Receptionist clarified, they was the USPS - United States Postal Service. In an interview on 09/19/19 at 1:57 PM, the USPS Letter Carrier (after delivering the mail) stated, We used to deliver on Saturdays and put it at the nurse's station, but items would disappear. It was not secure. So, when the office is closed, we don't have a secure place to deliver on Saturday. In an interview on 09/20/19 at 09:20 AM, the Administrator stated, They [Residents] should have Saturday mail delivered. Review of the facility policy, Mail, revised January 2011, showed: Policy Statement: Resident are allowed to communicate privately with individuals of their choice and may send and receive their personal mail unopened unless otherwise advised by the Attending Physician and documented in the residents' medical records. Policy Interpretation and Implementation: . 4. Mail will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). Page 1 of 24 056483 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to provide privacy during care for one Resident (R) 53 of three residents observed during the administration of insulin. The Director of Nurses (DON) verified that 12 residents, residing in the facility, received insulin injections. This failure had the potential to violate Resident 53's rights to privacy and confidentiality in all areas of care; and the potential to affect all residents who received personal care in the facility. Residents Affected - Few Findings: Review of the quarterly, Minimum Data Set (MDS) assessment dated 08/25/19, documented Resident 53 had a, Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. The assessment also included an active diagnosis of diabetes mellitus type two. On 09/19/19 at 8:30 AM, Licensed Vocational Nurse (LVN) 38 administered insulin to R53. R53 was sitting in his wheelchair, in the hallway outside his room. The LVN asked R53 if he wanted the insulin administered into his abdomen, and he stated he did. She lifted R 53's gown, exposing his bare skin to anyone who might have walked by in the hallway and administered the injection into his abdomen. On 09/19/19 at 8:38 AM, the LVN was asked if she had provided privacy during the administration of the insulin. She stated, No, not this time. On 09/20/19 at 9:10 AM, the Director of Nursing stated the facility did not have a policy and procedure regarding full visual privacy during the provision of care. When asked if she would expect her staff to provide privacy for an insulin injection in a resident's abdomen, she stated, Yes. 056483 Page 2 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and interviews, the facility failed to ensure its abuse policy was implemented; and failed to report and thoroughly investigate two of four allegations of abuse, which affected four Residents(R): R37, R41, R59 and R216, of seven sampled residents involved in the abuse allegations. Failure to report allegations of abuse, within federally mandated timelines, had the potential to result in a failure to provide adequate protections from abuse, for the health, welfare and rights of each of the 65 residents at the time of the survey. Residents Affected - Some Findings: The facility's abuse policy and procedure, effective 11/30/17, documented the following: All reports of resident abuse.shall be promptly reported to local state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Administrator shall report all incidents of alleged abuse or suspected abuse to.DPH within 5 working days of the incident. An alleged violation of abuse.will be reported immediately, but no later than: .Two (2) hours if the alleged violation involves abuse. Roll [sic] of the Investigator.Interview the person(s) reporting the incident; Interview any witnesses to the incident; interview the resident (as medically appropriate) . 1. Per his, admission Record, R41 had been admitted to the facility on [DATE], with diagnoses which included alcohol abuse and Wernicke's encephalopathy. The admission, Minimum Data Set, with an, Assessment Reference Date (ARD) of 02/10/19, documented R41 had a, Brief Interview for Mental Status, of 00, which indicated he had severe cognitive impairment. A, Nurse's Progress note, dated 03/04/19 at 11 PM, for R41, documented: Pt [patient] was involved in an altercation [with] other resident. [No] injuries. Pt moved to another room [and] will be under frequent supervision.Language barrier remains as well as dementia state. 2. Per his, admission Record, R37 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia without behavioral disturbance. The admission, MDS, with an, ARD of 02/05/19, documented R37 had a, BIMS, of 15, which indicated he was cognitively intact. A Nurse's Progress note, dated 03/04/19 at 11 PM, for R37, documented: This pt [patient] was involved in an altercation toward another pt. No injuries. Pt under frequent supervision to prevent any further incidences [with] any other pts. He is very protective toward his perceived territory [and] his agitation will markedly [increase] if he feels his territory is being violated. An investigation, dated 03/12/19, provided by the Administrator, of the altercation between R37 and R41, was reviewed. It documented: On March 4th at approximately [8:15 PM R37] was sitting hallway and [R41] passed close by and started to verbally assault [R37]. He got close to [R37] who then reached out to grab him. Residents were immediately separated and [R41] was moved to a room on the opposite station. Both residents have some degree of dementia. Follow up with both residents has resulted 056483 Page 3 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in no negative psychosocial problems. The investigation report documented there had been no further incidents involving either resident or with any other resident or staff. The report documented both residents continued to be monitored. The investigation revealed another version of the incident as follows: Abuser [R41] was intimidating victim [R37]. Angry at victim for sitting in hallway close to Abuser's room. In spite of multiple attempts to de-escalate, Abuser continued to verbally assault victim and finally laid hand on the Abuser, who has been moved. The investigation listed Certified Nurse Aide (CNA) 40 as a person believed to have knowledge of the abuse. There was no documentation in the abuse packet which indicated, R37, R41, CNA40, or any other staff, who were working the evening of the incident, had been interviewed regarding the incident. The investigation revealed the incident occurred on 03/04/19 at 8:15 PM, and was reported to the Department on 03/05/19. The final report was faxed to the Department on 03/12/19. On 09/21/19 at 10:15 AM, the Administrator was asked if the incident had been reported to the Department within two hours. He stated, No. He stated he had no additional documentation pertaining to the investigation of the incident. The Administrator was asked if a thorough investigation occurred, which would include interviews with the staff who were working the evening the incident, the person who reported the incident, any witnesses to the incident and the residents involved, had been completed and documented. He stated, No, because I don't have the witness statement. The administrator stated the results of the investigation had not been sent to the Department within five working days. The Administrator said the facility's abuse policy had not been followed by: Not sending an initial report about the incident to the Department within two hours (federally-mandated reporting timeline); failed to complete/document a thorough investigation; and failed to send the results of the investigation to the Department within five working days (federally-mandated reporting timeline). 2. Per her physician's orders, R59 was admitted to the facility on [DATE], with diagnoses which included unspecified alcohol use with alcohol-induced persisting dementia and unspecified dementia with behavioral disturbance. The quarterly, MDS, with an, ARD, of 06/05/19, documented R59 had a, BIMS of 09, which indicated she had moderate cognitive impairment. Per Physician's Orders, R216 was admitted to the facility on [DATE], with diagnoses which bipolar disorder, currently in remission and unspecified dementia without behavioral disturbance. The quarterly, MDS, with an ARD of 04/25/19, documented R216 had a, BIMS of 15, which indicated he had no cognitive impairment. A Nurse's Note, dated 06/30/19, for R216, documented: Pt was looking [at] books sitting in his [wheelchair] while holding the TV remote control [at] Station 2 entrance. Apparently, another resident attempted to grab the remote [and] hit this resident [with] a book on the back of his head. [No] injuries noted. An investigation report, dated 07/08/19, provided by the Administrator, documented: On June 30th at approximately [4:30 PM, R216] was sitting in the Station 2 foyer next to the book table attempting to choose a book, when [R59] picked up a book and hit him on the head for no apparent reason and attempted to grab the TV remote from him. This was witnessed by a staff member who immediately separated them and directed [R59] back to her room. [R216] was assessed by the licensed staff and had no 056483 Page 4 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some visible injuries. SSD [Social Services Director] assessed resident for emotional distress with none noted. [R59] has some degree of dementia. The report documented there had been no further incidents involving either resident or with any other resident or staff; and both residents continued to be monitored. A fax transmission verification report documented the initial report had been transmitted to the Department on 07/01/19 at 12:40 PM. There was no documentation which indicated R59, R216, the staff member who witnessed the incident, or any other staff member or resident, had been interviewed regarding the incident. On 09/21/19 at 10:20 AM, the Administrator was interviewed. When asked if he had reported the alleged abuse to the Department within two hours, he stated, No. He stated he had no additional documentation regarding the incident. When asked if a thorough investigation, including interviews with the witnesses, the person who completed the initial report, either resident or any other residents or staff, had been completed and documented, he stated, No. When asked if the facility's abuse policy and procedure had been implemented to report the alleged abuse to the Department within two hours and to complete and document a thorough investigation, as required, the Administrator stated, No. 056483 Page 5 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews, the facility failed to ensure two of four allegations of abuse were reported to the Department within the two hour and/or five-day federally-mandated reporting time line, as required. This affected four Residents (R): R37, R41, R59 and R216, of seven sampled residents involved in the abuse allegations; and had the potential to result in a failure to provide adequate protections from abuse for the health, welfare and rights of each of the 65 residents residing in the facility, at the time of the survey. Findings: The facility's abuse policy and procedure, effective 11/30/17, documented the following: All reports of resident abuse.shall be promptly reported to local state and federal agencies [as defined by current regulations] and thoroughly investigated by facility management. Administrator shall report all incidents of alleged abuse or suspected abuse to.DPH within 5 working days of the incident. An alleged violation of abuse.will be reported immediately, but no later than: .Two (2) hours if the alleged violation involves abuse. 1. Per his, admission Record, R41 had been admitted to the facility on [DATE], with diagnoses which included alcohol abuse and Wernicke's encephalopathy. The admission, Minimum Data Set, with an, Assessment Reference Date (ARD) of 02/10/19, documented R41 had a, Brief Interview for Mental Status, of 00, which indicated he had severe cognitive impairment. A Nurse's Progress Note, dated 03/04/19 at 11 PM, for R41, documented: Pt [patient] was involved in an altercation [with] other resident. [No] injuries. Pt moved to another room [and] will be under frequent supervision.Language barrier remains as well as dementia state. 2. Per his, admission Record, R37 had been admitted to the facility on [DATE], with diagnoses which included unspecified dementia without behavioral disturbance. The admission, MDS, with an, ARD of 02/05/19, documented R37 had a, BIMS, of 15, which indicated he was cognitively intact. A Nurse's Progress Note, dated 03/04/19 at 11:00 PM, for R37, documented: This pt [patient] was involved in an altercation toward another pt. No injuries. Pt under frequent supervision to prevent any further incidences [with] any other pts. He is very protective toward his perceived territory [and] his agitation will markedly [increase] if he feels his territory is being violated. An investigation, dated 03/12/19, provided by the Administrator, of the altercation between R37 and R41, was reviewed. It documented: On March 4th at approximately [8:15 PM, R37] was sitting hallway and [R41] passed close by and started to verbally assault [R37]. He got close to [R37] who then reached out to grab him. Residents were immediately separated and [R41] was moved to a room on the opposite station. Both residents have some degree of dementia. Follow up with both residents has revealed no negative psychosocial problems/outcomes. The investigation report documented there had been no further incidents involving either resident or with any other resident or staff. The report 056483 Page 6 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0609 Level of Harm - Minimal harm or potential for actual harm documented both residents continued to be monitored. The investigation listed Certified Nurse Aide (CNA)40 as a person believed to have knowledge of the abuse. The investigation revealed the incident had occurred on 03/04/19 at 8:15 PM and was reported to the Department on 03/05/19. The final report was faxed to the Department on 03/12/19. Residents Affected - Some On 09/21/19 at 10:15 AM, the Administrator was asked if the incident had been reported to the Department within two hours. He stated, No. The Administrator also stated the results of the investigation had not been sent to the Department within five working days, as required. 3. Per her Physician's Orders, R59 was admitted to the facility on [DATE], with diagnoses which included unspecified alcohol use with alcohol-induced persisting dementia and unspecified dementia with behavioral disturbance. The quarterly, MDS, with an, ARD, of 06/05/19, documented R59 had a, BIMS, of 09, which indicated she had moderate cognitive impairment. Per the Physician's Orders, R216 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, currently in remission, and unspecified dementia without behavioral disturbance. The quarterly, MDS, with an ARD of 04/25/19, documented R216 had a, BIMS, of 15, which indicated he had no cognitive impairment. A Nurse's Note, dated 06/30/19, for R216, documented: Pt was looking [at] books sitting in his [wheelchair] while holding the TV remote control [at] Station 2 entrance. Apparently, another resident attempted to grab the remote [and] hit this resident [with] a book on the back of his head. [No] injuries noted. An investigation report, dated 07/08/19, provided by the Administrator, documented: On June 30th at approximately [4:30 PM, R216] was sitting in the Station 2 foyer next to the book table attempting to choose a book, when [R59] picked up a book and hit him on the head for no apparent reason and attempted to grab the TV remote from him. This was witnessed by a staff member who immediately separated them and directed [R59] back to her room. [R216] was assessed by the licensed staff and had no visible injuries. SSD [Social Services Director] assessed resident for emotional distress with none noted. [R59] has some degree of dementia. The report documented there had been no further incidents involving either resident or with any other resident or staff. It documented both residents continued to be monitored. A fax transmission verification report documented the initial report had been transmitted to the Department on 07/01/19 at 12:40 PM. On 09/21/19 at 10:20 AM, the Administrator was interviewed. When asked if he had reported the alleged abuse to the state within two hours, as required, he stated, No. 056483 Page 7 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy reviews and interviews, the facility failed to thoroughly investigate, document and report, three of four allegations of abuse. This failure affected six sampled Residents (R): R37, R41, R59, R216, R49 and R51) involved in the abuse allegations. Additionally, the facility's failure had the potential to result in inadequate protections from abuse for the health, welfare and rights of each of the 65 residents residing in the facility at the time of the survey. Residents Affected - Some Findings: 1. a.) Per his, admission Record, R41 was admitted to the facility on [DATE], with diagnoses which included alcohol abuse and Wernicke's encephalopathy. The admission, Minimum Data Set (MDS),assessment with an, Assessment Reference Date (ARD) of 02/10/19, documented R41 had a, Brief Interview for Mental Status, of 00, which indicated he had severe cognitive impairment. A Nurse's Progress Note, dated 03/04/19 at 11 PM, for R41, documented: Pt [patient] was involved in an altercation [with] other resident. [No] injuries. Pt moved to another room [and] will be under frequent supervision. Language barrier remains as well as dementia state. b.) Per his, admission Record, R37 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia without behavioral disturbance. The admission, MDS, with an, ARD of 02/05/19, documented R37 had a, BIMS of 15, which indicated he was cognitively intact. A Nurse's Progress Note, dated 03/04/19 at 11 PM, for R37, documented: This pt [patient] was involved in an altercation toward another pt. No injuries. Pt under frequent supervision to prevent any further incidences [with] any other pts. He is very protective toward his perceived territory [and] his agitation will markedly [increase] if he feels his territory is being violated. An investigation, dated 03/12/19, provided by the Administrator, regarding an altercation between R37 and R41, was reviewed. It documented: On March 4th at approximately [8:15 PM, R37] was sitting hallway and [R41] passed close by and started to verbally assault [R37]. He got close to [R37] who then reach out to grab him. Residents were immediately separated and [R41] was moved to a room on the opposite station. Both residents have some degree of dementia. Follow up with both residents has not resulted in any negative psychosocial problems. The investigation report documented there had been no further incidents involving either resident or with any other resident or staff. The report documented both residents continued to be monitored. The investigation listed Certified Nurse Aide (CNA) 40 as a person believed to have knowledge of the abuse. There was no documentation in the abuse investigation which indicated, R37, R41, CNA40, or any other staff who were working the evening of the incident, had been interviewed regarding the incident. The investigation revealed the incident occurred on 03/04/19 at 8:15 PM, and was reported to the Department on 03/05/19. The final report was faxed to the Department on 03/12/19. On 09/21/19 at 10:15 AM, the Administrator stated there was no additional documentation pertaining to the investigation of the incident. The Administrator was asked if a thorough investigation, which would include interviews with the staff who were working the evening the incident occurred, the person who reported the incident, any witnesses to the incident and the residents involved, had been 056483 Page 8 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0610 completed and documented. He stated, No, because I don't have the witness statement. Level of Harm - Minimal harm or potential for actual harm 2. a.) Per her physician's orders, R59 was admitted to the facility on [DATE], with diagnoses which included unspecified alcohol use with alcohol-induced persisting dementia and unspecified dementia with behavioral disturbance. The quarterly, MDS, with an, ARD of 06/05/19, documented R59 had a, BIMS of 09, which indicated she had moderate cognitive impairment. Residents Affected - Some b.) Per the physician's orders, R216 was admitted to the facility on [DATE], with diagnoses which included bipolar disorder, currently in remission, and unspecified dementia without behavioral disturbance. The quarterly, MDS, with an ARD of 04/25/19, documented R216 had a, BIMS of 15, which indicated he had no cognitive impairment. A Nurse's Note, dated 06/30/19, for R216, documented: Pt was looking [at] books sitting in his [wheelchair] while holding the TV remote control [at] Station 2 entrance. Apparently, another resident attempted to grab the remote [and] hit this resident [with] a book on the back of his head. [No] injuries noted. An investigation report, dated 07/08/19, provided by the Administrator, documented: On June 30th at approximately [4:30 PM, R216] was sitting in the Station 2 foyer next to the book table attempting to choose a book, when [R59] picked up a book and hit him on the head for no apparent reason and attempted to grab the TV remote from him. This was witnessed by a staff member who immediately separated them and directed [R59] back to her room. [R216] was assessed by the licensed staff and had no visible injuries. SSD [Social Services Director] assessed resident for emotional distress with none noted. [R59] has some degree of dementia. The report documented there had been no further incidents involving either resident or with any other resident or staff. It documented both residents continued to be monitored. There was no documentation which indicated R59, R216, the staff member who witnessed the incident, or any other staff member or resident, had been interviewed regarding the incident. On 09/21/19 at 10:20 AM, the Administrator was interviewed. He stated he had no additional documentation regarding the incident. When asked if a thorough investigation, including interviews with the witness, the person who completed the initial report, either resident or any other residents or staff, had been completed and documented, he stated, No. 3. Review of a report to the State of California on 04/24/19, regarding Resident (R) 49 running over R57's foot with a wheelchair on 4/23/19, and bumping into R57's knee on 04/24/19, was submitted to the Department on 04/24/19. In an interview on 09/18/19 at 2:30 PM, a request was made to the Administrator to review the investigation related to this report. The Administrator provided a file and fax confirmation report. In an interview on 09/19/19 at 9:12 AM, the Administrator was made aware there was no 5-day report found in the file when it was reviewed. The Administrator stated, I can't believe I didn't do a 5 day [investigation] on this incident! I checked all the other files, and they had the five days [investigations] but I missed this one. A review of the facility policy, Resident-to-Resident Altercations Policy, effective 11/30/17, revealed: Purpose: All altercations, including those that may represent resident-to-resident abuse, 056483 Page 9 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0610 shall be investigated and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator. Procedure: . Level of Harm - Minimal harm or potential for actual harm If two residents are involved in an altercation, staff will: Residents Affected - Some -Separate the residents, and institute measures to calm the situation; -Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; -Notify each resident's representative and Attending Physician of the incident; . -Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; . -Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy Review of the facility, Abuse Investigation and Reporting Policy, effective 11/30/17, showed: Reporting .5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 056483 Page 10 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents, who received a Pre-admission Screening and Resident Review (PASARR) Level I, and were later identified with a newly-diagnosed serious mental disorder, were referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. This failure affected one of two sampled residents (R)52, reviewed for PASARRs, and had the potential to result in inappropriate placement and/or a failure to provide necessary mental health care and services. Findings: Interview, on 09/21/19 at 10:31 AM, with the Administrator, revealed the facility did not have a policy related to PASARR. Review of R52's, Face Sheet, dated 08/19/19, and located in R52's electronic medical record (EMR), revealed R52 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder and anxiety disorder. Continued review of R 52's face sheet revealed on 01/27/18, R52 was diagnosed with bipolar disorder. Review of R52's, Preadmission Screening and Resident Review (PASRR) Level I Screening Document, dated 11/13/15, revealed for, Section III-Mental Illness (MI) Screen, the only diagnoses selected was, Depression. Continued review of R52's screening revealed the diagnosis of, bipolar was not selected; and also revealed the, PASRR was a positive screening, and R52 was appropriately referred for a Level II screening. Interview, on 09/19/19 at 3:45 PM, with the Social Service Director (SSD) revealed she was responsible for completing the Level I PASARR. Continued interview revealed, if the Level I was positive, she would make the referral for a Level II PASARR. The SSD confirmed R52 received a new mental health diagnosis of bipolar disorder in January of 2018. The SSD further stated she did not know until yesterday (when she was questioned by the surveyor) that a new Level I needed to be completed. Continued interview revealed she completed a new Level I this day and it resulted as a, positive screening, so she referred it for a Level II review. Interview, on 09/21/19 at 10:01 AM, with the Director of Nursing (DON), revealed it was her expectation the SSD would have completed a new Level I PASARR screening once R52 received the new mental illness diagnosis. Continued interview revealed the relevance of a new Level I screening was to identify serious mental illness, and establish if the resident qualified for a Level II referral and to ensure the residents received the mental health services they were assessed for. Interview, on 09/21/19 at 10:30 AM, with the Administrator, revealed it was his expectation nursing staff would have let the SSD know a resident had received a new mental health diagnosis, and then the SSD would have reacted and completed a new Level I. Continued interview revealed it was important that a new Level I screening was completed, and it could potentially prompt a referral for a Level II and subsequent mental health care. Subsequent interview, on 09/21/19 at 10:53 AM, with the DON revealed, prior to the surveyor identifying the PASARR concern, it was not her expectation the nursing staff would have communicated a new 056483 Page 11 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0644 diagnosed mental illness to the SSD; however, that was the process now. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056483 Page 12 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to ensure a discharge plan of care was completed for one Resident (R) 67, reviewed for discharge home from the facility. This failure had the potential to affect any current or future residents admitted , with the intention of discharging back to the community. Residents Affected - Few Findings: Review of R67's 5-day admission, Minimum Data Set (MDS), assessment, dated 05/23/19, revealed an admission date of 05/16/19, with medical diagnoses of chronic obstructive pulmonary disease (COPD), cardiomegaly (enlarged heart), generalized muscle weakness, debility, and other fracture. Review of R67's hard (paper) chart and electronic medical record, showed no care plan regarding R67's anticipated discharge. R67's care plan addressed the following focus care areas: -Abnormal bleeding related to anticoagulant use; -Alteration in gas exchange related to COPD; -Psychosocial well being related to skilled nursing placement and decline in independence; -Alteration in cardiac function related to diagnosis atrial fibrillation; -Alteration in activities of daily living function related to weakness, shortness of breath and pain; -At risk for falls related to weakness; -Potential for pain related to lumbar compression fracture; and, -Activities: Resident has need for altered activity due to muscle weakness. In an interview on 09/21/19 at 11:10 AM, the Social Services designee stated she was in charge of discharge care plans and confirmed, The discharge care plan was not done. Review of the facility policy, Care Plans - Comprehensive Person-Centered, revised December 2016, showed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident The comprehensive, person-centered care plan will: -Include measurable objectives and timeframe's; -Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . -Include the resident's stated goals upon admission and desired outcomes; 056483 Page 13 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0660 -Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 056483 Page 14 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews, the facility failed to ensure dependent residents received required assistance for Activities of Daily Living (ADLs). This affected one Resident (R12) of three sampled residents reviewed for assistance with ADLs. The facility Census and Conditions of Residents, dated 09/17/19, documented 62 residents, residing in the facility, required assistance with, or were dependent upon, staff for ADLs. This failure had the potential to result in unmet resident needs and a lack of services for the residents to maintain good nutrition, grooming, and personal hygiene. Residents Affected - Few Findings: Per the current physician's orders for R12, dated 09/2019, R12 was admitted to the facility in 2013. His diagnoses included rheumatoid arthritis, swan-neck deformity of right and left fingers, and major depressive disorder. The quarterly, Minimum Data Set, with an, Assessment Reference Date, of 06/25/19, documented R12 had a, Brief Interview for Mental Status, score of 15, which indicated he had no cognitive impairment. The assessment documented R12 had not rejected care, required limited assistance with personal hygiene, and required extensive assistance with bathing. The care plan, most recently reviewed/revised 06/30/19, documented R12's problems included impaired mobility, which limited his ADL participation due to limited range of motion in extremities, due to contractures from rheumatoid arthritis. One intervention noted was to provide assistance to R12, as needed, for the performance and completion of ADL tasks. On 09/17/19 at 12:07 PM, R12's fingernails were observed to have a significant amount of black debris under them. R12's fingers of both hands were observed to be deformed; some fingers were unable to be bent. When asked if he needed assistance with fingernail care, R12 stated, the person who usually cleaned his nails, was on leave. A review of the, Nurses' Notes, from 06/25/19 to present, were reviewed. There was no documentation R12 had refused care. The, Weekly Nursing Summary, dated 08/14/19, 08/28/19, 09/04/19 and 09/18/19, were reviewed. There was no documentation R12 had interfered with, or refused, care. The facility's, ADL Flow Record, did not address the provision of nail care. On 09/18/19 at 3:28 PM, Certified Nurse Aide (CNA)55 was interviewed. He stated he cleaned residents' fingernails weekly. When asked if he documented nail care, he stated, No. When told R12's nails all had a significant amount of a black substance under them, CNA55 stated R12 used the bathroom by himself. On 09/18/19 at 3:43 PM, R12 stated he had been given a shower by CNA55, either on 09/11/19 or on 09/14/19. He stated CNA55 had not cleaned his fingernails during the shower. He stated he would allow someone to clean his fingernails if they offered to do so. On 09/18/19 at 3:44 PM, the Director of Nursing (DON) was interviewed. When asked if it was the 056483 Page 15 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility's policy that nails could only be cleaned in the bathing area, she stated it was not. When asked if the R12's nails should have been cleaned prior to this day, the DON stated, Yes. The facility's, Activities of Daily Living (ADLs), Supporting, policy/procedure, revised 03/2018, documented: 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. 056483 Page 16 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to ensure an as-needed (PRN) anti-anxiety medication was time limited in duration, for three of five residents reviewed, for unnecessary medications (Residents: R52, R64 and R49). Record reviews revealed Ativan (medication used to treat anxiety) PRN, was ordered for these three residents; however, the physicians failed to indicate the duration of use (psychotropic medications ordered on an as-needed basis require a 14-day stop date). Additionally, the facility failed to ensure non-pharmacological interventions were attempted and documented, prior to the administration of psychoactive medications for one of the five Residents (R49) reviewed for unnecessary medications. The facility's failures had the potential to result in unnecessary medication administration for any of the 65 residents residing in the facility at the time of the survey. Findings: Review of the facility's policy titled, Medication Therapy, revised April 2007, revealed each resident's medication regimen should include only those medication necessary to treat existing conditions, and all medication orders would be supported by appropriate care processes and practices. Continued review of the policy revealed, upon or shortly after admission and periodically thereafter, the staff and practitioner (assisted by the Consultant Pharmacist) would review an individual's current medication regimen to identify whether the frequency of administration and duration of use were appropriate. 1. Review of R52's, admission Record, dated 8/19/19, located in R52's Electronic Medical Record (EMR), revealed R52 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder. Review R52's, Physician Order, dated 07/24/19, revealed an order for Ativan tablet, 1 mg by mouth every 8 hours as needed for anxiety/panic attacks. Continued review of the order revealed no duration as to when the medication would be discontinued or re-evaluated. Review of R52's, Consultation Report, dated 08/20/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R52 has a PRN order for Ativan (Lorazepam), and CMS (Centers For Medicare And Medicaid) regulations require a stop order. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x3 more months? Further review of the consultation report revealed under, Physician's Response: a check mark was beside, I accept the recommendation(s) above, please implement as written, and the consultation report was signed by R52's physician, who was also the facility's Medical Director. There was no clinical rationale to support the continued use of the medication, x3 months. Interview, on 09/18/19 at 3:09 PM, with the facility's Medical Director and R52's Attending Physician, revealed he did not know it needed to be written in the original order for 14 days. The interview revealed he signed the pharmacy recommendation for a three-month continued use, and when he signed it, that became an order. When asked if he put a clinical rational on the pharmacy recommendation that became an order, he stated, It does ask for rational, but he meant for it to be used for initial use of anxiety attacks, and his clinical rational was, continue. Further interview with the Medical 056483 Page 17 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director revealed he would not have expected the facility to have shown a stop date on the order; he would have expected the responsibility be on the Consulting Pharmacist to catch it prior to the end of the three months. 2. Review of R64's, admission Record, dated, 9/21/19, located in R64's Electronic Medical Record (EMR), revealed R64 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder. Review R64's, Physician Order, dated 04/28/19, revealed an order for Lorazepam tablet 0.5 mg. Continued review of the order revealed the Lorazepam was ordered 0.25 mg by mouth every 24 hours, as needed, for anxiety related to anxiety disorder. The order revealed no duration as to when the medication would be discontinued or re-evaluated. Review of R64's, Consultation Report, dated 05/21/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order when used beyond 14 days. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? The Consultant Pharmacist's, Rationale for Recommendation: CMS requires that PRN order for non-antipsychotic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rational for the extended time period and the duration for the PRN order. Further review of the consultation report revealed no evidence the physician responded to the pharmacy recommendation. Review of R64's, Consultation Report, dated 06/26/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order when used beyond 14 days. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? Further review of the consultation report revealed no evidence the physician responded to the pharmacy recommendation. Review of R64's, Consultation Report, dated 07/23/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? Further review of the consultation report revealed no evidence the physician responded to the pharmacy recommendation. Review of R64's, Consultation Report, dated 08/20/19, completed by the facility's Consultant Pharmacist, revealed the pharmacist comment: R64 has a PRN order for Ativan (Lorazepam), and CMS regulations require a stop order. Continued review of the consultation report revealed the pharmacist recommendation: Would you want to authorize the order to be x90 more days? Further review of the consultation report revealed on 08/27/19, R64's physician circled the pharmacist recommendation of continuing the order x90 more days and initialed where he circled and signed and dated the recommendation; however, there was no documented clinical rational to support continuing the PRN anti-anxiety medication. Interview, on 09/18/19 at 3:23 PM, with the Medical Director, revealed he was just finding out about CMS's expectation to limit the first PRN prescription to 14 days, so he could not expect R64's Attending Physician (who wrote the order for the Ativan) to know the limited duration. 056483 Page 18 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 09/20/19 at 5:23 PM, telephone interview with R64's attending physician was attempted. There was no voicemail to leave a message for a return call. Interview, on 09/20/19 at 4:09 PM, with the Director of Nursing (DON), revealed it was her expectation if the physicians were going to extend the PRN order for anti-anxiety medications past 14 days, the physicians would have given a rational why they were going to extend it. Continued interview revealed she would have expected the physician to respond to the Consultant Pharmacist's recommendations in a timely manner. The DON stated she would not have expected the physician to write the PRN order with a stop date; however, she would expect the physician to indicate a duration on the order. Interview, on 09/21/19 at 10:34 AM, with the Administrator, revealed it was his expectation for PRN anti-anxiety medications, nursing would have checked the order, and if it did not have a duration, nursing should have contacted the doctor. 3. Review of R49's Annual, Minimum Data Set (MDS), assessment, dated 11/17/18, revealed an admission date of 11/13/18, with medical diagnoses that included generalized muscle weakness, dorsalgia (upper back pain), aortic valve disorder, panic disorder, and chronic pain. Review of R49's EMR, Orders, tab revealed the physician had prescribed Lorazepam (brand name Ativan; an anti-anxiety medication) 0.5 milligrams (mg) one tablet every 6 hours, as needed, for agitation related to panic disorder, not to exceed 2 mg per day. A review of the August PRN medication administration record (MAR) showed R49 received Ativan on 8/10/19, for anxiety; the result was, helpful, but no non-pharmacological interventions were noted as having been attempted prior to medication administration, as required. R49 received Ativan on 08/22/19, for increased anxiety; the result was, helpful, however, no non-pharmacological interventions were documented. R49 received Ativan on 08/26/19, for increased agitation, noted to be, effective, however, no non-pharmacological interventions were documented. A review of the July PRN MAR showed R49: 07/28/19, received Ativan for increased anxiety - noted, eff (effective); no non-pharmacological interventions documented; 07/26/19, Ativan for signs/symptoms (s/sx) of anxiety; noted, helps, no non-pharmacological interventions documented; 07/25/19, Ativan for s/sx of anxiety; noted, helps, no non-pharmacological interventions documented; 07/20/19, Ativan for complaints of anxiety; noted, helps, no non-pharmacological interventions documented; 07/19/19, Ativan for increased anxiety; noted, helps, no non-pharmacological interventions documented; 07/19/19 (second dose for the 24-hour period), Ativan for increased anxiety; noted, helps, no non-pharmacological interventions documented; and, 056483 Page 19 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0758 07/05/19, Ativan for anxiety; noted, helps, no non-pharmacological interventions were documented. Level of Harm - Minimal harm or potential for actual harm Review R49's hard chart July and August 2019, Interdisciplinary Progress Notes, did not show any non-pharmacological interventions, most of the PRN doses had no Nurses' Progress Notes at all. Residents Affected - Few In an interview on 09/19/19 at 4:14 PM, the Director of Nursing (DON) stated, Non-pharmacological interventions for PRN psychoactive medications are being done, but not documented. Like, I will have him in my office for coffee and cookies - but I don't document it. In an interview on 09/20/19 at 9 AM, the Administrator stated the facility did not have a policy regarding non-pharmacological interventions for psychoactive PRN medications. In an interview on 09/20/19 at 9:45 AM, regard non-pharmacological interventions before administering psychoactive medications, Licensed Vocational Nurse (LVN)38 stated, Oh, I try other things like redirection or toileting, but I don't chart them. 056483 Page 20 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, review of facility policy and review of a, User Instruction Manual, the facility failed to ensure adequate infection control standards of practice were implemented; and failed to follow manufacturer's recommended cleaning instructions for equipment cleaning and maintenance to prevent the spread of infections. Poor infection control standards of practice had the potential to spread infections from one resident to another for all 12 of the residents who received blood glucose monitoring at the time of the survey. Residents Affected - Some Findings: Multiple medication administration observations were conducted throughout the survey. These observations revealed the facility staff failed to: a. Clean the glucose meter with an EPA (Environmental Protection Agency)-registered disinfectant, as recommended in the, User Instruction Manual (specific to the glucometer used by the facility), for one Resident (R9) of three residents observed receiving a fingerstick blood sugar (FSBS) testing; and, b. Use appropriate infection control and hand hygiene procedures while obtaining FSBSs to prevent cross-contamination for one Resident (R20) of three residents observed receiving blood glucose monitoring. In an interview on 09/19/19 at 9:35 AM, the Director of Nursing (DON) stated 12 residents in the facility had a physician's order for a FSBS. 1. The undated, Face Sheet, for R9 documented he had been admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. R9's current physician's orders documented he was to have a FSBS with meals. On 09/19/19 at 8:18 AM, Licensed Vocational Nurse (LVN) 38 was observed as she performed blood glucose monitoring on R9. Upon completing the FSBS, LVN38 placed the glucose meter in a plastic container and set the container on top of the medication cart. She proceeded to administer R9's insulin. Without disinfecting the meter, LVN38 returned it to a drawer in the medication cart and moved the medication cart down the hall. On 09/19/19 at 8:35 AM, after she had administered oral medications to two residents, LVN38 was asked what the facility's policy was for disinfecting the glucose meter. She stated she cleaned the glucose meter with an alcohol pad prior to using it. She stated she cleaned the meter between residents throughout the shift with an alcohol pad. She stated she used a Sani Cloth, first thing in the morning, when she cleaned the medication cart. LVN38 stated she, generally didn't use a Sani Cloth between residents. She again stated she used just an alcohol pad to clean the glucometer between residents. On 09/19/19 at 9:35 AM, the DON stated there were 12 residents who had a physician's order for a FSBS. She stated seven of the 12 residents resided on the Station 2 hall where R9 resided and LVN38 was working. She further stated one of the residents on the Station 2 hall, who received FSBSs, had a history of receiving treatment for Hepatitis C. This resident had completed the 056483 Page 21 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatments/medication on 09/04/19, and would not be re-tested for Hepatitis C for six months from the last dose. When asked about the facility's policy for disinfection of a glucose meter, the DON reviewed the glucose meter. User Instruction Manual. and the facility's. Blood Sampling - Capillary (Finger Stick), policy and procedure, revised 09/2014. After her review, the DON stated the meter should be cleaned with an EPA-registered disinfectant between residents. When asked if an alcohol pad was appropriate to use for disinfection of a glucose meter between residents, the DON stated, It has to be an EPA-registered disinfectant. When asked if LVN38 had followed the facility's policy and procedure for cleaning the glucose meter, the DON stated, No. On 09/19/19 at 10:44 AM, LVN85, an agency nurse who was working her second shift at the facility, was interviewed regarding cleaning a glucometer. She stated she cleaned the glucose meter with alcohol pads after use and before putting the meter back into the medication cart drawer. She stated she had performed FSBS for residents during the previous shift she had worked at the facility and had cleaned the glucose meter with alcohol pads then. LVN85 stated she had received no orientation in the facility. She further stated she used either Sani Cloths and alcohol pads interchangeably, since they disinfect the same way. On 09/19/19 at 12:47 PM, LVN85 was observed as she performed a FSBS for R9. Following the FSBS, LVN85 used an alcohol pad to clean the glucometer. She stated she was the last one who used the meter prior to finger stick and used alcohol to clean it, so she knew it was clean. On 09/19/19 at 12:51 PM, LVN85 was informed she should speak to the DON prior to completing anymore blood glucose checks. 09/19/19 at 12:57 PM, the DON was informed the survey team had serious concerns regarding inadequate disinfecting of the glucose meters between resident testing. The observations of the use alcohol pads, only, failed to provide adequate disinfecting of the machines, per the manufacturer's guidelines (available on the medication carts); and interviews with the facility staff confirmed this was standard operating procedure for glucometer use in the facility. The glucose meter's, User Instruction Manual, documented: Cleaning [and] Disinfecting Guidelines Cleaning and disinfecting can be completed by using a commercially available EPA registered disinfectant detergent or germicide wipe. The facility's, Blood Sampling - Capillary (Finger Sticks), policy and procedure, revised 09/2014, documented: .Equipment and Supplies.Approved EPA registered disinfectant for cleaning of sampling device.Steps in the Procedure.Following the manufacturers' instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. 2. On 09/19/19 at 8:01 PM, LVN87 was observed as she prepared supplies to perform a FSBS for R20. LVN87 donned gloves at the medication cart, picked up the supplies (glucose meter, lancet, and cotton balls in a plastic medication cup), took them into R20's room and set them down onto the over-bed table. The over-bed table had not been cleaned. LVN87 realized she had forgotten to get an alcohol pad, removed her gloves and set them on the unclean over-bed table next to the other supplies. She then left the room, went to the medication cart, used her keys to unlock the cart, opened the drawer, removed an alcohol pad, closed the drawer, locked the cart and re-entered R20's room. LVN87 donned the same gloves she had left on the unclean over-bed table and administered R20's insulin. 056483 Page 22 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 09/19/19 at 8:11 PM, LVN87 was interviewed. When asked if the facility's policy required clean supplies to be placed on a clean barrier, she stated, Absolutely. When asked if she had set the FSBS supplies onto a clean over-bed table, she stated she had not. The observations of LVN87 leaving R20's room to get an alcohol pad was reviewed with her. When asked if she should have washed her hands and donned clean gloves after she left the room to get the alcohol pad and prior to administering the insulin, LVN87 stated, Yes, I should have. On 09/19/19 at 9:35 AM, the above observations were reviewed with the DON. When asked if LVN87 had used appropriate infection control standards of practice to prevent cross-contamination, the DON stated, No. The facility's, Blood Sampling - Capillary (Finger Sticks), policy and procedure, revised 09/2014, documented: .Steps in the Procedure.Place blood glucose monitoring device on clean field. On 09/20/19 at 9:07 AM, the above observations were reviewed with the DON. When asked if she would expect staff to set clean FSBS supplies on a clean barrier, she stated, Yes. When asked if she would expect staff to use good hand hygiene and clean gloves, she stated, Yes. 056483 Page 23 of 24 056483 09/21/2019 Sherwood Oaks Post Acute Care, LLC 130 Dana Street Fort Bragg, CA 95437

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to ensure the wheelchairs for two of seven Resident's (R57 and R62) had armrests which were not in a state of disrepair, potentially resulting in an alteration in the residents' skin integrity; additionally, the broken surfaces presented a potential source of contamination due to having un-cleanable surfaces that could harbor bacteria. This failure had the potential to affect any of the 65 residents who used a wheelchair while in the facility. Residents Affected - Few Findings: Observation of R57's wheelchair on 09/18/19 at 9:19 AM, showed the wheelchair's vinyl armrest was torn or worn off on a large section of the right armrest, and the vinyl on both armrests was cracked and no longer a smooth and cleanable surface. Observation of R62's wheelchair on 09/20/19 at 2:38 PM, showed the wheelchair's vinyl armrest was cracked and peeling. On 09/21/19 at 9:04 AM, the Administrator was shown R57's and R62's wheelchair armrests. Upon observation of R62's wheelchair, the Administrator confirmed the armrests had cracked, peeling vinyl that needed replacing. Upon observation of R57's wheelchair armrest with a large area of vinyl missing, the Administrator stated, it [armrest] should have been changed out a while ago. The Administrator confirmed the armrests needed replacing, and stated he did not believe his, maintenance supervisor had a PM [preventative maintenance] program for the wheelchairs yet. The Administrator was asked about a facility maintenance policy, and at 11:35 AM, the Administrator stated he was unable to find a policy regarding wheelchair maintenance. 056483 Page 24 of 24