Other·August 13, 2019

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a Federal Recertification survey. Representing the Department of Public Health: HFEN, 16519 HFEN, 29821 HFEN, 35598 HFEN, 39255 HFEN, 39797 The facility census was 97.

F609 SS=E Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 05/13/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on observations, interviews and record reviews, the facility failed to report 3 allegations of resident to resident and employee to resident abuse to the State Licensing Agency for three sampled residents (Residents 49, 392, and 47) for a facility census of 97. This failure resulted in the Department not being informed of information needed to guide investigations into potential risks of physical and or psychological harm to a vulnerable resident population. Findings: 1. Resident 49 was initially admitted to the facility in August of 2017. Resident 49's admission diagnoses included a stroke affecting left non-dominant side (injury to the nervous system resulting in a significant loss of strength and mobility on one side of the body), other abnormalities of gait and mobility, and generalized muscle weakness. Resident 49's Quarterly Cognitive Assessment, dated February 18, 2018, indicated the BIMS (a brief interview tool to assess resident mental status) 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE score was 14 out of a possible score of 15 (indicated Resident 49 had the mental capacity to understand choices and make healthcare decisions). During an interview on 4/10/18 at 10:15 a.m., when asked if any forms of abuse were experienced at any time during her stay in the facility, Resident 49 stated, "I have, but I just let it go. We have a lot of people coming into our rooms, they are mentally ill." When asked if the concern was reported to staff, she stated, "They know who they are." During concurrent interviews conducted in the Resident Council meeting on 4/11/18 at 10:10 a.m., when attendees were asked if they were aware of how grievances were reported, and if any of the attendees had submitted grievances 1 of 8 residents answered yes. Resident 49 was identified as the resident reporting a grievance. When asked if the grievance resolution met the Resident's expectation, Resident 49 again answered, "No, I just let it go." During a follow up meeting with Resident 49 on 4/11/18 at 11:15 a.m., the Department addressed Resident 49's grievance concerns. Resident 49 stated, "Nurse [Certified Nurse Assistant- CNA 1] left me in the floor (sic). I fell, she knew I was falling. I turned on my light, the help never came. I had to do it on my own. She [CNA 1] came by and saw me trying to get in bed alone. We got into an exchange of words. She yelled at me, I yelled back. I fell to the floor, more like slid to the floor." Per Resident 49, CNA 1 stated that it was the end of her shift. Resident 49 shared that she remained on the floor approximately 10-15 minutes before two nurses from the next shift arrived to assist resident from the floor. Resident 49 shared that [LN 2], "The medication pass nurse on the 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE night shift" provided the Resident with a copy of the facility's grievance form. Resident 49 explained she filled out the form and returned the form to LN 2 for submission to Administration. Resident 49's Progress note titled "Incident note" entered on 10/12/17 at 10:00 p.m., LN 2 stated "nt [sic] found on the floor, patient said that she has been on her w/c [wheelchair] for 2 hours, and she slide from the w/c while she was trying to transfer herself to bed. Has no c/o [complaint of] pain at this time. no sign and symptom of injury observed at this time. on neuro check. [Staff] informed and order to monitor the patient. RP [responsible party], daughter notified (sic)." During an interview on 4/13/18 at 10:30 a.m., the Administrator denied reporting the incident to the Ombudsman, California Department of Public Health, or Certified Nursing Assistant [CNA] Board. A review of undated facility policy titled "Reporting Abuse to State Agencies and Other Entities/Individuals", "Policy Statement indicated: All alleged/ suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate State agencies and other entities or individuals as may be required by law...Policy Interpretation and Implementation...Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: The State Licensing/Certification Agency responsible for surveying/licensing the facility...,The administrator, or his/her designee, 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE will provide the appropriate agencies/individuals listed above with a written report of the findings of the investigation within (5) days of the occurrence of the incident. Should the findings reveal that abuse did occur, the written report will include the corrective actions taken by the facility to prevent abuse from recurring...Verbal/written notices to the above agencies will be made with 24 hours of the occurrence of such incident..." 2. Resident 392 was initially admitted to the facility in March of 2017. The admitting diagnoses included unspecified cerebrovascular disease (disease of the blood vessels and arteries that supply the brain), Alzheimer's Disease (a disease that causes problems with memory, thinking and behavior), anxiety disorder (emotions that result in an extreme fear or worry), unspecified dementia with behavioral disturbances, muscle weakness, and difficulty walking. Resident A was initially admitted to the facility in January of 2017. The admitting diagnoses included unspecified dementia without behavioral disturbances, major depressive disorder, single episode (a mental disorder characterized by at least two weeks of low mood that is present across most situations). A Quarterly Minimum Data Set (MDS, a resident assessment tool), dated 05/07/17 indicated the resident's BIMS score was 14 out of a possible score of 15. Resident 49 had the mental capacity to understand choices and make healthcare decisions. During a concurrent observation and interview on 4/10/18 at 10:30 a.m., the Department observed the daughter and Resident 392 in the hallway by Resident 392's assigned room. The resident was resting in a Geri-chair [chairs 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE designed to provide support while sitting]. During an interview with resident 392's daughter, who is also documented in the resident's admission record as the responsible party, when asked if the facility provided updates for changes in Resident 392's condition, the daughter stated, "Yes, they called me once when my mother was touched inappropriately by another male resident." Review of Resident 392's medical record on 04/13/18 11:15 a.m., revealed the following: Progress note dated 09/15/17 8:12 p.m., titled "Incident Note" stated, "At around 2000 [8:00 p.m.] while resident was on a Geri-chair at the hallway her room, I found one of the [Resident A] was standing by side of chair and touching her private part over her covered sheet. I take them back to their respected his rooms. Desk nurse informed he wrote a note to the resident physician to request psych evaluation for the resident and prepared a care plan (sic)." Progress note entered on 09/18/17 at 9:48 p.m., titled "Incident Notes", stated, "At around 2000 while resident was on a Geri-chair at the hallway by her room [room number]. I found one of the residents in room [room number] was standing by the side of her chair and while I was walking to them to check what he was doing. I saw her touching her around her private part over her cloth and sheet she was covered with at the time. I took them back to their respected rooms. The charge nurse, [staff name] and the desk nurse notified about the incident. The DON, [staff name] has notified [name of hospital] about the incident (sic)." Social Worker Progress note documented on 09/20/18 at 2:59 p.m., stated, "Notified during morning meeting on 9/19/17, resident was on 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE chair, while other male resident in room [room number] as observed by staff touching resident's body, around resident's private part, over resident's bed sheet, resident covered at that time. Other male resident was separated per mandated reporter. This incident occurred on 09/15/17, mandated reporter notified abuse coordinator and ombudsman, charge nurse also aware. Investigation is further pending per facility protocol. Writer followed up regarding incident, resident was unable to recall, no emotional distress noted. Social service department will continue to visit resident 3 continuous working days. then 2 days x 1 week to monitor for any emotional distress, then discontinue. Resident will continue to be treated with dignity and respect. Family continues to visit and remains very supportive, plan of care continue (sic)." Review of Resident A's medical record on 04/13/18 3:14 p.m., provided the following documentation: Progress note dated 09/15/17 at 7:55 p.m., stated, "... notified me that pt was seen in another pts room and placing his hand in her lap/crotch area. Pt was removed from room and explained that he is not to enter other patients' rooms and not to touch other patients." Progress note dated 09/15/17 at 8:22 p.m., stated, "Resident has been having a change in behavior when it comes to females in the facility. Resident has been following a certain other resident around a couple of days, resident being monitored for behavior. Charge nurse on [unit] reported that he had witnessed the resident touch another female resident, hand on lap. Request for MMSE [mental assessment] and a behavior care plan has been done and placed in resident's chart. Will 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE continue to monitor." On 4/13/18 at approximately 10:30 a.m., the Administrator provided a document dated 9/25/2017 indicating the incident was reported to the Ombudsman. The facility did not provide documentation to indicate the incident was reported to the California Department of Public Health. A review of undated facility policy titled "Reporting Abuse to State Agencies and Other Entities/Individuals", "Policy Statement indicated: All alleged/ suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate State agencies and other entities or individuals as may be required by law." "Policy Interpretation and Implementation, indicated: Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: The State Licensing/Certification Agency responsible for surveying/licensing the facility...,The administrator, or his/her designee, will provide the appropriate agencies/individuals listed above with a written report of the findings of the investigation within (5) days of the occurrence of the incident. Should the findings reveal that abuse did occur, the written report will include the corrective actions taken by the facility to prevent abuse from recurring...Verbal/written notices to the above agencies will be made with 24 hours of the occurrence of such incident..." 3. Resident 47 was initially admitted to the facility in January of 2016. The admission 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE diagnoses including a stoke affecting right dominant side injury. Resident 47's Quarterly/Annual Assessment/ Significant Change Assessment dated 1/16/18 at 12:03 p.m., indicated the resident had mental capacity to understand choices and make healthcare decisions and was the responsible party for herself. Resident 47's BIMS score was 15 out of a possible score of 15. Resident 50 was initially admitted to the facility in the month of May, 2014. The admission diagnoses included dementia [a brain disease that decreases the ability to think and remember]. The Quarterly Assessment dated 02/22/18 at 10:09 a.m., indicated Resident's BIMS score was 6 out of a possible score of 15 (indicates severe mental and cognitive impairment). During an interview on 4/10/18 at 09:10 a.m., Resident 47 was asked if she experienced any form of abuse or feared for her safety anytime during her stay in the facility. Resident 47 stated "[Resident 50] came in our room and masturbated [to stimulate one's own genitals in a sexual manner]." When I woke up in the middle of the night, he was sitting in his wheelchair at the foot of my bed masturbating. When asked if she called for assistance when this incident occurred, Resident 47 stated that, "I pushed my button it would take an hour for anyone to come. I would just yell at him tell him to go away. It was startling the first time, he has not been here in a long time." Administrator's Progress note dated 4/12/18 at 9:06 p.m., stated, "The Administrator, Director of Staff Development and Social Service Director visited resident regarding resident's allegation of other male resident in room [room number]. Per the Administrator's documentation, the resident reported the 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE incident while having a "casual conversation with her Certified Nursing Assistant the next day." During an interview with the Director of Staff Development (DSD) on 4/13/18 at approximately 3:45 p.m., she stated that new hire orientation includes a video "Your Legal Duty, Reporting Elder and Dependent Adult Abuse." The video provides step by step directions on how to complete a reporting form. The DSD stated that CNAs are considered mandatory reporters and are required to report the incident immediately. Social Services progress note dated 09/29/17 at 5:25 p.m., stated, "Notified during morning meeting, observed by Resident's CNA, resident touching his roommate in bed A on his private area, both residents were separated by mandated reporter. [form] paper work was completed and also faxed to Ombudsman, abuse coordinator, charge nurse, and DON was also notified. Investigation is further pending per facility protocol....This incident occurred 09/28/17, resident was unable to recall incident upon visit..." The facility did not provide documentation that this incident was reported to the California Department of Public Health. In an interview on 04/13/18 at 10:30 a.m., when the Administrator was asked if the incidents were reported to the State Licensing and Certification agency, the Administrator shared that he was only required to report to the Ombudsman because both residents have dementia. A review of undated facility policy titled "Reporting Abuse to State Agencies and Other Entities/Individuals", "Policy Statement indicated: All alleged/ suspected violations and 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE all substantiated incidents of abuse will be promptly reported to appropriate State agencies and other entities or individuals as may be required by law." "Policy Interpretation and Implementation, indicated: Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse be reported, the facility administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: The State Licensing/Certification Agency responsible for surveying/licensing the facility...,The administrator, or his/her designee, will provide the appropriate agencies/individuals listed above with a written report of the findings of the investigation within (5) days of the occurrence of the incident. Should the findings reveal that abuse did occur, the written report will include the corrective actions taken by the facility to prevent abuse from recurring...Verbal/written notices to the above agencies will be made with 24 hours of the occurrence of such incident..." 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG

F697 Pain Management CFR(s): 483.25(k)

F697 SS=D DEFICIENCY) COMPLETE DATE 05/13/2018 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview, medical record and document review, the facility failed to routinely assess pain for 1 of 97 residents (Resident 74). This failure potentially precluded staff from promptly identifying and intervening for pain in a resident having multiple diagnoses in which pain is a common symptom. Findings: Resident 74 was readmitted to the facility with diagnoses including bladder cancer, stroke (loss of blood flow to an area of the brain), polyneuropathy (damage to multiple extremity nerves which can cause pain), gout (a form of the joint disease arthritis which causes sudden severe attacks of joint pain and swelling), low back pain, hand contracture (muscle shortening which limits or prevents movement) and chronic pain syndrome (long-term pain caused by a medical condition or body damage). In a 3:10 p.m., 4/10/18 interview, Resident 74 stated he was experiencing "nerve pain" and 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE asked if a pain-relieving ointment could be prescribed. Review of Resident 74's April 2018 "Order Summary Report" indicated he had already been prescribed two pain medications which he received daily and additional medicine which he could request as needed. Review of Resident 74's Medication Administration Record (MAR) for the months of March and April, 2018 revealed no routine assessments for pain each shift from 3/4/18 until 4/12/18. In an 11:39 a.m., 4/12/18 interview, Resident 74 confirmed staff were not asking him each shift about his level of pain. He stated that gabapentin, a pain medication ordered for nerve pain, was "not even close" to relieving his pain. During an 11:18 a.m., 4/12/18 interview, the Assistant Director of Nursing stated that staff should assess pain every shift. In an 11:22 a.m., 4/12/18 interview and concurrent medical record review, the Medical Records Supervisor explained that the reminder for staff to assess pain every shift was missing on Resident 74's MAR. Review of the resident's care plans reflected, "The resident's existing conditions which may increase pain and/or discomfort: arthritis, neuropathies, cancer, osteoporosis [bone tissue thinning], fractures, shingles [viral infection that causes a painful rash], peripheral vascular disease [blood vessel condition causing narrowing and hardening of the arteries supplying the legs and feet], ulcers [skin or mucous membrane sores], contractures, paresthesia r/t [tingling sensation 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE related to] stroke." Care plan interventions included: - "Assess for pain or discomfort...q [every] shift," - "Monitor/record pain characteristics q shift and PRN [as needed]," - "Monitor/record ...any s/sx [sign or symptom] of non-verbal pain," - "Anticipate the resident's need for pain relief," - "Assess whether pain intensity acceptable to resident," - "Monitor pain after exercise or weight bearing," and - "Monitor/document complications related to constipation...[including] abdomen tenderness." Care plan goals included, "The resident will be free of any discomfort." Review of the facility's 2001 "Pain Assessment and Management Policy" reflected, "The pain management program is based on a facilitywide commitment to resident comfort...Pain management...includes the following: Assessing the potential of pain...Effectively recognizing the presence of pain...Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain...Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record...." 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=D DEFICIENCY) COMPLETE DATE 05/13/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to properly label and store food for 1 of 22 sampled residents (Resident 75) when pickles and soy sauce were stored at the bedside. This failure had the potential to expose Resident 75 to unsafe food with the potential pathogen [dangerous bacteria/virus] exposure which can cause severe illness or death in the 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE elderly population. Findings: During an observation on 4/10/18 at 9:10 a.m., a jar of unopened pickles and half full bottle of soy sauce were noted on top of a bookshelf in Resident 75's room. The pickle manufacturer label read, "Always keep refrigerated" and "Use by 3/3/18". The soy sauce manufacturer label read, "Refrigerate after opening" and "Best by 2/22/17". There was no additional facility labeling noted on either container. During an interview with the Assistant Director of Nursing (ADON) on 4/11/18 at 3:25 p.m., she acknowledged the items should be refrigerated as per the labeled instructions. The ADON also confirmed the items were expired. The ADON stated she was unsure from whom or when the items were brought in for Resident 75, but it was not in accordance with the facility's policy. A review of the facility's undated policy titled, Bringing In Food For A Resident, instructed, "...Food...should be labeled and dated to monitor for food safety...Any suspicious or obviously contaminated food...will be thrown away immediately... The Facility does not provide refrigeration space for cooked or perishable foods brought in..."

F867 SS=E QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 05/13/2018 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on observation, interview with facility staff & residents, and document review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to develop and maintain an effective plan of action to correct an identified problem prone deficient practice, for a facility census of 78 residents. During the previous 4/21/2017 re-certification, survey the facility was cited for failure to provide a functioning resident call light system in one random resident room at nurses station one (1), and for resident room 36 on nurse's station two (2). During the current 4/13/18 re-certification survey the call light system was still not functioning properly in 19 resident rooms, (rooms 30 - 48). This failure prevented residents from being able to call caregivers in time of need and had the potential to cause serious harm if residents were unable to contact staff when needed. Findings: The facility's call light system included both visual and auditory components to alert nursing staff to resident need. The visual component included indicator lights located in the hallways above each resident room door, which 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE illuminated when a call light in that room was activated. A call light console located at the nursing station also displayed room light indicators. A second system component included an alarm designed to sound when a call light was activated. The alarm was audible throughout the nursing unit. On 4/10/18 at 3:29 p.m., the call light console in the Station 2 nursing desk was heard to be continuously ringing with no room indicator lights lit on the panel. Call light indicators located above each resident room door in the hallways did not light up, indicating no call light had been activated from that room. When the same observation was made at 8:19 a.m., 4/11/18, LVN 1 was asked in which resident room a call light had been activated. She was unable to determine this from the call light console. LVN 1 checked the hallway lights and said, "No [call] lights are on." At 8:27 a.m., 4/11/18, LVN 1 indicated the maintenance department had been called and would be assessing the situation. After multiple observations between 4/10/18 4/13/18, the situation remained unchanged as of 1:36 p.m., on 4/13/18. Staff could not be audibly alerted to a newly activated call light since the signal was sounding continuously. In order to know that a resident call light had been turned on, staff would have to notice a lit visual indicator in the hallway above that resident's door. On 4/13/18 at 8:31 a.m., an interview was conducted with the Maintenance Supervisor (MS). When questioned about repair progress the MS stated he was "still working on [the system]." He indicated he was being periodically called away from the project to address other maintenance issues and was 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE unable to state when the system would be repaired. During a 1:31 p.m., 4/13/18 interview, the Administrator indicated the nurse call system had a "short" in it and said it would take time to find the location of the electrical problem. He stated the MS was "actively trying to repair" the system and the Administrator hoped to locate the source of the short "within two weeks." Review of correspondence provided by the Administrator revealed that contractor bids for replacement of the call light system were sent to the facility on 5/16/17 and 5/18/17. The Administrator did not send the bid information to the owner for approval for 9 months, on 2/19/18. The Administrator acknowledged the call light system functionality had been identified as a deficient practice during the previous 4/21/17 re certification survey. The Plan of Correction for the 4/21/17 deficient practice read: "The maintenance supervisor shall monitor the call light system by completing a test of the call light system monthly for six (6) months. ... The maintenance supervisor shall review and monitor findings monthly for 6 months. Trends identified shall be reviewed for any changes with the quality assurance committee for the duration of six months for compliance by the maintenance supervisor." Review of the "Monthly Testing of Call Light System" log revealed the following: May 2017, Three (3) call light modules required repair, (room 14, 26, and 47). June 2017, One (1) call light module required repair, in room 47. 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE July 2017, Two (2) call light modules required repair, room 8, and 25. August 2017, Six (6) call light modules required repair, room 1, 6, 16, 32, 39, and 45. September 2017, Two (2) call light modules required repair, room 16, and 32. October 2017, Three (3) call light modules needed repair room 3, 23, and 36. From October 2017 until 4/13/18, (6 months), no further action was taken even though the call system was still malfunctioning, as evidenced by the 4/13/18 re-certification findings of faulty call lights in 19 resident rooms, and the malfunctioning audible alert at nurses station 2, when no call lights had been activated. The Administrator provided no documented evidence showing the malfunctioning call light system had been reviewed by the QA Committee, made a determination whether issue was resolved or required further ongoing, or more frequent monitoring, and/or if a new plan of action was warranted to address the deficient practice.

F919 SS=E Resident Call System CFR(s): 483.90(g)(2)

F919 05/13/2018 §483.90(g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. §483.90(g)(2) Toilet and bathing facilities. This REQUIREMENT is not met as evidenced 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE by: Based on observation, interview and document review, the facility failed to maintain and promptly repair the nurse call light system. This failure potentially affected responsiveness to residents in 19 rooms (rooms 30 - 48) because staff were unable to rely on the system's audible alarm to determine by that a call light had been activated. Findings: The facility's call light system included both visual and auditory components to alert nursing staff to resident need. The visual component included indicator lights located in the hallways above each resident room door which illuminated when a call light in that room was activated. A call light console located at the nursing station also displayed room light indicators. A second system component included an alarm designed to sound when a call light was activated. The alarm was audible throughout the nursing unit. At 3:29 p.m., 4/10/18, the call light console at the Station 2 nursing desk was heard to be continuously ringing. No room indicator light was lit on the panel and no hallway call light indicator was illuminated. When the same observation was made at 8:19 a.m., 4/11/18, LVN 1 was asked in which resident room a call light had been activated. She was unable to determine this from the call light console, checked the hallway lights and said, "No [call] lights are on." At 8:27 a.m., 4/11/18, LVN 1 indicated the maintenance department had been called and would be assessing the situation. 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE 4/13/18, the situation remained unchanged at 1:36 p.m., 4/13/18 When asked about repair progress in an 8:31 a.m., 4/13/18 interview, the Maintenance Supervisor (MS) stated he was "still working on [the system]." He indicated he was being periodically called away from the project to address other maintenance issues and was unable to state when the system would be repaired. During a 1:31 p.m., 4/13/18 interview, the Administrator indicated the nurse call system had a "short" in it and said it would take time to find the location of the electrical problem. He stated the MS was "actively trying to repair" the system and the Administrator hoped to locate the source of the short "within two weeks." Review of correspondence provided by the Administrator revealed that contractor bids for replacement of the call light system were sent to the facility on 5/16/17 and 5/18/17. Bid information was sent from the Administrator to the facility owner several months later on 2/19/18. The Administrator acknowledged call light system functionality had been written as a survey deficiency in the past.

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 05/13/2018 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain the roof and ceiling of the back dining room for a census of 97 when the ceiling was witnessed to be leaking and in disrepair. This failure had the potential to pose a safety risk due to the roof structure or dry wall being compromised. There was a concern for the potential health risks for Residents if moisture associated organism growth was occuring. Findings: During an observation on 4/11/18 at 5:07 p.m., extensive brown and black colored staining was noted on the back dining room ceiling. Portions of the drywall were cracking and deteriorating. The damage measured approximately 6 feet in length in two different sections of the ceiling. There were brown drip marks noted running down the support beams. A brown discoloration was noted on the floor under a portion where the ceiling was damaged and cracked. During the Resident Council Interview conducted on 4/11/18 at 10:00 a.m., a confidential Resident stated the back dining area, "Smells like black mold". Another Resident stated, "There is always a smell back there during rain days." In an interview with the Activities Lead (AL) on 4/11/18 at approximately 5:15 p.m., she stated the back dining room was used for residents 555673 04/13/2018 ASBURY PARK NURSING AND REHABILITATION CENTER 2257 Fair Oaks Boulevard Sacramento, CA 95825 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE who require assistance with dining and for activities. The AL stated the dining room was closed as recently as last week due to, "Bad weather". The AL stated the roof leaks, "When it rains". In a 4/12/18, 9:16 a.m. concurrent observation and interview with the Maintenance Supervisor (MS), he acknowledged the ceiling damage and the staining on the floor. The MS stated the ceiling has been in disrepair for, "About 6 months". The MS added the, "Roof and drywall needs to be replaced... I can't keep patching it, it will continue to leak until the roof is replaced." The MS stated when the roof is leaking buckets are placed on the floor to catch the dripping. Residents are moved out to the front dining room for activities and meals. In an interview with the Administrator (LNHA) on 4/13/18 at 1:30 p.m., he stated the ceiling had been that way for approximately 6 months. The LNHA stated the repairs were being held waiting for the, "Rainy season" to end. He explained the facility needed to get "new bids" for the repair work.