Health inspection·January 29, 2024

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure an assessment was completed upon readmission to the facility for one of one sampled resident (Resident 71). Residents Affected - Few This failure had the potential to result in unsafe and incompetent care provided to Resident 71 and had the potential to result in unaddressed changes of condition and a physical decline to Resident 71. Findings: During a review of Resident 71's admission Record (AR), the AR indicated Resident 71 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included dementia (a decline in mental ability severe enough to interfere with daily life), insomnia (problems falling and staying asleep) and hypertension (elevated blood pressure). During a review of Resident 71's Generations Post-Acute admission Data Collection (GPAADC), dated 1/1/24 at 6:31 pm, the GPAADC indicated Resident 71 did not have a history of skin issues. The skin evaluation section indicated Resident 71's skin was intact (not damaged or impaired in any way; complete) and did not indicate the presence of PIs upon admission. During a review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/18/24, the MDS indicated Resident 71 was cognitively intact (ability to think and process information). During a review of Resident 71's Generations Comprehensive Nursing Note (GCNN), dated 1/26/24 at 1:50 pm, the GCNN indicated Resident 71 was transferred to a general acute care hospital (GACH) at 8:35 am due to chest pain. The GCNN indicated Resident 71 did not have any wounds or PIs. During a review of Resident 71's Progress Notes (PN), dated 1/26/24 at 11:42 pm, the PN indicated Resident 71 was re-admitted the facility from GACH. The PN did not indicate any issues with Resident 71's skin. During a review of Resident 71's Generations Weekly Skin Evaluation (GWSE), dated 1/27/24 at 1 pm, the GWSE indicated Resident 71 had a new pink and dark red discoloration on Resident 71's left inner buttock measuring 2.5 centimeters (cm, unit of measurement) length x 1.6 cm width x 1 cm depth. During a review of Resident 71's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation Page 1 of 33 555737 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few note, dated 1/27/24 at 1:15 pm, the COC indicated Resident 17 had a new Stage 2 PI (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful). During an interview and concurrent record review with Licensed Vocational Nurse 2 (LVN 2) on 1/29/24 at 11:37 am, LVN 2 stated upon admission or re-admission to the facility, Resident 71's skin should have been assessed for any abnormalities (an abnormal feature, characteristic, or occurrence) such as skin discolorations, skin tears and PIs especially on the heels, sacrum (a triangular bone in the lower back), and coccyx (a small bone at the base of the spinal column). During an interview and concurrent record review of Resident 71's paper and electronic medical record, with the Director of Nursing (DON), on 1/29/24 at 3:01 pm, the DON stated licensed nurses should assess the resident's (in general) skin as soon as residents arrive to the facility for any skin impairments, discolorations, skin tears, or PI's and report any changes to the resident's physician. The DON stated accurate skin assessments were important to care for any skin issues [residents may present with upon admission]. The DON stated Resident 71's skin was not assessed directly upon readmission on [DATE] and a PI could develop within a couple of hours. The DON stated, I don't know where or when [Resident 71's] wound originated from. During a review of the facility's policy titled Skin Assessment, dated 1/26/24, indicated it was the facility's policy to perform full body skin assessments as part of our(facility) systemic approach to pressure injury prevention and management. This policy included the following procedural guidelines in performing the full body skin assessment. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. 555737 Page 2 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 173's admission Record, (AR), the AR indicated Resident 173 was admitted to the facility on [DATE] with multiple diagnoses including acute (sudden) respiratory failure (when the lungs can't get enough oxygen into the blood) with hypoxia (low levels of oxygen in your body tissues), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and neoplasm (cancer, a new and abnormal growth of tissue in some part of the body) related pain. During a review of Resident 173's BIMS (Brief Interview Mental assessment) SNF (Skilled Nursing Facility) Resident Interview, dated 1/25/23, the BIMS indicated Resident 174 had no impairment in cognitive skills (the ability to make daily decisions). During a review of Resident 173's Order Summary Report, the Order Summary Report (OSR), with active orders as of 1/26/24. The OSR indicated, Resident 173 had a physician's order, dated 1/23/24, to receive O2 (oxygen) at 2L (liter, unit of volume) by nasal cannula (N/C, a tube used to deliver oxygen to help with breathing). During a concurrent interview and record review on 1/27/24 at 11:57 a.m. with the Director of Nursing (DON), Resident 173's baseline care plan, titled Generations Post-Acute admission Data Collection, dated 1/23/24 was reviewed. The baseline care plan indicated Resident 173 did not have respiratory issues. The DON stated the base line care plan was incorrect and should indicate Resident 173 had respiratory issues and should also indicate interventions to address Resident 173's respiratory issues. The DON stated the baseline care plan needed to be accurate to know what staff must do to meet Resident 173's needs. During a review of the facility's P&P titled, Baseline Care Plan, dated 6/1/22, the P&P indicated, The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident During a review of the facility's policy and procedure (P&P), titled, Baseline Care Plan, date reviewed/revised 5/23/23, the P&P indicated, a baseline care plan will be developed within 48 hours of a resident's admission. The P&P indicated, interventions shall be initiated that address the resident's current needs including any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. The P&P indicated, a supervising nurse shall verify within 48 hours that a baseline care plan has been developed. Based on interview and record review, the facility failed to ensure baseline care plans plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) for two of two sampled residents (Resident 120 and 173) were developed, complete, and implemented within 48 hours of admission to include: 1. 555737 Page 3 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0655 Level of Harm - Minimal harm or potential for actual harm Resident 120's risk for developing a pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). 2. Residents Affected - Some Resident 173's respiratory (related to breathing) issues. These failures had the potential to result in Residents 120 and 173 not to receive interventions to address the residents' specific needs, and the failures could have resulted in Residents 120 and 173 to experience a physical decline. Cross Reference F695 Findings: 1. During a review of Resident 120's admission Record (AR) the AR indicated, Resident 120 was admitted to the facility on [DATE] with multiple diagnoses including unspecified fracture (bone break) of the shaft (main or midsection) of left tibia (a break of the larger lower leg bone below the knee joint), subsequent encounter for closed fracture with routing healing, unspecified fracture of upper end of left shaft tibia, subsequent encounter for closed fracture with routine healing, other abnormalities of gait (walk) and mobility (when a person is unable to walk in a typical way), need for assistance with personal care, and unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), without behavioral disturbance, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disturbance, and anxiety ( a feeling of fear, dread, and uneasiness). During a review of Resident 120's Progress Notes (PN) dated 1/19/24, timed at 10:50 p.m., the PN indicated, Resident 120 arrived from GACH (general acute care hospital). The PN indicated, Resident 120 had surgery on 1/18/24. The PN indicated, Resident 120 was incontinent (having no or no voluntary control over urination or defecation [discharge of feces from the body]) of bowel and bladder. During a review of Resident 120's admission Data Collection (ADC), dated 1/19/24, timed at 11:16 p.m., the ADC indicated Resident 120 had no history of skin issues and the skin integrity review did not indicate Resident 120 had PIs upon admission. The ADC indicated, Resident 120 was incontinent of bowel, had urinary incontinence, and had musculoskeletal (concerning, involving, or made up of both the muscles and the bones) issues. During a review of Resident 120's Braden Scale for Predicting Pressure Sore Risk (BSPPSR), dated 1/19/24 timed at 11:55 p.m. the BSPPSR indicated, Resident 120 was occasionally moist, mobility was slightly limited, and Resident 120 had a potential problem with friction (movement of one surface against another) and shear (a horizontal force that causes the bony prominence to move across the tissue as the skin is held in place). The BSPPSR indicated Resident 120 had a score of 17 and a score between 15 and 18 placed residents (in general) at risk for developing PIs. During a review of Resident 120's History and Physical (H&P), dated 1/22/24, the H&P indicated, Resident 120 was awake, alert, oriented, and not in distress. The H&P indicated, Resident 120 had an open reduction and internal fixation (ORIF, putting pieces of a broken bone into place using surgery) 555737 Page 4 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0655 of Resident 120's left tibia. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 120's Minimum Data Set (MDS, an assessment and screening tool), dated 1/25/24, the MDS indicated, Resident 120's cognitive (ability to think and process information) skills for daily decision making were moderately impaired. The MDS indicated, Resident 120 required partial to moderate assistance to roll from lying on back to Resident 120's left and right side and returning to lying on back on the bed. The MDS indicated, Resident 120 had frequent urinary incontinence and was always incontinent of bowel. The MDS indicated, Resident 120 was at risk of developing PU/PI. Residents Affected - Some During a concurrent interview and record review on 1/27/24 at 4 p.m. with the Director of Nursing (DON) and the Director of Clinical Resources (DCR), Resident 120's medical records were reviewed. The DON stated, Resident 120 was admitted to the facility from assisted living (a housing facility for people with disabilities or for adults who cannot or who choose not to live independently) where Resident 120 sustained a fall and went to GACH for a fracture (bone break). The DON stated, the DON was unable to find a baseline care plan in Resident 120's medical record that addressed Resident 120's risk for developing PIs. The DON stated, a baseline care plan should have been created for Resident 120. The DCR stated, Resident 120 did not have PI upon admission to the facility. The DCR stated, a care plan should have been created within forty-eight hours of admission even though Resident 120 did not have actual skin breakdown because Resident 120 was at risk. The DCR stated, it was important to create a baseline care plan for Resident 120 to minimize the risk of skin impairment and to address Resident 120's risk to ensure the interventions were implemented by staff to decrease the risk for developing PIs. 555737 Page 5 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP) for two for two of two sampled residents (Residents 174 and 12): a. For Resident 174, who required oxygen (O2) therapy, the resident's care plan did not address Resident 174's respiratory (related to breathing) issues. b. For Resident 12, the facility did not develop a comprehensive CP that addressed Resident 12 had an indwelling Foley catheter (F/C, a brand for one of many brands of urinary catheters [flexible tube used to empty the bladder and collect urine in a drainage bag] and the need for dialysis (hemodialysis, a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). These failures had the potential to result in Residents 12 and 174 not to receive interventions to address the residents' specific needs, which could result in no individualized care and specific interventions needed to attain or maintain Resident 12 and Resident 174's highest practicable physical, mental, and psychosocial well-being. The failure had the potential to result in physical declines to Residents 174 and 12. (Cross reference F695) Findings: a. During a review of Resident 174's admission Record (AR), the AR indicated Resident 174 was admitted to the facility on [DATE] with multiple diagnoses including pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and hypoxemia (low levels of oxygen in your blood). During a review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/15/24, the MDS indicated Resident 174 had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 174 required supervision or touch assistance from staff for toileting, dressing, and bathing. During an observation on 1/26/24 at 8:37 p.m. in Resident 174's room, Resident 174 was receiving 2L (liters, unit of volume) O2 via nasal cannula (N/C, a tube used to deliver oxygen to help with breathing). During a concurrent interview and record review on 1/27/24 at 11:57 a.m. with the Director of Nurses (DON), Resident 174's medical records were reviewed. The medical record did not include a comprehensive care plan that addressed Resident 174's respiratory issues. The DON stated Resident 174's need for O2 should be included in the comprehensive care plan so staff would know what interventions Resident 174 needed. b. During a review of Resident 12's admission Record (AR) the AR indicated, Resident 12 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses 555737 Page 6 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0656 Level of Harm - Minimal harm or potential for actual harm including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), unspecified, chronic (persisting for a long time or constantly recurring) kidney disease (CKD), stage 4 (severe), urinary tract infection (UTI, bladder infection) site not specified, dependence on renal (kidney) dialysis, unspecified hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine) and retention of urine, unspecified. Residents Affected - Some During a review of Resident 12's Progress Notes (PN), dated 1/9/24, timed at 5:15 p.m. the H&P indicated, Resident 12 arrived to the facility and had a portacath (a small medical appliance that is installed beneath the skin) on the right chest used for hemodialysis. During a review of Resident 12's Progress Notes (PN), dated 1/10/24, timed at 6:49 a.m. the PN indicated, Resident 12 was started on dialysis on 1/8/24 and had an indwelling F/C. During a review of Resident 12's History and Physical Examination (H&P), dated 1/11/24, timed at 6:02 p.m. the H&P indicated, Resident 12 was awake, alert, oriented and not in distress. The H&P indicated, Resident 12 had a history of recurrent UTIs. Resident 12 had worsening CKD and was started on hemodialysis and currently had a urinary catheter. During a review of Resident 12's Minimum Data Set (MDS, an assessment and screening tool), dated 1/12/24, the MDS indicated, Resident 12's cognitive (ability to think and process information) skills for daily decision making was intact. The MDS indicated, Resident 12 had a urinary catheter and was receiving hemodialysis on admission and while Resident 12 was a resident at the facility. During an observation on 1/26/24 at 6:47 p.m., Resident 12 was asleep in Resident 12's bed. Resident 12 had a F/C with the drainage unit inside a dark blue colored dignity bag. The F/C was draining small amount of yellow colored urine. During an observation and interview on 1/27/24 at 8:29 a.m., with Resident 12, Resident 12 was having breakfast in bed. Resident 12's F/C was draining small amount of yellow colored urine. Resident 12 stated, Resident 12 did not know why Resident 12 had a F/C I was still a little foggy. Resident 12 stated, Resident 12 had dialysis for a week. Resident 12 was observed to have a dialysis catheter with a clean and intact cover dressing on his right chest area. During a concurrent interview and record review on 1/27/24 at 3:08 p.m. with the Director of Nursing (DON), Resident 12's medical records including all care plans were reviewed. The DON stated, Resident 12 has a F/C due to urinary retention (when the bladder does not empty completely) and was being seen by a urologist (a doctor who specializes in diagnosing and treating diseases of the urinary system). The DON was unable to find a comprehensive CP that addressed Resident 12's F/C and dialysis. The DON stated, a comprehensive CP was a plan of care that entailed a problem, a goal, and interventions to help with resident's improvements or progress and prevention to minimize any risks of complications. The DON stated, a comprehensive CP was supposed to be created within seven days of admission. The DON stated, it was important to create a comprehensive CP to help solve problems or minimize any complications of the problem and for staff to know how to focus on the interventions, knowing that Resident 12 had a history of UTIs. During a review of the facility's P&P titled, Comprehensive Care Plans, revised 9/18/23, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are 555737 Page 7 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0656 identified in the resident's comprehensive assessment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555737 Page 8 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 14), to prevent the development of new pressure ulcers [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the others)] by failing to: Residents Affected - Few Provide a Bariatric bed (specialized, heavy duty, wider and longer than a standard bed for tall resident) for Resident 14 who was six feet and five inches (6'5) tall. As a result, Resident 14 developed four facility acquired PIs (new PIs developed after the resident's admission to the facility) on the bilateral (both sides, left and right) great toes and heels. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right arms, abnormality of gait (walking pattern) and mobility (ability to move). During a review of Resident 14's Generations Post-Acute admission Data Collection (GPAADC, New admission Assessment), dated 12/12/2023, at 8:31 pm, indicated Resident 14 had no history of skin issues (conditions that affect the skin), and did not require skin interventions. During a review of Resident 14's Progress Notes (PN), dated 12/15/23, the PN indicated Resident 14 had decreased range of motion (ROM, full movement potential of a joint) on both legs. During a review of Resident14's admission Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/18/23, the MDS indicated Resident 14 had intact cognition (ability to think and process information). The MDS indicated Resident 14 did not have any unstageable PI [full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed]. During a review of Resident 14's Generations Weekly Skin Evaluation (GWSK), dated 12/19/23 and 12/26/24 indicted Resident 14's skin was intact (not damaged or impaired in any way; complete). During a review of Resident 14's Situation, Background, Assessment, Recommendation (SBAR) Communication Form (a verbal, or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/29/23, indicated Resident 14 had a significant change in condition due to a change in skin color on bilateral heels. The form indicated staff (in general) would float heels to relieve pressure on both heels. A review of Resident 14's Care Plan titled, Pressure Injury/Skin Care, initiated on 12/31/23, indicated Resident 14 had facility acquired PIs on bilateral heels and great toes. The care plan's goal was for Resident 14's PIs to heal. The nursing interventions included to administer treatments as ordered. 555737 Page 9 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0686 During a review of Resident 14's Wound Physicians Progress Note (WPPN), dated 1/2/24, indicated Resident 14 had a total of 4 wounds that included: Level of Harm - Actual harm 1. PI on the left heel measuring 4.3 centimeters (cm, unit of measurement) in length by (x) 4.6 cm in width. Residents Affected - Few 2. PI on the right heel measuring 3.8 cm x 3.2 cm. 3. PI on the left great toe measuring 1.6 cm x 1.7 cm. 4. PI on the right great toe measuring 1.7 cm x 1.5 cm. During a review of Resident 14's WPP, dated 1/23/24, indicated Resident 14 had a total of 4 wounds: 1) unstageable PI om the left heel measuring 4.0 cm x 3.6 cm. 2) unstageable PI on the right heel measuring 3.5 cm x 2.4 cm. 3) PI on the left great toe measuring 1.6 cm x 1.6 cm. 4) PI on the right great toe measuring 1.3 cm x 1.2 cm. During a review of Resident 14's Change in Condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Evaluation note, dated 1/28/2023, at 8:52 am, indicated Resident 14's PI on bilateral great toes and bilateral heels were developed on 12/31/2023. The COC indicated Resident 14's PIs on bilateral great toes and bilateral heels were facility acquired. During an observation inside of Resident 14's room and concurrent interview with Resident 14 on 1/26/24, at 5:19 pm, Resident 14 was sitting on a wheelchair, awake and alert. Resident 14 stated Resident 14 was 6 feet 5 inches tall. Resident 14 stated this morning (1/26/24), a staff member (unidentified) changed Resident 14's bed to a longer bed frame and mattress (unknow name or length). Resident 14 stated Resident 14's old bed (previous bed, standard size bed was 80 inches long) was too short for Resident 14. Resident 14 stated Resident 14 would often bump Resident 14's feet (heals and toes) and Resident 14's feet rubbed against the footboard of Resident 14's old bed. Resident 14 stated Resident 14 did not have a wound prior to being admitted to the facility, but now Resident 14 had a few wounds at the bottom of both feet. Resident 14 stated my feet hurt when I bumped them (feet) against the footboard. During an interview with Certified Nurse Assistant 5 (CNA 5), on 1/26/24 at 5:52 pm, CNA 5 stated Resident 14 was too tall for Resident 14's old bed. Resident 14 stated Resident 14 often elevated Resident 14's feet on pillows for Resident 14's feet not to touch the footboard of Resident 14's bed. CNA 5 stated Resident 14 had wounds on the heels and great toes of Resident 14's left and right feet. During an interview with the Director of Clinical Services (DCS), on 1/27/24 at 6:59 pm, the DCS stated Resident 14's PIs located on Resident 14's bilateral heels and great toes were avoidable if the 555737 Page 10 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0686 proper (extra-long) bed length was provided to Resident 14. Level of Harm - Actual harm During an interview and concurrent record review of Resident 17's GPAADC, dated 12/12/23, and SBAR dated 12/29/23 with Licensed Vocational Nurse 1 (LVN 1), on 1/27/24 at 7:39 pm, LVN 1 stated Resident 14 was admitted to the facility without skin issues. LVN 1 stated upon admission, Resident 14's toes, heels were clear and Resident 14's skin was intact. LVN 1 stated Resident 14's bed was too short and Resident 14's feet would rub against the footboard while Resident 14 was lying in bed. LVN 1 stated the PIs on Resident 14's left, and right heels and great toes were avoidable if Resident 14's bed was long enough to accommodate Resident 14's height. Residents Affected - Few During an interview with the Director of Nursing (DON) on 1/28/24 at 2:08 pm, the DON stated special accommodations should have been done for Resident 14 due to Resident 14's height (6 feet 5 inches tall). The DON stated Resident 14's bed was too short, and the DON observed Residents 14' feet touching the footboard of the bed while Resident 14 was lying in bed. The DON stated Resident 14's PIs located on Resident 14's bilateral heels and great toes were preventable. During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention and Management, implemented on 5/23/23, the P&P indicated, the facility was committed to the prevention of avoidable PI, unless clinically unavoidable, and to provide treatment and services to heal the PU/PI, prevent infection and the development of additional PU/PI. The P&P indicated, the facility should establish and utilized a systematic approach for PU/PI prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. 555737 Page 11 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 10) who was receiving enteral feeding (medical device used to provide nutrition to people who cannot obtain nutrition by mouth) through a gastrostomy tube (G-Tube, a tube inserted through the belly that brings nutrition and medications directly to the stomach) received appropriate care and services to prevent complications and in accordance with the facility's policy and procedure (P&P), titled, Care and Treatment of Feeding Tubes. This deficient practice had the potential to cause complications such as skin irritation and local infection to Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with multiple diagnoses including gastrostomy status, dysphagia (difficulty swallowing) and unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) unspecified severity, without behavioral disturbance, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disturbance, and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 10's History and Physical Examination (H&P), dated 12/18/23 timed at 6:53 p.m., the H&P indicated, Resident 10 was aspirating (when something you swallow goes down the wrong way and enters your airway or lungs by accident) and not able to swallow food at the hospital, had dysphagia S/P (status post, a term used in medicine to refer to a treatment [often a surgical procedure], diagnosis or just an event, that a patient has experienced previously) G-Tube placement. During a review of Resident 10's Minimum Data Set (MDS, an assessment and screening tool), dated 12/25/23, the MDS indicated, Resident 10's cognitive (ability to think and process information) status for daily decision making was severely impaired. The MDS indicated, Resident 10's eating activity could not be attempted due to a medical condition or safety concerns. The MDS indicated, Resident 10 had a feeding tube on admission and while Resident 10 was at the facility. During a review of Resident 10's Order Summary Report (OSR), active date as of 1/28/24, the OSR indicated, an order dated 12/18/23 to cleanse G-Tube site with soap and water and pat dry. The order indicated to observe for tube leaking, signs and symptoms of skin breakdown/redness/drainage at the site every shift. During a review of Resident 10's Treatment Administration Record (TAR), dated 1/2024, the TAR did not indicate treatment care for Resident 10's G-Tube. During a concurrent observation and interview on 1/28/24 at 8:56 a.m. after Resident 10's medication administration with Licensed Vocational Nurse (LVN) 2, Resident 10's G-Tube had an abdominal binder on. The G-Tube insertion site had no dressing cover. There was crust, flaky dry brownish reddish colored material at and around the G-Tube insertion site. LVN 2 stated, the G-Tube site looked soiled, needs to be cleaned, a new split gauge (a gauze dressing to help keep patients' skin dry and clean 555737 Page 12 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few around patient's medical drains or tubes) [placed]. LVN 2 stated, it was the night shift who was responsible for doing G-Tube care. LVN 2 stated, G-Tube care was important for infection control [purposes]. During a review of the facility's P&P titled, Care and Treatment of Feeding Tubes, date implemented 5/21/23, the P&P indicated, it was the policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The P&P indicated, licensed nurses will monitor and check the enteral retention device will be checked daily to assure it is properly approximated to the abdominal wall and that the surrounding skin is intact. The P&P indicated, one of the directions for staff on how to provide care was examining and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infections. 555737 Page 13 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 173 and 174) were provided with appropriate care and/or services for oxygen (O2) treatment: Residents Affected - Some a. Resident 173 had an order for O2 at 2 liters (L, unit of volume) via nasal cannula (N/C, a tube used to deliver oxygen to help with breathing) and was observed to be receiving 4 L on 1/26/24. b. Resident 174 was receiving 2 L of O2 via N/C without a physician's order to administer O2. In addition, the facility failed to post a sign indicating Oxygen in Use outside of Resident 174's room door as indicated in the facility's P&P titled, Oxygen Administration. These failures had the potential to result too much O2 administration and the potential to result in physical declines to Residents 173 and 174. (Cross Reference F655 and F656) Findings: a. During a review of Resident 173's admission Record, (AR), the AR indicated Resident 173 was admitted to the facility on [DATE] with multiple diagnoses including acute (sudden) respiratory failure (when the lungs can't get enough oxygen into the blood) with hypoxia (low levels of oxygen in your body tissues), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and neoplasm (cancer, a new and abnormal growth of tissue in some part of the body) related pain. During a review of Resident 173's BIMS (Brief Interview Mental assessment) SNF (Skilled Nursing Facility) Resident Interview, dated 1/25/23, the BIMS indicated Resident 174 had no impairment in cognitive skills (the ability to make daily decisions). During a review of Resident 173's Order Summary Report, the Order Summary Report (OSR), with active orders as of 1/26/24. The OSR indicated, Resident 173 had a physician's order, dated 1/23/24, to receive O2 (oxygen) at 2L (liter, unit of volume) by nasal cannula (N/C, a tube used to deliver oxygen to help with breathing). During a concurrent observation and interview on 01/26/24 at 7:57 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 173 was receiving O2 via a N/C. The O2 was set at 4L. LVN 1 confirmed the physician's order indicated for Resident 173 to receive 2 L via a N/C. LVN 1 stated nursing staff should follow the physician orders to ensure the resident did not receive too much oxygen. LVN 1 stated too much oxygen could cause Resident 173's lungs to become dependent on O2. LVN 1 stated Resident 173 was weak and susceptible to becoming too dependent on supplemental O2. During an interview on 1/27/24 at 11:57 a.m. with the Director of Nursing (DON), the DON stated each resident needed a physician's order before receiving O2. The DON stated nurses needed to follow the physician's order and provide the amount of O2 ordered. The DON stated if the physician's order indicated 2 L, then the nurses should not give 4 L. The DON stated if a resident (in general) had chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems) and received too much O2, they could have increased respiratory problems. 555737 Page 14 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0695 Level of Harm - Minimal harm or potential for actual harm b. During a review of Resident 174's admission Record (AR), the AR indicated Resident 174 was admitted to the facility on [DATE] with multiple diagnoses including pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), and hypoxemia (low levels of oxygen in your blood). Residents Affected - Some During a review of Resident 174's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/15/24, the MDS indicated Resident 174 had no impairment in cognitive skills (the ability to make daily decisions). During an observation on 1/26/24 at 8:37 a.m. in Resident 174's room, Resident 174 was receiving 2L of O2 via N/C. Resident 174's door did not have a sign indicating Oxygen in Use. During an interview on 1/27/24 at 11:57 p.m. with the DON, the DON stated a sign indicating Oxygen in Use needed to be posted on Resident 174's room doorway [door]. The DON stated the sign needed to be posted because O2 is a fire risk. During a concurrent interview and record review on 1/28/24 at 1:54 p.m. with the DON, Resident 174's Order Summary Report, dated 1/27/23, indicated Resident 174 did not have an order to receive O2. The DON stated Resident 174 needed an order from the physician before receiving O2 because O2 was a medical treatment. The DON stated the physician needed to order the amount of O2 Resident 174 received because Resident 174 had COPD. The DON stated if Resident 174 received too much O2, Resident 174's COPD might worsen. During a review of the facility's P&P titled, Oxygen Administration, dated 1/1/21, the P&P indicated, Verify there is a physician's order for this procedure. Review physician's orders or facility protocol for oxygen administration. The P&P indicated, Place Oxygen in Use sign on outside of room door. The P&P indicated, Adjust oxygen delivery device so it is comfortable for resident and proper oxygen flow is administered. 555737 Page 15 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0732 Post nurse staffing information every day. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to, for two of 30 daily nurse staffing posting information, post actual worked nursing hours at the start of each shift. Residents Affected - Few This failure resulted in inaccurate nursing hours posted by the facility and had the potential to result in residents and family members to obtain misleading information posted. Findings: During a concurrent interview and record review on 1/28/24 at 2:41 p.m. with the Director of Staff Development (DSD), the facility's daily nurse staffing document, untitled, dated 1/25/24 and Nursing Staffing Assignment and Sign-In Sheet (CDPH 530), dated 1/25/24 were reviewed. The facility's daily nurse staffing document indicated the facility staffed two Certified Nursing Assistants (CNA) on the night shift (11 pm. to 7 am.). The CDPH 530 indicated only one CNA worked on the night shift. The DSD stated the facility's daily nurse staffing document only indicated projected staffing hours and not actual staffing hours. During a review of the facility's P&P titled, Nurse Staffing Posting Information, dated 5/23/23, the P&P indicated: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses 555737 Page 16 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0732 iii. Level of Harm - Minimal harm or potential for actual harm Certified Nurse Aides 2. Residents Affected - Few The facility will post the Nurse Staffing Sheet at the beginning of each shift . 555737 Page 17 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 10) was free of medication error (means the observed or identified preparation or administration of medications or biologicals) which was not in accordance with the manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication, Duloxetine (a delayed-release capsule[medication designed to last longer in the body] used to treat certain mental/mood disorders and used to help relieve nerve pain). Residents Affected - Few This failure could result by passing the extended time release of the capsule that could increase the risk of serious complications such as abdominal cramping, convulsions, and severe skin reactions to Resident 10. Findings: During a review of Resident 10's admission Record (AR), the AR indicated, Resident 10 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), single episode, unspecified, gastrostomy status (state of having a G-Tube, a tube inserted through the belly that brings nutrition and medications directly to the stomach), dysphagia (difficulty swallowing) and unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disturbance, and anxiety ( a feeling of fear, dread, and uneasiness). During a review of Resident 10's History and Physical Examination (H&P), dated 12/18/23, the H&P indicated, Resident 10 was aspirating (when something you swallow goes down the wrong way and enters your airway or lungs by accident) and not able to swallow food at the hospital, had dysphagia S/P (status post, a term used in medicine to refer to a treatment [often a surgical procedure], diagnosis or just an event, that a patient has experienced previously) G-Tube placement. During a review of Resident 10's Minimum Data Set (MDS, an assessment and screening tool), dated 12/25/23, Resident 10's cognitive (ability to think and process information) skills for daily decision making was severely impaired. The MDS indicated, Resident 10's eating activity could not be attempted due to a medical condition or safety concerns. The MDS indicated, Resident 10 had a feeding tube on admission and while a resident at the facility. During a review of Resident 10's Physician Orders (PO), active orders as of 1/28/24, the PO indicated, Duloxetine Hcl (hydrogen chloride [unit of measurement]) oral (by mouth) capsule delayed release particles 20 mg (milligrams, a unit of measurement), give 20 mg via G-Tube one time a day for depression m/b (manifested by) episodes of unprovoked crying or sadness that was ordered on 12/18/23. During an observation on 1/28/24 at 8:56 a.m. during Resident 10's medication administration, Licensed Vocational Nurse (LVN) 2, opened up a Duloxetine capsule and poured the particles into a 30 cc (cubic centimeters, unit of volume) medicine cup and added water to mix the medication. LVN 2 stated, Resident 10 had a G-Tube due to Resident 10 was not eating well. LVN 2 stated, Resident 10 started eating for oral gratification only (swallow testing), did well and was being weaned (gradually 555737 Page 18 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0760 withdrawing) from G-Tube feeding. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 1/28/24 at 9:18 a.m. with LVN 2, the Duloxetine Hcl oral capsule packet was reviewed. The packet indicated, Medication has boxed warning. SWALLOW WHOLE DON'T CHEW/CRUSH. LVN 2 stated, LVN 2 opened the Duloxetine capsule and mixed the medication with water as a routine. LVN 2 stated, the Duloxetine capsule was supposed to be taken whole. LVN 2 stated, LVN 2 opened Resident 10's Duloxetine capsule and thought it was okay since LVN 2 had asked a previous Director of Nursin and facility did not receive a recommendation. LVN 2 stated, opening the Duloxetine capsule was not the right way to administering the medication and LVN 2 should have consulted with the pharmacy. LVN 2 stated, Duloxetine was a delayed release [medication] and opening Duloxetine was no longer delayed release so the body absorbed Duloxetine at a quicker rate, metabolizing (breaking in the body) Duloxetine at a different rate than what was intended and that could cause adverse side effects and affect Resident 10. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2022, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. 555737 Page 19 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to follow safe and proper food storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to: a. Label, date food items and ensure opened food items were covered in one of one kitchen (Kitchen 1). These deficient practices could result in serious complications from food borne illness (illness caused by the ingestion of contaminated food or beverage) and/or affect the quality and palatability of food served to the residents. Findings: During a concurrent observation and interview on 1/26/24, at 3:35 p.m., with the Food Service Supervisor (FSS) in the initial tour of Kitchen 1, the following was observed: 1. a 17 oz (ounces, a unit of weight) can of Vegetable Oil pan coating spray had no cap on and was undated and located on the prep (preparation) counter by the stove. 2. an undated D'AllesandrO brand of Demerara sugar herbs & spices was located on the prep counter by the stove. 3. an undated tub of Salt had no cover or cap and was located on the prep counter by the stove. 4. 2 white colored uncovered plastic rectangular bins filled with red potatoes and Russet potatoes and a rectangular cartoon box filled with sweet potatoes, unlabeled and located on the bottom of a 4-tiered wire shelving unit. 5. green and yellow bananas stacked up on a white colored rectangular tray on the 3rd shelf of the 4-tiered wire shelving unit, all unlabeled. The FSS stated, the opened food items should be covered so no bacteria or anything, dirt can get in. The FSS stated, opened food items should be labeled for staff to know when the food item was opened and for food items not to be kept for too long because this could affect the flavor or [the food] will have a foul smell. The FSS stated, most of the produce (things that have been produced or grown, especially by farming such as fruits and vegetables) items lasted a week and should have been 555737 Page 20 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few labeled with a receive date to know when until when they were good for and if it had been a week and the produce items were still good, these items were to be used first. During a review of the facility's P&P titled, Date Marking for Food Safety, date implemented 5/23/23, the P&P indicated, the facility adhered to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. The P&P indicated, the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food was opened or prepared. During a review of the facility's undated P&P titled, Food Safety Requirements, the P&P indicated, food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. The P&P indicated, food safety practices shall be followed throughout the facility's entire food handling process which included storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. The P&P indicated, additional strategies to prevent foodborne illness includes preventing cross-contamination of foods. 555737 Page 21 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility's Quality Assurance Performance Improvement (QAPI, governing body, a group of people that meet regularly, data driven approach to maintaining and improving safety and quality of care, a proactive approach to quality improvement) corrected identified quality facility issues regarding pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). This deficient practice had the potential for residents to not receive appropriate PI care and treatment and the potential for the development of new PI's. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnosis that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right upper arms and needed for assistance with personal care. During a review of Resident 14's SBAR Communication Form (Situation, Background, Assessment, Recommendation, verbal, or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/29/23, indicated Resident 14 had a significant change in condition due to a change in skin color on bilateral heels (both heels). The form indicated staff would float heels and monitor to relieve pressure on heels. During a review of Resident 14's Care Plan titled Pressure Injury/Skin Care, initiated on 12/31/23, indicated Resident 14 had facility acquired PIs on bilateral (left and right) heels and bilateral great toes. The care plan's goal was for Resident 14's PIs to heal. The care plan's nursing interventions included to administer treatments as ordered. During a review of Resident 120's admission Record (AR) the AR indicated, Resident 120 was admitted to the facility on [DATE] with multiple diagnoses including unspecified fracture (bone break) of the shaft (main or midsection) of left tibia (a break of the larger lower leg bone below the knee joint), subsequent encounter for closed fracture with routing healing, unspecified fracture of upper end of left shaft tibia, subsequent encounter for closed fracture with routine healing, other abnormalities of gait (walk) and mobility (when a person is unable to walk in a typical way). During a review of Resident 120's SBAR (Situation, Background, Appearance, Review), dated 1/23/24, the SBAR indicated, discoloration on skin evaluation and Resident 120 was noted with redness to bilateral buttocks and left heel during skin assessment. The SBAR indicated, Resident 120 was immobile (unable to move) at time of assessment. During an interview and concurrent record review with the facility Administrator (ADM) and the Director of Nursing (DON), on 1/29/24 at 4:07 pm, the ADM and the DON stated that they were both recently employed by the facility. The ADM stated being employed as of November 2023 and the DON as of January 2024. The ADM and the DON stated, they were both current members of the QAPI committee. 555737 Page 22 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the ADM on 1/29/24 at 4:14 pm, the ADM stated the QAPI committee's main topic of improvement were pressure injuries. The ADM stated the ADM was unable to produce documentation regarding staff feedback, data collections, or monitoring regarding PI's. The ADM stated the facility did not have statistics and or trends to track interventions, possible root causes to prevent the development and monitoring of PI's prior to 12/2023. The ADM stated it was important to monitor and track issues with-in the facility. The ADM stated there was no other way to monitor facility issues than to sit and discuss with core management [QUAPI], come up with ideas and address the issues at hand. The ADM stated the facility's residents ultimately suffered and the (facility) determined the quality of care they (residents) were going to receive. The ADM stated, we [the facility] needed to bring us [QUAPI members] all together to make the (resident's) quality of life better. During an interview with the DON on 1/29/24 at 4:31 pm, the DON stated monitoring for PIs was important to ensure the proper care was done; to minimize problems that would create more complications and to improve performance and determine the root cause. During a review of the facility's policy and procedure (P&P) titled QAPI Program, dated 9/29/22, indicated the facility shall develop, implement, and maintain an ongoing facility-wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for residents we serve. The owner and/or governing body is ultimately responsible for the QAPI program. QAPI plan - describe process for identifying and correcting quality deficiencies. Key components include: track and measure performance, systemically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action or performance improvement activities and revising as needed and monitoring or evaluating effectiveness of corrective action or performance improvement activities and revising the plan. During a review of the facility's policy titled QAPI Program - Analysis and Action Policy, dated 9/29/22, indicated quality deficiencies identified through feedback and data will undergo appropriate corrective action. The QAPI program, overseen by the QAPI Committee, is designed to identify, investigate, and address quality deficiencies through analysis of underlying cause and actions targeted at correcting systems at a comprehensive level. QAPI Committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against established goals and benchmarks, communicating information to staff and residents, and report findings to the Administrative and governing body. 555737 Page 23 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

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** d. During a concurrent interview and record review on 1/28/24 at 4:33 p.m. with the Director of Plant Operations (DPO), updated 5/31/23, the facility's WMP, was reviewed. The WMP indicated the purpose of the WMP was to identify where bacteria can grow and/or spread and reduce that risk [of contracting Legionnaire's disease (LD, type of pneumonia [infection that inflames the air sacks in the lungs] cause by legionella bacteria). The WMP indicated If residents contract LD, it is often a result of exposure to inadequately managed building water systems which can be prevented. The WMP indicated the WMP included measures to monitor the identified areas that may promote growth of waterborne bacteria. The WMP indicated would monitor weekly the Cold Main and Hot Water Services. The WMP indicated the monitoring of the Cold Main consisted of weekly temperature checks and weekly checks of chlorine in the water. The WMP indicated the monitoring of the Hot Water Services consisted of weekly temperature checks of water storage and return water, and weekly thermostatic mixing valves (TMV) discharge water. The DPO stated the facility was not conducting the weekly control measures indicated in the WMP. Residents Affected - Some Based on observation, interview and record review, the facility failed to follow standard infection control practices for four of four sampled residents (Residents 9, 122, 10, 120) in accordance with the facility 's policies and procedures (P&P)and failed to follow the Water Management Plan, when the facility failed to: a.Ensure staff's personal belongings (backpacks) were not stored in the tiered food pantry shelf located inside the dry food pantry storage room in the kitchen. b.Ensure resident medical and care equipment was stored properly. c.Ensure personal toiletries were labeled for Resident 10 and Resident 122. d. conduct weekly control measures as indicated in the facility's Water Management Plan, updated 5/31/23. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another), Legionnaire's bacteria (infectious organism that causes pneumonia [infection that inflames the air sacks in the lungs]) growth in the facility's water system resulting in Legionnaire's disease (LD, type of pneumonia [infection that inflames the air sacks in the lungs]), and infections (the invasion and growth of germs in the body) to the all residents residing at the facility and facility staff. The failures had the potential to result in physical declines to the residents. Findings: a.During a concurrent observation and interview on 1/26/24 at 3:51 p.m. with the Food Service 555737 Page 24 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Supervisor (FSS) in the Dry Food Pantry storage room in the kitchen, two staff personal backpacks were hanging on the tiered pantry food shelf. The FSS stated, staff had lockers for their backpacks and the backpacks should not be kept on the pantry shelf because it was a cross contamination [concern]. During a review of Resident 9's admission Record (AR), the AR indicated, Resident 9 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including urinary tract infection (UTI, bladder infection) site not specified, need for assistance with personal care and essential (primary) hypertension (when you have abnormally high blood pressure that's not the result of a medical condition. During a review of Resident 9's History and Physical (H&P), effective date 1/3/24, timed at 7:14 a.m. the H&P indicated, Resident 9 was awake, pleasantly confused, not in distress, and had some redness around buttocks area. The H&P did not indicate Resident 9 was on supplemental oxygen therapy. During a review of Resident 9's Minimum Data Set (MDS, an assessment and screening tool), dated 1/4/24, the MDS indicated, Resident 9's cognitive status was intact. The MDS indicated, Resident 9 was not on oxygen (02, a colorless, odorless gas needed for animal and plant life) therapy on admission. During a review of Resident 9's Order Summary Report (OSR), active orders as of 1/28/24, the OSR did not indicate, orders for 02 therapy. During a review of Resident 122's AR, the AR indicated, Resident 122 was admitted to the facility on [DATE] with multiple diagnoses including urinary tract infection, site not specified and essential (primary) hypertension. During a review of Resident 122's H&P, effective date 1/25/24, timed at 9:32 p.m. the H&P indicated, Resident 122 was tolerating Resident 122's IV (intravenous, within a vein) antibiotics (medicines that fight bacterial infections in people and animals). During a review of Resident 122's MDS, dated 1/29/24, the MDS indicated, Resident 122's BIMS (Brief Interview for Mental Status) cognitive (ability to think and process information) status was moderately impaired and Resident 122 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene. During a review of Resident 10's AR, the AR indicated, Resident 10 was admitted on to the facility on [DATE] with multiple diagnoses including gastrostomy (a surgical opening into the stomach for feeding) status, dysphagia (difficulty swallowing) and unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disturbance, and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 10's H&P, effective date 12/18/23, the H&P indicated, Resident 10 was aspirating (when something you swallow goes down the wrong way and enters your airway or lungs by accident) and not able to swallow food at the hospital, had dysphagia S/P (status post, a term used in medicine to refer to a treatment [often a surgical procedure], diagnosis or just an event, that a patient has experienced previously) G-Tube (feeding tube) placement. 555737 Page 25 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 10's MDS, dated 12/25/23, the MDS indicated, Resident 10's cognitive skills for daily decision making were severely impaired and Resident 10 was dependent (helper does all the effort) for oral (mouth) and toileting hygiene. During a review of Resident 120's admission Record (AR) the AR indicated, Resident 120 was admitted to the facility on [DATE] with multiple diagnoses including unspecified fracture (bone break) of the shaft (main or midsection) of left tibia (a break of the larger lower leg bone below the knee joint), subsequent encounter for closed fracture with routing healing, unspecified fracture of upper end of left shaft tibia, subsequent encounter for closed fracture with routine healing, other abnormalities of gait (walk) and mobility (when a person is unable to walk in a typical way). During a review of Resident 120's H&P, dated 1/22/24, the H&P indicated, Resident 120 was awake, alert, oriented and not in distress. During a review of Resident 120's MDS, dated 1/25/24, the MDS indicated, Resident 120's cognitive skills for daily decision making were moderately impaired. b.During a concurrent observation and interview on 1/26/24 at 5:06 p.m. with Certified Nursing Assistant (CNA) 1 inside Resident 9's restroom, a portable 02 tank with an Oxygen Supply Kit bag were stored. CNA 1 stated, Resident 9 did not use 02. CNA 1 stated, the facility had two rooms out in the hallways where 02 tanks were kept [stored]. c.During a concurrent observation and interview on 1/26/24 at 5:39 p.m. with CNA 1 inside Resident 122's and Resident 10's shared restroom, a mustard-colored wash basin marked with Resident 10's name and bed number was tucked in the grab bar (also known as safety rails, handrails), the toilet seat was up and touching the wash basin. In addition, the following were found: - an unlabeled mustard colored bed pan tucked in the grab bar. - an unlabeled pink colored emesis basin with a toothbrush and unopened toothpaste. - a deodorant roll located next to an unlabeled plastic cup that contained a toothbrush and two tubes of toothpaste on the sink counter. CNA 1 stated, the basin and bedpan should not be kept tucked in the grab bar. CNA 1 stated, the bedpan belonged to Resident 10's husband who used to be Resident 10's roommate but was transferred out to a different room. CNA 1 stated, the toiletries should be labeled so staff knew who they belonged to and to avoid contamination. During a observation on 1/26/24 at 6:23 p.m. with Responsible Party (RP) 2. There was a gray colored commode (a type of chair used by someone who needs help going to the toilet due to illness) inside Resident 120's restroom, a bucket turned bottom side up, and a plunger on the floor next to the toilet. During an interview on 1/26/24 at 6:47 p.m. with CNA 1, CNA 1 stated, if two residents shared a room, the bedpan or urinal was placed in a plastic bag and stored in the resident's (in general) personal closet to avoid contamination and for infection control [purposes]. During an interview on 1/26/24 at 7:08 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, 555737 Page 26 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident 9 was not receiving 02 therapy and it was not the facility's practice to store 02 tanks inside the restroom. LVN 2 stated, the 02 tank should not be in Resident 9's restroom for safety and infection control [purposes]. During an interview on 1/28/24 at 1:54 p.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP stated, 02 tanks should not be stored inside the restroom since the facility had an 02 storage room for infection control [purposes]. The DSP/IP stated, resident care equipment should not be kept in the grab bars inside the restrooms even if the room was private and should be kept in the resident's closet for infection control. The DSP/IP stated, toiletries should be labeled with resident names for infection control and to avoid being switched and used by a wrong resident, causing cross contamination. During a review of the facility's P&P titled, Infection Prevention and Control Program, date implemented 5/23/23, the P&P indicated, the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The P&P indicated, all staff are responsible for following all policies and procedures related to the program. During a review of the facility's P&P titled, Disinfection of Bedpans and Urinals, date implemented 5/23/23, the P&P indicated, guidelines that included: bedpans and urinals are handled in a manner to prevent the spread of infection through personal equipment. Bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. Store bedpans and urinals in the resident's bedside cabinet or drawer after placing in a plastic bag or as per facility policy. If the resident uses the bedpan and urinal at will, do not allow placement on the floor or on a bedside table that is used for eating or drinking. During a review of the facility's undated P&P titled, Labeling Personal Belongings, the P&P indicated, all residents that share a room will have personal belongings including toiletries labeled with their name to prevent shared use. 555737 Page 27 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the facility's Policy and Procedure (P&P) titled COVID-19 Vaccination, dated 10/25/23 when: a. For two of five sampled residents (Residents 10 and 15), the facility failed to offer a COVID-19 (a respiratory illness that can spread from person to person) vaccination (vaccine, a preparation that is used to stimulate the body's immune response against diseases). b. The facility failed to maintain documentation related to COVID-19 vaccinations for staff currently employed at the facility. These failures had the potential to result in residents and staff to acquire, transmit, or experience complications from COVID-19. Findings: a. During a review of Resident 10's admission Record (AR), the AR indicated Resident 10 was admitted to the facility on [DATE] with multiple diagnoses including pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), unspecified fracture (broken bone) of first lumbar vertebra (back bone), and dysphagia (difficulty swallowing foods or liquids). During a review of Resident 10's Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 12/25/23, the MDS indicated Resident 10 was severely impairment (never/rarely made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 10 was dependent (helper does all the effort) on staff for toileting, dressing, and bathing. During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE] with multiple diagnoses including pian in left knee, unspecified fracture of left patella (kneecap), and hypertension (high blood pressure). During a review of Resident 15's MDS, dated 12/22/23, the MDS indicated Resident had no impairment in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 15 supervision or touch assistance from staff for toileting, dressing, and oral hygiene. During a concurrent interview and record review on 1/28/24 at 3:07 p.m. with the Infection Preventionist (IP), Residents 10 and 15's medical records were reviewed. The IP stated the medical records did not contain evidence that the COVID-19 vaccination was offered to Resident 10 or Resident 15, the IP stated, the COVID-19 vaccine was not offered to Resident 15. The IP stated the latest COVID-19 vaccination should be offered to each resident (in general) so they can make an informed decision about their medical care. The IP stated the facility should maintain records of who had been administered and who declined the COVID-19 vaccination. b. During a concurrent interview and record review on 1/28/24 at 3:07 p.m. with the IP, the facility's staff vaccination binder was reviewed. The staff vaccination information did not reflect the COVID-19 vaccination status of staff employed recently and did not include information regarding the 555737 Page 28 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some latest COVID-19 vaccination. The IP stated the facility did not have any records of staff being offered the latest COVID-19 vaccination. The IP stated the facility needed to maintain records in order to know all staff had been offered the latest COVID-19 Vaccination. During a review of the facility's Policy and Procedure (P&P) titled, COVID-19 Vaccination, dated 10/25/23, the P&P indicated, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. The P&P indicated, The facility will educate and offer the COVID-19 vaccine to residents, resident representatives and staff and maintain documentation of such. The P&P indicated, the facility will maintain documentation related to staff COVID-19 vaccination 555737 Page 29 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 4) was provided a safe, sanitary, and comfortable environment. On 1/26/24, Resident 10's ceiling had a leak. This failure resulted in Resident 4 having trouble sleeping and feeling unnerving and Responsible Party (RP) 1 concerned about the safety of Resident 4. Findings: During a review of Resident 4's admission Record (AR) the AR indicated, Resident 4 was originally admitted to the facility on [DATE] and last readmitted on [DATE] with multiple diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), recurrent severe without psychotic (a mental disorder characterized by a disconnection from reality) features, dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), in other diseases classified elsewhere, mild, with agitation and anxiety disorder (a feeling of fear, dread, and uneasiness), unspecified. During a review of Resident 4's History and Physical (H&P), dated 6/19/23, timed at 1:04 p.m. the H&P indicated, Resident 4 was awake, alert, oriented, anxious, not in distress. During a review of Resident 4's Minimum Data Set (MDS, an assessment and screening tool), dated 10/25/23, the MDS indicated, Resident 4's cognitive (ability to think and process information) status was moderately impaired. The MDS indicated, Resident 4 was taking an antidepressant. During a concurrent observation and interview on 1/26/24 at 5:44 p.m. with RP 1, Resident 4 was awake, alert, and sitting up in a wheelchair at Resident 4's bedside. The ceiling in Resident 4's room had areas of peeling, bubbles/buckling along the edges, a brownish colored stained area with stucco missing. and the ceiling had a hole. RP 1 stated, RP 1 noticed the condition of the ceiling on 12/20/23 and referred to her notes. RP 2 stated, RP 2 saw water dripping and was concerned since rain was in the forecast again. RP 2 stated, RP 2 reported the condition of the ceiling the first time on 12/20/23 to the Director of Plant Operations (DPO), to housekeeping, and Certified Nursing Assistant (CNA) 1. RP 1 stated, at one time, a CNA (unnamed) put a trash can with a towel so the leak would not make noise. RP 1 stated, the ceiling and drip had been unnerving and made a lot of noise to Resident 4. Resident 4 stated, the ceiling and dripping would happen all night long and caused Resident 4 trouble staying asleep. During an interview on 1/28/24 at 10:17 a.m. with CNA 2, CNA 2 stated, CNA 2 noticed the condition of Resident 4's ceiling back in 11/2023 or 12/2023 looking a little wet and peeling but only noticed the leaking when it rained really hard. CNA 2 stated, the ceiling's condition could potentially cause Resident 4 to feel worried. During an interview on 1/28/24 at 10:47 a.m. with the Maintenance Technician (MT), the MT stated, MT's duties included maintenance of the building. The MT stated, the MT was recently aware of Resident 4's ceiling and leak on 1/22/24. The MT stated, the MT saw the leak since it was raining. The MT 555737 Page 30 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated, there was nothing the MT could have done but put a bucket and a couple of towels. The MT stated, the MT went up to the roof as well to check if it was pooling water up in those areas and there was a couple of spots that it was [pooling water]. The MT stated, the MT reported the findings to the Administrator (ADM) and the Director of Plant Operations (DPO). The MT stated, the ceiling's condition and leak could cause a feeling of insecurity for the residents due to the building could come down and a safety hazard due to the floor getting wet and slippery, this could cause residents to fall and hurt themselves. During an interview on 1/28/24 at 1:26 p.m. with the DPO, the DPO stated, the DPO became aware of the ceiling's condition in Resident 4's room on 1/26/24 since the DPO was on vacation the week prior. The DPO stated, the DPO was not aware of a work order since the DPO was out of the country on vacation. During an interview on 1/28/24 at 2:27 p.m. with the ADM and the DPO, the ADM stated, the ADM saw the leak when it was raining, and the facility peeled the ceiling and cleaned it off on 1/22/24. The ADM stated, the facility had a cleaning, restoration, construction company (CRC) that come out on 1/23/24 to check the ceiling and recommended to get a leak company since the CRC did not know where the leak was located. During a review of the facility's email correspondence dated 1/23/24 timed at 5:24 p.m. between the (CRC) and the ADM, the email indicated, the CRC provided the facility two leak detection companies the CRC used. During a review of the facility's policy and procedure (P&P), titled Safe and Homelike Environment, date implemented 5/24/23, the P&P indicated, the facility will provide a safe, clean, comfortable and homelike environment. The P&P indicated, the facility will ensure that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not post a safety risk. The P&P indicated, environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms. 555737 Page 31 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0940 Develop, implement, and/or maintain an effective training program for all new and existing staff members. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an effective training program for facility staff: Residents Affected - Some a. The facility's previous Director of Staff Development (DSD) failed to conduct staff training to address a known facility problem regarding residents experiencing pressure injuries (PIs, localized damage to the skin and underlying tissue, primarily caused by prolonged pressure on the skin, shear (mechanical force that causes skin to break of), or friction [surfaces rub against each other]). This failure had the potential to result in unsafe and incompetent care provided to residents by facility staff. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnosis that included muscle wasting atrophy (decrease in size or wasting away of a body part or tissue) on the left and right upper arms and needed for assistance with personal care. During a review of Resident 14's SBAR Communication Form (Situation, Background, Assessment, Recommendation, verbal, or written communication tool that helps provide essential, concise information, usually during crucial situations), dated 12/29/23, indicated Resident 14 had a significant change in condition due to a change in skin color on bilateral heels (both heels). The form indicated staff would float heels and monitor to relieve pressure on heels. A review of Resident 14's Care Plan titled Pressure Injury/Skin Care, initiated on 12/31/23, indicated Resident 14 had facility acquired PIs on bilateral (left and right) heels and bilateral great toes. The care plan's goal was for Resident 14's PIs to heal. The care plan's nursing interventions included to administer treatments as ordered. During a review of Resident 120's admission Record (AR) the AR indicated, Resident 120 was admitted to the facility on [DATE] with multiple diagnoses including unspecified fracture (bone break) of the shaft (main or midsection) of left tibia (a break of the larger lower leg bone below the knee joint), subsequent encounter for closed fracture with routing healing, unspecified fracture of upper end of left shaft tibia, subsequent encounter for closed fracture with routine healing, other abnormalities of gait (walk) and mobility (when a person is unable to walk in a typical way). During a review of Resident 120's SBAR (Situation, Background, Appearance, Review), dated 1/23/24, the SBAR indicated, discoloration on skin evaluation and Resident 120 was noted with redness to bilateral buttocks and left heel during skin assessment. The SBAR indicated, Resident 120 was immobile (unable to move) at time of assessment. During a concurrent interview and record review on 1/27/24 at 4 p.m. with the Director of Nursing (DON) and the Director of Clinical Resources (DCR), Resident 120's medical records were reviewed. The DON stated, Resident 120 was admitted from assisted living (a housing facility for people with disabilities or for adults who cannot or who choose not to live independently) where Resident 120 sustained a fall and went to GACH (general acute [sudden] care hospital) for a fracture (broken bone). The 555737 Page 32 of 33 555737 01/29/2024 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0940 DON stated, Resident 120's PIs were facility acquired. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/29/24 at 9:51 a.m. with the Regional Director of Operations (RDO), the RDO stated the RDO knew the facility had an issue with the previous DSD. The RDO stated the previous DSD was not following through with facility staff education. The RDO stated the RDO had instructed the previous DSD to finish pressure injury education to the staff and the previous DSD did not comply. The RDO stated the previous DSD was supposed to educate the Registered Nurses (RN) and the Licensed Vocational Nurses (LVN) on their roles in assessing pressure injuries. The RDO stated the previous DSD needed to train staff regarding the Policy and Procedure (P&P) for pressure injury prevention. The RDO stated the previous Director of Nursing (DON) directly oversaw the previous DSD and the DON did not [ensure] the previous DSD [completed] the required education with the facility staff. The RDO stated the previous DSD, and the previous DON were terminated. Residents Affected - Some During an interview on 1/29/24 at 3:10 p.m. with the DON, the DON stated the DSD was expected to do in-service training to address issues discovered regarding care of residents (in general), such as pressure injuries. The DON stated the DSD should provide training right away to any staff involved. The DON stated if in services were not provided right away, staff might continue to provide the wrong type of treatment to residents. During an interview with the ADM on 1/29/24 at 4:14 pm, the ADM stated the QAPI (QAPI, a group of people that meet regularly, data driven approach to maintaining and improving safety and quality of care, a proactive approach to quality improvement) committee's main topic of improvement were pressure injuries. During a review of the facility's job description titled Job Title: Director of Staff Development, updated 2/2022, the job description indicated the duties of the DSD included: Schedule and coordinate an orientation program for all new facility staff, including licensed staff, and ensure training occurs prior to direct patient care assignments. Plan and deliver all staff in-service addressing mandatory topics annually using facility consultants where appropriate. Perform daily rounds in facility to assess and identify resident problems/needs. Conduct staff in-services, when needed, to abate known problems. 555737 Page 33 of 33