Health inspection·May 26, 2023

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 observation, interview, and record review, the facility failed to ensure written care plan interventions were implemented for four of six residents (Resident 2, 3, 4, and 5) when: 1. Resident 5 was not provided floor mats (used to prevent injuries from falls). 2. Resident 3 was not consistently provided Q15 (every 15 minutes) monitoring. 3. Residents 2 and 4 were not provided floor mats. As a result of these deficient practices, there was the potential for residents to experience injuries and to have their safety compromised. Findings: 1. A review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 5's written care plan for fall risk dated 6/22/23, indicated, .Floor mats at bedside On 7/12/23 at 11 A.M., an observation of Resident 5 was conducted inside the resident's room. Resident 5 was in bed and there were no floor mats observed inside the resident's room. On 7/12/23 at 11:50 A.M., an interview was conducted with the assistant director of nursing (ADON). The ADON stated Resident 5 should have been provided fall mats. The ADON stated, It's on the care plan and should have been implemented. On 7/13/23 at 11:55 A.M., an interview was conducted with the director of nursing (DON). The DON stated fall mats should have been provided to Resident 5 as it was indicated on the resident's fall care plan. The DON stated it was her expectation for residents' care plans to be fully implemented. 2. A review of Resident 3's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses to include respiratory failure with dependence on a ventilator (machine that breathes for a person), tracheostomy (opening in the windpipe for insertion of a breathing tube), and cognitive communication deficit. Page 1 of 26 555871 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 3's undated written care plan for having had an episode of pulling out life sustaining tubes (breathing tube or feeding tube), indicated, .Monitor and check resident at least q 15 mins for safety On 7/13/23 at 8:05 A.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated Resident 3 had to be checked up on every 15 minutes to prevent self-decannulation. CNA 1 stated Resident 3 had a history of trying to remove his own breathing tube. CNA 1 stated there had been times she observed Resident 3's hands near his breathing tube and she would educate the resident about his breathing tube and he would then lower his hands. A review of Resident 3's Risk Assessment Self-Decannulation dated 7/3/23, indicated the resident had a history of pulling life-sustaining tubes, was deemed to be at high risk for self-decannulation, and was to have the following interventions: Q15 minute visual checks and bilateral hand mittens (prevents fingers from grasping). A review of Resident 3's Q15 Monitoring Record was conducted. On 7/8/23, the 11 P.M. to 7 A.M., shift had no entries on the record and the 7 A.M. to 3 P.M., and 3 P.M. to 11 P.M., shifts had inconsistent entries on the record. On 7/9/23, the 11 P.M., to 7 A.M., shift had no entries on the record. On 7/11/23, there were inconsistent entries on the record for the 7 A.M. to 3 P.M. and 3 P.M. to 11 P.M. shifts. On 7/13/23 at 9 A.M., a joint interview and record review was conducted with respiratory therapist (RT) 2. RT 2 reviewed Resident 3's Q15 Monitoring Record on 7/8, 7/9, and 7/11/23 and stated the Q15 monitoring should have been consistently performed and documented. RT 2 stated staff had to be more careful with residents like Resident 3 who had a history of self-decannulation attempts. RT 2 stated if the residents with a self-decannulation history become short of breath, they may feel anxious and pull at their breathing tube. On 7/13/23 at 9:55 A.M., a joint interview and record review was conducted with the assistant director of nursing (ADON). The ADON stated the Risk Assessment Self-Decannulation was done for all residents admitted or readmitted with a breathing tube. The ADON reviewed Resident 3's Risk Assessment Self-Decannulation dated 7/3/23, and stated the resident was at high risk for a self-decannulation event and had Q15 monitoring and hand mittens as interventions to prevent self-decannulation. The ADON reviewed Resident 3's Q15 Monitoring Record and stated there were blank entries on 7/8, 7/9, and 7/11/23. The ADON stated it was his expectation that Resident 3's Q15 minute visual checks were being consistently done and documented. On 7/13/23 at 11:55 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation for written care plans to be fully implemented. The DON stated it was her expectation for Resident 3's Q15 monitoring to have been consistently provided and documented. 3a. Resident 2 was admitted to the facility on [DATE] with diagnoses which included loss of consciousness, hypertension (increase in blood pressure), tracheostomy per the facility's admission Record. Resident 2's fall care plan nursing intervention, dated 6/21/23, indicated, Resident 2 was at risk for falls related to impaired mobility, weakness. Floor mats at bedside A joint observation and interview was conducted on 7/12/23 at 10:10 A.M. with the clinical nurse consultant (CNC) inside Resident 2's room. The CNC stated there were no fall mats on the floor. 555871 Page 2 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0656 Level of Harm - Minimal harm or potential for actual harm A concurrent record review and interview on 7/12/23 at 11:15 A.M. was conducted with the assistant director of nursing (ADON). Resident 2's Fall Risk Evaluation dated 5/22/23, indicated a score of 13. The ADON stated a fall risk evaluation score of 13 indicated Resident 2 had a high risk of falling. The ADON further stated the floor mats should have been placed at bedside per care plan. Residents Affected - Some 3b. Resident 4 was admitted to the facility on [DATE] per the facility's admission Record. Resident 4's fall care plan nursing intervention, dated 6/21/23, indicated, Resident 4 was at risk for falls related to impaired mobility, weakness. Floor mats at bedside. An observation and interview were conducted on 7/12/23 at 10:29 A.M. inside Resident 4's room with certified nursing assistant (CNA 11). CNA 11 stated there were no floor mats at Resident 4's bedside. CNA 11 further stated she was not made aware by licensed staff that Resident 2 should have bedside floor mats. A concurrent record review and interview conducted on 7/12/23 at 11:22 A.M. with the ADON. Resident 4's Fall Risk Evaluation dated 5/20/23, indicated score of 11. The ADON stated a fall risk evaluation score of 11 indicated Resident 2 had a moderate risk of falling. The ADON further stated the floor mats should have been placed at bedside per care plan and should have been communicated to nursing staff for implementation. An interview conducted on 7/13/23 at 12:15 P.M. with the Director of Nursing (DON). The DON stated fall care plans should be implemented and should be communicated to nursing team to prevent or lessen the impact of a fall. A review of the facility's undated policy titled Care Planning/Care Conference did not provide guidance related to implementation of the residents' care plans. 555871 Page 3 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) had their written plan of care revised after a fall incident. As a result of this deficient practice, there was the potential for Resident 1 to experience further falls. Findings: A review of Resident 1's admission Record, dated 4/20/23, indicated the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance, and abnormalities of gait and mobility. A review of Resident 1's progress notes dated 3/7/23, indicated, .Resident is alert with bouts of confusion .Several times tried to get out of bed, found once sitting on the floor On 4/19/23 at 2:51 P.M., a joint interview and record review was conducted with licensed nurse (LN) 4. LN 4 reviewed Resident 1's progress note dated 3/7/23 and stated when a resident was found on the floor, and the incident was unwitnessed, it was considered a fall. LN 4 stated when a resident had a fall, the nurse was supposed to notify the physician and the resident's responsible party. LN 4 stated the nurse also was required to complete an incident report that was brought to the interdisciplinary team (IDT) for review. LN 4 stated the IDT would investigate the cause of the fall incident and recommend new interventions to prevent further falls. LN 4 stated the resident's written plan of care would then be revised to include the IDT's recommendations. LN 4 stated aside from documentation of the fall incident, none of the other expectations were completed. LN 4 stated when Resident 1 fell of 3/7/23, the fall policy should have been implemented to include revision of the resident's fall care plan. A review of Resident 1's care plan titled [Resident name] is at risk for falls dated 3/4/23, indicated the resident's plan of care had not been revised following the resident's actual fall on 3/7/23. On 4/22/23 at 4:46 A.M., a joint interview and record review was conducted with LN 3. LN 3 stated she was the medication nurse on 3/7/23 and had found Resident 1 sitting on the floor. LN 3 stated that was considered a fall. LN 3 stated she informed the charge nurse of the incident. LN 3 stated it was the charge nurse who called the responsible party and physician to notify them of the fall, performed a complete assessment of the resident, initiated neurochecks (monitoring of a resident in case they hit their head), and completed the incident report that was reviewed by the IDT. LN 3 stated the IDT would investigate the fall incident and update the resident's care plan. LN 3 reviewed Resident 1's clinical record and stated the resident's fall on 3/7/23 had not been acted upon and the fall policy had not been followed. LN 3 stated Resident 1's fall care plan had not been updated to reflect the 3/7/23 fall. On 5/10/23 at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON and ADON reviewed Resident 1's clinical record. Both the DON and ADON stated when Resident 1 was found on the floor on 3/7/23, it was 555871 Page 4 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0657 Level of Harm - Minimal harm or potential for actual harm considered a fall. The ADON stated the facility's fall protocol had not been followed. The ADON stated there was no documentation the IDT investigated the fall and updated the resident's care plan. A review of the facility's undated policy titled Fall Prevention, indicated, .If the resident sustains a fall . The care plan or an update to an existing care plan will then be generated Residents Affected - Few 555871 Page 5 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide timely care to one of one resident. (Resident 5) when Resident 5 ' s midline intravenous catheter (midline IV catheter, a long tubing placed into a peripheral vein) transparent dressing was not cared for. This had the potential for a delay in the provision of necessary care and treatment in accordance with professional standards of practice. Residents Affected - Few Findings: A review of Resident 5 ' s face sheet (document with resident ' s medical information) indicated medical diagnoses of altered mental status, intracranial injury (brain dysfunction). Review of Resident 5 ' s minimum data set (MDS, an assessment tool) indicated she was cognitively impaired. A concurrent observation and interview with licensed vocational nurse (LVN A) on 4/22/23 at 5:55a.m. inside Resident 5 ' s room. Resident 5 ' s midline IV catheter transparent dressing was observed soaked with red liquid. The midline catheter was not connected to an IV fluid. The LN A stated she reported the incident to registered nurse (RN B). LN A further stated she was not IV certified (post licensed credential that LVN ' s earn by passing an exam to have the authorization to administer IV medications) and was not allowed to assess or handle midline IV catheters. A follow up observation and interview were conducted with registered nurse (RN C) on 4/22/23 at 8:10 A.M. inside Resident 5 ' s room. Resident 5 ' s midline IV catheter dressing was still observed soaked with red liquid. LN C stated Resident 5 ' s midline catheter-soaked dressing should have been changed at the time the change of condition was reported to provide timely care and avoid complications. During a concurrent interview and record review with RN C on 4/22/23 at 9:30 A.M. in the nursing station. RN C stated there were no documentations that the soaked midline IV catheter dressing was changed. Review of RN B ' s nurses progress notes dated 4/22/23 at 5:49 A.M. indicated Line shows signs of bleeding. May be compromised. An interview conducted with the director of nursing (DON) on 4/22/23 at 10:45 A.M., the DON stated licensed nurses who were IV certified should change soaked midline IV catheter dressings immediately to prevent complications and must be reported to a prescriber on call for further orders. Review of the facility ' s policy IV Documentation (undated) indicated, Dressing changes for use in peripheral and central access. Include the actual time of change, dressing type. 555871 Page 6 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent an avoidable accident for one of three residents (Resident 1), when: - 1:1 supervision (one staff assigned to provide continuous supervision to a resident) was not provided when Resident 1 was agitated and pulling on her trach (tracheostomy tube/breathing tube) collar (device that secured a trach in position). - Resident 1 ' s cognitive impairment and behavior was identified, but was not evaluated, analyzed, or care planned with resident-specific interventions to meet the resident ' s behavioral, and supervision needs. - Resident 1 ' s quetiapine (a psychotropic medication used to control mood and behavior) indicated for use when resident pulled at life sustaining tubes (trach) was not administered when the resident ' s behavior was observed. As a result, Resident 1 removed her trach collar and decannulated herself (tracheostomy tube was removed from the trachea/windpipe) while unsupervised. Resident 1 had to be reintubated (reinsertion of the tracheostomy tube) at the facility, transferred to the hospital, and experienced an anoxic brain injury (brain death occurring from lack of oxygen) per the hospital record. Findings: A review of Resident 1 ' s admission Record, dated [DATE], indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, attention to tracheostomy (opening in the trachea to insert a breathing tube/trach), attention to gastrostomy (opening in the abdomen to insert a feeding tube/g-tube), unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance, and Alzheimer ' s disease (affects memory and other important mental functions). On [DATE] at 8:46 A.M., a telephone interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated she or another family member spent most of the day at the facility supervising Resident 1. FM 1 stated Resident 1 would touch and manipulate her trach and g-tube. FM 1 stated she would have to move the resident ' s hands away from those areas. FM 1 stated Resident 1 pulled out her intravenous line (IV, used to put medication or fluids into the bloodstream) and had pulled out her g-tube three times. FM 1 stated she had asked nursing staff to place mittens (a restraint device used to prevent fingers from grasping) or to tie the resident ' s hands down at night when she was not there to watch the resident. FM 1 stated Resident 1 had dementia and was confused. FM 1 stated Resident 1, Always tried to get up and would stand up. FM 1 stated she had asked nursing staff to place Resident 1 on 1:1 supervision at night and was told there was not enough staff to accommodate the family ' s request. FM 1 stated she told staff to call her day or night and she would come to watch Resident 1. FM 1 stated, It was my nightmare leaving her [Resident 1] at night that she ' d pull the trach out. FM 1 stated she did receive a call (on [DATE]) that Resident 1 had pulled her trach out and staff had to perform CPR (cardiopulmonary resuscitation-a hands on procedure to revive a person) and send the resident to the hospital via 911. FM 1 stated Resident 1 died four days later at the hospital. 555871 Page 7 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0689 Level of Harm - Actual harm Residents Affected - Few A review of Resident 1 ' s Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated [DATE], indicated the brief interview of mental status was not completed due to the resident ' s severe cognitive impairment. On [DATE] at 1:55 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she often took care of Resident 1 during the daytime and that the resident was confused and would be, Moving around too much. CNA 1 stated Resident 1 required close monitoring, but in the daytime the resident ' s daughters were in the facility to watch her. CNA 1 stated Resident 1 ' s daughters cared for their mom and, Helped a lot with taking care of her during the day. CNA 1 stated when Resident 1 was awake and alone in bed, Resident 1 would try to get up and would start grabbing things. A review of Resident 1 ' s progress notes indicated: [DATE], a licensed nurse (LN) documented, .Gtube was dislodged and replaced [DATE] at 6:23 A.M., a LN documented, .Resident is alert with bouts of confusion .Several times tried to get out of bed, found once sitting on the floor [DATE], a LN documented, .At around 0400H [4 A.M.] pt [patient] was found with her Gtube out [DATE] at 9:53 P.M., a respiratory therapist (RT) documented, .Pt is restless and refuses to stay in bed. Pt removes trach collar often and needs continuous supervising. RN [registered nurse] is aware [DATE], a LN documented, @ 2042H [At 8:42 P.M.] medication nurse went to give her due medication, nurse noted Pt ' s skin looked from pale to yellowish but warm. Nurse tried to shake pt on the shoulder to wake her up but there was no response. Upon checking her neck, nurse found out that her tracheostomy was gone .Pt has no pulse and not breathing . CPR started .@2050H [At 8:50 P.M.] 911 responders came .they left the facility with the pt @2109H [9:09 P.M.] [DATE], a RT documented, .Pt was received on trach collar stable but restless at the beginning of shift . At around 8:50 pm she was found unresponsive and without a pulse after self decannulation. Immediately trach tube was reinserted and CPR was initiated On [DATE] at 2:10 P.M., a joint interview and record review was conducted with licensed nurse (LN) 2. LN 2 stated Resident 1 required the trach and could not adequately breathe on her own without it. LN 2 stated Resident 1 was confused and had dementia. LN 2 stated Resident 1 ' s behavior was manageable in the daytime because the resident ' s family was present to watch the resident and kept her busy. LN 2 stated Resident 1 ' s hands were always moving, and when the resident ' s daughter was not there, staff had to sit the resident at the nurses ' station for increased supervision. LN 2 stated the resident liked to be in a place where she could see everyone. LN 2 stated staff would give her linens to fold, and it kept her busy. LN 2 stated she would hear from the NOC (night shift from7 P.M. to 7 A.M.) nurses that Resident 1 was difficult to take care of at night and was sometimes combative. LN 2 reviewed Resident 1 ' s clinical record and stated there should have been a written plan of care to address the resident ' s dementia and behavior especially at night. LN 2 stated Resident 1 would pull her life sustaining tubes (g-tube/trach) and that this was a dangerous behavior and an immediate safety concern. LN 2 stated Resident 1 could not be redirected in this behavior and did not comprehend the implications of pulling her life sustaining tubes. LN 2 stated when Resident 1 555871 Page 8 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0689 Level of Harm - Actual harm pulled out her g-tube on [DATE] and [DATE], was found sitting on the floor on [DATE], and was pulling at her trach collar on [DATE], these were behaviors that should have been immediately discussed with the interdisciplinary team (IDT) and a plan of care developed to address it. LN 2 stated she did not see any documentation the resident ' s unsafe behaviors had been addressed by the IDT or care planned. Residents Affected - Few A review of Resident 1 ' s physician ' s order dated [DATE], indicated the resident was to receive quetiapine 50 mg (milligrams) every six hours as needed for pulling at life sustaining tubes. There was also an order dated [DATE] to monitor the episodes of this behavior of pulling at the life sustaining tubes. A review of Resident 1 ' s medication administration record (MAR) for [DATE], indicated the resident ' s behavior of pulling at life sustaining tubes had been observed: 2 times on [DATE], 5 times on [DATE], 5 times on [DATE], 2 times on [DATE]. The same MAR indicated that Resident 1 had not been administered a quetiapine dose on 3/23, 3/24, 3/25, and [DATE]. On [DATE] at 2:51 P.M., a joint interview and record review was conducted with LN 4. LN 4 stated she was familiar with Resident 1. LN 4 stated Resident 1 was confused and had dementia. LN 4 reviewed Resident 1 ' s clinical record and stated when Resident 1 pulled out her g-tube on [DATE] and [DATE], was found sitting on the floor on [DATE], and pulled at her trach collar on [DATE], these were behaviors that should have been immediately discussed with the IDT and a plan of care developed to address it. LN 4 stated in the daytime, Resident 1 ' s daughters were in the facility and there were more staff and activities taking place. LN 4 stated there should have been an individualized dementia care plan that addressed Resident 1 ' s supervision and behavioral needs at night. LN 4 stated having a plan of care that addressed Resident 1 ' s behavior and supervision needs may have prevented her from pulling out her trach on [DATE]. LN 4 reviewed Resident 1 ' s quetiapine order dated [DATE] and the [DATE] MAR. LN 4 stated when the LN first observed Resident 1 pulling at life sustaining tubes, the resident should have been administered a dose of quetiapine. LN 4 stated, There ' s a reason for the quetiapine order. It should have been followed. LN 4 reviewed Resident 1 ' s progress note on [DATE] at 9:53 P.M., and authored by the RT. LN 4 stated she did not see documentation that the RT ' s concern about Resident 1 needing continuous supervision had been acted upon. LN 4 stated there was no documentation that Resident 1 had been provided increased supervision. LN 4 stated at a minimum, the resident should have been put on Q15 monitoring (checking up on a resident every 15 minutes). LN 4 stated when there was a risk to the airway, Q15 monitoring would not be frequent enough. On [DATE] at 3:55 P.M., a joint interview and record review, was conducted with LN 4 and the medical records director (MRD). Resident 1 ' s electronic medical record, paper chart, and the medication cart binders were reviewed. Both LN 4 and the MRD stated there was no documentation Resident 1 had been placed on increased or scheduled supervision such as Q15 monitoring. LN 4 and the MRD stated if Resident 1 had received increased or scheduled supervision it would have been documented in the EMR, 555871 Page 9 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0689 paper chart, or medication cart binders. Level of Harm - Actual harm On [DATE] at 4:26 A.M., an interview was conducted with RT 1. RT 1 stated she was familiar with Resident 1. RT 1 stated Resident was confused and would often pull at her trach and the oxygen mask that was applied to it. RT 1 stated if Resident 1 was really agitated or touching and pulling at her trach, then she needed to be placed on 1:1 supervision. RT 1 stated Resident 1 required the trach in order to adequately breathe. Residents Affected - Few On [DATE] at 4:46 A.M., a joint interview and record review was conducted with LN 3. LN 3 stated Resident 1 was confused most of the time. LN 3 stated Resident 1 would become anxious at night after her daughters left. LN 3 stated Resident 1 would pretend to sleep, and as soon as her daughters left, she would start getting up and asking to go home. LN 3 stated she started her shift on [DATE] at 7 P.M. and saw Resident 1 sometime between 7 P.M. to 8 P.M. LN 3 stated she had observed Resident 1 to be agitated and pulling at her trach and oxygen mask. LN 3 stated Resident 1 needed 1:1 supervision at that time, but there was no one to do it. LN 3 stated there was not enough staff. LN 3 reviewed Resident 1 ' s clinical record and stated when she went into Resident 1 ' s room at 8:42 P.M., she thought the resident was asleep in bed. LN 3 stated Resident 1 had her blanket pulled up to her chin and could not visualize her trach site. LN 3 stated when Resident 1 did not respond, she pulled the blanket down and found the resident ' s trach next to her hip on the bed. LN 3 stated Resident 1 was dependent on the trach and could not adequately breathe without it. LN 3 stated, She needed a sitter [1:1 supervision] at night when agitated. LN 3 stated she could have called Resident 1 ' s daughter to come in but had not done so. LN 3 stated she did not attempt to place mittens (restraint device that prevents finger grasping) on the resident or call the physician. LN 3 stated she was the only LN on the subacute unit on [DATE], and she was just too busy. LN 3 stated there should have been enough staff available to provide the supervision that Resident 1 required on [DATE]. LN 3 further stated she did not report the staff shortage in a timely manner to management. On [DATE] at 5:42 A.M., an interview was conducted with CNA 2. CNA 2 stated, It was hard taking care of her [Resident 1] at night. CNA 2 stated he worked day and NOC shift, and the resident ' s daughters took care of her needs during the day. CNA 2 stated at night, Resident 1 kept trying to get out of bed and was restless. CNA 2 stated Resident 1 was quick and that he had to reapply the resident ' s oxygen mask several times after the resident removed it from her trach. CNA 2 stated there were a couple times when he worked that he briefly provided 1:1 supervision for Resident 1 when the resident was agitated. CNA 2 stated Resident 1 would calm down when someone was there and responded well to 1:1 supervision. CNA 2 stated Resident 1 needed 1:1 supervision when she was awake at night because she was impulsive. On [DATE] at 6:20 A.M., a joint interview and record review was continued with LN 3. LN 3 reviewed Resident 1 ' s physician order dated [DATE], indicating the resident was to receive a dose of quetiapine every six hours as needed for pulling out life sustaining tubes. LN 3 stated when she observed Resident 1 attempting to pull at her trach on [DATE], she should have administered a quetiapine dose. LN 3 stated quetiapine would not work immediately but it could have helped, and should have been given. A review of the facility census, dated [DATE], indicated the subacute unit was at maximum occupancy with 16 resident and one resident listed as a bed hold (out on leave). On [DATE] at 10:30 A.M., an interview was conducted with the director of staff services (DSD). The DSD stated, It was a full house [maximum occupancy] on the subacute unit on [DATE] which was too 555871 Page 10 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0689 Level of Harm - Actual harm Residents Affected - Few much for one nurse to manage. The DSD stated the facility management should have been notified promptly that a LN did not show up to work so a replacement could have been found. The DSD stated if a resident required 1:1 then extra staff should have been provided to meet the resident ' s needs. On [DATE] at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON and ADON reviewed Resident 1 ' s clinical record. The DON stated Resident 1 ' s family was present to watch the resident during the day. The DON stated Resident 1 was a special case and the facility allowed the family to stay at night to watch the resident. The DON stated the family should have been called to come in to watch Resident 1 when LN 3 noticed the resident was agitated and pulling at her trach. The DON acknowledged it was the facility ' s responsibility to supervise the resident. The DON stated Resident 1 ' s behavior should have been discussed as an IDT and care planned. The DON further stated when LN 3 observed Resident 1 pulling at her trach, the resident should have been administered a quetiapine dose as was ordered. The DON stated LN 3 should have taken immediate action when she noticed Resident 1 ' s behavior on [DATE]. The DON stated Resident 1 should have been provided 1:1 supervision. The DON stated, More could have been done. A review of Resident 1 ' s hospital documentation titled Discharge summary dated [DATE], indicated, .Diagnoses . Anoxic brain injury . overall poor prognosis . family decided to transition to comfort care and the patient passed away on [DATE] at 1855 [6:55 P.M.] On [DATE] at 3:05 P.M., a virtual interview was conducted with hospital medical doctor (MD) 1. Also present during the interview was the hospital director of regulatory affairs. MD 1 stated he was a pulmonologist (physician specializing in the respiratory system) and ICU (intensive care unit) physician and had treated Resident 1 during her hospital ICU stay ([DATE] through [DATE]). MD 1 stated he could not say with 100% certainty that Resident 1 ' s self-removal of her trach (on [DATE] at the skilled nursing facility) was the direct or only cause of her anoxic brain injury. MD 1 stated Resident 1 ' s self-removal of her trach on [DATE] was, Most definitely a contributing cause of the anoxic brain injury. MD 1 further stated residents with cognitive impairment and behavioral issues, who were attempting to pull on their trach, should have a sitter (1:1 supervision), be given a psychotropic medication to calm them down, or placed in restraints (device such as mittens) as a last resort. A review of the facility ' s undated policy titled Accident Intervention, indicated, Policy .The purpose is to ensure that the facility provides an environment that is free of hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This includes systems and processes designed to: identify hazard(s) and risk(s); evaluate and analyze hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s) 555871 Page 11 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure sufficient nursing staff were on duty to provide nursing care and supervision to 16 residents on the subacute unit (residents with more complex illnesses, often reliant on breathing machines) on [DATE] during the NOC shift (7 P.M. to 7:30 A.M.), when licensed nurse (LN) 6 failed to report to work and a replacement LN was not called in. In addition, LN 6 ' s sign-in attendance sheet, time clock record, and time adjustment request form (TARF) were inaccurate. As a result, Resident 1, who was cognitively impaired and required increased nursing supervision, removed her trach collar (device that secured a breathing tube in position) and decannulated herself (tracheostomy tube was removed from the trachea/windpipe) while unsupervised. Resident 1 had to be reintubated (reinsertion of the tracheostomy tube) at the facility, transferred to the hospital and experienced an anoxic brain injury (brain death occurring from lack of oxygen) per the hospital record. Additionally, there was the potential for other residents on the subacute unit have their safety put at risk. Findings: A review of Resident 1 ' s admission Record, dated [DATE], indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, attention to tracheostomy (opening in the trachea to insert a breathing tube/trach), attention to gastrostomy (opening in the abdomen to insert a feeding tube/g-tube), unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance, and Alzheimer ' s disease (affects memory and other important mental functions). On [DATE] at 8:46 A.M., a telephone interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated she or another family member spent most of the day at the facility supervising Resident 1. FM 1 stated Resident 1 would touch and manipulate her trach and g-tube. FM 1 stated she would have to move the resident ' s hands away from those areas. FM 1 stated Resident 1 pulled out her intravenous line (IV, used to put medication or fluids into the bloodstream) and had pulled out her g-tube three times. FM 1 stated she had asked nursing staff to place mittens (a restraint device used to prevent fingers from grasping) or to tie the resident ' s hands down at night when she was not there to watch the resident. FM 1 stated Resident 1 had dementia and was confused. FM 1 stated Resident 1, Always tried to get up and would stand up. FM 1 stated she had asked nursing staff to place Resident 1 on 1:1 supervision at night and was told there was not enough staff to accommodate the family ' s request. FM 1 stated she told staff to call her day or night and she would come to watch Resident 1. FM 1 stated, It was my nightmare leaving her [Resident 1] at night that she ' d pull the trach out. FM 1 stated she did receive a call (on [DATE]) that Resident 1 had pulled her trach out and staff had to perform CPR (cardiopulmonary resuscitation-a hands on procedure to revive a person) and send the resident to the hospital via 911. FM 1 stated Resident 1 died four days later at the hospital. A confidential interview was conducted with a resident ' s FM 2. FM 2 stated she had concerns about 555871 Page 12 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0725 the facility ' s nurse staffing at night. Level of Harm - Minimal harm or potential for actual harm A confidential interview was conducted with a resident ' s FM 3. FM 3 stated the facility, Needed more help on the weekends -especially at night. FM 3 stated there were times when she visited her family member around 8 A.M. in the morning on the weekends, and she would find the resident soaked with urine. FM 3 stated they would see the resident ' s urinary catheter (tube used to drain urine from the bladder) crimped and that urine had escaped around the catheter and got the bed wet. FM 3 stated there had been so much urine in the bed that it had to have happened over a long period of time. FM 3 stated this had occurred on the last weekend of March (2023), but she did not recall the exact day. Residents Affected - Few On [DATE] at 1:38 P.M., an interview was conducted with activities aid (AA) 1. AA 1 stated Resident 1 ' s daughters were very involved and were at the facility every day. AA 1 stated Resident 1 was fidgety and, We had to keep her hands busy. On [DATE] at 1:55 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she often took care of Resident 1 during the daytime and that the resident was confused and would be, Moving around too much. CNA 1 stated Resident 1 required close monitoring, but in the daytime the resident ' s daughters were in the facility to watch her. CNA 1 stated Resident 1 ' s daughters cared for their mom and, Helped a lot with taking care of her during the day. CNA 1 stated when Resident 1 was awake and alone in bed, Resident 1 would try to get up and would start grabbing things. On [DATE] at 2:10 P.M., an interview was conducted with LN 2. LN 2 stated Resident 1 required the trach and could not breathe adequately on her own without it. LN 2 stated Resident 1 ' s hands were always moving but the family was present in the daytime to watch the resident and keep her busy. LN 2 stated she would hear from the NOC nurses that Resident 1 was difficult to take care of at night and sometimes combative. LN 2 stated she considered daytime staffing to be sufficient. LN 2 stated NOC shift nurses had complained about being short staffed at night and having to share staff with the skilled nursing side of the facility. A review of Resident 1 ' s progress notes indicated: [DATE], a licensed nurse (LN) documented, .Gtube was dislodged and replaced [DATE] at 6:23 A.M., a LN documented, .Resident is alert with bouts of confusion .Several times tried to get out of bed, found once sitting on the floor [DATE], a LN documented, .At around 0400H [4 A.M.] pt [patient] was found with her Gtube out [DATE] at 9:53 P.M., a respiratory therapist (RT) documented, .Pt is restless and refuses to stay in bed. Pt removes trach collar often and needs continuous supervising. RN [registered nurse] is aware [DATE], a LN documented, @ 2042H [At 8:42 P.M.] medication nurse went to give her due medication, nurse noted Pt ' s skin looked from pale to yellowish but warm. Nurse tried to shake pt on the shoulder to wake her up but there was no response. Upon checking her neck, nurse found out that her tracheostomy was gone .Pt has no pulse and not breathing . CPR started .@2050H [At 8:50 P.M.] 911 responders came .they left the facility with the pt @2109H [9:09 P.M.] 555871 Page 13 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0725 Level of Harm - Minimal harm or potential for actual harm [DATE], a RT documented, .Pt was received on trach collar stable but restless at the beginning of shift . At around 8:50 pm she was found unresponsive and without a pulse after self decannulation. Immediately trach tube was reinserted and CPR was initiated On [DATE] at 4:07 A.M., an onsite visit was conducted during the NOC shift. Residents Affected - Few On [DATE] at 4:26 A.M., an interview was conducted with RT 1. RT 1 stated she was familiar with Resident 1. RT 1 stated Resident 1 was confused and would often pull at her trach and the oxygen mask that was applied to it. RT 1 stated if Resident 1 was really agitated or touching and pulling at her trach, she needed to be placed on 1:1 supervision. RT 1 stated Resident 1 required the trach in order to adequately breathe. On [DATE] at 4:46 A.M., a joint interview and record review was conducted with LN 3. LN 3 stated Resident 1 was confused most of the time. LN 3 stated Resident 1 would become anxious at night after her daughters left. LN 3 stated Resident 1 would pretend to sleep, and then as soon as her daughters left, she would start getting up and asking to go home. LN 3 stated she started her shift on [DATE] at 7 P.M. and saw Resident 1 sometime between 7 P.M. to 8 P.M. LN 3 stated she had observed Resident 1 to be agitated and pulling at her trach and oxygen mask. LN 3 stated Resident 1 needed 1:1 supervision when she had observed that, but there was no one to do it. LN 3 stated there were two CNAs at that time that had other residents that needed care and could not be pulled to do 1:1 supervision. LN 3 stated there was not enough staff because LN 6 did not show up for work. LN 3 stated, I was by myself with about seventeen subacute patients. LN 3 reviewed Resident 1 ' s clinical record and stated when she went into Resident 1 ' s room at 8:42 P.M., she thought the resident was asleep in bed. LN 3 stated Resident 1 had her blanket pulled up to her chin and she could not visualize her trach site. LN 3 stated when Resident 1 did not respond, she pulled the blanket down and found the resident ' s trach next to her hip on the bed. LN 3 stated Resident 1 was dependent on the trach and could not adequately breathe without it. LN 3 further stated when the resident census was full, there was supposed to be two licensed nurses from 7 P.M. to 7 A.M. and two CNAs from 7 P.M. to 11 P.M., then from 11 P.M. to 7 A.M. there was one CNA. LN 3 reviewed a text message on her personal cell phone to LN 6 at around 9 P.M. on [DATE] asking where LN 6 was. There was a text response from LN 6 after 9 P.M. indicating he was on his way. LN 3 reviewed a text dated [DATE] at 6:52 A.M., to the director of staff development (DSD), informing him that LN 6 had not shown up for work. The DSD responded to LN 3 ' s text that LN 6 had reported at 3 A.M. that he was in the hospital having had a car accident. LN 3 reviewed the subacute staff sign-in sheet dated [DATE] and stated LN 6 signed that he was present, but he was not. LN 3 stated she should have notified the DSD or director of nursing (DON) in the beginning of the shift to inform them LN 6 did not show up and she needed help. LN 3 stated she had been too busy to call. LN 3 stated there should have been enough staff to provide the supervision that Resident 1 required. A review of the resident census dated [DATE] indicated there were 16 residents on the subacute unit [maximum capacity] and one resident listed as a bed hold (resident on leave of absence). On [DATE] at 7:25 A.M., an interview was conducted with LN 5. LN 5 stated Resident 1 had dementia. LN 5 stated Resident 1 would pretend to be asleep sometimes and then start to get up and pull on her tubes (g-tube and trach). LN 5 stated, It ' s easy in the daytime because her [Resident 1 ' s] daughters were here. LN 5 stated Resident 1 ' s behavior at night should have been discussed as an interdisciplinary team (IDT) and a dementia plan of care developed to help the NOC shift manage the resident ' s behavior. LN 5 stated it was unsafe on the subacute without enough staff. LN 5 stated management had to be promptly notified if there was a LN who did not show up. LN 5 stated staffing had 555871 Page 14 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few been a problem on the subacute. LN 5 stated there were instances wherein someone from the skilled nursing facility (SNF) side would get borrowed when the subacute was short staffed at night. LN 5 stated the SNF side will help but only after they took care of the residents on the SNF side first. LN 5 stated, When borrowing from the SNF side, you just pray to god the shift goes ok and no one gets hurt. LN 5 stated even when there were two LNs and two CNAs until 11 P.M. and then one CNA until 7 A.M., with a resident needing increased supervision, that was not enough. On [DATE] at 10:30 A.M., a joint interview and record review was conducted with the DSD. The DSD stated he was responsible for staffing and that the protocol was for nursing staff to send out a group text to the DSD, DON, and administrator within four hours of calling out so that a replacement could be found. The DSD stated LNs were required to report their peers as a no show within 30 minutes of the start of the shift. The DSD stated having enough staff on the subacute unit was important to meet the needs of the residents. The DSD reviewed the facility census dated [DATE] and stated it was a full house [maximum occupancy] on the subacute and that would have been too many residents for one LN to manage as the residents were very acute [had a lot of medical needs]. The DSD stated when the resident census was full, it was required to be staffed with two LNs from 7 P.M. to 7 A.M. and two CNAs from 7 P.M. to 11 P.M. then one CNA from 11 P.M. to 7 A.M. The DSD reviewed LN 6 ' s sign in-sheet, time clock entry, and text messages for [DATE]. The DSD stated it did not make sense that LN 6 text messaged that he was in the hospital during the 7 P.M. to 7 A.M. shift ([DATE] to [DATE]), and LN 3 reported he did not show up, and then he signed in as being present on the sign-in sheet and had a time clock entry for that timeframe. The DSD reviewed LN 6 ' s TARF dated [DATE]. LN 6 ' s TARF indicated that he worked on [DATE] from 7 P.M. to 7 A.M. on [DATE]. The DSD stated a TARF was completed when someone forgot to clock-in or out. The DSD stated when staff clocked-in a fingerprint was required, and when a TARF was done, the time was manually entered by human resources. The DSD stated the staff ' s supervisor was supposed to sign the TARF and that he did not recognize the supervisor signature on LN 6 ' s TARF. The DSD stated LN 6 was assigned on [DATE] as the subacute unit charge nurse. The DSD stated the charge nurse during a 12-hour shift would have been responsible for daily charting on the residents. At 11:36 A.M., the medical records director (MRD) joined the interview and stated there was no documentation from LN 6 during the entire 12-hours shift starting at 7 P.M. to 7 A.M. on [DATE]. The DSD stated, This doesn ' t add up and is suspicious. The DSD stated there was no evidence that LN 6 had worked on [DATE]. On [DATE] at 12:05 P.M., a joint interview was conducted with the DON and assistant director of nursing (ADON). The DON and ADON stated there was no evidence LN 6 had worked on [DATE] at 7 P.M. to 7 A.M. on [DATE]. The DON and ADON reviewed the facility census dated [DATE] and stated the subacute unit was full and there should have been two LNs on duty for the [DATE] NOC shift. The DON stated LN 3 should have reported LN 6 ' s absence by 7:30 P.M. so that a replacement LN could have been found and brought in to cover the shift. The DON stated on [DATE], when LN 3 noticed Resident 1 pulling on her trach, the resident should have been provided 1:1 supervision. The DON stated there should have been enough staff to provide the needed supervision to Resident 1. The DON stated, More could have been done. A review of Resident 1 ' s hospital documentation titled Discharge summary dated [DATE], indicated, .Diagnoses . Anoxic brain injury . overall poor prognosis . family decided to transition to comfort care and the patient passed away on [DATE] at 1855 [6:55 P.M.] On [DATE] at 3:05 P.M., a virtual interview was conducted with hospital medical doctor (MD) 1. Also present during the interview was the hospital director of regulatory affairs. MD 1 stated he was a pulmonologist (physician specializing in the respiratory system) and ICU (intensive care unit) 555871 Page 15 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician and had treated Resident 1 during her hospital ICU stay ([DATE] through [DATE]). MD 1 stated he could not say with 100% certainty that Resident 1 ' s self-removal of her trach (on [DATE] at the skilled nursing facility) was the direct or only cause of her anoxic brain injury. MD 1 stated Resident 1 ' s self-removal of her trach on [DATE] was, Most definitely a contributing cause of the anoxic brain injury. MD 1 further stated residents with cognitive impairment and behavioral issues, who were attempting to pull on their trach, should have a sitter (1:1 supervision), be given a psychotropic medication to calm them down, or placed in restraints (device such as mittens) as a last resort. On [DATE] at 8:56 A.M. a telephone interview was conducted with the DON. The DON stated the facility did not have a policy related to staffing based on resident needs. A review of the facility provided document titled Subacute Staffing -Requirements, revised 5/2010, described how to compute staffing hours, but did not provide guidance related to staffing levels to meet the needs of the residents. A review of the facility ' s undated document titled Attendance and Tardiness Policy Acknowledgement, indicated, .An employee shall be counted as ' absent ' if he or she fails to work more than one half of a scheduled shift . Failure to call in at least two (2) hours before the start of a shift is unacceptable and will result in disciplinary action . The document did not provide guidance related to reporting a peer ' s no-show. 555871 Page 16 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 three residents (Resident 1) with dementia (condition characterized by impaired judgement and memory loss) had a person-centered plan of care with individualized interventions that managed the resident ' s supervision and behavioral needs. Residents Affected - Few As a result, Resident 1, who required increased supervision and resident-specific behavioral interventions, removed her trach collar (device used to secure a tracheostomy/trach tube [breathing tube] in its position) and decannulated herself (tracheostomy tube was removed from the trachea/windpipe) while unsupervised. Resident 1 had to be reintubated (reinsertion of the tracheostomy tube) at the facility, transferred to the hospital, and experienced an anoxic brain injury (brain death occurring from lack of oxygen) per the hospital record. Findings: A review of Resident 1 ' s admission Record, dated [DATE], indicated the resident was admitted to the facility on [DATE], with diagnoses to include acute and chronic respiratory failure, attention to tracheostomy (opening in the trachea to insert a breathing tube/trach), attention to gastrostomy (opening in the abdomen to insert a feeding tube/gastrostomy tube [g-tube]), unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance, and Alzheimer ' s disease (affects memory and other important mental functions). On [DATE] at 8:46 A.M., a telephone interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated she or another family member spent most of the day at the facility supervising Resident 1. FM 1 stated Resident 1 would touch and manipulate her trach and g-tube. FM 1 stated she would have to move the resident ' s hands away from those areas. FM 1 stated Resident 1 pulled out her intravenous line (IV, used to put medication or fluids into the bloodstream) and had pulled out her g-tube three times. FM 1 stated she had asked nursing staff to place mittens (a restraint device used to prevent fingers from grasping) or to tie the resident ' s hands down at night when she was not there to watch the resident. FM 1 stated Resident 1 had dementia and was confused. FM 1 stated Resident 1, Always tried to get up and would stand up. FM 1 stated she had asked nursing staff to place Resident 1 on 1:1 supervision at night and was told there was not enough staff to accommodate the family ' s request. FM 1 stated she told staff to call her day or night and she would come to watch Resident 1. FM 1 stated, It was my nightmare leaving her [Resident 1] at night that she ' d pull the trach out. FM 1 stated she did receive a call (on [DATE]) that Resident 1 had pulled her trach out and staff had to perform CPR (cardiopulmonary resuscitation-a hands on procedure to revive a person) and send the resident to the hospital via 911. FM 1 stated Resident 1 died four days later at the hospital. A review of Resident 1 ' s Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated [DATE], indicated the brief interview of mental status was not completed due to the resident ' s severe cognitive impairment. On [DATE] at 1:38 P.M., an interview was conducted with activities aid (AA) 1. AA 1 stated Resident 1 ' s daughters were very involved and were at the facility every day. AA 1 stated Resident 1 was fidgety and, We had to keep her hands busy. AA 1 stated Resident 1 ' s hands were kept busy with a deck of playing card and magazines. 555871 Page 17 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 1:55 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated she often took care of Resident 1 during the daytime and that the resident was confused and would be, Moving around too much. CNA 1 stated Resident 1 required close monitoring, but in the daytime the resident ' s daughters were in the facility to watch her. CNA 1 stated Resident 1 ' s daughters cared for their mom and, Helped a lot with taking care of her during the day. CNA 1 stated when Resident 1 was awake and alone in bed, Resident 1 would try to get up and would start grabbing things. A review of Resident 1 ' s progress notes indicated: [DATE], a licensed nurse (LN) documented, .Gtube was dislodged and replaced [DATE] at 6:23 A.M., a LN documented, .Resident is alert with bouts of confusion .Several times tried to get out of bed, found once sitting on the floor [DATE], a LN documented, .At around 0400H [4 A.M.] pt [patient] was found with her Gtube out [DATE] at 9:53 P.M., a respiratory therapist (RT) documented, .Pt is restless and refuses to stay in bed. Pt removes trach collar often and needs continuous supervising. RN [registered nurse] is aware [DATE], a LN documented, @ 2042H [At 8:42 P.M.] medication nurse went to give her due medication, nurse noted Pt ' s skin looked from pale to yellowish but warm. Nurse tried to shake pt on the shoulder to wake her up but there was no response. Upon checking her neck, nurse found out that her tracheostomy was gone .Pt has no pulse and not breathing . CPR started .@2050H [At 8:50 P.M.] 911 responders came .they left the facility with the pt @2109H [9:09 P.M.] [DATE], a RT documented, .Pt was received on trach collar stable but restless at the beginning of shift . At around 8:50 pm she was found unresponsive and without a pulse after self-decannulation. Immediately trach tube was reinserted, and CPR was initiated On [DATE] at 2:10 P.M., a joint interview and record review was conducted with licensed nurse (LN) 2. LN 2 stated Resident 1 required the trach and could not adequately breathe on her own without it. LN 2 stated Resident 1 was confused and had dementia. LN 2 stated Resident 1 ' s behavior was manageable in the daytime because the resident ' s family was present to watch the resident and keep her busy. LN 2 stated Resident 1 ' s hands were always moving, and when the resident ' s daughter was not there, we had to sit her at the nurses ' station for increased supervision. LN 2 stated the resident liked to be in a place where she could see everyone. LN 2 stated staff would give her linens to fold, and it kept her busy. LN 2 stated she would hear from the NOC (night shift from7 P.M. to 7 A.M.) nurses that Resident 1 was difficult to take care of at night and sometimes combative. LN 2 reviewed Resident 1 ' s clinical record and stated there should have been a written plan of care to address the resident ' s dementia and behavior especially at night. LN 2 stated Resident 1 would pull her life sustaining tubes (g-tube, trach) and that this was a dangerous behavior and an immediate safety concern. LN 2 stated Resident 1 could not be redirected in this behavior and did not comprehend the implications of pulling her life sustaining tubes. LN 2 stated when Resident 1 pulled out her g-tube on [DATE] and [DATE], was found sitting on the floor on [DATE], and was pulling at her trach collar on [DATE], these were behaviors that should have been immediately discussed with the interdisciplinary team (IDT) and a plan of care developed to address it. LN 2 stated she did not see any documentation the resident ' s unsafe behavior had been addressed by the IDT or care planned. LN 2 stated 555871 Page 18 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few there was a care plan for risk for impaired cognitive function/dementia dated [DATE], but it was not individualized and did not address Resident 1 ' s specific behavior. LN 2 further stated Resident 1 had dementia and cognitive impairment and was not at risk for cognitive impairment or dementia. LN 2 stated there was a care plan for Resident 1 ' s quetiapine use (a psychotropic medication that controlled mood and behavior) dated [DATE], but it had automated interventions that were not resident specific. LN 2 stated one of the interventions in this care plan was to provide snacks and Resident 1 had a physician ' s order for nothing by mouth. LN 2 stated another intervention was redirection, which did not work for Resident 1. On [DATE] at 2:51 P.M., a joint interview and record review was conducted with LN 4. LN 4 stated she was familiar with Resident 1 and that the resident was confused and had dementia. LN 4 reviewed Resident 1 ' s clinical record and stated when Resident 1 pulled out her g-tube on [DATE] and [DATE], was found sitting on the floor on [DATE], and pulled at her trach collar on [DATE], these were behaviors that should have been immediately discussed with the IDT and a plan of care developed to address it. LN 4 stated in the daytime, Resident 1 ' s daughters were in the facility and there were more staff and activities taking place. LN 4 stated there should have been an individualized dementia care plan that addressed Resident 1 ' s supervision and behavioral needs at night. LN 4 stated Resident 1 ' s behaviors could have been sundowning (symptom of dementia characterized by a state of confusion occurring in the late afternoon and lasting into the night with behaviors such as anxiety, aggression, ignoring directions, pacing, or wandering) and that this should have been discussed as an IDT and care planned. LN 4 stated having a dementia plan of care that addressed Resident 1 ' s behavior and supervision needs may have prevented her from pulling out her trach on [DATE]. On [DATE] at 4:26 A.M., an interview was conducted with RT 1. RT 1 stated she was familiar with Resident 1 and that the resident was confused and would often pull at her trach and the oxygen mask that was applied to it. RT 1 stated if Resident 1 was really agitated or touching and pulling at her trach, she needed to be placed on 1:1 supervision. RT 1 stated Resident 1 required the trach in order to adequately breathe. On [DATE] at 4:46 A.M., a joint interview and record review was conducted with LN 3. LN 3 stated Resident 1 was confused most of the time. LN 3 stated Resident 1 would become anxious at night after her daughters left. LN 3 stated Resident 1 would pretend to sleep and then as soon as her daughters left, she would start getting up and asking to go home. LN 3 stated Resident 1 did not have anything to do at night. LN 3 stated she started her shift on [DATE] at 7 P.M. and saw Resident 1 sometime between 7 P.M. to 8 P.M. LN 3 stated she had observed Resident 1 to be agitated and pulling at her trach and oxygen mask. LN 3 stated Resident 1 needed 1:1 supervision at that time, but there was no one to do it. LN 3 stated there was not enough staff. LN 3 reviewed Resident 1 ' s clinical record and stated when she went into Resident 1 ' s room at 8:42 P.M., she thought the resident was asleep in bed. LN 3 stated Resident 1 had her blanket pulled up to her chin and could not visualize her trach site. LN 3 stated when Resident 1 did not respond, she pulled the blanket down and found the resident ' s trach next to her hip on the bed. LN 3 stated Resident 1 was dependent on the trach and could not adequately breathe without it. On [DATE] at 5:42 A.M., an interview was conducted with CNA 2. CNA 2 stated, It was hard taking care of her [Resident 1] at night. CNA 2 stated he worked both day and NOC shift, and the resident ' s daughters took care of her needs during the day. CNA 2 stated at night, Resident 1 kept trying to get out of bed and was restless. CNA 2 stated Resident 1 was quick and that he had to reapply the resident ' s oxygen mask several times after the resident removed it from her trach. CNA 2 stated there were a couple times when he worked that he briefly provided 1:1 supervision for Resident 1 when the 555871 Page 19 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident was agitated. CNA 2 stated Resident 1 would calm down having someone there and responded well to 1:1 supervision. CNA 2 stated Resident 1 needed 1:1 supervision when she was awake at night because she was impulsive. On [DATE] at 6:20 A.M., a joint interview and record review was continued with LN 3. LN 3 reviewed Resident 1 ' s clinical record and stated there was no documentation of an IDT to discuss Resident 1 ' s dementia care, behavioral, and supervision needs. LN 3 stated Resident 1 did not have an individualized written care plan to address and manage her dementia care. On [DATE] at 7:25 A.M., an interview was conducted with LN 5. LN 5 stated Resident 1 had dementia. LN 5 stated Resident 1 would pretend to be asleep sometimes and then start to get up and pull on her tubes (g-tube and trach). LN 5 stated, It ' s easy in the daytime because her [Resident 1 ' s] daughters were here. LN 5 stated Resident 1 ' s behavior at night should have been discussed as IDT and a dementia plan of care developed to help the NOC shift manage the resident ' s behavior. On [DATE] at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON stated Resident 1 ' s family was present to watch the resident during the day. The DON stated Resident 1 was a special case and the facility allowed the family to stay at night to watch the resident. The DON acknowledged it was the facility ' s responsibility to supervise the resident. The DON and the ADON stated the difficulties at night managing Resident 1 ' s behaviors were not communicated to them. The DON stated Resident 1 ' s behaviors should have been discussed as an IDT and care planned. The DON stated potential person-centered interventions to manage Resident 1 ' s behavior at night were: call the family to come stay with the resident, bring the resident out to the nurses ' station, place mittens (restraint device that prevented fingers from grasping) on the resident, a resident-centered activity like folding linens, or provide 1:1 supervision. The DON stated there should have been an individualized dementia plan of care in place to meet Resident 1 ' s needs. The DON stated Resident 1 should have been provided 1:1 supervision. The DON stated, More could have been done. A review of Resident 1 ' s hospital documentation titled Discharge summary dated [DATE], indicated, .Diagnoses . Anoxic brain injury . overall poor prognosis . family decided to transition to comfort care and the patient passed away on [DATE] at 1855 [6:55 P.M.] On [DATE] at 3:05 P.M., a virtual interview was conducted with hospital medical doctor (MD) 1. Also present during the interview was the hospital director of regulatory affairs. MD 1 stated he was a pulmonologist (physician specializing in the respiratory system) and ICU (intensive care unit) physician and had treated Resident 1 during her hospital ICU stay ([DATE] through [DATE]). MD 1 stated he could not say with 100% certainty that Resident 1 ' s self-removal of her trach (on [DATE] at the skilled nursing facility) was the direct or only cause of her anoxic brain injury. MD 1 stated Resident 1 ' s self-removal of her trach on [DATE] was, Most definitely a contributing cause of the anoxic brain injury. MD 1 further stated residents with cognitive impairment and behavioral issues, who were attempting to pull on their trach, should have a sitter (1:1 supervision), be given a psychotropic medication to calm them down, or placed in restraints (device such as mittens) as a last resort. A review of the facility ' s policy titled Dementia Care Policy, revised 1/2021, indicated, It is the policy of this facility to provide residents who displays or is diagnosed with dementia with the appropriate treatment and services, that is person-centered through an interdisciplinary team (IDT) approach to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being . 2. Develop and implement person-centered care plans that include and support the dementia 555871 Page 20 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0744 care needs . 3. Develop individualized interventions related to the resident ' s symptomology and rate of progression Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555871 Page 21 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was administered a prn (as needed) medication according to the physican ' s instructions when licensed nurses (LN) observed the resident ' s behavior of pulling at life sustaining tubes (such as breathing tubes and feeding tubes). As a result of this deficient practice, there was a potential for Resident 1 ' s behavior to increase in severity and for life sustaining tubes to become pulled out. Findings: A review of Resident 1 ' s admission Record, dated 4/20/23, indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, attention to tracheostomy (opening in the trachea to insert a breathing tube/trach), attention to gastrostomy (opening in the abdomen to insert a feeding tube/g-tube), and unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance. A review of Resident 1 ' s physician ' s order dated 3/6/23, indicated the resident was to receive quetiapine (a psychotropic medication used to control mood and behavior) 50 mg (milligrams) every six hours as needed for psychosis as evidenced by pulling out life sustaining tubes (g-tube and/or trach). There was also an order dated 3/6/23 to monitor the episodes of this behavior of pulling at the life sustaining tubes. A review of Resident 1 ' s medication administration record (MAR) for March 2023, indicated the resident ' s behavior of pulling at life sustaining tubes had been observed: 8 times on 3/6/23, 8 times on 3/7/23, 8 times on 3/8/23, 6 times on 3/9/23, 6 times on 3/10/23, 6 times on 3/11/23, 4 times on 3/12/23, 2 times on 3/23/23, 5 times on 3/24/23, 5 times on 3/25/23, 555871 Page 22 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0755 2 times on 3/26/23. Level of Harm - Minimal harm or potential for actual harm The same MAR indicated quetiapine 50 mg had been given once on 3/10/23. Residents Affected - Few On 4/19/23 at 2:51 P.M., a joint interview and record review was conducted with LN 4. LN 4 reviewed Resident 1 ' s physician order dated 3/6/23 for quetiapine and the resident ' s March 2023 MAR. LN 4 stated the behavior monitoring for Resident 1 ' s quetiapine marked the number of times the behavior was observed by the LN. LN 4 stated Resident 1 should have been administered a dose of quetiapine when the LN first observed the resident pulling at her g-tube or trach. LN 4 stated, There ' s a reason for the quetiapine order. It should have been followed. On 4/22/23 at 6:20 A.M., a joint interview and record review was conducted with LN 3. LN 3 reviewed Resident 1 ' s order for quetiapine order dated 3/6/23 and March 2023 MAR. LN 3 stated when Resident 1 was first observed pulling at her life sustaining tubes, she should have been administered a dose of quetiapine. On 5/10/23 at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON and ADON reviewed Resident 1 ' s clinical record and stated the resident ' s quetiapine order should have been followed. The DON and ADON both stated Resident 1 should have been administered the quetiapine when she was first observed to have been pulling at life sustaining tubes. A review of the facility ' s undated policy titled Medication Administration, indicated, It is the policy of this facility to accurately prepare. [sic] Administer and document medications . 2. Review and verify physician ' s orders 555871 Page 23 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure nursing documentation in one of three residents ' ( Resident 1) medical records was accurate. As a result, there was the potential residents ' medical records would not truly reflect care that was provided and/or received. Findings: A review of Resident 1 ' s admission Record, dated 4/20/23, indicated the resident was admitted to the facility on [DATE] with diagnoses to include acute and chronic respiratory failure, attention to tracheostomy (opening in the trachea to insert a breathing tube/trach), attention to gastrostomy (opening in the abdomen to insert a feeding tube/g-tube), and unspecified dementia (condition characterized impaired judgement and memory loss), severe, with behavioral disturbance. A review of Resident 1 ' s progress notes dated 3/21/23, indicated, .At around 0400H [4 A.M.] pt [patient] was found with her Gtube out A review of Resident 1 ' s change of condition note dated 3/21/23, indicated the resident ' s gtube was pulled out. A review of Resident 1 ' s physician ' s order dated 3/6/23, indicated licensed nurses (LN) were to monitor the resident ' s behavioral episodes of pulling out the life sustaining tubes (gtube and/or trach). A review of Resident 1 ' s medication administration record (MAR) for March 2023, indicated the resident ' s behavior of pulling out life sustaining tubes was marked as zero episodes on 3/21/23. On 4/19/23 at 2:51 P.M., a joint interview and record review was conducted with LN 4. LN 4 reviewed Resident 1 ' s progress note and change of condition note dated 3/21/23 and the March 2023 MAR. LN 4 stated Resident 1 ' s behavior monitoring on the MAR when marked as zero episodes on 3/21/23 was not accurate because the resident had pulled out her g-tube. On 4/22/23 at 6:20 A.M., a joint interview and record review was conducted with LN 3. LN 3 reviewed Resident 1 ' s progress notes on 3/21/23 and March 2023 MAR. LN 3 stated she was the nurse taking care of Resident 1 when the resident pulled out her g-tube. LN 3 stated her documentation on 3/21/23 was not accurate when she marked zero episodes of pulling out life sustaining tubes. On 5/10/23 at 12:05 P.M., a joint interview and record review was conducted with the director of nursing (DON) and assistant director of nursing (ADON). The DON and ADON reviewed Resident 1 ' s clinical record. The ADON stated Resident 1 ' s MAR for monitoring episodes of pulling life sustaining tubes on 3/21/23 was not accurate. The ADON stated Resident 1 pulled out her g-tube and the MAR should not have been marked as zero episodes on 3/21/23. The ADON stated documentation should have been accurate. A review of the facility ' s policy titled Daily Skilled Nursing Documentation dated 10/1/13, did 555871 Page 24 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

F 0842 not provide guidance related to accuracy of nursing documentation. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555871 Page 25 of 26 555871 05/26/2023 Somerset Subacute and Care 151 Claydelle Ave El Cajon, CA 92020

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. Based on interview and record review, the facility ' s Quality Assurance and Performance Improvement (QAPI- a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) failed to identify areas of improvement related to resident safety after one resident (Resident 1), who was cognitively impaired, pulled out her trach (a breathing tube inserted into a surgical opening into the windpipe). This failure placed cognitively impaired residents who used a trach for breathing at increased risk of self-decannulation events (removal of the breathing tube). Cross reference F689, F725, and F744. Findings: On 4/22/23 at 12:45 P.M., an interview was conducted with the director of nursing (DON) and the clinical consultant (CC). Resident 1 ' s incident of self-decannulation that took place on 3/26/23 was discussed. The DON stated the facility had not investigated the incident and had not brought the issue to QAPI. The DON stated the facility ' s QAPI should have investigated the incident. The DON stated self-decannulation was considered an immediate safety concern and did not have to wait to be reviewed during the quarterly QAPI. Both the DON and CC stated the incident on 3/26/23 involving Resident 1 should have been brought to the QAPI and the safety committee immediately after the incident occurred. A review of the facility ' s policy titled Quality Assurance and Performance Improvement, revised 1/2022, indicated, .The facility will .continually assess the facility ' s performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual ' s highest practicable physical, mental, and social well-being . b. The committee will meet at least quarterly or more often as the facility deems necessary . d. Committee functions include: QAPI plan, identifying and prioritizing PIPs [performance improvement projects], implementing actions to correct quality issues . 3. Identification of, and prioritizing of, PIPs through: .f. Prioritizing through identification of high-risk, high volume, or problem-prone issues 555871 Page 26 of 26