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Based on observation, interview, and record review, the facility failed to ensure patient assessments, and Peripherally Inserted Central Catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart) Intravenous (IV) antibiotic medication administration was performed by a Registered Nurse (RN).

These facility failures had the potential to compromise patient's health and safety when a dedicated RN was not made available to supervise and oversee LVNs patient assignments, and an infusion of IV medication administration.

Findings:

On August 11, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility.

On August 11, 2025, at 8:58 a.m., a tour of Unit 200 was conducted with the Nurse Manager (NM). During the tour, the bed board indicated there were 20 patients in the unit, and staffing consisted of two RN's and two LVN's, assigned five patients each.

An interview was conducted on August 11, 2025, at 9:05 a.m., with the NM. The NM stated the LVNs work on their own. The NM stated the LVNs and RNs have a rotating shift coverage, and patient assessments were completed by an RN every 24 hours.

On August 11, 2025, at 11:41 a.m., a review of the facility policy titled, "Reassessment", was conducted with the Director of Compliance (DOC). The DOC stated, "Patient assessment should be done every 12 hours."

On August 12, 2025, at 9:20 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated, "It is not team nursing. Nurses have their own patient assignments. They have 1:5 nurse to patient ratio. This is for RNs and LVNs both." The CNO further stated, "The House Supervisor is supervising the LVN's. They have RN assessment done every day. It is not done every 12 hours. The LVN gathers information, the RN does the full assessment every day."

On August 12, 2025, at 1:42 p.m., an interview was conducted with RN 1. RN 1 stated, "An assessment should be done by an RN on every shift."

On August 12, 2025, at 2:00 p.m., an interview was conducted with LVN 1. LVN 1 stated, "It [a full body assessment] should be done every shift, and LVNs should be under the RN supervision."

On August 12, 2025, at 3:38 p.m., an interview was conducted with the House Supervisor (HS) 2. HS 2 stated, "An RN assessment every 24 hours based on policy, and nurse assessment every shift, RNs minimum once every 24 hours." HS 2 stated, LVNs have their own patient assignment, if there is anything not in their LVN scope of practice, the RN supervisor or another RN on the floor will assist if they need it. HS 2 further stated, "I am responsible for the patient, the staff, and everybody."

On August 13, 2025, at 9:28 a.m., a review of the facility's RN and LVN morning schedules and patient assignments dated June 21, 2025, through July 5, 2025, and August 11, 2025, through August 13, 2025, was conducted with the NM. The documents indicated LVNs took full patient assignments and was the primary care nurse on: June 21, 2025, by LVN 2; June 22, 2025, by LVN 3; June 24, 2025, by LVN 3; June 25, 2025, by LVN 2; June 26, 2025, by LVN 2; June 27, 2025, by LVN 1; June 28, 2025, by LVN 1; June 29, 2025, by LVN 3; July 1, 2025, by LVN 2; July 2, 2025, by LVN 1; July 3, 2025, by LVN 1; July 4, 2025, by LVN 2; July 5, 2025, by LVN 2; August 11, 2025, by LVN 4 and 5; August 12, 2025, by LVN 5 and 6; and August 13, 2025, by LVN 5 and 6.

An interview was conducted on August 13, 2025, at 9:30 a.m., with the NM. The NM stated the RN assessments were completed by an RN every 24 hours. The regulation for compliance with Federal, State and Local Laws was reviewed with NM that indicated RN assessment should be completed every shift.

On August 12, 2025, at 1:42 p.m., an interview was conducted with RN 1. RN 1 stated HS 2 instructed him to administer the IV medication to the patient in Room 203. RN 1 stated he then informed HS 2 that the antibiotic medication will be infused over 30 minutes. RN 1 stated usually the RN monitors the IV medication for potential side effects or a reaction. RN 1 stated "I am not sure who took the medication off. It was already done when I checked the room. I hung the medication, told [Name of HS 2] and that was it."

On August 12, 2025, at 2:00 p.m., an interview was conducted with LVN 5. LVN 5 stated RN 1 was the nurse she had to go to for any IV medication administrations. LVN 5 explained that it was pre-arranged before the shift. LVN 5 stated RN 1 or the RN who started the IV medication was responsible for the follow up and monitoring. LVN 5 further stated the RNs had to do an IV site assessment, monitor to make sure there was no infiltration or infection, ensure the right rate of the infusion, and monitor the patient for any adverse reactions. LVN 5 stated, for many things out of the LVN practice, she had to go to the RN or somebody higher up. LVN 5 stated, "I am not allowed to hang or remove any IV medications from a PICC Line."

On August 12, 2025, at 3:38 p.m., an interview was conducted with HS 2. HS 2 stated she informed RN 1 about the patient in Rm 203 needing a PICC Line IV antibiotic medication. HS 2 stated she went in, shut it off, and flushed the line. HS 2 further stated, the infusion needs to be monitored to ensure the infusion is running properly if it is a PIV (peripheral IV), monitor for infiltration, or signs or symptoms of a medication reaction. HS 2 stated she was responsible for things that happen, including medication administration, and she can delegate if needed. HS 2 stated the RN supervisor or another RN on the floor will assist LVNs if needed. HS 2 stated, "I am responsible for all patients, the staff, and everybody."

A review of facility policy and procedure titled, "Admission Assessment & Screen", dated November 2023, indicated, "The registered nurse will complete the nursing assessment and perform a systems review, patient medical history, psychosocial screen, functional screen, nutritional screen, respiratory screen, discharge planning screen, and identify patient problems...NURSING ASSESSMENT...The Registered Nurse is responsible for initiation and completion of the nursing assessment. Data on the form may be collected by other health care professionals, but the admitting registered nurse has the responsibility for the accuracy and completeness of the assessment..."

A review of the facility policy and procedure titled, "Reassessment," dated November 2023, indicated, "A patient's need for care related to his/her admission is assessed by a Registered Nurse (RN). Patient needs, response to treatments/interventions, and change in condition or diagnosis are re-evaluated at least every 12 hours and when warranted by a change in the patient's condition...The RN will perform reassessment and will direct patient care through a variety of mechanisms including notification of the change to the physician, change to plan of care, and other interventions based on the patient need...An interdisciplinary team throughout the organization assesses and reassesses the patient's need for care, treatment and/or intervention at time intervals as outlined within the policy..."

A review of California Code of Regulations (CCR) Title 22 Division 5, Chapter 1, Article 3, 70215 (a)(1), "Planning and Implementing Patient Care" indicated, "...(a) A registered nurse shall directly provide: (1) Ongoing patient assessments as defined in the Business and Professional Code, section 2725 (b)(4). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area."

Based on observation, interview, and record review, the facility failed to ensure patient assessments, and Peripherally Inserted Central Catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart) Intravenous (IV) antibiotic medication administration was performed by a Registered Nurse (RN).

These facility failures had the potential to compromise patient's health and safety when a dedicated RN was not made available to supervise and oversee LVNs patient assignments, and an infusion of IV medication administration.

Findings:

On August 11, 2025, at 8:30 a.m., an unannounced visit was conducted at the facility.

On August 11, 2025, at 8:58 a.m., a tour of Unit 200 was conducted with the Nurse Manager (NM). During the tour, the bed board indicated there were 20 patients in the unit, and staffing consisted of two RN's and two LVN's, assigned five patients each.

An interview was conducted on August 11, 2025, at 9:05 a.m., with the NM. The NM stated the LVNs work on their own. The NM stated the LVNs and RNs have a rotating shift coverage, and patient assessments were completed by an RN every 24 hours.

On August 11, 2025, at 11:41 a.m., a review of the facility policy titled, "Reassessment", was conducted with the Director of Compliance (DOC). The DOC stated, "Patient assessment should be done every 12 hours."

On August 12, 2025, at 9:20 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated, "It is not team nursing. Nurses have their own patient assignments. They have 1:5 nurse to patient ratio. This is for RNs and LVNs both." The CNO further stated, "The House Supervisor is supervising the LVN's. They have RN assessment done every day. It is not done every 12 hours. The LVN gathers information, the RN does the full assessment every day."

On August 12, 2025, at 1:42 p.m., an interview was conducted with RN 1. RN 1 stated, "An assessment should be done by an RN on every shift."

On August 12, 2025, at 2:00 p.m., an interview was conducted with LVN 1. LVN 1 stated, "It [a full body assessment] should be done every shift, and LVNs should be under the RN supervision."

On August 12, 2025, at 3:38 p.m., an interview was conducted with the House Supervisor (HS) 2. HS 2 stated, "An RN assessment every 24 hours based on policy, and nurse assessment every shift, RNs minimum once every 24 hours." HS 2 stated, LVNs have their own patient assignment, if there is anything not in their LVN scope of practice, the RN supervisor or another RN on the floor will assist if they need it. HS 2 further stated, "I am responsible for the patient, the staff, and everybody."

On August 13, 2025, at 9:28 a.m., a review of the facility's RN and LVN morning schedules and patient assignments dated June 21, 2025, through July 5, 2025, and August 11, 2025, through August 13, 2025, was conducted with the NM. The documents indicated LVNs took full patient assignments and was the primary care nurse on: June 21, 2025, by LVN 2; June 22, 2025, by LVN 3; June 24, 2025, by LVN 3; June 25, 2025, by LVN 2; June 26, 2025, by LVN 2; June 27, 2025, by LVN 1; June 28, 2025, by LVN 1; June 29, 2025, by LVN 3; July 1, 2025, by LVN 2; July 2, 2025, by LVN 1; July 3, 2025, by LVN 1; July 4, 2025, by LVN 2; July 5, 2025, by LVN 2; August 11, 2025, by LVN 4 and 5; August 12, 2025, by LVN 5 and 6; and August 13, 2025, by LVN 5 and 6.

An interview was conducted on August 13, 2025, with the NM. The NM stated the RN assessments were completed by an RN every 24 hours. The regulation for compliance with Federal, State and Local Laws was reviewed with NM that indicated RN assessment should be completed every shift.

On August 12, 2025, at 1:42 p.m., an interview was conducted with RN 1. RN 1 stated HS 2 instructed him to administer the IV medication to the patient in Room 203. RN 1 stated he then informed HS 2 that the antibiotic medication will be infused over 30 minutes. RN 1 stated usually the RN monitors the IV medication for potential side effects or a reaction. RN 1 stated "I am not sure who took the medication off. It was already done when I checked the room. I hung the medication, told [Name of HS 2] and that was it."

On August 12, 2025, at 2:00 p.m., an interview was conducted with LVN 5. LVN 5 stated RN 1 was the nurse she had to go to for any IV medication administrations. LVN 5 explained that it was pre-arranged before the shift. LVN 5 stated RN 1 or the RN who started the IV medication was responsible for the follow up and monitoring. LVN 5 further stated the RNs had to do an IV site assessment, monitor to make sure there was no infiltration or infection, ensure the right rate of the infusion, and monitor the patient for any adverse reactions. LVN 5 stated, for many things out of the LVN practice, she had to go to the RN or somebody higher up. LVN 5 stated, "I am not allowed to hang or remove any IV medications from a PICC Line."

On August 12, 2025, at 3:38 p.m., an interview was conducted with HS 2. HS 2 stated she informed RN 1 about the patient in Rm 203 needing a PICC Line IV antibiotic medication. HS 2 stated she went in, shut it off, and flushed the line. HS 2 further stated, the infusion needs to be monitored to ensure the infusion is running properly if it is a PIV (peripheral IV), monitor for infiltration, or signs or symptoms of a medication reaction. HS 2 stated she was responsible for things that happen, including medication administration, and she can delegate if needed. HS 2 stated the RN supervisor or another RN on the floor will assist LVNs if needed. HS 2 stated, "I am responsible for all patients, the staff, and everybody."

A review of facility policy and procedure titled, "Admission Assessment & Screen", dated November 2023, indicated, "The registered nurse will complete the nursing assessment and perform a systems review, patient medical history, psychosocial screen, functional screen, nutritional screen, respiratory screen, discharge planning screen, and identify patient problems...NURSING ASSESSMENT...The Registered Nurse is responsible for initiation and completion of the nursing assessment. Data on the form may be collected by other health care professionals, but the admitting registered nurse has the responsibility for the accuracy and completeness of the assessment..."

A review of the facility policy and procedure titled, "Reassessment," dated November 2023, indicated, "A patient's need for care related to his/her admission is assessed by a Registered Nurse (RN). Patient needs, response to treatments/interventions, and change in condition or diagnosis are re-evaluated at least every 12 hours and when warranted by a change in the patient's condition...The RN will perform reassessment and will direct patient care through a variety of mechanisms including notification of the change to the physician, change to plan of care, and other interventions based on the patient need...An interdisciplinary team throughout the organization assesses and reassesses the patient's need for care, treatment and/or intervention at time intervals as outlined within the policy..."

Based on observation, interview, and record review, the facility failed to ensure a percutaneous endoscopic gastrostomy (PEG) tube (feeding tube inserted into the stomach through the abdominal wall), and the water flush bag was labeled for one (Patient 16) of 20 sample patients.

This failure had the potential for the staff to infuse a feeding bag and water flushes hanging for over the recommended open use dates (this practice could result to bacterial growth that may cause harm to vulnerable patients in the facility).

Findings:

On August 11, 2025, at 9:40 a.m., a tour of Unit A was conducted with the Director of Compliance (DOC). During the tour in Patient 16's room, a bag of enteral feeding and a water flush bag was observed hanging and was not labeled with the date and time.

A review of Patient 16's medical record was conducted on August 13, 2025, at 8:30 a.m., with the Chief Nursing Officer (CNO) and the Assistant Vice President Licensure, Quality Compliance, Risk (AVPLQCR).

A facility document titled, "History and Physical," dated April 3, 2025, at 10:13 a.m., was reviewed. The document indicated Patient 16 was admitted to the facility on April 3, 2025, at 11:59 a.m., for traumatic subdural hemorrhage with midline shift (collection of blood between the dura mater (brain's outer covering) and the brain, caused by head trauma(injury to the head), with the blood mass causing the brain to shift away from its normal position in the skull) status post s/p (after) right mini craniotomy (minimally invasive surgical procedure where a small opening is made in the skull on the right side to access and treat a specific area of the brain).

The facility document titled, "Dietary (3) Orders" dated August 7, 2025, at 7:01 p.m., was reviewed and indicated, Jevity 1.5 (type of feeding), by PEG tube, at a rate of 60 ml/hr (milliliters, unit of measurement, hour) for continuous feeding.

The facility document titled, "Treatment Administration Record [TAR]," dated August 13, 2025, was reviewed with the CNO. The CNO stated the TAR is the same as the Medication Administration Record (MAR) only relating to any treatments required. The patient (Patient 16) was ordered Enteral Flush (the process of using water to keep the an enteral feeding tube clear and provide water for the patient), every six hours, as a routine, 200 mLs (unit of measurement) if water was to be given.

The facility document titled, "Discharge Summary," dated August 3, 2025, was reviewed and indicated Patient 16's PEG tube was placed on July 25, 2025.

On August 11, 2025, at 9:53 a.m., an interview was conducted with Registered Nurse (RN) 2. RN 2 stated the PEG feeding and flush should have been labeled when it was started. RN 2 further stated the feeding should have had the date and time started and identified the feeding that was being administered, and was not done.

On August 13, 2025, at 10:29 a.m., an interview was conducted with the CNO. The CNO stated it is a nursing standard that the feeding and flush should be labeled. The CNO further stated it is a common nursing practice taught in nursing school that anything being administered to a patient should be labeled. The feeding and flush should have identified the patient, and the date and time it was started. The CNO stated the facility does not have a policy or procedure indicating the feeding and flush should be labeled, however it is just common sense.

Based on interview and record review, the facility failed to ensure Patient 1's medical record was accurate, documented, and signed off in a timely manner when multiple late entries were noted on June 28, 2025, after Patient 1's hospital transfer and demise.

The facility failure did not reflect the patient's current status and disposition when multiple late entries were noted upon record review on August 13, 2025.

Findings:

On August 13, 2025, at 9:03 a.m., Patient 1's record was reviewed with the Director of Compliance (DOC). The record indicated the following late entries:

-Late entry dated June 28, 2025, at 8:40 a.m., electronically signed by Licensed Vocational Nurse (LVN) 1, on June 26, 2025, at 3:26 p.m., indicated, "...pt...alert...vs stable...";

-Late entry dated June 26, 2025, at 2:17 p.m., electronically signed by LVN 1 on June 26, 2025, at 4:15 p.m., indicated, "...BP [blood pressure] drop tp [sic] 98/58 and Hr [heart rate] 124...On call...doctor contacted recommendation to send out to [Name of receiving hospital];

-Late entry dated June 28, 2025, at 12:30 p.m., electronically signed by LVN 1 on June 26, 2025, at 5:07 p.m., indicated, "...blood draw, collected...pt desat [patient desaturate] to 84 % [normal oxygen saturation levels typically range from 95% to 100%. This indicates that 95% to 100% of the red blood cells in the body are carrying oxygen.]...Temp [temperature] 101.3 [normal body temperature is generally considered to be around 98.6°F (37°C).]...Doctor saw patient in room at this time..."; and

-Late entry dated June 26, 2025, at 4:38 p.m., electronically signed by House Supervisor (HS) 1, indicated, "...monitoring patient per Dr. [doctor] suggestion every Hour, Dr.s [doctors] were in room while vital signs being taken and Dr. did a patient assessment, a short time later notified by primary nurse that patients BP dropped and heart rate increased and was running a temp called [name of doctor] and was told to transfer patient to ER [emergency room]...".

Review of Patient 1's record did not provide an accurate and timely reflection of the patients actual status and disposition.

An interview was conducted on August 13, 2025, with the DOC. The DOC stated, "Staff should document notes, medication, treatment, and assessments according to our policy."

An interview was conducted on August 13, 2025, at 9:20 a.m., with the Assistant Vice President Licensure, Quality Compliance, Risk (AVPLQCR). The AVPLQCR stated staff can open a note for record entry and leave it open for the duration of the day until they are ready to close the documentation. The AVPLQCR stated, "Ideally, we expect that staff should document on time."

A review of the facility policy and procedure titled, "Medical Record Documentation & Content," dated November 2023, indicated, "...PURPOSE: To initiate standards for sufficient information to be documented to create a legal documentation, which identifies the patient, support diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers...PROCEDURE...Entries should be dated and timed...Entries should be made as soon as possible after an event or observation is made..."

Based on observation, interview, and record review, the facility failed to ensure expired products were removed from readily available supplies for patient use.

This failure had the potential for staff to use expired products for patient care and services that may cause patient harm.

Findings:

On August 11, 2025, 9:19 a.m., a tour of Unit A was conducted with the Director of Compliance (DOC). During the tour of Unit A, in the medication room, the following expired products and supplies were observed:

- two packages, each containing 100 purple top vacutainers (blood collection tubes used to test for different diseases and blood type) with an expiration date of May 31, 2025;

-three packages, each containing 50 red top serum clot activators (blood collection tube used for testing clotting in the blood) with and expiration date of May 2, 2025; and

-eight bottles of Nepro with Carb Steady (special type of liquid feeding) 1.8 cal (calories) with an expiration date of August 1, 2025.

On August 11, 2025, at 9:22 a.m., an interview was conducted with the DOC. The DOC stated both the purple top vacutainers, and the red top activators, were expired and should not have been on the shelf.

On August 11, 2025, at 9:33 a.m., an interview was conducted with the DOC. The DOC stated the eight bottles of Nepro with Carb Steady feedings were expired and should not have been on the shelf for use. The DOC further stated the bottles should have been discarded.

On August 11, 2025, at 9:34 a.m., an interview was conducted with the Dietitian (D). The D stated the use by date of August 1, 2025, is the expiration date and the feeding should not be used or available for use after that date.

On August 11, 2025, at 10:38 a.m., an interview was conducted with the Facilities Director (FD). The FD stated the vacutainers appeared to be expired according to the date on each package.

On August 11, 2025, at 10:50 a.m., an interview was conducted with the Chief Executive Officer (CEO). The CEO stated the vacutainers were expired.

A review of the facility policy and procedure (P&P) titled, "Infection Control," dated November 2023, was conducted. The document indicated, "...Product shelf life will be based on the expiration date or manufacturer recommendation. The central stores manager is responsible to ensure that all products remain within the expiration date...No product that has gone beyond the published/labeled expiration date will be utilized in patient care..."