PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 000} INITIAL COMMENTS SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 000} The following reflects the findings of the California Department of Public Health during a first revisit of an Abbreviated Standard Survey conducted from 9/3/19 to 9/6/19. Revisit of facility reported incidents: CA00623517, CA00639036, CA00639047, CA00639051, CA00639848, CA00639918, CA00639866, CA00640598, CA00621775, CA00638524 and CA00621433 Additional facility reported incidents investigated: CA00648637, CA00650413 and CA00648652 The inspection was limited to the specific facility reported incidents investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 40537, Health Facilities Evaluator Nurse 33819, Health Facilities Evaluator Nurse 40619, Health Facilities Evaluator Nurse 29548, Health Facilities Evaluator Nurse 26917, Pharmaceutical Consultant 29915, Health Facilities Evaluator Nurse Federal deficiencies F583 and F605 were corrected. Federal deficiencies F600 was still not in compliance and F557, F607, F689 and F755 were written as a result of facility reported incidents CA00648637, CA00650413 and CA00648652 . LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (X6) DATE TITLE 10/07/2019 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 1 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 557 Respect, Dignity/Right to have Prsnl Property SS=D CFR(s): 483.10(e)(2) SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG F 557 (X5) COMPLETION DATE 9/6/19 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure residents are treated with dignity and respect when two staff members (Porter 1 and Patient Care Assistant 1) were photographed laying in a compromised position at the foot part of the bed of one of 18 sampled residents (Resident 34) while Resident 34 sat upright on the bed. The deficient practice could potentially have negative psychsocial outcome on the resident. Findings: Resident 34 was admitted with a diagnosis of cortical blindness (partial or total loss of eyesight). The Minimum Data Set (an assessment tool), dated 6/26/19, indicated a Brief Interview for Mental Status (a screener for cognitive impairment), score of "15" indicated that Resident 34 is, "cognitively intact". Section G of the Minimum Data Set, dated 6/26/19, indicated a functional status of, "independent", regarding mobility. During a review of the facility's digitally encrypted FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 2 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 557 Continued From page 2 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 557 files of photos, videos and text messages from the personal cellular phone of Licensed Vocational Nurse (LVN) 1, included two photographs dated 1/15/18 at 1:22 pm. Photograph 1, labeled IMG - 7052, showed Resident 34 sitting upright in bed from neck to foot, wearing dark shoes and partially covered with a stained white material, two staff members, identified by the facility as Porter 1 and Patient Care Assistant (PCA)1, were laying across the foot of the bed. Porter 1 was on top of PCA 1, their heads were in proximity to each other. Porter 1, who was wearing a blue shirt with a baseball cap looks like his left hand was under the head part of PCA 1, with dark long hair laying underneath him. Photograph 2, labeled IMG 7053, also showed a stained white material and the Resident 34's feet with dark shoes and two staff members, Porter 1 and PCA1. Porter 1 is on top of PCA1 laying on the foot part of the bed. During a review of the facility document titled "Preliminary Report", dated 7/30/2019: it indicated " ...as part of concurrent Human Resources investigation regarding the pictures and videos discovered on staff member's cell phone ..." with an incident date of 7/ 2018, at [Facility Name] North One Neighborhood, "two photographs dated 1/15/18, showed two staff members laying on the foot of the resident's bed, while the resident sat up right further up the bed." The report identified Resident 34, Porter 1 and PCA1 as the two staff members. During an observation with concurrent interview on 8/2/19 at 3:45 PM with Resident 34, Resident 34 was in bed. She said, "Hi. Go away. I'm tired." to the surveyor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 3 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 557 Continued From page 3 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 557 During an interview with the Director of Quality Management (DQM), on 8/13/19, at 2:04 pm, she stated, "the city attorney interviewed the two staff in the picture and they said they accidentally fell on the resident's bed and no other explanation given why the two staff are on top of each other in the resident's bed..." During an interview with Porter 1, on 8/13/19, at 2:48 pm, he stated that no one had talked to him about the incident of abuse the last two weeks. During an interview with the Director of Regulatory Affairs (DRA), on 8/13/19, at 3 pm, he stated, "the two employees accidentally fell onto the resident's bed ..." During a subsequent interview with the Director of Quality Management (DQM) on 8/22/19, at 4 pm, she stated "Porter 1 was told yesterday by his supervisor that he will be reassigned to a non-patient area, he was upset and he called off today ..." During a review of document titled "Investigation of Alleged Abuse", page five (5) of six (6) Part VII: Conclusion, dated 7/31/19, entered by DRA, indicated " ...I conclude that the abuse is not substantiated ...abuse on the part of the two staff members in the picture was not substantiated, as they both stated that the fall/trip was accidental ..."The investigation did not provide any details or logical explanation on how the two staff "accidentally fell" on the resident's bed in a compromised position. {F 600} Free from Abuse and Neglect SS=E CFR(s): 483.12(a)(1) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 {F 600} Facility ID: CA220000512 10/6/19 If continuation sheet Page 4 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 600} Continued From page 4 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 600} §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure an environment free from abuse for all residents, when a corrective action to conduct employee supervision and check in with all nursing staff members to identify staff burn out and to provide opportunities for staff to privately voice concerns with regards to any peers was not implemented in 3 of 4 randomly selected nursing units (Units 1, 2 and 3 ). Failure to implement action plans regarding staff supervision is a potential risk for residents, who may be subject to abuse by staff. Findings: Record review of the the facility's plan of correction (POC) dated 8/9/19, indicated "...Corrective Actions: ...15. Nurse Managers for all Neighborhoods [Units] initiated a standardized tool and process to conduct employee supervision and check in with all nursing staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 5 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 600} Continued From page 5 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 600} members, this supervision...employee interview to identify any staff burn out, and establish venue if employee have any concerns with regards to any peers or overall feedback...This process gives staff an opportunity to raise concerns privately and allows the Nurse Manager to observe staff performance...Completion Date: July 15 and ongoing..." Record review of a facility form titled, "Nurse Manager Employee Supervision and Check In (FY (Fiscal Year) 2019 Thru FY 2020" showed four columns identifying the date, unit, employee's name and shift of when an employee would be supervised by the Nurse Manager on "A. Care Observation: Staff demonstrated providing care in a manner that took account resident's comfort, safety, and dignity... B. Communication: Staff Demonstrated respectful and therapeutic communication..." During an interview with the Nurse Manager of Unit North 1 (NM 1), on 9/3/19 10:30 AM, NM 1 stated, "Yes, I am expected to do check-in with 1 staff member daily, Monday to Friday, about 5 staff every week...This has been in place for about 7-8 weeks since mid July..." During an interview with the Manager of Administration (MOA) and the Director of Quality Management (DQM) on 9/4/19 at 1:25 PM, while reviewing data from the facility's POC, MOA stated, "No, we do not know how many staff members have been interviewed by each Nurse Manager from each unit...Nurse Managers in all units are expected to complete these check-in since about July 15...I understand this is an important item since the incidents of abuse involved the issue of supervision..." A random FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 6 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 600} Continued From page 6 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 600} sample of employees rosters from 4 of the facility's 13 units was requested. Record review of a facility form titled "[Nursing Unit] Staff Check -In", of nursing staff roster interviewed by the Nurse Manager of Unit 1 indicated 12 of 43 staff members had been interviewed per POC Corrective Action #15. (28 %). Record review of the same form for Unit 2, of nursing staff roster interviewed by the Nurse Manager of Unit 2 indicated 18 of 50 staff members had been interviewed per POC Corrective Action #15. (36%). Record review of nursing staff roster interviewed by the Nurse Manager of Unit 3 indicated 5 of 55 staff members had been interviewed per POC Corrective Action #15. (9%). During an interview with DQM on 9/5/19 at 10:15 AM, upon reviewing the information above for Units 1, 2 and 3, DQM stated "...Yes, I agree the numbers are not even the majority of staff. It has been a few weeks since July 15...Yes, I know that the investigated incidents of abuse involved the issue of staff supervision and staff did not report them..." During an interview with the Risk Manager Director, (RMD), on 9/6/19 at 11 AM, upon reviewing the numbers of staff from Units 1, 2 and 3 undergoing "check-in" with their manager, per the POC language, RMD stated "Yes, I get it... the numbers should be higher after the findings related to supervision of staff...it has been a lot work..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 7 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 607} Continued From page 7 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG {F 607} {F 607} {F 607} Develop/Implement Abuse/Neglect Policies SS=D CFR(s): 483.12(b)(1)-(3) (X5) COMPLETION DATE 10/9/19 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure a thorough investigation of abuse for one of 18 sampled residents (Resident 34) when two staff members (Porter 1 and Patient Care Assistant 1) were photographed laying at the foot part of Resident 34's bed while the resident sat upright on the bed. This failure had the potential to compromise Resident 34's psychosocial well-being. Findings: Resident 34 was admitted with a diagnosis of cortical blindness (partial or total loss of eyesight). The Minimum Data Set (an assessment tool), dated 6/26/19, indicated a Brief Interview for Mental Status (a screener for cognitive impairment), score of "15" indicated that Resident 34 is, "cognitively intact". Section G of the Minimum Data Set, dated 6/26/19, indicated a functional status of, "independent", regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 8 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 607} Continued From page 8 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 607} mobility. During a review of the facility's digitally encrypted files of photos, videos and text messages from the personal cellular phone of Licensed Vocational Nurse (LVN) 1, included two photographs dated 1/15/18 at 1:22 pm. Photograph 1, labeled IMG - 7052, showed Resident 34 sitting upright in bed from neck to foot, wearing dark shoes and partially covered with a stained white material, two staff members, identified by the facility as Porter 1 and Patient Care Assistant (PCA)1, were laying across the foot of the bed. Porter 1 was on top of PCA 1, their heads were in proximity to each other. Porter 1, who was wearing a blue shirt with a baseball cap looks like his left hand was under the head part of PCA 1, with dark long hair laying underneath him. Photograph 2, labeled IMG 7053, also showed a stained white material and the Resident 34's feet with dark shoes and two staff members, Porter 1 and PCA1. Porter1 is on top of PCA 1 across the foot part of the bed. During a review of the facility document titled "Preliminary Report", dated 7/30/2019: it indicated " ...as part of concurrent Human Resources investigation regarding the pictures and videos discovered on staff member's cell phone ..." with an incident date of 7/ 2018, at [Facility Name] North One Neighborhood, "two photographs dated 1/15/18, showed two staff members laying on the foot of the resident's bed, while the resident sat up right further up the bed." The report identified Resident 34, Porter 1 and PCA1 as the two staff members. During an interview with the Director of Quality Management (DQM), on 8/13/19, at 2:04 pm, she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 9 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 607} Continued From page 9 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 607} stated, "the city attorney interviewed the two staff in the picture and they said they accidentally fell on the resident's bed and no other explanation given why the two staff are on top of each other in the resident's bed..." During an interview with Porter 1, on 8/13/19, at 2:48 pm, he stated that no one had talked to him about the incident of abuse the last two weeks. During an interview with the Director of Regulatory Affairs (DRA), on 8/13/19, at 3 pm, he stated, "the two employees accidentally fell onto the resident's bed ..." During a subsequent interview with the Director of Quality Management (DQM) on 8/22/19, at 4 pm, she stated "Porter 1 was told yesterday by his supervisor that he will be reassigned to a non-patient area, he was upset and he called off today ..." During a review of document titled "Investigation of Alleged Abuse", page five (5) of six (6) Part VII: Conclusion, dated 7/31/19, entered by DRA, indicated " ...I conclude that the abuse is not substantiated ...abuse on the part of the two staff members in the picture was not substantiated, as they both stated that the fall/trip was accidental ..."The investigation did not provide any details or logical explanation on how the two staff "accidentally fell" on the resident's bed in a compromised position. During a review of the facility policy and procedure titled "Abuse and Neglect Prevention, Identification, Investigation, Protection, Reporting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 10 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 607} Continued From page 10 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 607} and Response dated July 9, 2019 indicated "[Facility Name] shall promote an environment that enhances resident well-being and protects residents from abuse ... 4. Identification ...(a) Abuse may result in psychological, behavioral or psychosocial outcomes. The following signs may alert [Facility Name] staff ...(iv) illogical accounts given by resident or staff member ..." {F 689} Free of Accident Hazards/Supervision/Devices SS=D CFR(s): 483.25(d)(1)(2) {F 689} 10/6/19 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide adequate supervision to one of 18 sampled residents (Resident 33) when the resident eloped from the facility on 8/12/19 at 12:26 PM. Resident 33 was found collapsed in a park and sent to a hospital for DKA (diabetic ketoacidosis -occurs when the body produces high levels of blood acids called ketones), atrial fibrillation with relatively rapid venticular response (rapid irregular heart rate) on 8/14/19 at 9:50 AM. This deficient practice placed the resident at risk for serious injury or death. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 11 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 689} Continued From page 11 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 689} Record review of physician's notes dated 6/15/18 on Neuropsychological Capacity Evaluation for Resident 33 indicated the resident had diagnoses including DM (diabetes mellitus) type 2, and peripheral neuropathy . The resident had a significant decline in cognitive functioning with a history of crack cocaine, speed, alcohol, and cannabis use. He demonstrated a lack of insight and displayed impairment in executive functioning. During observation on 9/4/19 at 10:00 AM, Resident 33 was dressed with a colorful sequenced dress with earrings and necklace. The resident had a sitter at the bedside. During an interview on 9/4/19 at 10:05 AM, Resident 33 admitted he had gone out of the facility several times. Stated that he was hospitalized, the last time he went out of the facility. During an interview with RN 3 on 9/4/19 at 10:45 AM, RN 3 said that he saw Resident 33 leave the unit on 8/12/19 at around 8:30 AM, with the thought that Resident 33 had a written Out On Pass (OOP) by the physician. During an interview with RN 4 on 9/4/19 at 11:00 AM confirmed that there was no written OOP order but rather a previous order dated 8/29/19 for "participation in organized out-of-hospital function ..." Record review of facility's policy and procedure titled, "Leave of Absence (Out On Pass) revised 5/14/19 indicated, "Residents who wish to leave the grounds of Laguna Honda Hospital and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 12 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {F 689} Continued From page 12 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE {F 689} Rehabilitation Center (LHH) shall have written orders from their attending physician and appropriate pass medication. Compliance/Adherence with Pass Privilege:When leaving on pass and on returning from pass, residents shall check in and out with the nursing staff on the care unit." Review of MD Note 8/14/19 1:49 PM , " ... I have remained reluctant to grant passes for resident to go ..." Record review of RN 3's Nurses Notes dated 8/12/19 at 12:26 PM indicated, "Resident left out on pass today around 8:30 AM to the community ..." Review of physician's notes dated 8/20/19 11:46 AM, " ...the next thing we heard about the resident was he had been admitted to a hospital ...sick with severe hyperglycemia/DKA. ..." F 755 Pharmacy Srvcs/Procedures/Pharmacist/Records SS=E CFR(s): 483.45(a)(b)(1)-(3) F 755 10/6/19 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 13 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 755 Continued From page 13 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 755 §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review the facility failed to provide pharmaceutical services to meet the needs of each resident as evidence by: 1. The staff failed to properly dispose of medications in accordance with facility policy. 2. The facility failed to have developed a policy to dispose of disguised (hidden in food) medications. These failures resulted in Resident 31 taking medications and self-administering medications that were not prescribed which then exposed Resident 31 to the side effects of multiple non-prescribed medications. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 14 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 755 Continued From page 14 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 755 1. A review on 8/14/19 of Resident 31's clinical record indicated that Resident 31 has a medical history of dementia, schizophrenia, and psychogenic polydipsia (excessive drinking). Resident 31 was prescribed Olanzapine to treat these conditions. Resident 31 had behaviors that manifested as taking used cups out of the garbage bin and then filling the cups with water and drinking the contents. Resident 31's Minimum Data Set (MDS) assessment dated 5/18/19 indicated a Brief Interview of Mental Status (BIMS) score of 0 which indicated that Resident 31 had significant cognitive deficits. During an interview on 8/14/19 at 10:51 AM, Physician 1 stated Resident 31 was her patient. Physician 1 also stated that Resident 31 had been disrobing which was not a behavior that Resident 31 had exhibited in the past. Physician 1 then ordered a urine toxicology screen (Utox) because of Resident 31's unusual behavior on 7/23/19 which then resulted in a positive test for Levetiracetam (Keppra anti-seizure medication). Physician 1 said that she reordered the Utox again on 7/29/19 which tested positive for Hydrocodone (opioid medication) and Gabapentin (Neurontin anti-seizure medication). Physician 1 also said that the Levetiracetam, Hydrocodone, and Gabapentin were non-prescribed medications. A review on 8/14/19 of Resident 31's Interdisciplinary Team Meeting Note dated 8/7/19 at 9:30 AM indicated, "Utox test carried out on 7/23/19 revealed patient had Keppra in his urine sample. Even though patient did not have order for Keppra. A repeat test on 7/29/19 revealed he had hydrocodone and Neurontin in urine sample even though resident did not have order for these FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 15 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 755 Continued From page 15 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 755 too ...Resident has behavior by grabbing ...patient cups and picking up cups from garbage and adding more water from it and drinking from it. Also since many other residents have their meds disguised its possible he drank from it." During an interview on 8/14/19 at 9:15 AM, Registered Nurse (RN) 1 stated that she saw Resident 31 take medication cups from the medication cart trash bin around 7/23/19 and 7/29/19. RN 1 also stated that she had seen Resident 31 take cups before and fill them with water and drink the contents of what was inside the cups. She said that Resident 31 also would take and hoarded any type of cup. RN 1 said that she had seen Resident 31 take and drink from cups in the trash for the last 8 years. She also said that if you try and take the cups away from Resident 31 he would be combative. During an observation on 8/15/19 at 8:52 AM of three medication cart trash bins with open lids contained the following: *Medication Cart Trash Bin 1-multiple used cups, a unidentifiable bottle of medication opened, and two used liquid medication cups with remnants of solution. *Medication Cart Trash Bin 2-two unit dose medication packages opened, a medication cup that had crushed medications that was visible in some sort of yellow paste, part of a medication capsule. *Medication Cart Trash Bin 3-one unit dose medication package opened, a cup with orange solution and visible particles of medications. During an interview on 9/04/19 between 2:24 PM and 2:27 PM, RN 2, LVN 1, and LVN 2 all stated that after administering medications that they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 16 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 755 Continued From page 16 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 755 would discard the used medication cups into the medication cart trash bin. They stated that the medication cart trash bin where left open instead of closing the lid so the contents of the trash were visible. The above indicated that the nurses would leave used medication cups with medication left in the cups which could be available for residents to take and self-administer the left over medication. A review on 9/5/19 of the facility policy dated 7/9/19 entitled, "Medication Administration" indicated "If medications have been prepared/removed from packaging, and resident does not take, medication must be wasted and documented in eMAR ...Medications that are not administered must be disposed of in the appropriate medical waste container ..." During an interview on 9/5/19 at 10:27 AM, the Director of Pharmacy stated that non-hazardous medications were to be disposed of in the white and blue bins and hazardous (potential threat to public health) medications were to be disposed of in the yellow bins. The DOP said that the medication cart trash bin should not have any medications discarded in it. 2. During an interview on 8/14/19 at 8:41 AM Administrator 1 stated that Resident 32 was the only resident that was on Hydrocodone where Resident 31 resided. He said that Resident 31 and Resident 32 resided in a locked unit. He also stated that Resident 32 had his medication disguised because he did not like taking his medications. Resident 32 would take his medications with ice cream. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 17 of 18 PRINTED: 10/30/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ______________________ (X3) DATE SURVEY COMPLETED R-C 555020 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 375 LAGUNA HONDA BLVD. LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF (X4) ID PREFIX TAG 09/06/2019 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 755 Continued From page 17 SAN FRANCISCO, CA 94116 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE F 755 During an interview on 8/14/19 at 11:06 AM the Laboratory Services Personnel 1 stated that for Resident 31 to test positive for Hydrocodone he would have had to have taken more than a ½ a tablet of Resident 32's Hydrocodone. If it was less than a ½ a tablet Resident 31 would not have tested positive. The above indicated that Resident 32's Hydrocodone was disguised in ice cream which would mean that Resident 31 had to have taken Resident 32's ice cream which would have had more than a ½ a tablet of Hydrocodone. During an interview on 9/5/19 at 10:27 AM the DOP stated that there was no specific facility policy that addressed disposal of medications that are disguised. She acknowledged that developing and implementing facility policy to securely dispose of disguised medications could prevent reoccurrence of residents taking medications that were not prescribed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8EBF12 Facility ID: CA220000512 If continuation sheet Page 18 of 18