Every finding on record at Almond View Care Center

Based on observations, interviews, and record reviews, the facility did not ensure infection control practices were maintained for one out of three sampled Residents (Resident 2) when Resident 1's soiled laundry was placed against Resident 2's bed.This had the potential to contribute to the spread of infection.A review if the facility's policy and procedure (P&P) titled Laundry and Linen Infection Control, dated 9/20/16, indicated the purpose of the policy was to ensure the facility followed infection control practices when handling linen. The P&P indicated that clean linen would be handled differently to prevent cross contamination (spreading or transferring germs accidentally) and soiled linen would be stored separately from clean linen.A review of Resident 1's admission Record, dated 12/9/23, indicated admission to the facility on [DATE] with the diagnoses of open wound to the buttock and hypertension (high blood pressure). Resident 1 was not their own responsible party (RP, did not make own decisions).A review of Resident 2's admission Record, dated 1/28/25, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of dementia with behavioral disturbances (memory loss with behaviors that could include aggression or wandering). Resident 2 was not their own RP. During a concurrent observation and interview on 8/5/26 at 9:03 am, in Resident 1 and 2's shared bedroom, Certified Nurse Assistants (CNA) B and C were observed changing Resident 1's bed linen and t-shirt following Resident 1's incontinence episode (accidentally leaked urine because they cannot control it). CNA B placed Resident 1's soiled linen on top of a small trash can that was positioned next to Resident 2's bed, and the soiled linen was observed resting against Resident 2's bed. CNA C exited the room with the soiled linen. CNA B indicated that the soiled linen was placed on top of the trash can to keep it up off the floor and was unaware the soiled laundry was touching Resident 2's bed. The observation ended at 9:31 am and no attempt had been made to change Resident 2's bed linen. During an interview on 8/5/25 at 10:05 am, the facility's Infection Preventionist (IP) confirmed CNAs B and C did not follow infection control practices. IP indicated that Resident 1's soiled linens should not have made contact with Resident 2's bed and once the concern was identified, Resident 2's linens should have been changed.

Based on interviews and record reviews, the facility did not ensure one out of two sampled residents (Resident 1) had a complete medical record when: 1. Certified Nursing Assistant (CNA) documentation did not accurately show the number of incontinent episodes (accidentally leaked urine because they cannot control it) that Resident 1 had on each shift.2a. Licensed Nurse (LN) A did not document an assessment of Resident 1's left cheek.2b. The record did not contain documentation explaining a three month delay in obtaining the Physician ordered computed tomography (CT, a super-powered x-ray machine that took pictures of the inside of the body) scan of Resident 1's left cheek. These failures limited the facility's ability to maintain an accurate and complete clinical record and had the potential to impede Resident 1's ability to attain or maintain their highest practicable physical, mental, and psychosocial well being.Findings:1. A review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, dated 5/1/26, indicated, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.A review of Resident 1's admission Record, dated 12/9/23, indicated admission to the facility on [DATE] with the diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a brain stroke that caused weakness and the inability to move the left side of the body on their own) and personal history of traumatic brain injury (a brain injury that was caused by a hard hit or shaking of the head), Resident 1 was not their own responsible party (RP, did not make own decisions).During an interview on 8/5/26 at 3:00 pm, CNAs D and E stated residents were checked every two hours and as needed, and that incontinent care was provided when required. CNA E further indicated incontinent episodes could only be documented once per shift, typically at the end of the shift. CNA D confirmed CNA E's statements. Both CNA D and CNA E reported there was no place in the record to add notes that accurately reflected the actual number of incontinent episodes occurring during the shift.During a concurrent interview and record review on 8/6/26 at 10:21 am, with Director of Staff Development (DSD), Resident 1's Documentation Survey Report v2 (CNA documentation) dated 10/1/24 through 10/31/24 was reviewed. The DSD confirmed the CNA documentation was incomplete and stated that incontinent episodes were typically recorded only once during an eight hour shift. The DSD indicated that CNAs are expected to document each incontinent episode occurring during their shift and confirmed that failure to do so may prevent identification of changes in Resident 1's urinary status.2a. During an interview on 8/4/26 at 2:30 pm, Resident 1's RP indicated that during a visit with Resident 1, RP had noticed that Resident 1's entire cheek was swollen and had notified the nurse.During a concurrent interview and record review on 8/6/26 at 10:21 am, with DSD, Resident 1's Progress Note, dated 8/4/24 was reviewed. DSD confirmed writing the Progress Note and indicated RP had reported swelling and a hard area on Resident 1's left cheek. When asked if an assessment had been performed, the DSD stated an assessment was performed but acknowledged the Progress Note did not include the assessment. The DSD requested time to review the medical record.During an interview on 8/6/26 at 11:42 am, the DSD confirmed there was no documentation in the medical record showing a nursing assessment of the left cheek. During an interview on 8/6/26 at 11:44 am, Director of Nursing (DON) indicated the DSD should have performed an assessment of Resident 1's left cheek and documented it.2b. A review of Resident 1's Physician's order dated 7/4/24 indicated the Physician had ordered a CT scan of the left cheek.During a concurrent interview and record review on 8/6/26 at 10:21 am, with DSD, Resident 1's Progress Note, dated 7/4/24 was reviewed. DSD indicated that Resident 1's RP expressed concerns that Resident 1's left cheek was swollen and had a hard area. DSD confirmed, Resident 1's Physician was notified and an order was received for a CT scan of Resident 1's left cheek. The DSD indicated the process included printing the order and giving it to CNA F to schedule the appointment. During a concurrent interview and record review on 8/6/26 at 10:57 am, with CNA F, Resident 1's Progress Note, dated 9/18/24 was reviewed. CNA F confirmed the Progress Note showed Resident 1 had a CT scan scheduled for 10/3/24. CNA F explained they faxed referrals for appointments, usually the same or next day and followed up in a week or two if no call was received. CNA F confirmed there was no documentation showing difficulties or delays in scheduling the CT scan. CNA F stated, I don't know what happened with his CT scan or why it took so long.A review of Resident 1's Report, dated 10/4/24 indicated, Resident 1 received the CT scan on 10/4/24.During an interview on 8/6/26 at 11:44 am, the DON confirmed the medical record did not include documentation that described the delay and indicated the current process did not require CNA F to document reasons for diagnostic delays.

Based on observation, interview, and record review the facility failed to maintain adequate measures of infection control while administering medications. Licensed Nurse (LN) D failed to properly clean or sanitize medical equipment and medication containers for one of two residents sampled (Resident 40) when:1.The blood pressure cuff (medical device placed on the arm to measure blood pressure), was not cleaned nor sanitized prior to nor after it was used on Resident 40.2.The pulse oximeter (medical device clips on finger to measure blood oxygen saturation and heart rate), was not cleaned nor sanitized prior to nor after it was used on Resident 40.3.The Lidocaine Pain Relief Patch (a pain patch) 4% (percent), package was opened prior to administration, taken into Resident 40's room, and set on the resident's bedside table with no barrier. Resident 40 refused the Lidocaine pain patch and LN D returned it to the medication cart and was available for use.4.The container for Dorzolamide Solution 2% (eye drops) was taken into Resident 40's room and set on the resident's bedside table with no barrier. The eye drops were administered and the container returned to the medication cart without being cleaned nor sanitized before replacing it in the cart with the other medication containers.These failures had the potential to result in unknowingly spreading infection and disease to residents during medication administration creating an unclean habitat for uncontrolled bacterial and viral growth resulting in increased infectious processes, undue recurrent health deterioration, mental and emotional distress, and quality of life complications.During a review of the facility's policy titled, Administering Medications, dated Revised April 2019, indicated, Staff follows established facility infection control procedures.for the administration of medications.During a review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items, Surfaces and Equipment, dated Revised January 2026, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control, national public health agency) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration, government agency created to provide safety) Bloodborne Pathogens Standards.Single resident-use items are cleaned/disinfected between uses by a single resident.Single-use items are disposed of after a single use.Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.During a concurrent observation and interview on 7/22/26 at 07:35 am, with LN D on station two. LN D was preparing to administer medication to Resident 40. This required taking Resident 40's BP and HR as per standard of care guidelines. LN D completed medication administration to Resident 2, returned to the medication cart with the blood pressure cuff and pulse oximeter without cleaning or sanitizing them. LN D then prepared the medications for Resident 40; included was the plastic box container for eye drops, and the Lidocaine Pain Relief Patch within its packaging container. Additionally, LN D went into Resident 40's room with the reusable blood pressure cuff, pulse oximeter, and stethoscope (medical device used to listen to internal body sounds). 1.The BP cuff was not cleaned after use with Resident 2, it was then taken into Resident 40's room and used on Resident 40's left arm. Upon completion it was set on Resident 40's bed. It was removed from the room but not cleaned nor sanitized before going into the next resident's room for use.2.The pulse oximeter was not cleaned after use with Resident 2, it was then taken into Resident 40's room and used on Resident 40s finger. Upon completion it was set on Resident 40's bed. It was removed from the room but not cleaned nor sanitized before going into the next resident's room for use.3.The lidocaine pain patch was cut open for easy access prior to administration and taken into Resident 40's room. The patch was then placed on the resident's bedside table amongst the resident's personal effects with no barrier present. Resident 40 refused the application of the patch for the shift, requesting to have the next shift apply the nighttime dose at bedtime. Upon completion of medication administration, LN D removed the patch from the room and returned it to the medication cart, the packaging was not cleaned nor sanitized. LN D stated the lidocaine patch packaging would be resealed and held in the cart for the nighttime shift to apply. 4.The plastic eye drop container was taken into Resident 40's room and placed on the resident's bedside table amongst the resident's personal effects with no barrier present. The eye drops were administered and returned to the plastic container. The plastic container was removed from the room, it was not cleaned nor sanitized and was then returned to the drawer in the medication cart amongst other resident medication containers.LN D cleaned the stethoscope, but not the BP cuff nor the pulse oximeter and prepared to go to the next resident's room. Upon questioning, LN D confirmed that in hindsight the BP cuff and pulse oximeter needed to be cleaned and sanitized prior to being used on the next resident, and the plastic container the eye drops were in needed to be cleaned and sanitized before returning to the medication cart drawer. LN D also confirmed the lidocaine patch package container could not be resealed, nor cleaned and sanitized, nor saved for the next shift, but that it needed to be placed in the bin for destruction.During an interview on 7/22/26 at 11:50 am with DON, in DON's office. DON confirmed that all DME must be cleaned and sanitized before and after using on different residents. Medication containers that are taken into resident's rooms must be cleaned and sanitized prior to returning them into the medication cart. Additionally, open single use packaging for topical medication cannot be cleaned and saved for later applications, but must be destroyed.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed in the kitchen when opened food items were not labeled and dated.This failure increased the risk of residents being served unsafe food, placing them at risk for foodborne illness. Findings:During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, indicated, that all food items stored in the storeroom, refrigerator, and freezer must be labeled and dated. The policy further indicated that opened food items must be resealed, labeled with the open date, and used within the applicable storage guidelines.During a concurrent observation and interview on 7/20/26 at 10:14 am, with the Dietary Assistant (DA) in the kitchen dry storage area, an open container of oatmeal was observed without an open date. The DA confirmed the container did not have an open date and indicated that a new label had not been applied when the oatmeal was transferred from it's original container into the storage container earlier that day.During a concurrent observation and interview on 7/20/26 at 10:16 am, with the DA in the kitchen dry storage area, an open container of dry cereal was observed without an open date. The DA confirmed the cereal container did not have an open date and indicated that the date it had been opened was unknown. The DA then removed the container from the pantry and discarded it in the trash.During an interview on 7/22/26 at 11:16 am, with the facility Registered Dietician (RD), the RD indicated that all food stored in the kitchen was required to be labeled and dated, including open dates and expiration dates, in accordance with the facility policy. The RD indicated that proper labeling and dating helps ensure food is used within recommended storage time frames and confirmed that expired food or improperly dated food can increase the risk of foodborne illness.

Based on observation, interview, and record review the facility failed to label and store medications in accordance with professional standards for two of four medication carts when:1. Latanoprost Solution 0.005% (percent) (eye drops) container was found in Cart B on the locked dementia unit that was labeled with an expiration date that had already passed.2.An Insulin Lispro Kwikpen - 100 units (multi-dose insulin syringe) that required refrigeration prior to opening was found unopened and unrefrigerated in the medication cart on station one.These failures had the potential to result in residents receiving medications that are inactive and unable to provide effective results for the health conditions the residents are receiving the medications for, placing residents at risk for physical deterioration, emotional distress, and overall diminished quality of life.During a review of the facility's policy titled, Storage of Medications, dated Revised June 2026, indicated, Discontinued, outdated, or deteriorated drugs or biologicals are placed on designated appropriate bins for destruction.Medications requiring refrigeration are stored in a refrigerator.1.During a concurrent observation and interview on 7/22/26 at 10:38 am, with Licensed Nurse (LN) A and LN B, medication cart B on the locked dementia unit was examined. A plastic container containing Latanoprost Solution 0.005 % was observed with a past expiration date of 7/2/26, and still available for use. LN A and LN B confirmed the eye drops were expired, and the current eye drops were on Cart A. The expired eye drops should have been removed and placed in the bin for destruction.During an interview on 7/22/26 at 11:50 am, with Director of Nursing (DON), in DONs office, DON confirmed expired medications should have been removed from the medicine cart and placed in the destruction bin.2.During a concurrent observation and interview on 7/22/26 at 12:25 pm, with LN C, on station one, the medication cart on station one was examined. An unopened package of Insulin Lispro Kwikpen - 100 units was observed labeled with instructions to refrigerate until opened. LN C confirmed that the insulin pen was not opened and was not refrigerated.During a concurrent observation and interview on 7/22/26 at 12:35 pm, with DON on station one, the medication cart on station one was examined. An unopened package of Insulin Lispro Kwikpen - 100 units was found labeled with instructions to refrigerate until opened. DON confirmed that the insulin pen was not opened and was not refrigerated per instructions and per pharmacological guidelines.

Based on interview and record review, the facility failed to revise the comprehensive care plan for one of three residents (Resident 24) reviewed for activities to include Resident 24's expressed preference for one-on-one walking after identifying Resident 24's activity needs were not met.This failure resulted in Resident 24 remaining socially isolated and feeling lonely, placing Resident 24 at risk for diminished psychosocial well-being and quality of life.Findings:During the review of the facilities policy and procedure (P&P) titled, Comprehensive Care Plans, dated 1/2025, the P&P indicated the facility would develop and implement a comprehensive, person-centered care plan for each resident based on the comprehensive assessment to address identified medical, nursing, mental, and psychosocial needs. The policy further indicated care plans would include measurable goals, interventions, and time frames, be reviewed and revised after comprehensive and quarterly assessments, and updated as needed to monitor progress and reflect changes in the residence needs.During a review of Resident 24's admission record indicated that Resident 24 was admitted on [DATE] with diagnoses that included breast cancer, heart disease (conditions that affect the structure and function of the heart or its surrounding blood vessels), abnormal mobility, glaucoma (eye disease that damage the optic nerve), and depression.During a review of Resident 24's Minimum Data Set (MDS-assessment tool) section C, dated 6/6/26, indicated Resident 24 had a Brief Interview for Mental Status score of 13 out of 15, indicating no cognitive impairment.During a review of Resident 24's MDS section GG, dated 7/7/26, indicated Resident 24 was able to walk 150 feet with supervision or touch assistance.During a review of Resident 24's Care Plan Report, dated 7/6/25 and revised on 4/11/26, the care plan indicated that Resident 24 would be invited to activities of interest, provided a calendar of events, and offered activities compatible with the resident's physical and mental abilities, known interest and preferences, and adapted as needed to meet the resident's individual needs. The care plan further indicated Resident 24 would receive one-on-one bedside in-room visits if unable to attend out-of-room activities. The care plan did not identify Resident 24's expressed preference for assisted walking as a preferred individualized activity or include interventions to provide routine walking opportunities.During an interview on 7/23/26 at 10:15 am, in the resident's room, Resident 24 indicated that prior to admission, she had been very active but now spends most of her time alone in her room because she is unable to participate in activities due to her limited vision. Resident 24 indicated she had attempted to participate in activities, including bingo, but was unable to enjoy the activity because her vision impairment prevented her from seeing the bingo card. Resident 24 further indicated that her vision impairment made it difficult to meet other residents, causing her to feel lonely as though she was surrounded by strangers. Resident 24 indicated that her preferred activity was taking walks but required staff assistance because she was unable to see. Resident 24 stated that she hardly ever got to go for walks and was lucky if staff took her walking once a week. As a result, Resident 24 indicated she remained isolated in her room most of the time.During an interview on 7/23/26 at 10:28 am, with the facility Activities Director (AD), the AD indicated that Resident 24 enjoyed walking and acknowledged there was no regularly scheduled walking program or individualized activity care , plan in place for the resident. The AD indicated staff occasionally approached the resident to ask if she would like to walk but confirmed this was not planned or scheduled.During an interview on 7/23/26 at 11:36 am, with the facility Administrator (Admin), the Admin indicated that the facility's expectation was for activities to be person-centered and individualized to each resident's preference. The Admin indicated that resident 24's preferences had been incorporated into the care plan upon admission but acknowledged the interdisciplinary team (IDT, a group of facility managers that oversee quality care), had not been informed that Resident 24's preferred activity had changed to walking. The Admin confirmed that Resident 24 primarily participated in in-room activities and acknowledged the care plan could have been revised to include routine walking as a preferred activity. The Admin further indicated the AD should have communicated Resident 24's expressed preference for walking to the IDT so the comprehensive care plan could have been revised accordingly.

Based on interview, observation, and record review, the facility failed to ensure one of three residents reviewed for activities (Resident 24) received an individual activity program that accommodated the residents vision impairment and supported the resident's interest, independence, and psychosocial well-being when the facility failed to identify and implement meaningful individualized activities that promoted social interaction and engagement consistent with the residents preferences and abilities.This failure resulted in Resident 24 remaining socially isolated and feeling lonely, placing Resident 24 at risk for diminished psychosocial well-being and quality of life.Findings:During the review of the facilities policy and procedure (P&P) titled, Activity Programs, dated 9/2025, the P&P indicated that the activity program was to provide individualized, person-centered activities based on each resident's assessment, interest, preferences, and abilities to support physical, cognitive, emotional, and psychosocial well-being. The policy further indicated residents were to have opportunities to participate in planning activities, and the activities were to be adapted to reflect the resident's individual choices, needs, and preferences.During a review of Resident 24's admission record indicated that Resident 24 was admitted on [DATE] with diagnoses that included breast cancer, heart disease (conditions that affect the structure and function of the heart or its surrounding blood vessels), abnormal mobility, glaucoma (eye disease that damage the optic nerve), and depression.During a review of Resident 24's Minimum Data Set (MDS-assessment tool) section C, dated 6/6/26, indicated Resident 24 had a Brief Interview for Mental Status score of 13 out of 15, indicating no cognitive impairment.During a review of Resident 24's MDS section GG, dated 7/7/26, indicated Resident 24 was able to walk 150 feet with supervision or touch assistance.During an observations conducted on 7/21/26 at 8:54 am, 7/22/26 at 3:04 pm, and on 7/23/26 at 10:10 am, Resident 24 was observed alone in her room lying in bed. During an interview on 7/23/26 at 10:15 am, in the resident's room, Resident 24 indicated that prior to admission, she had been very active but now spends most of her time alone in her room because she is unable to participate in activities due to her limited vision. Resident 24 indicated she had attempted to participate in activities, including bingo, but was unable to enjoy the activity because her vision impairment prevented her from seeing the bingo card. Resident 24 further indicated that her vision impairment made it difficult to meet other residents, causing her to feel lonely as though she was surrounded by strangers. Resident 24 indicated that her preferred activity was taking walks but required staff assistance because she was unable to see. Resident 24 stated that she hardly ever got to go for walks and was lucky if staff took her walking once a week. As a result, Resident 24 indicated she remained isolated in her room most of the time.During a review of the Activity Director (AD) job description, dated 2023, the job description indicated that the AD was responsible for developing, implementing, and evaluating an individualized activity program based on each resident's comprehensive assessment, interest, abilities, and preferences. Responsibilities included contributing to the comprehensive care plan, planning individual and group activities, ensuring individualized activities were provided for residents unable or unwilling to participate in group activities, evaluating residents' responses to activities, and revising activity approaches as needed to meet each resident assessed needs.During a concurrent interview and record review on 7/23/26 at 10:28 am, with the facility AD, the facility's July Activity Log for Resident 24 was reviewed. The activities log indicated Resident 24 had been offered a walk on 11 occasions during July and contained daily documentation indicating Resident 24 had participated in physical activity or exercise. When asked about the documentation, the AD indicated the notation A indicated the activity was active and had been documented because the resident was capable of performing the activity independently in her room. The AD acknowledged Resident 24 was unable to walk independently in the hallway due to her vision impairment. The AD further indicated Resident 24 enjoyed walking but confirmed there was no regularly scheduled walking program or individualized activity plan in place. The AD indicated staff occasionally asked Resident 24 if she wanted to go for a walk but confirmed the walks were not planned or routinely scheduled. The AD also indicated that audio books were available but had not been offered to Resident 24. The AD indicated Resident 24 did not like attending activities in the dining room because her vision impairment prevented her from seeing or interacting with other residents and acknowledged Resident 24 would benefit from more personalized activities that took her vision impairment and individual preference into account.During an interview on 7/23/26 at 11:36 am, with the facility Administrator (Admin), the Admin indicated that the facility's expectation was for activities to be person-centered and individualized to each resident's preference. The Admin indicated that resident 24's preferences had been incorporated into the care plan upon admission but acknowledged the interdisciplinary team (IDT, a group of facility managers that oversee quality care), had not been informed that the residents preferred activity had changed to walking. The Admin confirmed that Resident 24 primarily participated in in-room activities and acknowledged the care plan could have been revised to include routine walking as a preferred activity. The Admin further indicated the AD should have communicated the resident's expressed preference for walking to the IDT so the comprehensive care plan could have been revised accordingly.

Based on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program, when the committee did not monitor, evaluate and track outcomes of a performance improvement plan to ensure sustainability to reduce resident to resident altercations in the secure dementia unit (a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters to prevent wandering while maintaining a safe, structured environment).This resulted in repeated resident to resident altercations, injuries, nonconsensual sexual conduct, fear, and anxiety. Refer to F600 and F725. Findings:A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), implemented in September 2024, indicates that the facility will maintain an effective, comprehensive, data driven QAPI program that monitors indicators of quality of care, quality of life, and all services provided; identifies quality deficiencies; and develops and implements corrective action plans. The policy requires regular review and analysis of data collected from multiple sources-including staff, residents, families, and departmental reports-and outlines procedures for feedback, data collection, monitoring, and adverse event surveillance. It directs the QAPI committee to prioritize identified problems, establish subcommittees as needed, and ensure that care and services meet accepted standards of quality. The program further requires the facility to conduct at least one performance improvement project (PIP) annually in a high risk or problem prone area, with additional clinical or non clinical PIPs initiated as necessary. A Review of facility-reported incidents revealed California Department of Public Health (CDPH), received 25 facility-reported incidents (FRIs) from June 2026 through March 2026. The reported incidents included 25 allegations of resident-to-resident abuse, three of these allegations involved sexual abuse. A review of the facility's detailed monthly census report for the period ending July 2025, dated April 15, 2026, showed that the secured dementia unit had an average daily census of 41 residents, with a full capacity of 42. A review of the 25 FRIs, indicated:1.Resident 8 was on top of Resident 7 with his genital (male private part) in her mouth.2. Resident 13 was holding Resident 23's hand over his penis and stroking it.3. Resident 11 was using his hand on Resident 14's hand to stroke his penis.4. a. Resident 4 struck Resident 11 in the face. b. Resident 4 grabbed Resident 1's wrist very aggressively. c. Resident 4 pushed Resident 6 to the ground. d. Resident 4 walked up to Resident 18 and pushed her forehead back. e. Resident 19 would not let go of Resident 4 hand then he grabbed Resident 19's arm. f. Resident 4 hit Resident 20 with his fist, on the left side of her forehead. g. Resident 4 swung to hit staff then struck Resident 21 instead, in the face. h. Resident 4 slapped Resident 22 and knocked her glasses off her face. 5. Resident 5 hit Resident 4 in the face causing a skin tear to his right cheek.6. Resident 10 struck Resident 9, leading to a fight.7. Resident 3 struck Resident 1 in the back of the head.8. Resident 2 hit Resident 1 on her left cheek.Resident 4 was involved in 8 resident to resident altercations where he was the perpetrator and one incident as a victim. Resident 1 was the victim of three altercations. A review of the QAPI meeting minutes dated 11/21/25, indicated that the facility identified an increase in resident to resident incidents as a significant problem. The root causes were determined to include insufficient staff education, a higher number of residents who ambulate and pace in the hallways, and the need for enhanced dementia specific activities. The stated goal was to reduce these incidents. The improvement plan outlined the implementation of a culture change in service for staff, assignment of a hall monitor, and increased activity staffing. The evaluation plan reflected that the Assistant Director of Nursing would conduct monthly follow up to monitor progress and effectiveness of the interventions. A review of the QAPI meeting minutes dated January 2026 indicated that, on 11/10/25, the facility identified an increase in resident to resident incidents over a two month period and implemented corrective measures that included culture change initiatives, assignment of a hall monitor, increased activity staffing, an all staff dementia in service, and licensed nurse training on behavior management. Evaluation dated 12/17/25, indicated a reduction in incidents for November 2025, with one resident to resident aggression incident, one sexual incident, and one family to resident physical incident. Additional measures dated 12/17/25 included staff reassignment to support culture change efforts. Evaluation on 1/24/26, for the period of 12/1/25 to 12/31/25, indicated two reportable incidents-one sexual and one aggression-with a referral for further evaluation. On 1/24/26, the facility determined that ongoing monitoring of staffing levels and reinforcement of culture change practices would continue.During a concurrent interview and record review on 3/10/26 at 3:21 pm, with Administrator (ADM), ADM was questioned about the multiple facility reported incidents that involved resident to resident altercations (a total of 25 from June 2025 to March 2026). ADM stated the QAPI team identified that there was an increase in the resident altercations on the dementia secure unit in November 2025. ADM stated the team has attempted interventions and the facility hasn't been able to resolve, by providing dementia and culture change staff training. ADM stated they were doing all they could and really did not know how to address the complex issue. ADM confirmed the QAPI plans and intervention measures had not been changed since they started back in November 2025. ADM stated they have not reached out to their corporate clinical consultants to assist with coming up with a plan to address the ongoing resident altercations in the secure dementia unit. During an interview on 4/15/26 at 10:32 am, with Activities Director (AD), when asked about the number of CNA staff that AD has. AD stated, CNA activity staff do activities for the entire facility. There are two CNA staff dedicated to the dementia unit. When asked whether two staff were sufficient for that unit, the AD responded, No, two is not enough. AD stated when there are only two CNA activity staff scheduled, the residents' quality of life and quality of care was hard to meet and was important. AD stated they used to schedule three CNA activity assistants in the past. AD further stated there was no additional specialized dementia training for staff in the secured unit. AD explained the type of activities they provide could be improved, which could help reduce resident altercations. During an interview on 6/4/26 at 9:30 am, with Director of Staff Development (DSD), DSD explained that Resident 4 had mood swings and at times did not like to be redirected and did not like anyone in his personal space. DSD stated Resident 4 required a lot of CNA and Nursing resource time to calm him down during his multiple episodes. DSD confirmed that having more direct care staff in the secure dementia unit has helped especially during the 12-8:30 pm times. DSD confirmed the dementia unit had a long hallway and one hall monitor was not enough especially when they are dealing with a resident who required redirection. DSD stated administrative staff did discuss resident issues during the Interdisciplinary Team meetings and morning reports although they did not track time of day, occurrences, injuries, repeated resident altercations, time of day, location etc. DSD confirmed 15 min checks may not work since some of the altercations happened right after the check and one on one observation worked better. DSD stated earlier identification and intervention with Resident 11 who had sexual behaviors with staff, then had an episode with Resident 14 could have been avoided. During an interview on 6/4/26 at 9:50 am, with Licensed Nurse (LN 2), LN 2 stated the facility previously had only one hall monitor, and additional monitors had only recently been added to the schedule. LN 2 stated it had given the staff the ability to redirect and diffuse resident to resident interactions and altercations. LN 2 stated she could not recall a recent one. LN 2 confirmed that Residents 4, 10, 11, and 12 often require substantial staff time due to dementia related behaviors, which can pull both licensed nurses and CNAs away from the needs of other residents. LN 2 also stated the hallway is long, with the dining room located at the far end, making it difficult to observe residents adequately. LN 2 described Resident 4 as very quick and aggressive and stated that relocating Resident 4 from the dementia unit to room [ROOM NUMBER] with continuous one-to-one supervision had helped the unit. LN 2 stated, We needed more staff resources for hallways and activities for residents.During a concurrent interview and record review on 6/4/26 at 10:15 am, with Director of Nursing (DON), the DON discussed the increase in resident-to-resident altercations occurring on the secured dementia unit between June 2025 and March 2026. The DON stated they received information about these incidents during morning meetings but did not track or trend the data to analyze contributing factors such as location, time of day, type of injury, direct care staffing, or repeated resident involvement. The DON confirmed that adding three hall monitors during the evening shift recently had reduced the number of resident altercations.

Based on interview and record review the facility failed to ensure vulnerable demented residents were free from physical abuse and inappropriate sexual behaviors for 12 of 23 sampled residents when:1. Resident 8 was on top of Resident 7 with his genital (male private part) in her mouth.2. Resident 13 was holding Resident 23's hand over his penis and stroking it.3.Resident 11 was using his hand on Resident 14's hand to stroke his penis.4. a. Resident 4 struck Resident 11 in the face. b. Resident 4 grabbed Resident 1's wrist very aggressively. c. Resident 4 pushed Resident 6 to the ground. d. Resident 4 walked up to Resident 18 and pushed her forehead back. e. Resident 19 would not let go of Resident 4 hand then he grabbed Resident 19's arm. f. Resident 4 hit Resident 20 with his fist, on the left side of her forehead. g. Resident 4 swung to hit staff then struck Resident 21 instead, in the face. h. Resident 4 slapped Resident 22 and knocked her glasses off her face. 5. Resident 5 hit Resident 4 in the face causing a skin tear to his right cheek.6. Resident 10 struck Resident 9, leading to a fight.7. Resident 3 struck Resident 1 in the back of the head.8. Resident 2 hit Resident 1 on her left cheek.Due to the repeated resident to resident altercations, this resulted in resident injuries, nonconsensual sexual conduct, fear, anxiety (fear of the unknown), and put all the vulnerable residents with dementia at risk for abuse. Findings: A review of the facility policy titled Abuse, Neglect, and Exploitation, implemented February 2026, indicated it is the policy of the facility to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The policy requires thorough investigation of all allegations, ongoing staff training on abuse prevention-including dementia management-and coordination with the Quality Assurance and Performance Improvement (QAPI) program. Staff are trained to identify behavioral symptoms that may increase the risk of abuse or neglect, and to assess, care plan, and monitor residents with behaviors that could lead to conflict or neglect. The policy mandates prompt reporting and response to all allegations, analysis of incidents to determine root causes, implementation of changes to prevent recurrence, and ongoing staff education on any revised procedures. The facility ensures communication and coordination of abuse-related issues with the QAPI program to support continuous quality improvement.1. A record review of Resident 8's Interdisciplinary Team (IDT, a group of multidisciplinary staff who develop resident plans of care) note, dated 8/1/25 at 2:46 pm, indicated, on 7/31/25 at 6:41 pm, Certified Nursing Assistant (CNA) noticed Resident 7's door was closed and went to open it. CNA 3 observed Resident 8 on top of Resident 7 with his penis (male private part) in her mouth. Resident 7 was asked about the event and stated this man came into my room and started talking to me about sex. He seduced me and put his dick into my mouth.A review of Resident 8's admission record indicated he was originally admitted to the facility on [DATE], then readmitted on [DATE] with diagnoses of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), dementia (a progressive state of decline in mental abilities), and muscle weakness.A review of Resident 7's admission record indicated she was admitted to the facility on [DATE], with diagnoses of Alzheimer's, dementia, and difficulty walking.A record review of Resident 7's Nurses Note, dated 8/1/25 at 7:04 pm, Resident 7 had increased anxiety and shouted out I was raped last night.A record review of Resident 7's Nurses Note, dated 8/2/25 at 5:31 pm, Resident 7 stated, I hate it here I want to leave.A record review of Resident 7's Social Service Notes indicated:-On 8/1/25 at 2:09 pm, Social Services (SS) asked Resident 7 if she felt safe, and Resident 7 stated, I am not sure, I don't think so.-On 8/2/25 6:28 pm, Resident 7 stated I hate it here.-On 8/3/25 at 8:56 pm, Resident 7 stated It was a male he raped me. Resident 7 appeared anxious.2. A record review of Resident 13's IDT note, dated 11/19/25 at 1:36 pm, indicated Resident 13 was the alleged aggressor of incident that occurred on 11/18/25 at 7:58 am, in station 200 hallway. CNA was doing room changes and noticed Resident 13 holding Resident 23's hand over his penis and stroking it. As soon as CNA turned the corner, she noticed Resident 13 attempts to cover up with a black blanket. When CNA asked Resident 13 what he was doing he became upset. A review of Resident 13 admission record indicated he was admitted to the facility on [DATE], with diagnoses that included Alzheimer's (a disease characterized by a progressive decline in mental abilities), dementia with other behavioral disturbance, and major depressive disorder.3.A record review of Resident 11's IDT note, dated 1/2/26 at 3:02 pm, indicated a Resident-to-Resident incident occurred on 1/1/26 at approximately 5:15 pm. Licensed Nurse (LN) was notified by CNA that she was picking up trays from dinner and saw Resident 11 was in the dining room with penis out and his hand on Resident 14's hand to stroke his penis. Residents immediately separated. When asked by social services what had happened this Resident 11 stated I put her hand on my penis to have her jack me off. I was hard.A review of Resident 11's admission record indicated he was admitted to the facility on [DATE], with diagnoses that included vascular dementia, other behavioral disturbance, major depressive disorder, and general anxiety.A review of Resident 14's admission record indicated she was admitted to the facility on [DATE], with diagnoses that included Alzheimer's, dementia with other behavioral disturbance and anxiety disorder.4.a. A review of Resident 4's admission record indicated he was admitted to the facility on [DATE] with diagnosis that included Alzheimer's, psychosis, and dementia.During an interview on 1/8/26 at 10 am, with CNA 2, CNA 2 stated, I heard [Resident 11] yelling out from his room. I went to his room and [Resident 4] was just coming out of the room. [Resident 11] told me [Resident 4] came over to him while he was lying in bed and started talking crap, then hit me in the face. CNA 2 stated [Resident 11] had a cut to his forehead. A review of Resident 11's Nurses Note dated 8/12/25 11:31 pm, indicated Resident 11 was noted to with a small 0.2-centimeter (cm, a unit of measurement) by 0.2 cm abrasion to his forehead.A review of Resident 4's Nurses Note dated 8/13/25 12:43 am, indicated Resident 4 had a 1cm abrasion to his right thumb with some bleeding.During an interview on 1/8/26 at 8:30 am, with Resident 11, Resident 11 stated, [Resident 4] came into my room and started yelling at me about being in his bed. Then [Resident 4] started hitting me. I yelled and someone came and got him out. [Resident 4] is not a nice guy. During an interview on 1/8/25 at 12:30 pm, with CNA 1, CNA 1 stated Resident 11 was afraid of Resident 4. During a concurrent interview and record review on 1/8/26 at 4:55 pm, with the Director of Nursing (DON), Resident 4's Watch List dated 8/12/25 was reviewed. The Watch List indicated that Resident 4 had been checked on at 10:15 pm and at 10:30 pm. The DON confirmed the physical abuse occurred at 10:30 pm right after he was checked on.4.b. A review of Resident 4's IDT note dated 7/14/25 at 2:02 pm, indicated on 7/12/25 at 5:30 pm, Resident 4 grabbed Resident's 1 wrists. Resident 4 was agitated and struck out. A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with diagnoses that included psychosis, dementia, anxiety, falls, and agitation. During an interview on 1/7/26 at 9 am, with CNA 1, CNA 1 confirmed Resident 4 and Resident 1 were in the dining room for dinner when, I heard a noise and looked over and saw Resident 4 standing up by Resident 1. CNA 1 stated Resident 4 was grabbing Resident 1's wrist aggressively. During a concurrent interview and record review on 1/7/26 at 10 am, with Social Services (SS), SS confirmed Resident 1 had been the victim of three resident to resident altercations on 6/6/25, 6/22/25, and 7/12/25. 4.c. During a review of Resident 4's IDT note dated 7/24/25 at 3:24 pm, a resident-to-resident incident on 7/23/25 at 6:35 pm, a Licensed Nurse heard CNA call out for help, and upon arrival Resident 6 was laying on the floor on her back holding her head, crying. Resident 6 was sent out to the hospital for evaluation.A review of Resident 6's admission record indicated she was admitted to the facility on [DATE], with diagnoses that included diabetes, unspecified psychosis, and anxiety. During an interview on 1/7/26 at 12 pm, with CNA 1, CNA 1 stated, I was the hall monitor that day 7/23/25, and [Resident 4] was going in and out of rooms. I had just removed [Resident 4] from two different rooms. CNA 1 further stated, I was standing by [Resident 11] because she was afraid of [Resident 4] when I saw [Resident 6] approaching [Resident 4]. [Resident 6] came up to [Resident 4] and gave him a hug. [Resident 4] pushed [Resident 6] hard with full force and [Resident 6] fell to the ground. [Resident 6] hit her head then lay flat on the floor and started crying. During a concurrent interview and record review on 1/7/26 at 5 pm, with DON, Resident 4's, 15-minute Watch Log dated 7/23/25 was reviewed. The Watch Log indicated Resident 4 had been checked on 7/23/25 at 6:15 pm and again at 6:30 pm. The DON confirmed the physical abuse occurred at 6:35 pm right after Resident 4 was checked on.During a review of Resident 6's Social Service Note, dated 7/25/25 at 4:01 pm, indicated SS followed up with Resident 6. Resident 6 was noted to be agitated, and CNAs were attempting to redirect away from a peer. During a review of Resident 4's, Physician Progress Note, dated 7/18/25, indicated escalation of behavior and that Resident 4 was involved in an altercation with another resident two days ago without injuries to both parties. Reportedly Resident 4 was very intrusive regardless of other boundaries. 4.d. A review of Resident 4's IDT note dated 10/28/25 at 11:27 am, indicated Resident 4 was the alleged aggressor of incident that occurred on 10/27/25 at 9:10 am, in the hallway, involving Resident 18. LN overheard yelling in the hallway and went to investigate. LN was notified that Resident 4 walked up to Resident 18 and pushed her forehead back.4.e. A review of Resident 4's IDT note, dated 10/31/25 at 3:27 pm, indicated a CNA reported that Resident 4 was seen walking out of his room holding Resident 19's hand. Resident 19 would not let go. CNA attempted to separate residents and then Resident 4 grabbed Resident 19's arm. CNA noticed this Resident 4 had a skin tear to right wrist. LN assessed skin tear to right wrist measuring 1.5 cm by 1.5 cm.4.f. A review of Resident 4's IDT note, dated 11/18/25 at 4:37 pm, indicated on 11/16/25 at 9 pm, Resident 4 entered Resident 20's room which was closed with a STOP sign across the doorway. Resident 20 stated Resident 4 walked into room, and she attempted to redirect him then he proceeded to turn his hand and hit her with his fist, on the left side of Resident 20's forehead.4.g. A review of Resident 4's IDT note, dated 1/5/26 at 11:48 am, indicated on 1/3/26 at 5:20 pm, Resident 4 was in the dining room attempting to eat food from Resident 21's food tray at the table when the CNA attempted to redirect. CNA observed Resident 4 became upset and swung to hit staff and accidentally struck Resident 21 in the face instead. Resident 21 had a 2 cm x 2 cm bruise underneath her right eye. 4.h. A review of Resident 4's IDT note, dated 1/8/26 at 2:53 pm, indicated on 1/7/26 at 5:30 pm, CNA reported to LN that Resident 4 slapped Resident 22 and knocked her glasses off her face. 5. During a review of Resident 5 and Resident 4's IDT note, dated 7/14/25 at 2:07 pm, indicated Resident 4 and 5 were in the dining room at dinner time, when CNA 1 heard Resident 4 call Resident 5 an idiot. Resident 5 hit Resident 4 in the face with a closed fist causing a skin tear to Resident 4's right cheek.During an interview on 1/7/26 at 8:30 am, with CNA 1, CNA 1 said, I was in the dining room and heard Resident 4 calling Resident 5 an idiot. Resident 4 stood up and then Resident 5 hit Resident 4 in the face with his fist.A review of Resident 5's admission record indicated he was admitted to the facility on [DATE], with diagnoses that included dementia, alcohol use, and anxiety. During a concurrent interview and record review on 1/7/26 at 9:45 am, with SS, SS confirmed Resident 4 had two altercations over the weekend. First incident occurred at 5:30 pm with Resident 1. Resident 4 was the aggressor. Second incident occurred at 6 pm with Resident 5. Resident 4 was the victim. During a concurrent interview and record review on 1/7/26 at 4 pm with DON, Resident 4's, 15-minute Watch Log dated 7/12/25 was reviewed. The Watch Log indicated Resident 4 had been checked on at 5:45 pm. and again at 6 pm. The DON confirmed the physical abuse occurred at 6 pm right after he was checked on.6. A record review of Resident 9's IDT note, dated 8/4/25 at 11:42 am, indicated, staff upon arrival observed Resident 9 and Resident 10 were on the floor fighting. Resident 10 explained that Resident 9 started yelling when she came into her room. Resident 10 stated she then decked Resident 9. A review of Resident 10's admission record indicated she was admitted to the facility on [DATE], with diagnoses that included dementia, visual hallucinations (seeing things that are not real), and psychosis. A review of Resident 9's admission record, indicated Resident 9 was admitted to the facility on [DATE], with diagnoses that included dementia and difficulty walking. A review of Resident 9's medical record, dated 8/9/25 at 9:06 pm, indicated Resident 9 stated she avoids Resident 10, like the plague and that she can be overbearing. A review of Resident 10's Nursing Skilled Services note signed by LN on 8/5/25, indicated Resident 10 required supervision due to her frequent wandering into other resident rooms. 7. A review of Resident 1 and Resident 2's IDT notes, dated 6/9/25 3:12 pm, indicated that Residents 1 and 2 were watching a movie in the dining room after dinner and Resident 1 backed into Resident 2's wheelchair multi times. Resident 2 became upset saying, stop hitting my chair! then Resident 2 proceeded to slap Resident 1 on the left cheek. Resident 1 stated, she hit me in the face. Resident 2 stated, Resident 1 kept hitting my chair, so I hit her.A review of Resident 2's admission record indicated she was admitted to the facility on [DATE], with diagnoses that included Alzheimer's, dementia, and muscle weakness.During an interview on 1/6/26 at 9 am., with Activities Assistant (AA 1), AA 1 said he was in the dining room and saw Resident 1 back her wheelchair up into Resident 2. Resident 2 immediately raised her arm up and hit Resident 1 on the cheek. 8. A review of Residents 1 and Resident 3's IDT note, dated 6/23/25 at 2:37 pm, indicated that Resident 1 was sitting at a table in the dining room when Resident 3 was being taken to the dining room by staff for dinner. Resident 3 was waiting behind Resident 1 when Resident 3 reached up and hit Resident 1 on the back of the head.A review of Resident 3's admission record indicated she was admitted to the facility on [DATE], with diagnoses that included Alzheimer's and anxiety.During an interview on 1/7/26 at 9 am with AA 2, AA 2 stated they were getting ready for a meal and Resident 1 was in her wheelchair heading towards the right side of the dining room and Resident 3 was being wheeled in behind her. Resident 1 stopped and Resident 1 and Resident 3 bumped into each other. Resident 3 hit Resident 1 on the back of her head. During a concurrent interview and record review on 1/8/26 at 4:30 pm, with DON, Resident 1's Care Plan dated June 2025 was reviewed. The DON confirmed that Resident 1 was the victim of three resident-to-resident physical altercations on 6/6/25, 6/22/25, and 7/12/25.During a concurrent interview and record review on 3/10/26 at 3:21 pm, with Administrator (ADM), ADM was questioned about the multiple facility reported incidents that involved resident to resident altercations (a total of 25 from June 2025 to March 2026). ADM stated the QAPI team identified that there was an increase in the resident altercations on the dementia secure unit November 2025. ADM stated the team has attempted interventions and the facility hasn't been able to resolve, by providing dementia and culture change staff training. ADM stated they were doing all they could and really did not know how to address the complex issue. ADM confirmed the QAPI plans and intervention measures had not been changed since they started back in November 2025. ADM stated they have not reached out to their corporate clinical consultants to assist with coming up with a plan to address the ongoing resident altercations in the secure dementia unit.During a concurrent interview and record review on 6/4/26 at 10:15 am with DON, DON discussed the increase in resident-to-resident altercations occurring on the secured dementia unit between June 2025 and March 2026. The DON stated they received information about these incidents during morning meetings but did not track or trend the data to analyze contributing factors such as location, time of day, type of injury, direct care staffing, or repeated resident involvement. The DON confirmed that adding three hall monitors during the evening shift recently had reduced the number of resident altercations.

Based on observation, interview, and record review, the facility failed to ensure the residents in the secured dementia unit (unit that is a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters, such as locked exterior doors or fenced areas, to prevent wandering while maintaining a safe, structured environment) had sufficient and competent nursing staff and were available to provide nursing and related services to meet the residents' needs when:1 Acuity (complexity and intensity rather than just resident numbers) levels for dementia residents and increased resident altercations were not considered when scheduling Certified Nursing Assistants (CNA) staff in the secured dementia unit.2. Direct care staff did not receive specialized training for advanced stages of dementia.This resulted in vulnerable residents experiencing physical abuse, inappropriate sexual behavior, injuries, anxiety and fear. Refer to F600.Findings:1. A review of the facility's detailed monthly census report for the secured dementia unit, ending July 2025 and dated 4/15/26, showed the unit maintained an average daily census of 41 residents, with a full capacity of 42 residents.A review of Facility Reported Incidents (FRIs)from June 2025 through March 2026 indicated that the California Department of Public Health (CDPH) received 25 allegations of resident to resident abuse, including three allegations involving sexual abuse.A review of the 25 FRIs indicated:1. Resident 8 was on top of Resident 7 with his genital (male private part) in her mouth.2. Resident 13 was holding Resident 23's hand over his penis and stroking it.3.Resident 11 was using his hand on Resident 14's hand to stroke his penis.4. a. Resident 4 struck Resident 11 in the face. b. Resident 4 grabbed Resident 1's wrist very aggressively. c. Resident 4 pushed Resident 6 to the ground. d. Resident 4 walked up to Resident 18 and pushed her forehead back. e. Resident 19 would not let go of Resident 4 hand then he grabbed Resident 19's arm. f. Resident 4 hit Resident 20 with his fist, on the left side of her forehead. g. Resident 4 swung to hit staff then struck Resident 21 instead, in the face. h. Resident 4 slapped Resident 22 and knocked her glasses off her face. 5. Resident 5 hit Resident 4 in the face causing a skin tear to his right cheek.6. Resident 10 struck Resident 9, leading to a fight.7. Resident 3 struck Resident 1 in the back of the head.8. Resident 2 hit Resident 1 on her left cheek.A review of Resident 4's nursing notes indicated that between July 2025 and January 2026, Resident 4 was involved in nine resident-to-resident altercations. On 7/12/25 at 6:00 pm, while in the dining room, Resident 4 struck Resident 5 with a closed fist, resulting in a small skin tear to Resident 5's right cheek. On 7/23/25 at 6:35 pm, Resident 4 and Resident 6 had an alteration and when residents were found by CNA, Resident 6 was lying flat on her back while holding her head crying. Resident 6 was sent to the hospital for further evaluation.A review of the July 2025 staffing schedules for Nursing Station 300, the secured dementia unit, showed that on 7/12/25 there was no dining room CNA assigned during the evening shift and only one hall monitor CNA. On 7/23/25, the evening shift again had no dining room CNA assigned and one hall monitor CNA. These dates correspond to two resident to resident altercations involving Resident 4 that occurred during the evening hours.During an interview on 1/7/26 at 12 pm with CNA 1, CNA 1 stated, I was the hall monitor on 7/23/25, and [Resident 4] was going in and out of rooms. I had just removed [Resident 4] from two different rooms. CNA 1 further stated, I was standing near [Resident 11] because [Resident 11] was afraid of [Resident 4] when I saw [Resident 6] approaching [Resident 4]. [Resident 6] came up to [Resident 4] and gave a hug. [Resident 4] pushed [Resident 6] hard with full force, causing [Resident 6] to fall to the ground and hit their head. [Resident 6] then lay flat on the floor and began crying.During a concurrent interview and record review on 1/7/26 at 9:45 am with SS, SS confirmed Resident 4 had two altercations over the weekend. First incident occurred at 5:30 pm with Resident 1. Resident 4 was the aggressor. Second incident occurred at 6 pm with Resident 5. Resident 4 was the victim.During a concurrent interview and record review on 1/7/26 at 10 am with Social Services (SS), SS confirmed Resident 1 had been the victim of three resident to resident physical altercations on 6/6/25, 6/22/25, and 7/12/25. During a concurrent interview and record review on 1/7/26 at 4 pm with Director of Nursing (DON), Resident 4's, 15-minute Watch Log dated 7/12/25 was reviewed. The Watch Log indicated that Resident 4 had been checked on at 5:45 pm. and again at 6 pm. The DON confirmed the physical abuse occurred at 6 pm right after he was checked on.During concurrent interview record review on 3/17/26 at 11:10 am with Scheduler (Sched), Sched stated that standard staffing assignments for Nursing Station 300, the secured dementia unit, included: four CNAs on the day shift (6:00 am-2:30 pm) and evening shift (2:00 pm-10:30 pm); two Hall Monitor CNAs, one assigned from 8:00 am-5:00 pm and one from 12:00 pm-8:30 pm; and two CNAs assigned to the dining room-one on the morning shift and one on the evening shift. Sched confirmed that the staffing schedules did not consistently have enough CNAs to fill all assigned shifts.A review of the staffing schedules and sign in sheets for the Nursing Station 300 secured dementia unit indicated:For the day shift (6:30 am-2:30 pm), no CNA staff were scheduled for the dining room on 6/22/25 and from 10/2/25 through 10/5/26. On the following dates, only one CNA-rather than the expected two-was scheduled for the dining room: 7/12/25, 7/23/25, 8/01/25, 8/12/25, 9/12/25, 9/15/25, 9/23/25, 9/29/25, 9/30/25, 10/1/25, 10/6/25, 10/7/25, 10/27/25, 12/17/25, 12/28/25, 1/1/26, 1/3/26, 1/4/26, 1/7/26, 1/9/26, 1/15/26, 2/05/26, and 3/02/26.For the evening shift (2:00 pm-10:30 pm), only one hall monitor CNA-rather than the expected two-was scheduled on 6/6/25, 7/12/25, 7/23/25, 7/31/25, 9/12/25, 9/23/25, 9/30/25, 10/1/25, 10/3/25, 10/4/25, 10/5/25, 10/10/25, 10/23/25, 10/27/25, 10/31/25, 9/18/25, 12/17/25, 1/1/26, 1/3/26, 1/4/26, 1/7/26, 1/9/26, 1/15/26, and 3/2/26.During an interview on 12/18/25 at 11:41 am with CNA 5, CNA 5 stated that they sometimes had to rush while providing care to residents on the secured dementia unit in order to redirect residents and prevent potential altercations.During an interview on 3/10/26 at 10:29 am with Registered Nurse (RN) 1, RN 1 stated there were two RNs and one hall monitor assigned to assist on the secured dementia unit. RN 1 explained that four CNAs were assigned, along with activity staff who were also certified as CNAs. When asked whether Resident 4 triggered other residents, RN 1 stated this occurred 1000%, depending on Resident 4's mood and the day of the week. RN 1 further stated they believed Resident 4's behaviors were related to pain that the resident was unable to verbally express.During an interview on 3/10/26 at 10:50 am with CNA 6, CNA 6 stated that Resident 12 would get up, enter other residents' rooms, and take their food. CNA 6 further stated that Resident 12 had scratched them and that Resident 12 liked to scratch people. CNA 6 reported that many residents had complained about Resident 12's behaviors.During an observation on 3/10/26 at 11 am in activities room, Resident 10 was observed walking around the room and moving chairs. Resident 10 attempted to move the state computer stand; however, staff had positioned it out of the resident's reach. Resident 10 then picked up another resident's cup of liquid, and staff intervened before the resident could drink from it. Two staff members were present during the observation-one CNA and the Activities Director (AD) dealing with eight residents after an activity was completed.During an interview on 3/17/26 at 3:21pm with CNA 7, when asked, CNA 7 stated that their primary role was providing activities. When asked about staffing, CNA 7 stated the unit would benefit from having at least one additional staff member to assist with resident supervision. CNA 7 further stated that a typical shift consisted of one activities staff member and the Activities Director.During an interview on 3/17/2026 at 2:35 pm with CNA 8, CNA 8 stated that the facility needs more eyes on the residents due to the high number of residents who wander (walk without a planned destination or purpose).During an interview on 4/7/2026 at 1:49 pm with CNA 9, CNA 9 stated that sometimes we do not have enough staff due to not being able to fill call offs. CNA 9 further stated that the facility had been short staffed (less than scheduled) over the past several months on both weekdays and weekends.During an interview on 4/15/2026 at 10:25 am with CNA 5, CNA 5 stated the facility was short staffed at least twice per month, occurring mostly on the evening shift. CNA 5 further stated that during the day shift, she has been assigned 10-12 residents to care for and on the evening shift 10-15 residents.During an interview on 4/15/26 at 10:32 am, with AD, when asked about the number of CNA staff that AD has. AD stated, CNA activity staff do activities for the entire facility. There are two CNA staff dedicated to the dementia unit. When asked whether two staff were sufficient for that unit, the AD responded, No, two is not enough. AD stated when there are only two CNA activity staff scheduled, the residents' quality of life and quality of care was hard to meet and was important. AD stated they used to schedule three CNA activity assistants in the past.2. During an interview 3/10/26 at 10:50 am with CNA 6, when asked about training, CNA 6 stated that at the start of their employment they received general orientation but did not receive any specialized dementia care training.During an interview on 4/15/26 at 10:32 am, AD stated there was no additional specialized dementia training for staff in the secured unit. AD explained the type of activities they provide could be improved, which could help reduce resident altercations.During an interview on 4/15/2026 at 11:50 am with the Director of Staff Development (DSD), DSD stated that no specialty dementia training had been provided to staff working on the secure dementia unit. The DSD explained that they offer behavioral training during all staff meetings to address care concerns and review updated policies and procedures.During an interview on 6/4/26 at 9:30 am with DSD, DSD explained that Resident 4 had mood swings and at times did not like to be redirected and did not like anyone in his personal space. DSD stated Resident 4 required a lot of CNA and Nursing resource time to calm him down during his multiple episodes. DSD confirmed that having more direct care staff in the secure dementia unit has helped especially during the 12-8:30 pm times. DSD confirmed the dementia unit had a long hallway and one hall monitor was not enough especially when they are dealing with a resident who required redirection. DSD stated administrative staff did discuss resident issues during the Interdisciplinary Team meetings and morning reports although they did not track time of day, occurrences, injuries, repeated resident altercations, time of day, location etc. DSD confirmed 15 min checks may not work since some of the altercations happened right after the check and one on one observation worked better. DSD stated earlier identification and intervention with Resident 11 who had sexual behaviors with staff, then had an episode with Resident 14 could have been avoided. During an interview on 6/4/26 at 9:50 am, with Licensed Nurse (LN 2), LN 2 stated the facility previously had only one hall monitor, and additional monitors had only recently been added to the schedule. LN 2 stated it had given the staff the ability to redirect and diffuse resident to resident interactions and altercations. LN 2 stated she could not recall a recent one. LN 2 confirmed that Residents 4, 10, 11, and 12 often require substantial staff time due to dementia related behaviors, which can pull both licensed nurses and CNAs away from the needs of other residents. LN 2 also stated the hallway is long, with the dining room located at the far end, making it difficult to observe residents adequately. LN 2 described Resident 4 as very quick and aggressive and stated that relocating Resident 4 from the dementia unit to room [ROOM NUMBER] with continuous one-to-one supervision had helped the unit. LN 2 stated, We needed more staff resources for hallways and activities for residents.During a concurrent interview and record review on 6/4/26 at 10:15 am with DON, DON discussed the increase in resident-to-resident altercations occurring on the secured dementia unit between June 2025 and March 2026. The DON stated they received information about these incidents during morning meetings but did not track or trend the data to analyze contributing factors such as location, time of day, type of injury, direct care staffing, or repeated resident involvement. The DON confirmed that adding three hall monitors during the evening shift recently had reduced the number of resident altercations.

Based on observation, interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS, resident assessment tool) assessment was accurately coded for wandering behavior (the act of moving from place to place with or without a specified course or known direction) for one of three sampled residents (Resident 12) when the Social Services (SS) did not follow required assessment procedures, relied solely on chart review.This failure resulted in inaccurate assessment coding and failure to fully identify the resident's behavioral needs. It had the potential for staff not to be fully informed of the residents' health status to determine the need for further assessment and care interventions.Findings:During a review of the facility's policy titled, Resident Assessment - Resident Assessment Instrument (RAI), revised [DATE], indicated, The facility makes a comprehensive assessment of each resident's needs, goals, life history and preferences using the resident assessment instrument (RAI) specified by Centers for Medicare & Medicaid Services (CMS); The assessment process will include document review and observation/interview as needed. During a review of the facility's policy titled, Wandering Residents, revised [DATE], indicated, The facility ensures that who exhibit wandering behavior receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering.; Documentation in the medical record will include: findings from nursing and social service assessments. During a review of Long -Term Care Facility CMS's Resident Assessment Instrument (RAI) 3.0 User's Manual, version, dated 10/2025, at the section: E0900: Wandering, indicated the Steps for Assessment are: 1. Review the medical record and interview staff to determine whether wandering occurred during the 7-day look-back period - Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to their physical or safety needs. The resident may have a purpose such as searching to find something, but they persist without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes they must find their parent, who staff know is deceased ). 2. If wandering occurred, determine the frequency of the wandering during the 7-day look-back period. During a review of Resident 12's medical record, indicated that Resident 12 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included unspecified psychosis (loss of contact with reality, involves disruptions in thought, perception, and behavior), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), unspecified severity, with other behavioral disturbance, and history of fall. Resident 12 was not her healthcare decision maker. During a review of Resident 12's admission MDS, dated [DATE], indicated Resident 12 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15, indicating her cognition was severely impaired. The MDS further indicated that Resident 1 did not exhibit Wandering behavior in the section E - Behavior. During review of Resident 12's current care plan, the plan instructed staff to monitor and document behaviors per shift-wandering behaviors redirect as needed. The care plan further indicated interventions including administration of Ativan for anxiety and Seroquel for dementia with behavioral disturbance and noted an increase in aggressive behaviors toward staff when the resident was being redirected. The care plan also included a goal for Resident 12 to wander safely within the secured unit, with an initial date of [DATE] and a target date of [DATE].During a concurrent observation and interview on [DATE] at 10:36 am with Certified Nursing Assistant (CNA) 4, in the hallway of Station X, and in ROOM XX. Resident 12 was observed pacing in the hallway then entering ROOM XX and lying on Bed A. CNA 4 approached Resident 12 inside ROOM XX, and stated, This is not your room, I'll take your back to your room. Resident 12 replied, No! When interviewed, CNA 4 stated, [Resident 1] does this all the time. I tried to take her back to her room and redirected her, but she wouldn't cooperate. We just have to keep trying, until she would follow our instructions. CNA 4 further explained that the resident assigned to Bed A was currently hospitalized and added, Otherwise, there might be an altercation, referring to Resident 12's behavior of entering other resident's beds. At 10:40 am, observed Resident 12 got up, followed CNA 4 out of ROOM XX and proceeded to enter another resident's room, ROOM TT.During a concurrent interview and record review on [DATE] at 11:06 am, with MDS Nurse, the MDS Nurse stated she primarily completed medical sections of the MDS while Social Services completed behavioral sections. A review of Resident 12's care plan, medical diagnoses, and MDS dated [DATE], the MDS Nurse stated she recalled Resident 12 aimlessly walking around the station and assumed she was a wanderer based on her care plan and diagnoses, but acknowledged the resident may not have demonstrated wandering during the seven day look back period. When asked how the assessment should be completed, the MDS Nurse stated she would observe the residents on the unit, interview staff, and review behavior monitoring records. She further stated, I would assume that it's wrong code and we could go back and change it. we don't have an audit system to audit every single MDS assessment; usually it happened when an issue was identified during survey, and we would go back and fix it even after the resident was discharged . The MDS Nurse confirmed the [DATE] MDS Section E wandering assessment was completed by SS. During a concurrent interview and record review on [DATE] at 11:58 a.m. with SS, Resident 12's record was reviewed; the SS stated she recalled the resident was intrusive and exhibited behaviors every other day. When asked how wandering was assessed, the SS stated she only reviewed the resident's chart, including behavior monitoring records in the Medication Administration Record (MAR), and did not observe the resident or interview nursing staff, stating, We don't have to; that's how I was taught. A review of Residet 12's behavior monitoring records from [DATE] to [DATE] (the 7 day look back period) indicated multiple documented episodes of anxiety, mood swings, and non redirectable aggression, which the SS confirmed; a nursing progress note dated [DATE] at 2:49 am, documented the resident was Out of room throughout shift and required redirection from other residents' rooms, which the SS also confirmed. After reviewing the CMS RAI Manual guidance on wandering assessment, the SS stated she would not code wandering unless the word wandering was explicitly written in the record and confirmed she would still code No wandering even after reviewing the manual definition.During a concurrent interview and record review on [DATE], at 12:51 pm, with Director of Nursing (DON), Resident 12's MDS section E, dated [DATE], was reviewed. The DON stated the expectation for the MDS nurse while performing Wandering assessment is to review the residents' MARs, observe the residents and interview the staff. When informed the DON of the SS comment on how she was taught and coded Resident 12's wandering assessment, the DON confirmed Resident 12 did exhibit wandering behavior and stated that the SS was inaccurate and she needed to be reeducated.

Based on Observation, Interview, and Record Review the facility failed to ensure federal regulations related to the certification qualification requirement of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with resident assessment accuracy, meal distribution accuracy, safe food handling, and sanitation guidelines. Findings: According to the HSC 1265.4 (a) Shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association and maintains this certification. A record review of the facility's job description titled, Dietary Manager, dated 2022, indicated, Minimum requirements include .Certification as a dietary manager .Must also meet State requirements for food service managers or dietary managers. During a concurrent interview and record review on 11/19/2024 at 11:00 am with Dietary Manager (DM) and Registered Dietician (RD) 1 in the office of DM and RD. DM's education certificates were observed hanging on the wall with a passing date of April 12, 2023. The actual Dietary Manager Certificate was not observed, thus requested. DM stated, I am not certified yet. I have not passed the test. I am scheduled to take the test on 1/3/24. I have been performing duties of the position for three (3) years. RD 1 stated, I am here at the facility one (1) time a month, I only started two (2) months ago, so I have only been here twice, and I have four (4) other facilities that I oversee. I am always available for DM if needed. During an interview on 11/21/2024 at 2:00 pm with Administrator (Admin) in the Administrator office, Admin stated, we know the DM does not have the certificate and is working on getting it, the test is scheduled for January. We thought we were covered with our RD in place and the other Certified Dietary Manager (CDM) with a current certificate in the building now serving as the Medical Records Director.

Based on interview and review of Resident Council Minutes the facility failed to act promptly to resolve resident grievances in a timely manner and demonstrate their response and rationale for their response. This action had the potential to violate residents' rights. Findings: A review of a facility policy titled, Resident and Family Grievances dated 1/24/24, indicated grievances may be voiced verbally during resident or family council meetings. Under procedure, the policy included the following directions: The staff person receiving the grievance would record the nature and the specifics of the grievance. Steps would be taken to resolve the grievance, and record information about the grievance and actions taken on the grievance form. All staff involved in the grievance investigation should make prompt efforts to resolve the grievance. The Social Service Designee (SSD) would keep residents appropriately appraised of the progress and the resolution of the grievance. The SSD would issue a written decision on the grievance and a conclusion of the investigation. The facility would make prompt efforts to resolve grievances. During an interview with the Activities Director (AD) on 11/20/24 at 4:35 pm she stated there was one missing follow up from a resident council meeting grievance. She provided six months of Resident Council Minutes minutes from June to November 2024. A review of the six months of Resident Council minutes from June to November 2024 indicated during a Resident Council meeting on September 17, 2024, there was one complaint about noise in the facility. There was no follow up documentation of who made the complaint, or a documented effort to resolve the grievance or a conclusion of the investigation. The Resident Council minutes from June to November 2024 did not have any documented food complaints. During an interview with the Administrator (Admin) on 11/20/24 at 4:45 pm she stated the facility is supposed to have follow up on all concerns brought up by Residents Council members. She stated the concerns are to be brought up to the Department Managers. She also stated this was part of their grievance process which included being discussed with their Interdisciplinary Team (IDT, a group of professionals that meet and plan care and services for the residents). During a confidential interview on 11/21/24 at 10:30 am, five residents stated the food in the facility was not good. Residents stated, the hot food was not hot, the cold food was not cold, and the meat was tough and hard to chew. One resident stated the meat was hard to swallow due to how tough it was. The residents stated this had been an ongoing problem and had been brought up at previous council meetings.

Based on observations and interviews, the facility failed to ensure the facility food was an appetizing temperature and palatable texture when 14 of 21 sampled residents (Residents 17, 9, 51, 70, 16, 36, 85, 72, 80, and five confidential residents), who received food prepared in the facility kitchen were not satisfied with the facility food temperature and texture. This failure had the potential to result in residents not obtaining appropriate nutritive intake, unplanned weight loss, increased health issue complications, and diminished emotional well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Food Preparation Guidelines, dated February 2023, Revision, indicated, Food shall be palatable attractive, and at a safe and appetizing temperature. 1. A review of Resident 17's medical record indicated that Resident 17 was admitted on [DATE] with diagnoses that included Dementia with mood disturbance (loss of memory, language, problem solving, and thinking ability with mood issues such as depression, anxiety, and apathy), Hypertension (HTN, high blood pressure), and Syncope and Collapse (fainting). The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 9/19/24, indicated Resident 17 rates 14/15, which equates to having cognition intact. During an interview on 11/20/24 at 12:40 pm, with Resident 17 while in the dining room, Resident 17 stated, Food is bland, mostly cold, and veggies are mushy. 2.A review of Resident 9's medical record indicated that Resident 9 was admitted on [DATE] with diagnoses that included Diabetes Mellitus (DM), Chronic Kidney Disease (Progressive damage and loss of function to the kidneys), and Cerebral Infarction (Stroke, blockage of blood flow to the brain). The MDS BIMS, Section C score dated 11/20/24, indicated Resident 9 rates 10/15, which equates to having moderately impaired cognition. During an interview on 11/20/24 at 12:40 pm, with Resident 9 while in the dining room, Resident 9 stated, Food is cold. 3.A review of Resident 51's medical record indicated that Resident 51 was admitted on [DATE] with diagnoses that included Alzheimer's Disease (brain disease which causes brain to shrink and brain cells to die) , Chronic Obstructive Pulmonary Disease (COPD, ongoing lung condition causing damage to the lungs and difficulty to breathe), and Heart Failure. The MDS BIMS, Section C score dated 10/24/24, indicated Resident 51 rates 5/15, which equates to having severely impaired cognition. During an interview on 11/21/24 at 12:35 pm, with Resident 51 while in the dining room, Resident 51 stated, Food is cold. 4.A review of Resident 70's medical record indicated that Resident 70 was admitted on [DATE] with diagnoses that included Neurocognitive disorder with Lewy Bodies (progressive damage to the brain with build-up of Lewy body cells which are clumps of proteins causing the brain to have symptoms of hallucinations, lack of focus and attention, and movement tremors), Parkinsonism (Neurologic condition that causes movement abnormalities such as tremor and impaired speech), and Generalized Muscle Weakness. The MDS BIMS, Section C score dated 11/7/24, indicated Resident 70 rates 2/15, which equates to having severely impaired cognition. During an interview on 11/19/24 at 1:35 pm, with Resident 70 while in the resident's room, Resident 70 stated, I am picky, the Food isn't to my taste, I get food out from my daughter. 5.A review of Resident 16's medical record indicated that Resident 16 was admitted on [DATE] with diagnoses that included Alzheimer's Disease , DM, and HTN. The MDS BIMS, Section C score dated 10/2/24, indicated Resident 16 rates 14/15, which equates to having intact cognition. During an interview on 11/19/24 at 2:00 pm, with Resident 16 while in the resident's room, Resident 16 stated, Food is cold, not good, I just have to eat it. 6.A review of Resident 36's medical record indicated that Resident 36 was admitted on [DATE] with diagnoses that included Cerebral Vascular Accident (Stroke, Blood flow to the brain is cut off and can lead to brain cell death, and neurologic damage), Monoplegia to Left Lower Limb (paralysis to one leg), and DM. The MDS BIMS, Section C score dated 10/30/24, indicated Resident 36 rates 7/15, which equates to having severely impaired cognition. During an interview on 11/20/24 at 12:40 pm, with Resident 36 while in the resident's room, Resident 36 stated, Food is cold. 7.A review of Resident 85's medical record indicated that Resident 85 was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbances, Heart Failure, and Cardiomyopathy (disease of the heart muscle causing the heart to have a difficulty pumping blood to the body). The MDS BIMS, Section C score dated 9/23/24, indicated Resident 85 rates 8/15, which equates to having severely impaired cognition. During an interview on 11/21/24 at 12:35 pm, with Resident 85 while in the dining room, Resident 85 stated, Food does not taste good and is cold. During an interview on 11/21/22 at 3:00 pm, with DM in the DM and RD office, DM stated, I understand the food must meet the resident's tastes. 45315 8. A review of the undated Admission Record, indicated, Resident 72 was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease (affected the lungs and made breathing difficult). Resident 72 was her own responsible party (RP, could make own decisions). During an interview on 11/19/24 at 11:58 a.m., Resident 72 stated, the hot foods were not always hot, the cold foods were not always cold, and the meat was tough and over cooked. 9. A review of Resident 80's undated Admission Record, indicated, Resident 80 was admitted to the facility on [DATE] with the diagnosis of type 2 diabetes (body was not able to control blood sugar levels). Resident 80 was her own RP. During an interview on 11/19/24 at 3:44 p.m., Resident 80 stated, the dietary department had served tomato soup the other day. Resident 80 had tears in her eyes and stated, I had my heart set on that hot tomato soup, on a cold evening, and it was stone cold. A review of the facility's weekly meal menu, titled Good for Your Heart Health Menus, dated 11/18/24 through 11/24/24, indicated, on 11/18/24, the residents received tomato soup with dinner. 10 - 14. During a confidential interview on 11/21/24 at 10:30 a.m., five residents stated the food in the facility was not good. Residents stated, the hot food was not hot, the cold food was not cold, and the meat was tough and hard to chew. One resident stated the meat was hard to swallow due to how tough it was.

Based on observation, interview and record review, the facility failed to ensure residents environment was clean, safe, comfortable, and homelike when: A drain in the kitchen was observed to have missing tile with exposed wood. Two tub and shower rooms used by residents were observed to contain excessive brown stains resembling rust on a handrail and on metal baskets used to hold soap and wash cloths. Doors in residents' rooms bathrooms were observed with scrapes, and gouges of exposed wood. One resident's wall next to his bed had multiple scrapes with exposed drywall. These findings had the potential for injuries to residents and an un home like environment. Findings: A review of a Safe and Homelike Environment policy dated 1/24/24 indicated the facility would provide a safe, clean and homelike environment to ensure residents can receive care and services safely. The policy additionally instructed that the facility maintenance and housekeeping would provide services as needed to maintain a safe, orderly, and comfortable environment. 1.During an observation on 11/19/24 at 11:00 am, in the kitchen during the walk through, the sink drain on the floor was missing tile with bare, water damaged wood exposed. During a concurrent interview and observation on 11/21/24 at 3:00 pm, with Dietary Manager (DM), and Registered Dietician (RD) 2 in the kitchen, DM stated, That drain really needs to be fixed with tiles, maintenance has ordered tiles and is in the process of starting to fix it, and RD 2 concurred in agreement that the drain needed to be fixed. 2. During a concurrent observation and interview on 11/20/24 at 8:55 am, with LN B in the Tub/Shower Room in the hall of the locked unit across from the nurse's station and utility room. Extensive rust was observed on metal baskets with plastic coating used for holding items such as soap and resident's wash cloths, also observed substantial rust on and in a floor drain with capped off spickets entirely coated in corrosion and rust which appears to not be in current use. LVN B concurred that rust and corrosion were evident, and this did not appear to be a satisfactory environment for someone's home. 3. During an observation on 11/20/24 at 9:15 am, in the Tub/Shower Room across from room [ROOM NUMBER] in the locked unit, observed rust on metal plastic coated baskets, rusted washers on shower safety handlebars, and 3 circular spackled areas in the shower exposed to water. During a concurrent observation and interview on 11/21/24 at 2:00 pm, with Admin in the Administrator's Office. Pictures recently obtained of the kitchen drain, and Tub/Shower Rooms with apparatus' observed with rust and corrosion issues were reviewed. Admin concurred the items were not in good shape and needed to be fixed. Admin stated we are in the process of fixing them. During a concurrent observation and interview on 11/21/24 at 4:30 pm, with MS, in the hall outside the Theatre Room. Pictures recently obtained of the kitchen drain, and Tub/Shower Rooms with apparatus' observed with rust and corrosion issues were reviewed. MS concurred he has been made aware of the issues and is in the process of fixing them. There is only one person in maintenance with a part time person recently hired. MS concurs many things need to be fixed. 23083 4. On 11/19 24 at 11:30 am, room [ROOM NUMBER]-bathroom door was observed to have a long gouge of exposed wood measuring approximately 9 inches by 1 inch long above the door handle. Concurrently, on the same day room [ROOM NUMBER]c bed wall next to his bed was observed to have scrapes with exposed drywall the length of his bed. At 11:40 am, the bathroom door of room [ROOM NUMBER] was observed to have exposed wood gouges by the doorknob measuring one foot in length by 1 inch in length. The inside door of this room also had wood gouges observed by the door knob measuring approximately 15 inches in length by 1 inch in width. On 11/21/24 at 4:15 pm, the above rooms and disrepair was observed with the Maintenance Supervisor (MS). He acknowledged at this time the findings and the measurements. MS stated these areas needed to be repaired. He stated sometimes the staff tell him about needed repairs. 40425

Based on observation, interview, and record review, the facility failed to provide two out of eight sampled residents (Residents 80 and 92) with dignity and respect when: 1. Resident 80's bed was not made every day. 2. Resident 92 stated, facility staff spoke in a manner, that led her to believe, facility staff did not want to provide care to Resident 92 and had overheard staff talking disrespectfully about her just outside of the door. This failure had the potential to impact resident well-being and cause psychosocial harm. Findings: A review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 11/1/23, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The P&P indicated, staff would speak with respect and would have conversations regarding residents in an area that residents could not overhear. A review of the undated Admission Record, indicated, Resident 80 was admitted to the facility on [DATE] with the diagnoses of hypertensive heart disease without heart failure (heart problems that were caused by high blood pressure), anxiety (feelings of fear), and a history of falling. Resident 80 was her own responsible party (RP, made own decisions). A review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 10/17/24, Section C, indicated, Resident 80 had a Brief Interview for Mental Status (BIMS, an assessment that tested a resident's ability to recall information and memory. The test was scored from 0-15 where 0 meant the resident was not able to remember and 15 meant the resident had intact memory) and scored a 14. During an interview on 11/19/24 at 3:44 p.m., Resident 80 stated, not every day, but often, Resident 80 had to ask facility staff to make the bed. Resident 80 stated, inability to make own bed anymore due to being [AGE] years old, a fear of falling again, and stated feeling upset because Resident 80 was not able to perform activities of daily living for herself like she used to. Resident 80 stated, when the bed was left unmade, it bothered her. During an interview on 11/19/24 at 4:03 p.m., Certified Nurse Assistant (CNA) B stated, it was the responsibility of the CNA on the morning shift to make resident's beds. CNA B confirmed Resident 80's allegations that the bed was left unmade and stated, CNA B would come to work in the afternoon and find Resident 80's bed unmade all the time. During an observation on 11/22/24 at 8:57 a.m., Resident 80's room was observed. Resident 80 was not in the room, and the bed had been stripped of all the linen (bed did not have sheets, blanket, or pillowcase). During a concurrent observation and interview on 11/22/24 at 9:18 a.m., Resident 80 was observed standing next to the stripped bed holding on to a walker (metal frame on wheels used by residents that had difficulty walking or were at risk for falls). Resident 80 stated, she had just had a shower. During a concurrent observation and interview, on 11/22/24 at 9:40 a.m., Resident 80's room was observed. Resident 80's bed was stripped of linen. The Director of Staff Development (DSD) was observed walking past Resident 80's room. DSD confirmed Resident 80's bed was stripped of linen and stated, after the CNA provided Resident 80 with a shower, the CNA was expected to make the bed. DSD stated earlier in the week, it was brought to DSD's attention that Resident 80's bed had been left unmade and had planned to re-educate the CNA assigned to Resident 80. During the concurrent observation and interview with the DSD, a request was made to interview Resident 80's CNA. The CNA agreed to an interview after providing resident care. The CNA completed resident care, walked out of the room, and quickly walked down the hall into another resident room and closed the door. 2. A review of the undated Admissions Record, indicated, Resident 92 was admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), anxiety, and need for assistance with personal care (bathing, using bathroom, and rolling in bed). Resident 92 was her own RP. A review of the admission MDS, dated [DATE], Section C, indicated, Resident 92 had a BIMS assessment score of 13 (able to recall and remember information). A review of the undated Admission Record, indicated, Resident 6 was admitted to the facility with the diagnoses of muscle weakness and major depressive disorder (a sad mood). Resident 6 was her own RP. A review of Resident 6's quarterly MDS, dated [DATE], Section C, indicated, Resident 6 had a BIMS assessment score of 14. During a concurrent observation and interview on 11/20/24 at 10:17 a.m., Resident 92 was observed lying in bed and maintained good eye contact during the interview. Resident 92 stated, I hear staff talking about me in the hallways all the time. Resident 92's roommate, Resident 6, joined the interview and stated, Resident 6 was treated differently than Resident 92. Resident 6 stated, facility staff treated her with dignity and respect and when facility staff spoke to Resident 92, they were short and sharp. Resident 6 and 92 described short and sharp as not having time and not wanting to care for Resident 92. Resident 92 began to cry and stated being afraid to say anything for fear staff would treat her worse. During an interview on 11/21/24 at 3:05 p.m., the Director of Staff Development (DSD) stated, it had been brought to the DSD's attention, at the end of last week, that two staff members had talked badly and mean to Resident 92. DSD stated one staff member had been identified and one staff member was unknown. DSD stated, DSD had not had an opportunity to follow up with facility staff regarding Resident 92's statements and DSD had previously counseled the identified staff in the past regarding how they spoke to residents.

Based on observation, interview and record review, the facility failed to maintain personal hygiene to one sampled resident that was unable to carry out his activities of daily living (Resident 8). Resident 8 was observed to have long dirty fingernails. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches) and poor hygiene. Findings: On 11/19/24 at 12:38 pm, Resident 8 was observed eating his lunch in the Dining Room with his fingers. His nails on his fingers were observed long with black particles in the nails. A review of Resident 8's record indicated he was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healinge), and the need for assistance with personal care. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/30/24, indicated Resident 8 was severely impaired for decision making, and dependent on staff for personal hygiene. On 11/20/24 at 8:45 am, Resident 8 was observed with Licensed Nurse (LN) C. Resident 8's fingernails on all his fingers were approximately one inch in length with brown substance under the nails. LN C confirmed the findings stating nail care is usually done on a weekly basis during their showers and with activities. LN C acknowledged all Resident 8's nails were at least one inch long on all his fingers and dirty. During an interview with the Activity Director (AD) on 11/22/24 at 10 am, she stated she usually does rounds to observe the residents. She stated Resident 8 is usually resistant to care and she did not know his nails were a concern. A review of a facility policy titled, Activities of Daily Living (ADLs) dated 1/24/24, indicated grooming and personal hygiene would be provided to residents who are unable to carry out activities of daily living. Additionally the policy directed it would identify resident triggers and inform the resident or his representative about the benefit verses benefit of the proposed treatment, and offer an alternative action if the resident refusals continue.

Based on observation, interview, and record review the facility failed to include nail care to one sampled residents comprehensive care plan (Resident 8). Resident 8 was observed to have long dirty fingernails, and was observed eating with his fingers. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches), and poor hygiene. Findings: On 11/19/24 at 12:38 pm Resident 8 was observed eating his lunch in the Dining Room with his fingers. His nails on his fingers were observed long with black particles in the nails. A review of Resident 8's record indicated he was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healinge), and the need for assistance with personal care. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/30/24, indicated Resident 8 was severely impaired for decision making and dependent on staff for personal hygiene. On 11/20/24 at 8:45 am, Resident 8 was observed with Licensed Nurse (LN) C. Resident 8's fingernails on all of his nails were approximately one inch in length with brown substance under the nails. LN C confirmed the findings stating nail care is usually done on a weekly basis during their showers and with activities. LN C acknowledged all Resident 8's nails were at least one inch long on all fingers and dirty. On 11/20/24 at 9 am, LN D was interviewed while reviewing Resident 8's record. LN D confirmed a care plan for refusal of ADLS (Activities of Daily Living) was present in the record but nothing about his refusal or need for nail care. On 11/21/24 at 7:35 am the Director of Nurses (DON) stated during an interview that nail care should have been included in Resident 8's ADL care plan. During an interview with the Activity Director (AD) on 11/22/24 at 10 am, she stated she usually does rounds to observe the residents. She stated Resident 8 is usually resistant to care, and she did not know his nails were a concern. A review of a facility policy titled, Care Planning / Interdisciplinary Team Care Planning Conference dated 9/2016, indicated the purpose of resident care plans were to assure resident care needs are identified through continuous assessment with measurable objectives and adequate interventions. The policy additionally indicated care plans would be reviewed, evaluated and updated as necessary by nursing staff.

Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one out of eight sampled residents (Resident 92) when Resident 92 notified Licensed Nurse (LN) A that facility staff working the night shift provided rough care (too much force, not careful or gentle). This failure had the potential for allegations of abuse to go unrecognized and placed residents at risk for abuse. Findings: A review of the facility's policy and procedure titled, Abuse-Reporting & Investigating, revised 11/1/16, indicated, when an allegation of abuse was made, the facility would notify CDPH. A review of the undated Admission Record, indicated, Resident 92 was admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), anxiety (feelings of fear), and need for assistance with personal care (bathing, using bathroom, rolling in bed). Resident 92 was her own responsible party (made own decisions). A review of the admission Minimum Data Set (MDS, an assessment tool), dated 10/17/24, Section C, indicated, Resident 92 had a Brief Interview for Mental Status (BIMS, an assessment that tested a resident's ability to recall information and memory. The test was scored from 0-15 where 0 meant the resident had poor memory and 15 meant the resident had good memory) and scored a 13. During a concurrent observation and interview on 11/20/24 at 10:17 a.m., Resident 92 was observed in bed and maintained good eye contact during the interview. Resident 92 stated, One night, the nurses were really rough turning me and changing me. Resident 92 was observed to lower her head, broke eye contact, and began to cry. During an interview on 11/21/24 at 12:26 p.m., LN A stated, Resident 92, came to me with concerns about rough care provided by NOC [nighttime] shift on last Friday and had reported to the Director of Staff Development (DSD). During an interview on 11/21/24 at 2:29 p.m., with the facility's Administrator (ADMIN), Resident 92's allegations of potential abuse were discussed. ADMIN confirmed, there was no report of Resident 92's allegations of potential abuse made to CDPH and stated, ADMIN was not notified of Resident 92's statements. During an interview on 11/21/24 at 3:05 p.m., DSD stated, last Friday, LN A notified DSD that Resident 92 alleged the NOC shift staff was rough while providing care, the Director of Nursing (DON) was aware, and it wasn't abuse. During an interview on 11/21/24 at 3:21 p.m., DON stated, LN A notified DON that Resident 92 alleged something happened a while ago, and the night shift didn't seem nice. DON stated, asking LN A what had happened and if Resident 92 was abused. DON confirmed, Resident 92's allegation of potential abuse was not reported.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) dignity was honored when Certified Nursing Assistant C (CNA C) provided personal cares with the window covering open which exposed Resident 3 to an outside courtyard accessible to staff and residents. This failure had the potential to negatively affect Resident 3 ' s physical and mental well-being. Findings: A review of the facility ' s policy titled Promoting/Maintaining Resident Dignity dated 11/2023, indicated It is the practice of this facility to protect and promote residents ' rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. Compliance Guidelines 11. Maintain resident privacy. A review of Resident 3 ' s Admission Record (undated) indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s Disease (a disease that destroys memory and other important mental functions), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic (ongoing) pain, need for assistance with personal care. A review of Resident 3 ' s Quarterly Minimum Data Set (MDS, a complete clinical assessment) dated 9/10/24, indicated a Brief Interview for Mental Status (BIMS, an evaluation of cognition [thinking, recalling, and making decisions]) was done with results indicating her cognition was severely impaired. Section GG indicated Resident 3 was dependent on staff for toileting needs. Section H indicated Resident 3 was always incontinent with urination and bowel movements. During an observation on 11/15/24 at 1:33 pm, Resident 3 ' s room was observed. Resident 3 was in bed and the right side of her bed was against an outside wall. There was a window alongside the lower half of her bed that looked outside onto a courtyard (grassy area and a sidewalk). The window shade was completely open. CNA C was observed entering Resident 3 ' s room and pulling a privacy curtain around Resident 3 ' s left side of the bed and the end of the bed but stopped a foot short of the wall. The window shade was all the way up and Resident 3 was in full view of the outside. CNA C was observed changing Resident 3 ' s brief (incontinent product worn like a diaper that collects bowel and urine). Resident 3 ' s peri area (resident ' s private area) was exposed to the outside area through the uncovered window. During a concurrent observation and interview with Licensed Vocational Nurse A (LVN A) on 11/15/24 at 1:35 pm, in Resident 3 ' s room. LVN A entered the room and when it was pointed out by the surveyor that the window shade was up and Resident 3 was having personal cares done, LVN A immediately pulled the window shade down. During a concurrent observation and interview with the Activity Director (AD) on 11/15/24 at 1:40 pm, the outside courtyard was observed. The AD indicated this area was accessible to staff and residents. The AD confirmed that she was able to see in the windows when the shades were up. The AD indicated it would be a dignity issues to do personal cares for a resident with the window shades up exposing private areas of a resident. During an interview on 11/15/24 at 1:45 pm, CNA C indicated she should have pulled the window shade down before she started to give cares and it was a dignity issue that she had not. During an interview on 11/15/24 at 2:59, the Administrator and Director of Nursing both concurred that window shades should be closed to maintain privacy when doing personal cares with a resident.

Based on observation, interview, and record review, the facility failed to implement the infection prevention and control measures when: 1. 55 of 139 employees did not have evidence of current screening for [MEDICAL CONDITION] (TB, is caused by a bacterium called [DIAGNOSES REDACTED]. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection (LTBI) and TB disease. If not treated properly, TB disease can be fatal). This was identified as an immediate jeopardy situation due to infection control prevention measures not adequate to for the avoidable potential for the spread of TB 2. Seven of 139 employees did not have evidence of receiving or refusing the current flu vaccination. This contributed to an immediate jeopardy situation when infection control prevention measures were not in place for consistent monitoring and/or administration of employee flu vaccinations. 3. For Resident 394: a. Two confidential staff (were wearing gloves only) did not use correct PPE (personal protective equipment, gloves, gown, and mask) for Resident 394, who was on transmission based droplet precautions (while being tested for influenza). This had the potential for avoidable transmission of germs [MEDICAL CONDITION] to residents. b. The process to follow up on lab test results for the flu test was delayed. This resulted in the potential for an outbreak of the flu to not be identified timely. This put residents at an avoidable risk for the spread of the flu. 4. Staff did not perform required hand hygiene during a wound dressing change for Resident 41. 5. Staff did not perform required hand hygiene during wound care for Resident 82 and between resident contact, laundry storage and processing practices were not adequate, and the facility was not maintained in a sanitary condition when: a. Routine maintenance for showers was not adequate. b. Cleaning between resident showers was not adequate. c. Clean linen in the shower was touching the soiled linen container. d. Rips/tears were found in multiple fall mats, wheelchairs, and cushions. e. Brown matter was found on the fall mats in room [ROOM NUMBER]. f. Brown matter (appeared to be feces) was found in a shower available for use. g. Sit to stand lifts and Hoyer lifts (devices used to transfer residents) were not cleaned between use. h. Oral care products were stored next to peri-care products in a resident bathroom. i. Hand hygiene not adequate during wound care and between resident care. The deficient practices were determined to constitute an Immediate Jeopardy (IJ) situation due to infection control issues related to 55 of 139 employees without evidence of current TB screening and seven of 139 employees without evidence of receiving or refusing the flu vaccine with no preventive measures were in place to protect residents from the potential for the preventable spread of TB and the flu (if these employees were unknowingly carriers of the disease). The Administrator and the Director of Nursing (DON) were verbally notified of the IJ on 2/7/19, at 5:15 pm. Through interviews and reviews of facility documentation, infection control manual, policies and procedures, the facility showed they initiated the plan of action through administration of TB skin tests and flu vaccination, and resident protections as required. The IJ was lifted on 2/11/19 at 6 pm, in the presence of the Administrator and DON Findings: 1. The facility's infection control policy titled, TB Testing - Resident, Employee and Volunteer, dated 9/20/16, indicated All staff shall be screened for active TB on hire and annually.Employees having direct resident contact will be skin tested annually if last test was negative.Employees with positive TB skin test shall receive an initial chest x-ray and an annual follow-up questionnaire. On 2/7/19 at 3:40 pm, during an interview and concurrent record review, the Director of Nurse (DON) provided a list of current employees and their current TB screening and flu vaccination status. Review of the documentation showed that 40 of 139 employees (one activity staff, 13 Certified Nursing Assistants (CNA's), 15 licensed nurses (LN's), four dietary staff (DS), three housekeeping staff (HKS), one maintenance staff (MS), one therapy staff (TS), one student and one medical records staff) did not have evidence of TB screening. The documentation indicated an addition 15 of 23 employees (four CNA's, five HKS, two DS, three LN's, and one TS) with a history of a positive TB skin test did not receive an annual follow-up questionnaire, to screen for symptoms of TB. The DON confirmed these employees were allowed to work without updating their TB screening information. No precautions were in place to protect residents for the potential spread of TB from these staff. 2. The facility's infection control policy, regarding flu vaccination, approved (YEAR), indicated employees would be offered a flu vaccine annually. The policy indicated that all employees who chose not to receive the vaccine would be required to wear a mask while in the facility. On 2/7/19 at 3:40 pm, during an interview, the DON provided a list of current employees and the status of the flu vaccination. The DON confirmed that seven of 139 employees with no evidence of receiving or refusing the vaccine. No precautions were in place to protect residents from the potential spread of flu from these staff. The DON confirmed the infection control policies were not implemented when employees that did not receive the flu vaccine, were not required to wear a mask. On 2/7/19 at 5:15 pm, the Admin and DON were notified of an immediate jeopardy. The immediate jeopardy was abated on 2/11/19 at 6 pm. 3. Review of the admission records indicated Resident 394 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/7/19 at 2:15 pm, during an interview, LN SS stated Resident 394 was tested for the flu. LN SS stated the results would be back by the end of the day. Resident 394 was on droplet transmission based precautions while waiting for the results of the laboratory test. On 2/7/18 at 2:25 pm, during an observation, two staff were at Resident 394's bedside without required protective equipment for the transmission based precautions in place. On 2/7/18 at 2:30 pm, during an interview, the two confidential staff confirmed they were not wearing the required PPE while in the room with Resident 394. One of the two confidential staff was not aware the resident had been tested for the flu or that droplet precautions were in place. On 2/11/19 at 12:43 pm, during an interview, LN QQ stated the resident was re-tested for the flu again this morning. LN QQ explained the specimen collected on 2/7/19 was placed in the wrong specimen container so the lab could not run the test. On 2/12/19 at 2:55 pm, during an interview, the DON confirmed a Resident 394's lab test to determine if he had the flu, should have been followed up on if the results did not come back from the lab when expected. The DON confirmed correct PPE for transmission based precautions were required for all staff entering the resident's room. 4. A review of Resident 41's clinical record indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, a standardized resident assessment) dated 11/26/18, indicated that Resident 41 had mild cognitive impairment (ability to think and reason), was dependent for bed mobility and did not have any pressure injuries (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure). A review of Resident 41's physician's orders [REDACTED]. During a concurrent observation and interview on 2/11/19 at 9:32 am, LN N completed the dressing change for Resident 41's right ankle pressure injury. LN N washed her hands at the nurses station. She retrieved keys from her pocket and opened the treatment cart to get the tape. Gathered supplies and entered the room. LN N reached down to untangle the call light from the wheels of the over bed table. LN N donned clean gloves, removed the old dressing and walked into the bathroom to change her gloves. LN N was not observed to perform hand hygiene in the bathroom. LN N then cleansed the wound with normal saline, dried her gloves with a gauze pad and applied a clean dressing. LN N confirmed that she did not perform hand hygiene while in Resident 41's bathroom and she changed her gloves one time. A review of the facility's policy titled Wound Care, revised 2/2002, instructed staff perform hand hygiene before the procedure and when changing gloves. 5a. A review of the facility's policy titled, Hand Washing, dated 3/23/16, indicated staff members are required to wash their hands after direct or indirect contact of residents, before and after patient care, in-between tasks, and before the application of gloves and after the removal of gloves. On 2/5/19 at 9:35 am, a concurrent observation and interview was conducted with LN Q. LN Q was not observed performing any type of hand hygiene in between resident treatments for wound care. LN Q confirmed the above. On 2/6/19 at 9:45 am, a concurrent observation and interview was conducted with LN N, Certified Nurse Assistant (CNA) AA, and CNA Y. LN N, CNA AA, and CNA Y were observed performing resident care without performing hand hygiene prior to care. CNA AA confirmed the above and stated, I was in a hurry. On 2/6/19 at 10:35 am, a concurrent observation ad interview was conducted with the activities assistant (AA) A. AA A was observed passing out snacks to residents and did not perform hand hygiene in between resident contact. AA A indicated she was not aware of the hand hygiene policy or protocol and stated, I only do what I have been instructed. AA A confirmed the above. On 2/11/19 at 3:16 pm, an observation of wound care for Resident 82 and concurrent interview was conducted with LN V. LN V did not use gloves or perform hand hygiene prior to touching the resident's wound. LN V was observed placing the treatment bag full of supplies on the resident's bed. LN V then donned (put on) gloves without performing hand hygiene, removed the supplies from his bag, and proceeded to perform a wound assessment. LN V, while wearing soiled gloves, handled a cell phone from the treatment bag, placed the cell phone back in the bag, and continued with touching the resident's open wound. LN V was not observed taking any measures to sanitize his hands or the bag after leaving the resident's room. LN V indicated he took his treatment bag with him to all resident rooms and that he did not clean or sanitize his treatment bag. LN V confirmed the findings. During an interview on 2/11/19 at 3:24 pm, the DON stated all staff, including contract staff, were expected to follow universal precautions 5b. On 2/12/19 at 8:57 am, a tour of laundry services was conducted with the Director of Environmental Services (ESD) and the facility Administrator (FA). The ESD and FA confirmed the following observations: a. An open package of female feminine products was on top of linen in the linen storage room. b. A basket of found items, with a removable film of dust, were on the linen folding station. ESD indicated she was unaware if the items were contaminated or clean. c. The linen storage and folding station was located in the first front half of ESD office, with a fan mounted on the upper wall pointing toward the linen folding station. d. Uncovered food and drink was on ESD desk. e. Household plants were on a shelf above the folding station. f. Laundry room window was open and the screen was torn on bottom right corner. g. Staff passed between contaminated laundry area to clean laundry area, over red line on floor, without any type of decontamination or use of standard precautions. h. Environmental Services staff (ES) moved laundry collection basket from in front of a washing machine on the soiled side of the laundry room and placed it in front of a clothes dryer that had dried clothing inside (indicating use between soiled and clean areas without sanitizing). i. There was no ventilation in the laundry processing room. During an observation on 2/12/19 at 9 am, ES opened the window in the laundry processing room. The window had no screen. On 2/12/19 at 9:15 am, a concurrent interview was conducted with ESD, FA, ES, and the Maintenance Supervisor (MS). ES indicated she was unaware of a process to ensure linens were sanitized. ES stated the laundry processing room got very hot and humid and that she opened the windows to ventilate. ES stated the fan had not been working for about a year. MS confirmed that the whole house fan had been broken for an unknown time period. During an interview on 2/12/19 at 9:45 am, ESD and FA confirmed the above findings. 5c. On 2/12/19 beginning at 9:50 am, a concurrent observation and interview was conducted during infection control tour of the facility with LN Q. LN Q confirmed the following unsanitary conditions: a. Routine maintenance for showers was not adequate. b. Cleaning between resident showers was not adequate. c. Clean linen in the shower was touching the soiled linen container. d. Rips/tears were found in multiple fall mats, wheelchairs, and cushions. e. Brown matter (appeared to be feces) was found on the fall mats in room [ROOM NUMBER]. f. Brown matter (indicated to be pieces of feces) was found in a shower available for use. g. Sit to stand lifts and Hoyer lifts (used to transfer residents) were not cleaned between use. h. Oral care products were stored next to pericare products (used to clean private areas) in a resident bathroom.

Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers (pressure injuries to skin and underlying tissue resulting from prolonged pressure on the skin. These injuries most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone) for four of 24 sampled residents (Residents 85, 48, 4, and 79) when. 1. Resident 85 developed three preventable pressure injuries to his heels/feet including when his heels were not floated (heels should be positioned in such a way as to remove all contact between the heel and the bed) and there was no documentation the resident was being turned or weekly assessments being completed. 2. Resident 48 developed a preventable Unstageable Deep Tissue Pressure Injury to her left heel. 3. Resident 4 developed a preventable Stage 2 pressure injury to her sacrum (tailbone). 4. Resident 79 developed a preventable Stage 1 pressure injury to her buttocks. This resulted in harm to resident 85, 48, and 41, and the potential for harm to Residents 4 and 79. Findings: 1. A review of the admission records indicated Resident 85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission assessment, dated 11/13/18, was reviewed and included a section to identify alterations in the resident's skin integrity. The assessment indicated Resident 85's skin was intact with no issues identified. A review of the baseline care plan for Resident 85, dated 11/13/18, to address prevention of alteration in skin integrity, indicated he was to be turned every two hours and his heels were to be floated (heel should be positioned in such a way as to remove all contact between the heel and the bed). The care plan to address his activities of daily living, dated 11/13/18, was reviewed and indicated Resident 85 was dependent on staff for all activities of daily living, including turning/bed mobility, transfers, toileting, wheelchair positioning/locomotion, and eating. The care-plan further indicated that Resident 85 had dementia with severe memory impairment and was non-verbal. The Interdisciplinary Team Incident Review (IDT, a team of health care professionals who work in a coordinated fashion toward a common goal for the patient): Skin, dated 12/14/18, was reviewed and indicated that Resident 85 had in-house acquired fluid filled blisters to both heels. The document indicated Resident 85 was at high risk for developing a pressure ulcer as indicated on his Braden Score (assessment instrument used for predicting pressure sore risk). The root cause was identified as improper positioning and preventative care. The interventions included float heels and educate staff. Review of the interdisciplinary progress notes, dated 12/17/18, indicated that Resident 85 had been given a new specialized wheelchair (Broda chair) and to use heel protectors. The social service notes, dated 12/17/18, was reviewed and indicated that Resident 85 had blisters to the heels, staff was told to float the heels and do a wheelchair change, since that was thought to be the cause of the heel blisters. Physician orders [REDACTED].>a. dated 12/14/18, included treatment orders for the blisters to the heels b. dated 12/25/18, indicated culture wound left heel (new wound treatment orders were placed and implemented) and an order for [REDACTED].>c. dated 12/25/18, indicated update pressure ulcer assessment and notify MD weekly. A laboratory report dated 12/27/18, was reviewed and indicated the presence of an infection to the left heel and the physician orders [REDACTED]. A follow up culture was done on 1/22/19 resulting in new orders for antibiotic therapy to treat newly identified bacteria causing a wound infection (included [MEDICAL CONDITION] bacteria-[MEDICAL CONDITION]). During an interview and concurrent record review on 2/6/19 at 4 pm, Licensed Nurse (LN) S demonstrated that the Treatment Administration Records (TAR), dated 12/2018, 1/2019 and 2/2019, included documentation the wound treatments had been performed as ordered, but no evidence was found that weekly assessments/measurements (Pressure Ulcer Assessments) had been performed from 12/14/18 through 1/9/19 (when the resident was seen by the WCMD). When asked if the blisters, which had been identified on 12/14/18, had been classified as pressure ulcers, LN SS stated they had not been staged until the resident had been seen by the WCMD (on 1/9/19). LN S stated he wanted to have someone with more experience stage the wounds. LN S confirmed that there was no documentation that weekly assessments of Resident 85's wounds had been performed from 12/14/18 through 1/9/19 and without weekly wound assessments, it was not possible to know if the wounds were getting worse or healing. The WCMD's documentation dated 1/9/19, was reviewed and identified an Unstageable Deep Tissue Injury of the left heel measuring 1.3 centimeters (cm) in length (L) by 1.3 cm wide (W) by 0.2 cm in depth (D); an unstageable of the right heel, measuring 6 cm L by 6.3 cm W; the depth was not measurable. On 2/5/19 at 9:20 am, during an interview, the WCMD stated he had just completed his evaluation of Resident 85's pressure ulcers. The WCMD explained the resident had a Stage 4 pressure ulcer (on the left outside of the right heel), a Stage 3 pressure ulcer (on the left outside of the left heel) and a newly identified Deep Tissue Injury on the right inside ankle as of today. A record review of the wound evaluation and management summary (completed by the WCMD), dated 2/5/18, was reviewed and indicated the Stage 3 pressure ulcer of the left heel, measured 0.4 cm L by 0.4 cm W by 0.1 cm D. The Stage 4 pressure ulcer of the right heel measured, 3 cm L by 3.2 cm W by 1.6 cm D. The Unstageable Deep Tissue Injury on the inside of the right, ankle measured, 2 cm L by 1.5 cm W. On 2/5/19 at 10 am, Resident 85 was observed seated in his wheelchair at his bedside. His right heel was observed with the heel dressing hanging off of the foot (so that it was not covering the wound) and with his heel pressed directly on the leg support surface of his specialized (Broda) wheelchair so that the open wound was in direct contact with the chair's surface. On 2/5/19 at 12:30 pm, Resident 85 was observed positioned on his back and sitting up in bed for lunch. Resident 85 had total dependence on staff for feeding (due to contractures of his arms and hands). During a concurrent interview, Certified Nursing Assistant (CNA) N confirmed that the two pillows that were placed under Resident 85's knees, did not result in floating of the heels. Resident 85 was observed with pressure relieving boots on both feet. Resident 85 was observed with significant contractures of the knees and tonic muscle movements of his legs (sustained contraction of the leg muscles) causing him to press his heels down into and drag them across the bed. On 2/5/19 at 2:40 pm, during an observation and concurrent interview, Resident 85 was observed in bed, turned on his left side. His legs were observed to have pillows for positioning and heel protective boots on, but the heels were not floated off of the bed. On 2/5/19 at 4:20 pm, during a concurrent interview and observed, Resident 85 resting on his left side, CNA R confirmed positioning pillows were in place, but the heels were not floating off of the bed. On 2/6/19 at 7:45 am, A concurrent observation of Resident 85 was made with LN Q. Resident 85 was resting on his left side with pillows in place under his legs and with protective heel booties on, but his heels were not floated. LN QQ confirmed this observation. During an observation on 2/6/19 at 12:20 pm, Resident 85 was sitting up in bed for lunch with pillows under his legs and protective heel booties in place, but his heels not floated. On 2/7/19 at 2:40 pm, during an interview, CNA M, stated this was her first day working in this area CNA M stated she had not been made aware of a process to identify resident care needs other than asking the nurse or getting report. CNA M stated that in report she was told to turn Resident 85 and keep his heels floated. Resident 85 was observed on his left side. CNA M stated there was no way to know which side the resident had been on earlier in the day, other than to turn him to the opposite side when found. CNA M stated she had been told not to turn the resident on his back. During an observation on 2/11/19 at 11:39 am, Resident 85 was up in a chair with a pillow under his legs and his heels floated. Resident 85 was contracting his legs and arms in regular intervals (in a sit-up type motion) and letting out a sigh as released, approximately every 5 to 20 seconds. During an interview on 2/11/19 at 12:03 am, LN Q confirmed she was aware of the resident having the tonic muscle movements as described above. During a concurrent record review (from admission to present), no documentation was found regarding the presents of these tonic muscle movements (sustained contraction of the muscles), no evidence was found that the physician had been notified. No evidence of these muscle movements were noted in the physician progress notes [REDACTED]. On 2/12/19 at 11 am, during an interview and concurrent observation, the Physical Therapist (PT) (had recently completed evaluation and treatment for [REDACTED]. floated. The PT confirmed extra pressure on the heel during these movements (sometimes causing the resident's heels to be dragged against the bed) could negatively impact skin integrity even with the protective booties on. On 2/12/19 at 4:19 pm, during an interview with LN Q and concurrent review of Resident 85's record, dated 11/13/18 through 2/12/19; a. The Treatment Administration Record (TAR), from 11/13/18 to 2/12/19, showed documentation that Resident 85's heels were floated (signed two times each day by the licensed nurse). LN Q stated the documentation meant the nurse checked if Resident 85's heels were floated and if found not floated, would reposition the resident's heels. The nurse would also communicate with CNAs regarding the need to keep Resident 85's heels floated. LN Q stated this did not verify that Resident 85's heels were floated at all times. b. CNA documentation for 11/13/18 through 2/12/19, revealed no documentation of the frequency of turning Resident 85 from side-to-side, if protective heel booties were on, or if his heels were floated. LN Q indicated that these activities were part of CNA duties and verified the lack of documentation to show that they were done. c. The care plan regarding skin breakdown included a revision, dated 1/24/19, that indicated the Resident had been noted by staff to dig heels into his bed causing sheer and pressure to the heels. No evidence was found that the physician was notified of this condition. New interventions on the care plan, dated 1/24/19, included Prevalon boots to bilateral feet (special pressure relieving booties). LN Q confirmed, after reviewing the nurses notes and CNA documentation, it was unclear when the Prevalon boots were first applied, or how often they were kept in place. On 2/13/19 at 9:15 am, during an interview, the Medical Director (MD) was asked about Resident 85's tonic muscle activity. The MD stated he had not observed this activity and did not recall if he had been informed. 2. A review Resident 48's admission records indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record also indicated that Resident 48 was alert, oriented, and capable of making her own health-care decisions. A nursing admission assessment, dated 1/21/19 at 2:45 pm, was reviewed and indicated Resident 48 had five ischemic wounds (due to poor blood flow) to her toes. No other alterations in skin integrity were identified. On 2/7/18 at 10:40 am, Resident 48 was observed with cushioned booties on both feet/heels. Resident 48 stated, They just put those on me. On 2/7/19 at 10:50 am, during an interview, LN S stated a Deep Tissue Injury (DTI) had been identified on Resident 48's left heel. On 2/7/19 at 2:20 pm, during an interview and observation, CNA V stated this was her first time working with her residents today. When asked if she had been told anything about Resident 48's feet, during report, she checked her notes and replied, No. During a concurrent interview, LN Q confirmed there was no formalized method in place to communicate resident specific care needs to CNA staff, other than verbal report. On 2/11/19 11:59 am, during a concurrent interview and observation, LN Q confirmed an area on the outer aspect of Resident 48's left heel appeared with a scabbed over area (less than one centimeter in appearance) with blanchable redness the approximate size of a quarter. LN Q stated Resident 48 would be seen by the WCMD on his next visit to the facility (scheduled for 2/12/19). 3. A review of Resident 4's clinical record indicated that Resident 4 was readmitted on [DATE], with a [DIAGNOSES REDACTED]. Resident 4 required extensive assistance of staff for all activities of daily living (ADL - care such as feeding, bathing, dressing, grooming, bed mobility, transfers, and leisure). A review of Resident 4's Resident Care Plan, dated 4/28/18, indicated concerns and problems identified were potential for impairment to skin related to history of pressure ulcers and totally incontinence (no voluntary control over urination or defecation). Resident 4's care plans approach plan (interventions) to prevent concerns and/or problems were: turns and reposition frequently and wears briefs, check and change frequently. A review of Resident 4's Pressure ulcer Care Plan, dated 1/6/19 indicated, Concerns and Problems Identified: Pressure ulcer site sacrum, onset date 01/06/2019 expected due to diabetes and poor appetite. Approach/Goals: reposition frequently and nutritional supplements and diet per orders. A review of Resident 4's nurses notes, dated 1/6/19 at 12:45 pm, indicated, resident has two pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue) on her sacrum (The large heavy bone at the base of the spine, which is made up of fused sacral vertebrae. It is roughly triangular in shape and makes up the back wall of the pelvis). A nurses notes, dated 1/6/19 at 02:02 pm indicated, treatment on AM shift done for stage 2/3 pressure ulcer. A review of Resident 4's ADL Charting for month 12/2018 and 1/2019 indicated that Resident 4 required extensive assistance and was total dependence (totally dependent on staff for the entire task) with bed mobility (how resident moves, turns and positions body while in bed). A review of Resident 4's weekly pressure ulcer record dated 1/6/19 indicated: a Stage 2 sacrum pressure ulcer with maceration (the softening and breaking down of skin) to surrounding tissue/wound edges with an onset date of 1/6/19, measuring 1.3 centimeter in length, width of 1 centimeter in width and 0.2 centimeters in depth. A review of Resident 4's weekly pressure ulcer record dated 1/24/19, indicated stage 2 and wound dimensions of 1 centimeter in length, 0.5 centimeters in width and superficial in depth documented. LN N indicated that the pressure ulcer assessment dated [DATE] was incomplete. There was no documentation for the following: exudate type, exudate amount, tunneling or undermining, odor surrounding skin color, surrounding tissue/wound edges, wound bed tissue type and signature. Resident 4's clinical record of weekly pressure ulcer record dated 2/5/19 indicated a Stage 2 sacrum pressure ulcer with maceration to surrounding tissue/wound edges and measuring 0.7 centimeter in length, width of 0.4 centimeter in width and superficial in depth. LN N confirmed above findings and indicated that thorough and complete weekly assessments were not being documented or done. On 02/06/19 at 09:45 am, an observation of Resident 4's pressure ulcer to her sacrum was conducted with LN N and CNA AA, while performing perineal care. Stage 2 pressure ulcer approximately 0.5 millimeters in circumference (size of a pea) with dark tissue was observed. LN N confirmed observation. On 02/06/19 at 11:40 am, a concurrent interview and record review of Resident 4's clinical records was conducted with LN Q. LN Q confirmed all above clinical record findings. LN Q indicated that resident 4's care plan dated 4/28/19 had not been updated and changed ad needed. LN Q indicated Resident 4's needs were not being met. LN Q indicated Resident 4 acquired a preventable pressure ulcer while at the facility. 4. A review of Resident 79's clinical record indicated that Resident 79 was admitted on [DATE], with a [DIAGNOSES REDACTED]. Resident 79 needs extensive assistance to being totally dependent of staff for all activities of daily living (ADLs) On 02/05/19 at 03:39 pm, a concurrent interview and record review of Resident 79's clinical records was conducted with LN N. Resident 79's clinical record titled, ADL Charting for month 12/2018 and 1/2019 indicated that Resident 79 required extensive assistant while eating and total dependence with bed mobility. LN N confirmed above documentation. On 02/07/19 at 3:25 pm, an interview with LN N was conducted. LN N stated that the facility has no documentation to confirm or ensure dependent that residents were repositioned. LN N confirmed Resident 79 was totally dependent of staff for all needs. On 02/11/19 at 12:30 pm, a concurrent interview and record review was conducted with Director of Nursing (DON). The DON stated that Resident 79 did not have a pressure ulcer only has excoriation and defined it as redness with ruff skin. The DON stated pressure ulcers only occur over bony prominences. A record review of Resident 79's weights indicated a significant weight loss of eleven pounds in past twenty-one days. DON confirmed significant weight loss and stated, Resident 79 should be placed on hospice care. On 02/11/19 at 12:34 pm, interview conducted with Licensed Nurse (LN) N. LN N indicated staff instructed that possible pressure ulcers were reported to the DON and the DON classified wounds as pressure ulcers. On 02/12/19 at 08:46 am, an interview with CNA S was conducted. CNA S stated she did not keep track of time care was provided for residents and only provided care when needed and then routinely checked on resident's needs. CNA S stated, for residents that were dependent, she checked their diaper's and gets them up out of bed if needed. On 02/12/19 at 7:44 pm, an interview was conducted with CNA U. CNA U stated she had been the only CNA assigned to entire hall on afternoon shift with 1 Licensed Nurse for past 3 months. CNA U stated she felt rushed with resident's care and felt bad that residents did not get the care needed. A record review of the facility document titled, Weekly Pressure Ulcer Record, under the heading Description of stages indicated: Stage 1: intact non-blanchable redness . usually over bony prominence. Darkly pigmented skin . blue or purple hues. Stage 2: Partial thickness loss of dermis . with red or pink wound bed. (MONTH) also present as blisters. Stage: Full thickness tissue loss . Slough may be present but does not obscure the depth of tissue loss. On 02/13/19 at 11:30 am, an observation and concurrent interview was conducted with LN Q of Resident 79's moisture associated [MEDICAL CONDITION] (skin inflammation). Resident 79 had fecal matter that had to be cleansed from wound prior to description and measurements. LN Q indicated skin was peeling off and has small blisters as wound as being cleansed. LN Q indicated poor lighting in room making hard to visualize wound. LN Q described wound reddish skin in center, surrounded by deep purple skin, with measurements of fifteen centimeters by nine and a half centimeters to right buttocks (15 X 9.5) and eleven centimeters by nine and a half centimeters (11 X 9.5) to right buttocks. LN Q stated that Resident 79's wound was excoriation and moisture associated [MEDICAL CONDITION] and not a pressure ulcer because it was not on a bony prominence as he pushed in on Resident 79's buttock tissue (no blanching of skin was observed). LN Q stated that Resident 79's skin was dark purple from poor tissue perfusion from Resident 79's wound infection on his foot. Resident 79's wound was observed reddish skin over coccyx (tailbone) area that was surrounded by approximately 1.5 to 2 inches of deep dark purple skin. The wound covered approximately fifty percent of Resident 79's sacral/coccyx region (buttocks area). On 02/13/19 at 12 pm , a review of Resident 79's clinical record was conducted with LN Q. The record titled, NON-PRESSURE SORE SKIN PROBLEM REPORT, dated 1/11/19 indicated, Excoriation identified on 1/11/19, description 4 x 0.5 skin peeling to left buttock with excoriation to left and right buttocks. Under the title, weekly progress report dated 2/7/19 was documented:, size 3 x 0.5 centimeters, skin clean, dry and intact on buttocks with decreased excoriation. Only the left buttock was marked for location indicated on the body diagram. LN Q confirmed the above. On 02/13/19 at 12 PM, a review of Resident 79's clinical record was conducted with LN Q. The record titled, SHORT TERM CARE PLAN, indicated the following: Concerns and Problems Identified: excoriation to left and right buttock were shin is peeling, onset date 01/11/2019. An approach/plan of monitor for complications, report changes to doctor, monitor for pain, update skin sheet weekly, administer treatments as ordered, cleanse and dry with saline, apply zinc oxide every shift until resolved. A review date of 2/11/19. LN Q confirmed the above and indicated that frequent turning of every two hours should also be part of the plan. On 02/13/19 at 11:30 AM, an interview with Licensed Nurse (LN) N was conducted. LN N stated that some residents don't get care needed, such as repositioning. LN N further stated that there was no documentation to ensure residents were reposition as needed.

Based on observation, interview, and record review, the facility failed ensure residents were free from abuse when it failed to follow its Abuse policy to protect 7 of 45 sampled residents (Residents 42, 10, 11, 39, 40, 16 and 41) from abuse, neglect, intimidation, harassment, and mistreatment by Certified Nursing Assistants (CNAs) when: 1. CNAs were taking pictures and videos of Resident 42 inappropriatley in the bathroom and shared them with others. 2. Resident 10 sustained large areas of bruising during a catheterization. 3. Resident 14 had a zig zag shaped 2.5 cm. cut to the left ear when slapped by CNA 30. 4. Resident 11 received a black eye during a transfer with a Sit to Stand mechanical lift, with CNA 30. 5. CNA 30 and CNA 26 were observed pinching Resident 39's nipples while on the ground after a fall. 6. Resident 40 obtained a black eye while having her eyelid wiped with a washcloth during a shower by CNA 33. 7. Resident 16 was told to Shut up, by CNA 30. 8. Resident 41 stated that CNA 37 was mean to him and staff would just close Resident 41's door and leave him in his bed. These incidents resulted in harmful abuse that resulted in injuries. Due to a systems failure to protect residents from actual and potential abuse, neglect and mistreatment of [REDACTED]. The Immediate Jeopardy was abated with the Director of Clinical Services on 1/26/18 at 2 pm, when an acceptable corrective action plan was validated by record reviews of inservices, staff and resident interviews and observations. Findings: A review of a facility policy titled Abuse Prevention and the Reporting of Alleged Abuse and Suspicion of Crime revised 11/2016, indicated the purpose was to ensure that residents' rights are protected by providing a method for the prevention of any type of resident abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. It includes deprivation by an individual of good and services necessary too maintain physical, mental and psychosocial well-being. Also, verbal, sexual, physical and mental abuse including abuse facilitated or enabled through use of technology. Each resident has to right to be free from abuse. An untitled and undated facility policy was provided and indicated under Electronic Devices Policy that in order to provide our residents with the best care in the safest manner, the use of cell phones or any electronic device with audio or video capabilities is prohibited during working time. Employees should not take pictures, or make audio video recordings in private areas such as changing room locker rooms and restroom or share such pictures via social media or any other means. Due to the confidential nature of our business and to protect privacy of our residents electronic devices able to take pictures, video or audio shall not be used in patient care areas or other workrooms. 1. A complaint was received by the California Department of Public Health (CDPH) on 11/16/17, that indicated CNAs were taking Snapchat (images or videos sent via phone message to individuals) photos of a resident on the toilet (Resident 42). A review of Resident 42's admission record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 42 was not able to make health care decisions for herself though able to think and reason. A Confidential Personnel Investigation Report dated 12/22/17, created by a third party, hired by facility administration to investigate an internal employee allegation was reviewed. The document indicated that on 10/31/17,CNA 30 made an allegation that Nursing Assistant (NA, in training not certified) 6 asked a resident if they wanted to see a Snapchat photo of his penis. The report included an interview with CNA 8 and she stated she communicated primarily via Snapchat with CNA 30 because they worked different shifts. During an interview on 1/5/18 at 3:30 pm, CNA 21 stated she heard that Resident 42 was being Snapchatted while naked on the toilet. CNA 21 also stated that most of the Snapchatting occured during evening and night shifts. CNA 21 identified CNAs 12, 23, 26, and 30 were the staff that were regularly observed using Snapchat while working. CNA 21 stated that CNA 30 would take pictures/Snapchat then would draw inappropriate stuff on their faces. During an interview on 1/8/18 at 12:05 pm, CNA 29 stated that CNA 26, CNA 12, CNA 18, CNA 23, and NA 6 all had knowledge of the use of Snapchat in the facility. CNA 29 stated that CNA 18 showed her the Snapchat photo of Resident 42 while she was naked on the toilet. CNA 29 stated that Resident 42 told her that CNAs asked her to flip off (show her middle finger) at the camera while naked on the toilet. During an interview on 1/8/18 at 3 pm, CNA 13 stated she heard about people taking Snapchat pictures but never saw them herself. During an interview on 1/8/18 at 3:40 pm, Resident 42 was concerned about being in trouble when questioned about being photographed naked on the toilet. During an interview on 1/9/18 at 1:50 pm, CNA 12 stated that the majority of staff used cell phones on their breaks. CNA 12 stated they observed NA 3 and CNA 19 taking pictures of residents with their cell phones. During an interview on 1/10/18 at 12 pm, CNA 21 stated that during an interview by the third party investigator, she was questioned about inappropriate behaviors regarding staff members, NA 6, CNA 30, CNA 26 and CNA 23. CNA 21 informed the third party investigator about NA 6 and CNA 30, CNA 26 and CNA 23 drawing penises on their resident assignment sheets. CNA 21 informed the investigator about seeing lots of inappropriate stuff such as the Snapchat by nursing staff. During an interview on 1/10/18 at 12:15 pm, Licensed Nurse (LN) 11, stated she observed staff using cell phone while caring for residents. LN 11 stated she would ask them to put their cell phones away. During an interview on 1/10/18 at 3:32 pm, CNA 18 acknowledged that she had witnessed staff Snapchatting other staff while at the facility. During an interview on 1/17/18 at 12:52 pm, Director of Staff Development (DSD) stated that only recently did she hear about Snapchat from staff that were interviewed by CDPH. DSD stated that if she was aware of staff using Snapchat she would send them home and would notify the Administrator (Admin). The DSD did not indicate she would report it as abuse to the appropriate agencies. During an interview on 1/19/18 at 11:53 am, the Director of Nursing (DON) acknowledged seeing staff with cell phones while caring for residents in the hall and in the dining room. The DON stated that it was possible they could have been taking photographs of residents. During an interview on 2/2/18 at 12:07 pm, with Director of Clinical Services (DCS), she stated that the third party investigative report results had not been reviewed by herself or the Admin. She stated that the facility attorney informed DCS that the report contained two Snapchat allegations by staff. During an interview on 2/2/18 at 2:30 pm, the Admin stated that she was unaware of the third party investigation report completed on 12/22/17. A Facility Reported Incident dated 2/5/18 at 7:22 am, was received at CDPH and it reported an allegation of staff taking a photograph of an unknown resident's private parts. During an interview on 2/5/18 at 2:20 pm, Assistant Director of Nursing (ADON) acknowledged there was a new Snapchat allegation at the facility. CNA 26 and CNA 19 were seen by the DSD taking pictures of each other's butts. ADON stated that the Human Resource Department was processing a termination date of 2/5/18 for CNA 19 and CNA 26. 2. A review of Resident 10's admission record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 10 was not able to make health care decisions, and was dependent on staff for all ADLs (Activities of Daily Living) which included eating, bed mobility, and hygiene. During a review of Resident 10's Non-Pressure Sore Skin Problem Reports from 7/7 to 12/11/17, documentation indicated that Resident 10 received 31 different bruises and skin tears. Some of the areas reported were on her pelvic area, inner thigh, cheek, hands, shins, chest, hips and other areas. A review of Interdisciplinary (IDT- many healthcare disciplines that direct resident plan of care) Progress Note dated 10/30/17, indicated that Resident 10 had an unwitnessed fall while attempting to transfer herself from her wheelchair to her bed on 10/28/17, with no injuries noted. A review of Resident 10's Physician's Telephone Order dated 10/29/17 at 1 pm, indicated urinalysis (UA, laboratory test used to analyze urine for abnormalities via straight catheterization (I&O, a flexible plastic tube inserted into the bladder to obtain a urine sample then immediately removed). A review of a nursing note dated 10/28/17, indicated a UA was obtained for Resident 10, five days after the physician order [REDACTED]. During a review of Nurses Notes dated 11/4/17 at 9:30 pm, LN 1 indicated that Resident 10 had a bruise to her left inner thigh measuring 15.5 centimeters (cm) x 10 cm and indicated it was dark purple (new) in color. LN 1 indicated that Resident 10 had a second bruise to her pelvic area measuring 33 cm x 7 cm and was purple and yellow in color. LN indicated that Resident 10 had a fall on 10/28/17, that was unwitnessed, and resulted in late bruising from that fall. During a review of Facility Investigation dated 11/6/17 at 1:55 pm, CNA 23 indicated she Reported bruise in pelvic area on Resident 10 to LN 1. A review of the Physicians Progress Record dated 11/6/17 (not timed), indicated that Medical Director (MD) was asked to see Resident 10 due to bruising on abdomen and left inner thigh. The MD Progress Notes indicated Resident 10 had a fall 10/28/17, No new injury with yellow/greening (older) bruise noted. MD indicated Old hematoma (bruise) - on low dose aspirin (ASA, thins blood). MD indicated that the Bruising most likely from fall, given being on ASA and coloring. During a review of a Facility Investigation dated 11/6/17 at 3:35 pm, NA 5 was asked if he knew of any incidents with Resident 10 that may have resulted in bruising in the pelvic area and left thigh and he stated Not that I remember. A review of Diagnostic Laboratories & Radiology report dated 11/7/17, indicated that Resident 10's PT/INR (Blood test that indicates how well blood-thinning medications are working to prevent blood clots) lab results were below normal which would indicate that Aspirin 81 milligrams (mg) was not a significant factor in her bruising. A review of a Facility Investigation dated 11/8/17 at 1:50 pm, regarding Resident 10, indicated that LN 12 told DON that the pelvic area and thigh bruising might have occurred Possibly due to helping to hold leg during cathing for UA. A review of a fax received from the facility dated 11/9/17 at 10:21 am, titled Final Investigation Summary Report regarding Resident 10, indicated that bruising on left inner thigh was Related to helping to hold leg during in and out cath. The report indicated that Resident 10's 33 cm x 7 cm bruise on her pelvic area was obtained by a fall on 10/28/17, per MD and Investigation Summary where Resident 10 may have fallen and rolled to side. A review of Activities of Daily Living (ADL) Charting for 11/2017, indicated that from 11/3 to 11/4/17, Resident 10 was assisted in voiding (urinating) either in a brief (adult diaper) or on the toilet by CNAs 15 times. There was no documentation found in the record about the bruising on her pelvic area. During an interview on 12/18/17 at 11:22 am, CNA 10 stated that she held Resident 10's hands during transfers which had resulted in bruising. During an interview on 12/18/17 at 12:10 pm, Resident 10 was alert and not able to respond to questions or verbalize any needs. Resident 10 just giggled and nodded when questioned. During an interview on 12/18/17 at 1:32 pm, CNA 6 stated she remembered seeing bruising on Resident 10's inner thigh and felt that it is was due to her briefs (adult diapers). CNA 6 stated that Resident 10 had frequent bruising and during care when she screamed and pushed staff away. During an interview on 1/16/18 at 11:10 am, Social Service Director (SSD) stated that Resident 10 laughed with her and she did not see behavioral issues. SSD stated that she did not not recall any discussion of Resident 10's mulitple bruising ever being discussed during the IDT meetings or during the daily morning stand up meeting, where issues at the facility and with residents were discussed. During an interview on 1/16/18 at 12 pm, DON stated Resident 10 was mostly cooperative but did strike out during care. DON stated that not all bruises were investigated nor was the reason for the number of bruises investigated. The DON stated that there were no nursing notes in Resident 10's record that indicated the nursing staff had any difficulty obtaining a urine sample at anytime. The DON stated the UA was ordered on [DATE], and that it was not obtained until 11/3/17. The DON stated if they had trouble obtaining a urine sample from Resident 10 that her expectation would be that it should have been documented and that the MD should have been notified. The DON stated that when PT/INR for Resident 10 came back below normal, no other action was taken to investigate Resident 10's 31 injuries of unknown origin. During an interview on 1/19/18 at 9:02 am, LN 12 stated that there were times where Resident 10 was able to do a clean catch ( method of collecting urine sample to be tested to prevent bacteria from the skin around the vagina from contaminating the urine specimen). LN 12 stated that NA 5 and another female CNA, who she was not able to remember, helped to I & O cath Resident 10 by helping to hold up Resident 10's legs. LN 12 stated that she remembered Resident 10 striking out causing them to have to come back another day and that was why it took about 5 days to obtain the UA. There was no charting that indicated any attempts or issues while obtaining a UA. LN 12 stated that she did not notify the MD of any trouble obtaining the UA or that it took three people to get the I & O cath. LN 12 stated that there was one CNA on each side of Resident 10 during the I & O cath and that NA 5 was on Resident 10's left side. LN 12 stated their first attempt was around 10 pm, then they tried again at 12 am the same evening on 11/3/17, and they were successful. LN 12 stated that Resident 10 usually slept pretty good at night. LN 12 stated she felt it was appropriate to obtain a urine sample at midnight from Resident 10 since they work nights and the lab comes at 3 am at night. LN 12 stated that she did not feel that day shift would have been any better to get the urine sample. During a concurrent interview and record review on 1/19/18 at 11:53 am, the Admin and DON acknowledged that Resident 10 had fallen 5 days prior to the I & O Cath procedure and that it was possible she could have been in pain from the fall on 10/28/17. The DON stated that Midnight was not an appropriate time to do an I & O Cath on any resident. The Admin and DON both agreed that No training or investigation was done regarding the care with holding legs during I & O procedures. DON stated, We failed to educate or re-educate on the issue of catheterization. During an interview on 1/26/18 at 2:15 pm, NA 5 stated they placed Resident 10 on the toilet at 10 pm on 11/3/17, but she contaminated the urine sample with stool and the urine could not be used as a sample. NA 5 stated they moved Resident 10's bed out from the wall and he stood on Resident 10's left side. NA 5 stated that he held Resident 10's left leg up with one arm and with his other arm held her arm against her chest. NA 5 stated NA 4 was holding Resident 10's right leg up while LN 12 did the I & O cath with help from another nurse that he could not remember. NA 5 stated that Resident 10 kept sliding her arm out of his hold. NA 5 stated she was swinging her arms and screaming while they tried to I & O cath her at midnight. NA 5 acknowledged that maybe they should not have forced her since she was fighting, but he did not say anything to the nurses since he was new. NA 5 acknowledged that by holding her down and forcing her it could be considered abuse. 3. A review of Resident 14's admission record indicated he was admitted to the facility on [DATE], and is [AGE] years old with [DIAGNOSES REDACTED]. Resident 14 needed extensive assistance with ADLs which included bed mobility, transfer, hygiene and toileting. A review of the most recent Minimum Data Set (MDS, a resident assessment) dated 8/18/17, indicated Resident 14 had an intact cognition (ability to think and reason). A review of a Non-Pressure Sore Skin Problem Report dated 12/5/17, indicated Resident 14 had a zig zag shaped 2.5 cm. cut to the left ear. A review of Daily Skilled Nurses Notes dated 12/5/17, indicated Resident 14 obtained his laceration injury to his left ear when he was being assisted by CNA 30. During a review of Facility/CDPH Event Investigation Summary Report (ISR) dated 12/5/17 at 9 pm, CNA 13 stated that Resident 14 told her CNA 30 hit him on the ear and he did not want CNA 30 near him. LN 11 indicated she went into Resident 14's room where he way lying in bed and told her that she slapped me. CNA 30 indicated while toileting Resident 14 on the Sit-to-Stand (mechanical transfer lift used to help assist a sitting resident to standing position and a standing resident to a sitting position), Resident 14 became agitated, pulled the harness over his head, so CNA 30 re-fastened it and transferred him to bed and notified the charge nurse of the situation. During a review of Daily Skilled Nurses Notes dated 12/6/17, LN indicated Resident 14 had a bruise to his right inner arm as well. A review of ISR with a completion date of 12/7/17 at 2 pm, indicated LN 11 was approached by CNA 30 who told her that Resident 14 was on the Sit-to-Stand and Resident 14 took the sling off while being toileted which caused a cut on his left ear. LN 11 went to Resident 14's room where she found him in bed and he stated that CNA 30 slapped him. CNA 30 was sent home pending further investigation. During a review of ISR dated 12/7/17, Investigation Outcome indicated that There was no witness to the incident. The facility was Unable to substantiate the allegations since there were no witnesses and due to the fact that the resident had a dementia diagnosis. The report also indicated that the New Intervention was a psychiatry referral. A review of Psych Progress FFT notes dated 12/7/17 at 11:46 am, indicated that Psychology Nurse Practitioner (Psych 1) reported that Resident 14 recently accused CNA 30 of slapping him and cutting his ear. Psych 1 also documented that there was another bruise to his arm in addition to the laceration to his left outer ear. Psych 1 also documented that on 9/18/17, Resident 14 returned from hospital with a [MEDICAL CONDITION] and was on [MEDICATION NAME] (a strong blood thinner) because of a blood clot which makes his potential for bleeding from a head injury much greater. During an interview on 12/13/17 at 9:20 am, Resident 14 stated that CNA 30 was always kind of a trouble maker. Resident 14 stated he was not that nice to CNA 30, maybe because she wasn't nice to me. Resident 14 stated CNA 30 was helping him to go to the bathroom with a machine. Resident 14 stated he wanted off the machine and CNA 30 wanted him on it so they got into an argument. CNA 30 got mad and hit me. During an interview on 12/13/17 at 3:45 pm, LN 11 stated she was the nurse that responded to the incident. LN 11 stated that Resident 14 was real agitated and said that CNA 30 slapped him. LN 11 stated she was not aware of any other issues with CNA 30 before the 12/5/17 incident. LN 11 stated that Resident 14 is Very delusional and it was probable Resident 14 cut himself with the Sit-to-Stand straps that he was trying to remove. During an interview on 1/8/18 at 3 pm, CNA 13 stated that Resident 14 told her that CNA 30 hit him. CNA 30 refused to go back into Resident 14's room. CNA 13 said that CNA 30 quit shortly after that. During an interview on 1/9/18 at 1:50 pm, CNA 12 stated that CNA 26 was told by CNA 30 that CNA 30 was annoyed with Resident 14 so CNA 30 tossed Resident 14 into bed, cutting his ear. During an interview on 1/10/18 at 12:15 pm, LN 11 stated that Resident 14 accused CNA 30 of slapping him a couple months ago. LN 11 stated they did everything they are supposed to and that Resident 14 was just confused and LN 11 just doesn't believe it happened. LN 11 stated that she reported it to Admin, who serves as the facility's Abuse Officer. During an interview on 1/16/18 at 11:10 am, SSD stated that Resident 14's delusions are not normally around abuse but of his wife's affairs. During an interview on 1/19/18 at 11:53 am, Admin stated that there were no witnesses to the alleged abuse allegation that CNA 30 slapped Resident 14. Admin stated that since Resident 14 had dementia, Admin stated that it was Not substantiated. Admin stated that out of the facility's population, 90% of residents have dementia. The Admin stated it was difficult to come to a conclusion when their are no witnesses and posed a question if residents with dementia are believable. 4. A review of Resident 11's record, indicated he was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 11 was unable to make decisions for himself. During a review of an Ombudsman (county advocacy group) Crisis Line report dated 7/12/17 at 6:51 am, an anonymous caller indicated that Resident 11 had a black eye and there was no report of how it happened. During a review of an Ombudsman Crisis Line report dated 7/12/17 at 7:18 am, an anonymous visitor for another resident indicated Resident 11 had bruising on his arm, a black eye, and an injured lip. The document indicated the caller stated that the nurses claimed to not know what happened. During an interview on 7/14/17 at 2:07 pm, CNA 32 stated that Resident 11 was resistant to care and not combative. During an interview on 7/14/17 at 3:10 pm, CNA 30 stated she was working with CNA 23 on 7/12/17 to put Resident 11 back to bed using the Sit-to-Stand device. CNA 30 stated that Resident 11 got Frustrated, fell forward and hit his left eye on the arm support. During an interview on 7/14/17 at 3:29 pm, CNA 23 stated herself and CNA 30 were assisting Resident 11 back to bed on 7/12/17 when Resident 11 leaned forward in the Sit-to-Stand device hitting his left eye on the left arm support. CNA 23 stated the charge nurse was then notified. During a review of a Constituent Affairs - Email Unit's email dated 9/26/17 at 10:15 am, CNA 29 stated when she asked Resident 11 about his black eye and fat lip he loudly replied Someone hit me! During an interview on 1/8/18 at 12:05 pm, with CNA 29, stated that she relieved CNA 30 for the care of Resident 11 on 7/12/17 and found a bruise on his arm, a fat lip and a black eye. CNA 29 stated that she immediately reported it to LN 11. During an interview on 1/10/18 at 12:15 pm, LN 11 stated she knew about Resident 11's black eye, fat lip and bruised arm. LN 11 stated that when Resident 11 got upset in the Sit-to-Stand lift, he almost hits himself, so she believed Resident 11's injuries occurred in the Sit-to-Stand. LN 11 stated that CNA 23 and CNA 30 were transferring Resident 11 when he pulled back and hit himself with the Sit-to-Stand. During an interview on 1/17/18 at 12:50 pm, with the Director of Staff Development, she could not provide any documentation that supplemental compentency training was provided to the CNA's for safety related to falls, sit to stand injuries, and the multiple injuries of unknown origin for Resident 11 for the last year. During an interview on 1/19/18 at 11:53 am, Admin was discussing CNA 30's disciplinary actions and mentioned that CNA 30 was warned regarding Resident 11's bruised left eye caused by the Sit-to-Stand. 5. A review of Resident 39's admission record showed that he was a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Nurses Notes dated 4/28/17 at 6:50 pm, indicated that LN was summonsed by CNA (Not identified) and found Resident 39 tipped backwards in his wheelchair on the floor bleeding from his head. During an interview on 1/8/18 at 12:05 pm, CNA 29 stated approximately eight months ago, she observed CNA 30 and CNA 26 pinching Resident 39's nipples and laughing while he was lying on the ground bleeding from his head after a fall. CNA 29 stated that she stopped CNA 26 and CNA 30 from continuing the behavior. CNA 29 did not report this incident to the facility nor to the appropriate agencies. 6. A review of Resident 40's admission record indicated she was an [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 40 was not able to make health care decisions for herself. A review of Nurse's Notes dated 12/15/16 at 9:50 pm, LN 10 indicated that CNA 33 notified her of bruising to Resident 40's left eye and that the am (day) shift used a Hoyer Lift (a mechanical lift used to move or lift residents) and Resident 40 Accidentally bumped her left side in the Hoyer lift. LN 10 indicated Cause to bruise complete. During a review of a Facility/CDPH Event Investigation Summary Report with date of event of 12/15/16, indicated LN 10 and CNA 33 Came to the conclusion that Resident 40 had gotten her head bumped by the Hoyer lift during a transfer earlier in the day. The ADON reviewed the documentation and observed the resident on 12/16/16 and determined that Bruising was more consistent with wiping or washing the lid of her eye during a shower on 12/13/16. ADON also indicated that two staff are required to assist Resident 40 in the Hoyer lift. During an interview on 1/19/18 at 11:53 am, the Admin and DON indicated that Resident 40 obtained a black eye while having her eyelid wiped with a washcloth during a shower. There was no training documentation found in CNA 33's record that indicated any safety training around safety with using the Hoyer lift and how to prevent injuies to residents when cleaning around the eyelids. 7. A review of Resident 16's admission record, indicated that she was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 16 was not able to make medical decisions for herself. A review of the MDS for the Brief Interview for Mental Status dated 8/17/17, indicated Resident 16 was moderately impaired with a score of 12 (13 was considered cognitively intact). A review of a facility reported incident sent to CDPH with a date of event on 9/26/17, indicated that Resident 16 informed LN 4 that while she was sleeping, two CNAs came in to change her roommate and were talking, giggling and being loud. LN 4 indicated that when Resident 16 told the two CNAs to be quiet, CNA 30 told Resident 16 to Shut up, and they continued to be loud and talk. LN 4 indicated that Resident 16 did not know who the other CNA was. During a review of All Employees - Witness Statement Information dated 9/26/17 at 3 pm, CNA 30 indicated that she and NA 3 were getting Resident 26 ready for a shower and when they assisted her to her wheelchair, the bed alarm went off. This woke Resident 16 up who then said, Thanks a lot and stated Resident 26's name. CNA 30 indicated that she told Resident 16 it wasn't Resident 26's fault but that Resident 16 was Very upset with Resident 26. CNA 30 indicated that after she finished Resident 26's shower, she walked past Resident 16 and overheard her telling LN 4 that she Was going to shoot CNA 30. CNA 30 stated when she walked by, Resident 16 Said some things to me and LN 4 told CNA 30 to just keep going. During an interview with Resident 16 on 10/5/17 at 9:45 am, she stated she heard staff giggling, laughing and talking out loud and stated they might be doing it on purpose. Resident 16 stated that this happened mostly at noon, evening and during change of shift. Resident 16 further stated that it affected her sleep and took her an hour to go back to sleep. During an interview on 1/25/18 at 2:35 pm, Resident 16 stated she remembered CNA 30 telling her to Shut up, and being pushed into a chair but stated that CNA 30 has not cared for her in a while. During an interview on 10/5/17 at 10:10 am, LN 4 stated that Resident 16 was very upset on 9/26/17 when she came out from her room and went to the hallway. LN 4 stated she had not talked to the staff involved but went to talk to the ADON. LN 4 stated that she had known the staff involved and that they could use more in-service training in terms of handling residents with difficult behavior. During an interview on 1/25/18 at 3:35 pm, LN 4 stated she had observed Resident 16 was visibly upset on 9/26/17, and when LN 4 questioned Resident 16 about it, she stated CNA 30 told her to shut up. LN 4 stated Resident 16 was hard to calm down after the verbal incident. 8. A review of Resident 41's admission records indicated he was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview with Resident 41's Responsible Party (RP) on 2/26/18 at 10:30 am, he stated that Resident 41 indicated that CNA 37 was mean to him. RP stated that the staff would just close Resident 41's door and leave him in his bed. RP would bring rootbeer into Resident 41 and it would disappear and the staff would not know what happened to it. RP stated that the money allocated for Resident 41's incidentals was never available and told him the State controls how much money Resident 41 gets. RP stated the facility also would not put Resident 41's dentures in unless he used denture cream which Resident 41 refused to use. RP stated that during several conference care meetings where the DSD, MD, Admin, ADON were all in attendance, RP told MD that he felt Resident 41 was being drugged. RP stated that MD responded that the facility is a five star facility and they are doing what is best for Resident 41. RP stated that Resident 41 was like a wet noodle and could not hold a conversation. RP also stated the facility asked him to sign a paper indicating that he would not sue the facility, RP refused to sign but kept the paper. RP stated that o

Based on observation, interview and record review the facility failed to consistently implement resident specific interventions to provide adequate supervision and safety and to ensure its Fall Prevention Program policy was followed for six of 45 sampled residents (Residents 14, 18, 24, 34, 39 and 41) when: 1. Resident 14 was not adequately assessed and evaluated by the Interdiscipilinary Team (IDT-group of different disciplines that meet to discuss and review residents' care needs) for repeated falls for root causes, did not provide adequate supervision and interventions to prevent further falls, and failed to track and trend what time of the day the falls happened. There was no bowel and bladder assessment done when most causes of repeated falls resulted when going to the bathroom. These failures resulted in avoidable falls with significant injury; a hip fracture that required hospitalization for surgical intervention that was not reported to CDPH (California Department of Public Health) and skin tears. 2. Resident 24 was not provided adequate supervision and individualized care interventions to prevent two avoidable falls, and the IDT did not adequately assess and evaluate Resident's 24's root causes when being transferred from the locked unit (secure area of the facility) due to history of exit seeking/wandering to another unit of the facility and left unattended by staff at the patio when he should have not been. These failures resulted in two avoidable falls that resulted in two major injuries including a right hip fracture that required hospitalization for surgical intervention. The first unwitnessed fall with major injury was not reported to CDPH. 3. Resident 41 did not have a comprehensive, individualized plan of care to meet Resident 41's supervision and care needs to prevent injuries from falls. This resulted in an avoidable fall with significant injury of left patellar (knee) fracture. 4. Resident 18 was not provided adequate supervision and care to prevent falls and accidents and from other major injuries. This resulted in avoidable fall with significant major injury (hip fracture) that required transferred to the hospital for surgical intervention. 5. Resident 34 had a lack of adequate supervision and care to prevent falls and accidents, and the facility did not adequately assess and evaluate the root causes in order to have an individualized interventions to prevent and monitor avoidable falls. This failed practice resulted in avoidable falls with significant injury of a right hip fracture, that was not reported to CDPH. 6. Resident 39 was not provided adequate supervision and care to prevent falls and accidents from other injuries, was not adequately assessed and evaluated for root causes and the facility did not provide adequate interventions when he was left alone unsupervised/unattended when a mechanical transfer device (Sit-to-Stand) was used. This failed practice resulted in an avoidable fall and lacerations. Due to the facility's systemic failures not to follow their fall prevention program this resulted in avoidable harm for Residents 14, 24, and 34 and the cumulative effects had the potential for other residents who are at risk for accidents and falls to be injured . Refer F 223, F 226, F 248, F 329, F 353, F 490, F93, f 497, F501 and F 520. Findings: A review of a facility policy titled Fall Prevention Program revised 9/2016, indicated the purpose was to prevent accidents by providing an environment that is free from hazards over which the facility has control. The policy indicated that all residents' environment shall remain as free of accident hazards as is possible and all residents will receive adequate supervision and assistive devices to prevent accidents. All residents shall be assessed for being at risk for falls. Any residents identified as at risk for falls shall have an individual plan of care that includes interventions to prevent falls from occurring, and a method for identifying residents at high risk. A fall was defined as an unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall unless there is evidence suggesting otherwise, when a resident is found on the floor a fall is considered to have occurred. The facility policy and procedure titled, Incident and Accident Reporting, dated 9/2016 instructed facility staff that all accidents/incidents involving residents will be accurately and completely reported on the facility incident form, documented, investigated and analyzed. Incident/unusual occurrences such as major accidents which included an unusual event or happening involving resident with undesirable or unexpected results which threaten the safety or health of the residents. 1. A review of Resident 14's admission record indicated he was admitted to the facility on [DATE], and was [AGE] years old with [DIAGNOSES REDACTED]. in any part of the urinary system, the kidneys, bladder or urethra), and recent falls with a hip fracture. A review of Note to Attending Physician/Prescriber printed date 10/30/16, indicated that Pharmacist (Pharm) D informed physician of Resident 14's increased fall risk due to him currently taking Norco (narcotic pain medication), Proscar (a medication to treat benign prostatic hyperplasia), Diltiazem (a medication to treat high blood pressure), Lisinopril (a medication to treat high blood pressure) and Effexor (a medication to treat depression). The physician's response was that he felt the Fall was more to do with safety awareness and less with medications. No changes were made to Resident 14's medication regimen. A review of a Clinical Review dated 9/18/17, indicated the facility's pharmacy consultant advised that taking Ativan (a medication for anxiety) and Norco (a narcotic pain medication) together can cause respiratory depression and drowsiness and recommended staff to monitor Resident 14 for those symptoms. Lexicomp, a nationally recognized medication resource, indicated that opiod, antidepressant, antianxiety and hypertension medications have side effects which can put residents at risk for falls. A review of a Fall Risk assessment dated [DATE], indicated that Resident 14 was HIGH RISK for falls. A review of Daily Skilled Nurses Notes dated 9/19/17, 12/22/17, 12/23/17, 12/26/17, and 12/29/17, indicated that for toilet use Resident 14 needed two or more persons to assist him. Fall #1 A review of an IDT Note dated 3/3/17, indicated on 3/2/17 at 12 pm, Resident 14 was heard hitting the floor in the bathroom. The Licensed Nurse (LN) (not identified) saw Resident 14's wheelchair move into the bathroom door which was open. The LN entered Resident 14's bathroom and saw him on the bathroom floor holding onto the transfer pole. Resident 14 told her he was done so he tried to transfer himself from the toilet to his wheelchair. The new intervention was to encourage Resident 14 to wear non-slip gripper socks and to remove wheelchair from the bathroom when toileting the resident. This was an unwitnessed fall. A review of a document for fall, provided by the Director of Nursing (DON) with the date of falls, root cause and new intervention showed Resident 14's 3/2/17 fall resulted from attempted to transfer self from toilet to chair and wearing slippers without grips. The new intervention was to remove wheelchair from the bathroom when toileting resident and encourage to wear non-slip socks rather than slippers. Fall #2 A review of the Nurses Notes dated 3/29/17 at 5:40 pm, indicated Resident 14 was in the bathroom when he was yelling out for help. Resident 14 noted to be lying to his left side and stated he was trying to pull down his pull ups and fell . This was an unwitnessed fall which occurred 27 days after the prior fall on 3/2/17. A review of an IDT Note dated 3/31/17, indicated that on 3/29/17, (no time noted) LN (not identified) responded to Resident 14's wheelchair alarm and was yelling for help in his bathroom. LN found Resident 14 lying on his left side on the bathroom floor. Resident 14 told the LN that he was trying to pull down his pull-ups and fell while trying to use the bathroom. The new intervention was to increase toileting. Fall #3 A review of the Nurses Notes dated 5/10/17 at 11:05 am, indicated Resident 14 was using his wife's wheelchair as a walker when he fell to his left side. When Resident 14 was asked how it happened, he stated he wanted to go to the bathroom. Body checks completed and sustained bruises to right inner elbow, left hand, left lower back and skin tear to left hand and right inner elbow. A review of an IDT Note dated 5/11/17, for event date 5/10/17, indicated that Resident 14 was seen by Certified Nursing Assistant (CNA) (not identified) attempting to take himself to the bathroom. Resident 14 was observed using his wife's wheelchair as support when he hit the side of the bed causing him to fall. The new intervention indicated to ensure that alarm box is not within resident's reach due to Resident 14 had broken the cords off. This was an unwitnessed fall. Fall #4 A review of the Nurses Note dated 9/4/17 at 1 pm, indicated Resident 14 was on the floor lying on left side. Complete body checks done by LN on duty and Resident 14 had no ROM (Range of Motion) to left lower extremity. Resident 14 complained of pain to left thigh and was sent to acute hospital for evaluation. A review of an IDT Note dated 9/7/17, indicated that CNA (not identified) responded to Resident 14's wheelchair alarm sounding in his room. Resident 14 had an unwitnessed fall on 9/4/17 at 1 pm. Resident 14 was noted to be on the floor lying on his left side in front of the closed bathroom door. Resident 14 was unable to complete range of motion on left leg and was sent to the hospital for evaluation. The facility noted that Resident 14's Depakote (a modd stabilizer medication) dose was recently doubled to 125 milligrams (mg) twice a day and Ativan (a medication used to treat anxiety disorders) was also recently added. The evaluation was that Resident 14 was attempting to toilet self. The facility failed to report the hip fracture to CDPH. A review of a document for fall, provided by the DON with the date of falls, root cause and new intervention showed Resident 14's 9/4/17 fall resulted from resident attempting to toilet self, decreased safety awareness. The new intervention was to monitor location frequently after meals when up in wheelchair. Resident 14 had a total of 4 unwitnessed falls from 1/2017 to 9/2017, which resulted to one fall with major injury (fracture). The total of 4 falls were all bathroom related when Resident 14 was not assisted or supervised by staff when going to the bathroom. The facility failed to track and trend Resident 14's recurrent falls and what time of the day the fall happened. There was no specific identification of the root causes of the recurrent falls that resulted to new interventions not clearly defined. There was no current bowel and bladder training found in Resident 14's record. During an interview on 10/19/17 at 1:30 pm, the Assistant Director of Nursing (ADON) stated Resident 14 had a fall with major injury (fracture) and was sent to hospital for treatment. The ADON acknowledged that is was not reported to CDPH. The ADON stated this was not considered an unusual occurrence because it was not unusual for Resident 14 to fall. During an interview on 10/27/17 at 11:40 am, MDS (Minimum Data Set) Nurse A stated that DCS (Director of Clinical Services) made the decision if a fall should be reported to CDPH. When questioned why Resident 14 was not on bowel and bladder training, she stated she would put him on for training next week. A review of a Physician order [REDACTED]. A review of a Physical Therapy (PT) Clarification Order dated 9/19/17, PT was ordered 5 times a week for 4 weeks. A review of Physician's Telephone Orders dated 10/12/17 at 11 am, indicated the physician ordered to continue toe touch weight bearing for left leg through 10/25/17 for Resident 14. A review of Physician's Telephone Orders dated 10/12/17 at 12:10 pm, indicated the physician ordered to hold current therapy orders PT, Occupational Therapy (OT) and or Speech Therapy (ST) until a there was an updated therapy plan for Resident 14. A review of IDT note dated 10/12/17, indicated that the facility spoke with Resident 14's responsible party (RP, decision maker) regarding the potential staffing issues with PT, OT and ST services. The IDT note indicated they informed the RP they may not meet the current therapy orders/needs. The facility offered the RP assistance in finding a new facility that could offer those services if they were unable to provide them for Resident 14. A record review of the Physician's Telephone Orders dated 10/26/17 at 6 pm, indicated that the physician ordered PT and ST to evaluate and treat as indicated. Fall #5 A review of the Nurses Notes dated 12/23/17 at 12:30 pm, indicated Resident 14's bed alarm was answered by LN and Resident 14 was on the floor laying on face with the right shoulder on side. Resident 14 stated he was trying to get into bed with wife. Resident 14 sustained skin tear on forehead and left wrist. A review of an IDT Note Post-Fall Review for Fall dated 12/23/17 at 12:45 am, indicated that LN (not identified) responded to a sounding alarm and witnessed resident roll out of bed and onto the floor. Resident 14 indicated that he was trying to turn off his alarm. The new intervention was to move alarm to the wall side of the bed. Fall #6 A review of Daily Skilled Nurses Note dated 12/23/17 at 12:45 am, LN (unable to identify) indicated that she witnessed Resident 14 roll out of bed onto the floor while answering the sounding bed alarm. LN indicated that Resident 14 told her he was trying to turn off alarm. LN recorded he had no pain and that she medicated him with Norco (Narcotic pain reliever) and it was affective for pain. Fall #7 A review of Daily Skilled Nurses Note dated 12/23/17 at 2:30 am, LN (unable to identify) indicated that Resident 14's bed alarm was sounding, she found Resident 14 face down on the floor. Resident 14 stated he was trying to get into bed with his wife. The LN indicated Resident 14 received a skin tear to his forehead and left wrist. A review of an IDT Note Post-Fall Review for Fall Event Date 12/23/17 at 2:30 am, Resident 14 was trying to get into bed with his wife that he shares a room with. A new intervention was to place a floor mat next to bed. During an interview with Resident 14's RP on 11/7/17 at 12:35 pm, RP stated that Resident 14 had to use the bathroom often and his urgency made his wait for assistance seem even longer which led to Resident 14 attempting to use the bathroom alone. RP stated that the facility had never discussed bladder training with him. RP stated that Resident 14's wheelchair was on his weak side and unlocked so when he attempted to transfer by himself it led to falls. During a concurrent interview and record review on 11/9/17 at 12:55 pm, the ADON stated that depending on the resident they can be left alone in the bathroom, even when Resident 14 had a Fall Risk Score of 20, which indicated high risk. The DCS stated there was a pattern of Resident 14 having several falls related for a need to use the bathroom. The DCS stated the IDT had not identified this. The DON stated that time of day could have been identified as root cause of his falls. During an interview with LN 8 on 11/16/17 at 10:30 am, she stated that Resident 14 would have been a candidate for bowel and bladder training prior to his hip fracture on 9/4/17. LN 8 stated that Resident 14 was stronger and would be a candidate for bowel and bladder training now. LN 8 stated the training had not been implemented. During an interview on 11/16/17 at 2:10 pm, the ADON stated that Resident 14 had not been on bowel and bladder training since returning from his hip fracture 9/18/17. 2. A review of Resident 24's admission records indicated he was an [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 24 was alert but his cognition was not intact (unable to reason and think). Resident 24 required assistance with all Activities of Daily Living (ADLs) such as dressing, toileting and hygiene due to impaired decision making skills. Resident 24's baseline was independent for ambulation and transfers but required supervision. Resident 24 had a history of [REDACTED]. Resident 24 was originally placed in the locked unit and was currently transferred to Station 1 (100 Unit). A review of the Nurses Notes dated 10/30/17 at 3:04 pm, indicated Resident 24 was no longer in need of locked unit, no longer exit seeks. Resident 24 was transferred to 100 unit. Resident 24's record regarding the need to be transferred to 100 unit was not meaningful when there was no criteria/guidelines for the transfer. Resident 24's record did not indicate that IDT met regarding the reason for room change. A review of the facility's Fall Risk Assessment, instructed facility staff to assess the resident status in the eight clinical condition parameters such as; level of consciousness/mental status, history of falls (past 3 months), ambulation/elimination status, vision status, gait/balance, systolic blood pressure, medications and predisposing diseases. The form instructed facility nursing staff to assign corresponding score which best described the resident in the appropriate assessment. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A review of a Fall Risk Assessments dated 12/19/16, 3/21/17, 6/15/17, 8/3/17 and 12/31/17, indicated that Resident 24 was at HIGH RISK for falls (total score higher than 10). For 12/19/16 = 13; 3/21/17= 13; 6/15/17=11; 8/13/17=11 and 12/31/17=12. Fall #1 A review of Resident 24's Fall Care Plan, revised on 6/22/15, showed Resident 24 was at risk for falls/injuries related to unaware of safety needs, forgets to put shoes, shoes/socks on at times. A review of the Nurses Notes dated 8/3/17 at 6:10 pm, indicated Resident 24 was found on left side on ground in hallway ., Resident refused ambulation stating, I am scared. Resident 24 sustained a skin tear to right wrist after the fall with treatment orders received and initiated. The record indicated that 30 minutes after the fall, Resident 24 was assessed further for ROM (Range of Motion). Resident 24 was able to stand but refused to bear weight to right lower extremities and stated, it hurts. Resident 24 was transferred to acute hospital for evaluation. A review of an IDT note dated 8/4/17 at 8:05 am, indicated Resident 24 had an unwitnessed fall on 8/3/17 at 6 pm, due to his pants being loose and hanging over his heels of his shoes on the locked unit. The facility report indicated that they were informed that Resident 24 had fractured his right femur and was surgically treated then returned to the facility. The new intervention was to ensure pants are up at the waist when ambulating. The report indicated there was nothing that caused the fall. The fall was not reported to CDPH. The root cause was not specific or adequate to indicate the reason Resident 24 had fallen. Resident 24 needed assistance with dressing, yet pants were below waist and legs, loose and hanging over resident's heels of his shoes. On 8/9/17 at 12:45 pm, Resident 24 returned from the acute care hospital with [DIAGNOSES REDACTED]. During a concurrent interview and record review on 11/3/17 at 8:40 am, DON and ADON acknowledged that some falls with fractures, they don't consider major accidents, because they fall often, even when they are not witnessed. Fall #2 A review of a Facility/CDPH Event Report dated12/20/17, indicated Resident 24 had an unwitnessed fall with fracture on 12/20/17 at 9:05 pm, while alone on the interior patio. The facility received a call from the hospital who indicated that Resident 24 sustained a right hip fracture and was being admitted and will be having surgery to repair it. A review of a Daily Skilled Nursing Notes dated 10/5/17, indicated Resident 24 required a two person extensive assist with transfers. This resulted after Resident 24's prior fall on 8/3/17 when he sustained a fractured right femur (thighbone). A review of a Facility/CDPH Event Report Fall with fracture on 12/20/17, indicated that on 12/20/17 at 9:05 pm, Resident 24 was found on the ground in the patio by CNA 21 due to a sounding alarm. Resident 24 was alone out on the patio. It was not indicated how long Resident 24 was left alone out on the patio. While at the hospital, the facility received a call that Resident 24 had fractured his right femur (thighbone) a second time, the first time was when he had fallen while at the facility on 8/3/17. A review of an IDT Post-Fall Review for a Fall Event Date of 12/20/17, indicated Resident 24 was found on the ground in the patio with an alarm sounding reported by CNA 21 to a charge nurse (not identified). The new intervention was to do orthostatic blood pressure (difference between blood pressure from sittting to standing) checks twice a day for two days upon return from hospital, due to possible fluctuations in blood pressure when attempting to stand. There were no new interventions to prevent Resident 24 from wandering out onto the patio. During an interview on 1/9/18 at 1:50 pm, CNA 12 stated Resident 24 would wander and try to open all the doors. CNA 12 indicated that while Resident 24 was wandering, the alarm sounded and CNA 19 silenced the door alarm and left Resident 24 in the patio where he ended up falling and re-fractured his right femur. An interview was conducted with both the DON and ADON on 1/2/18 at 3:45 pm. DON had completed the fall investigation and stated that Resident 24 was last seen by LN 5 at around 8:15 pm. Resident 24 was last seen by CNA 21 at around 9:05 pm and heard the alarm sound and found Resident 24 in the patio. Both the DON/ADON confirmed there was no IDT meeting regarding Resident 24 being moved from the locked unit to 100 unit. When both of them were asked why Resident 24 was moved from the locked unit to 100 unit, ADON stated Resident 24 was no longer exit seeking but was wandering around the facility. ADON confirmed that Resident 24 needed supervision and that she was not aware how long Resident 24 was outside the patio unsupervised on 12/20/17. During an interview with Admin on 11/9/17 at 10:30 am, she stated that Resident 24's fall was expected due to his [DIAGNOSES REDACTED]. 3. A review of Resident 41's admission records indicated he was an [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a review of the facility's Fall List from 1/1 to 6/24/16 (6 months), the facility indicated that Resident 41 had fallen on 4/28/16, 5/20/16 and 5/26/16 during that period of time. Resident 41's Progress Notes were reviewed and indicated the following: On 5/24/16 at 5:17 pm, the Director of Staff Development (DSD) 2 indicated that Resident 41's order for Ativan was decreased from 1 milligram (mg) to 0.5 mg every 12 hours as needed (PRN) due to decreased use. On 5/23/16 at 4:45 pm, the DSD 2 indicated that the physician ordered laboratory tests to see why Resident 41 was loopy. On 5/26/16 at 12:50 pm, LN 15 indicated that Resident 41's Fall risk score was 23 (High Risk). LN 15 indicated that Resident 41 was walking from his bed to the bathroom with his family member when he caught his leg in the door. Resident 41 fell to the floor where he hit his head. On 5/26/16 at 3:49 pm, the ADON indicated that Resident 41's Ativan was decreased this morning after his fall. On 5/27/16 at 3:11 pm, the ADON indicated that Resident 41's new intervention was to encourage family to ask for nursing assistance when taking resident to the bathroom. On 5/27/16 at 4:05 pm, LN 13 indicated that Resident 41 had episodes of increased behaviors that shift. On 5/29/16 at 1:41 am, LN 8 indicated that Resident 41 had episodes of increased behaviors earlier in the evening. During a review of PT Daily Treatment Note dated 6/6/16, the PT 1 indicated Resident 41 stated that he was having pain all over. PT 1 indicated that when she tried to get Resident 41 to bend his knee he indicated that it doesn't work. During a review of Occupational Therapist (OT) Daily Treatment Note dated 6/9/16 at 3:56 pm, the OT 2 indicated Resident 41 stated that he really hurt and motioned to his left side and lower back when asked where he hurt. The OT 2 indicated that nursing was aware and that Resident 41 had reported left side and lower back pain earlier. A review of a Progress Note dated 6/10/16 at 3:04 am, Registered Nurse (RN) 1 indicated that Resident 41 had shown signs of pain and anxiety during the shift. A review of a Progress Note dated 6/11/16 at 5:32 pm, LN 13 indicated Resident 41 had been experiencing pain upon ambulation (walking), and when turning in bed. A review of a Progress Note dated 6/13/16 at 4:04 pm, LN 13 indicated that Resident 41 had episodes of increased behaviors that shift. A review of a Progress Note dated 6/12/16 at 4:09 pm, LN 13 indicated that MD was notified about Resident 41's pain in arms, legs and abdomen and his Inability to ambulate comfortably. A review of a Progress Note dated 6/13/16 at 3:27 am, RN 1 indicated that Resident 41 had some weakness upon standing. During a review of the hospital's History of Present Illness dated 6/16/16 at 6:02 pm, indicated Resident 41 had ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) of the left knee region. During a review of the hospital's [DIAGNOSES REDACTED]. status and interactiveness were quite different 2-3 weeks ago prior to his fall where he hit his head. During a review of History and Physical, from the hospital, dated 6/17/18, indicated Resident 41 had a small right parietal subdural hematoma (bleeding from bruise on brain) .also possible chronic subdural hematoma, minimal intraventricular hemorrhage (brain bleed) .lethargy and malaise (tiredness) for the past week or two .left patellar (knee) fracture from a recent fall. During an interview with Resident 41's Responsible Party (RP) on 2/26/18 at 10:30 am, RP stated that nothing but problems, with the facility. RP stated that during Resident 41's stay at the facility, he had multiple fractures that included his elbow, ribs, knee and the brain bleed from a head injury. 4. A review of Resident 18's admission records indicated she was an [AGE] year old female, who was originally admitted to the facility on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. She was unable to make her own healthcare decisions. A review of the MDS dated [DATE], indicated Resident 18 required extensive assistance from staff with ADLs such as bed mobility, transfer and ambulation. A review of a Fall Risk assessment dated [DATE], indicated that she is a HIGH RISK for falls with a total score of 12. A review of the Nurses Notes dated 6/26/17 at 6:45 am, indicated Resident 18 was found in the dining room when she stood up from chair and lost her balance and fell backwards on the right hip and hit head on chair. Resident 18 was unable to bear weight to right leg and complained of pain. Resident 18 was sent to acute hospital for evaluation. A review of an IDT Note dated 6/27/17 at 9:40 am, indicated that on 6/26/17 at 6:45 am, Resident 18 was in the dining room and became unsteady on her feet causing her to fall and fracture her right hip. The new intervention indicated the facility will ensure Resident 18 had non-slip socks/shoes and re-direct Resident 18 to put them back on if she takes them off. The facility failed to report the hip fracture to CDPH. 5. A review of Resident 34's record indicated he was a [AGE] year old male originally admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 34 required extensive assistance from staff with ADLs such as bed mobility, transfer, dressing, toileting and hygiene. Resident 34 was unable to make his own healthcare decisions. Resident 34 had a history of [REDACTED]. A review of Resident 34's MARs (Medication Administration Record) dated 10/2017, indicated he was receiving the following medications; Norco (opioid pain medication), Risperdal (antipsychotic), Ramipril (hypertension) and Ativan (antianxiety). According to Lexicomp, these medications indicated that opioid, antipsychotic, antianxiety and hypertension have side effects which can put Resident 34 at risk for falls. Fall #1 Resident 34's Nurses Notes were reviewed and indicated the following: On 5/29/17 at 8:30 pm, indicated that Nursing Assistant (NA) called in LN, where Resident 34 was found on the floor on his left side but did not complain of pain. On 5/29/17 at 10:20 pm (almost 2 hours later), LN (unable to identify) duing the 9:45 pm neurological examination, found Resident 34 unable to move his left leg and complained of pain. LN received an order to send Resident 34 to acute hospital for evaluation where he was later found to have fractured his left hip. A review of the Fall Risk Assessment, dated 5/29/17 indicated, Resident 34's total score was 18=HIGH RISK for falls. A review of the IDT note dated 5/30/17, indicated that on 5/29/17 at approximately 8 pm, CNA (not identified) summoned LN (not identified) to Resident 34's room, where he was found lying on the floor. Resident 34 reported he was warm. Later that evening, Resident 34 complained of left hip pain and was sent to the hospital where he was diagnosed with [REDACTED]. The IDT Review indicated that Falls are probable and future injuries from falls are possible related to resident's risk factors. The facility failed to report Resident 34's unwitnessed fall that resulted to a major injury (hip fracture) to CDPH. Resident 34 returned to the facility on [DATE] (5 days later) after the repair of his hip fracture. Fall #2 A review of the Nurses Notes dated 6/28/17 (time not specified), indicated Resident 34 was found sitting on the floor next to his wheelchair and bed with his alarm sound

Based on interview and record review, the facility failed to provide ongoing assessments and intervention to prevent a decline in the physical health for one out of one sampled resident(s) Resident 1, when an injury of unknown origin, a large bruise, was discovered on Resident 1's abdomen. The facility failed to monitor and document the size and progression of the bruise, which would have allowed them to identify and report changes in the resident's condition to the resident's doctor. This failure resulted in a delay in treatment for [REDACTED]. He was admitted to the intensive care unit with [DIAGNOSES REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (a standardized resident assessment tool) dated 10/30/15, indicated that the resident was not able to verbally communicate and he required physical assistance of two staff for all of his daily care needs. During an interview on 12/1/15 at 7 p.m., Licensed Nurse (LN) 2 stated that on 10/10/15 at approximately 10 p.m., Certified Nurse's Assistant (CNA) 3 told her that Resident 1 had a bruise on his abdomen. LN 2 said that she asked CNA 3 how Resident 1 could have gotten this bruise and CNA 3 told her that sometimes Resident 1 leans in his wheelchair. There are different types of bruises which include contusions and hematomas. Contusions are a common type of bruise caused by trauma, often [MEDICATION NAME]-force injury, that damages and breaks open the tiny blood vessels in the tissues of the skin, other organs, or muscles. A [MEDICATION NAME] abdominal injury is a direct blow to the abdomen without an open wound. These injuries can be life threatening and are generally caused by a traumatic event, such as a fall. These injuries may cause internal bleeding and are often accompanied by pain and swelling. A hematoma is a collection of blood outside of a blood vessel that has clotted. During an interview on 12/1/15 at 7 p.m., LN 2 stated that she looked at Resident 1's bruise, notified the doctor, and completed a Non-Pressure Sore Skin Problem Report identifying the skin problem as a bruise, the location of the injury as right side of abdomen, and the description of the injury as 15 cm X 9 cm (6 inches by 3 ½ inches) purple. A generic care plan for skin conditions that included a bruise was initiated on 10/10/15. The bruise site was identified as being located on the left side of the abdomen. This did not correlate with information documented by the LN 2 in the nurse's notes. The goal was for Resident 1's bruise to resolve within 30 days without complications. The facility's plan to meet the goal included; monitoring for complications and reporting changes to the doctor. However, the method of monitoring, such as marking the edges of the bruise or measuring the resident's abdominal girth to see if there was enlargement of either, was not defined. The facility also planned to monitor for pain. Documentation in Resident 1's October 2015 Medication Administration Record [REDACTED]. On 10/11/15 at 12:30 p.m. and 10/13/15 at 12:52 p.m., Resident 1 required additional doses of pain medication for moaning, increased facial grimacing, and abdominal guarding, behaviors that indicate the person is experiencing pain. There was no documentation in the record to show that the facility had considered or investigated the underlying cause of Resident 1's increased pain. Almost two and a half days later, on 10/14/15 at 7 a.m., LN 1 made an entry in Resident 1's record that read, Resident noted to have increase(d) abdominal swelling and bruise noted to be spreading from right side of abdomen to abdomen and down towards pubic region. Bruising yellow in color. Abdomen soft and tender. Pain to right flank area upon palpation (touch) .MD notified and new order to transfer resident to (hospital) for evaluation. During a concurrent interview and record review on 11/25/15 at 1:30 p.m., the Assistant Director of Nursing (ADON) confirmed that Resident 1's medical record contained no further assessments or documentation of Resident 1's abdominal bruise from 10/11/15 at 2:09 a.m., when the bruise was first discovered through 10/14/15 at 7 a.m., when Resident 1 was transferred to the emergency room . The ADON explained, We do weekly skin assessments. Resident 1 was evaluated in the hospital emergency department for a mass that could be felt around his belly button, and bruising throughout his abdomen, right side and back. A CT scan (computer assisted x-ray) identified a blood clot measuring 5.6 cm (2 inches) deep, by 14.9 cm (6 inches) wide, by 14.9 cm (6 inches) long along the rectus sheath (layers of abdominal muscles). The blood clot was putting pressure on Resident 1's intestines (ascending colon and cecum). Resident 1 was admitted to the intensive care unit with [DIAGNOSES REDACTED]. A rectus sheath hematoma can cause a severe loss of circulating blood resulting in shock and death. (Medscape, Rectus Sheath Hematoma, November 2, 2014).

Based on interview and record review, the facility failed to perform complete assessments as required by their falls policy and notify the physician of changes in the condition of one of 15 sampled residents (Resident 15), in a timely manner. These failures resulted in delayed assessment, evaluation, and treatment for [REDACTED]. Resident 15 died at the hospital on [DATE]. Findings: 1. A review of Resident 15's record disclosed he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A document titled, "Physician Discharge Summary," dated [DATE], indicated that Resident 15 was transferred to a local hospital with discharge [DIAGNOSES REDACTED]. A nursing document titled, "Resident Transfer Record (record)," dated [DATE], indicated that Resident 15 was transferred due to an altered mental status, fever of 100.7, weakness, and emesis (vomit) times two. The record noted that Resident 15's baseline (ordinary) mental status was oriented times 2 (aware of self and place), physically aggressive, verbally aggressive and resistive to care. The skin and body portion of the assessment indicated that Resident 15 had abrasions on both knees and a bruise on the left shoulder. A review of nursing documentation, dated [DATE] and timed 5:30 am, indicated Resident 15 was found by staff, kneeling on the floor by his bed with small abrasions on both knees. A short term care plan dated [DATE], indicated that Resident 15 had new abrasions on both his knees. The facility's policy, dated ,[DATE], titled, "Fall Prevention Program," was reviewed. It defined a fall as, "A fall without injury is still a fall unless there is evidence suggesting otherwise, when a resident is found on the floor a fall is considered to have occurred." Section 2 titled, Post Falls, Section C, read, "Licensed nurses will document ongoing assessments including neuro checks (assessment of level of consciousness and neurological function) for unwitnessed falls...and response to care and treatment each shift for 72 hours and PRN (as needed) if necessary." A copy of the facility's "neurological assessment" flowsheet included the following items to be completed: vital signs (VS); pupil response and eye reaction; eye response; level of consciousness; speech; response to name, pain, environment, or unresponsive; and other which included [MEDICAL CONDITION], headache and vomiting. The neurological assessment flowsheet (record that documents the nurses' assessment of his consciousness) had not been completed for Resident 15 after he was found on the floor on [DATE] at 5:30 am. A nurse's note, dated [DATE] and timed 6 pm, read, "Resident alert with confusion per usual. Resident with complaint of two headaches this am (morning) shift (the resident had a headache on two different times)." A nurse's note, dated [DATE] and timed 4:30 am, noted, "Resident complained of headache times one at beginning of shift. Emesis time one this shift." A nurse's note, dated [DATE] and timed 7 am, read, "Upon beginning of shift, Resident noted to have a change in mental status non-responsive to name or touch. . . . Per noc (night) nurse, Resident had an episode of emesis at 10 pm on ,[DATE] and another episode of approximately 50 milliliters at 4 am. VS at 5:30 am: 100.7 (higher temperature than normal 98.6), ,[DATE] (blood pressure was lower than his usual), 102 (pulse was higher than usual), 22 (respirations). . . . At 6:15 am . . . MD (physician) notified. 6:25 am: called for non-emergency transfer." Resident 15 was transferred to a local hospital at 6:45 am on [DATE]. In an interview on [DATE] at 8:50 am, the DON stated that Resident 15 was always on the floor in his room checking on his belongings and the staff did not consider this a fall, so the fall protocol including the neurological assessment was not implemented. When asked about the new abrasions on his knees, the DON stated that Resident 15 had "old skin." The DON confirmed that the facility's "Fall Prevention Program" policy instructed staff to consider all residents found on the floor to have fallen. During an interview on [DATE] at 1 pm, Registered Nurse (RN) C confirmed that the falls policy was not followed and that Resident 15's headaches and vomiting should have triggered the thought process of a possible head injury. The neurological assessment flowsheet could help alert staff to any changes in the Resident's condition. RN C stated that nausea and vomiting and headaches are symptoms of a head injury. A computer tomography (CT- computerized image) of the head, dated [DATE], revealed that Resident 15 had a large subdural hematoma (collection of blood on the surface of the brain, suggest that this was a recent bleed although there may be chronic and subacute blood also present. (According to Medline Plus, subdural hematomas are usually the result of a serious head injury). A nursing document, dated [DATE], read that the hospital called to report that Resident 15 had died that day at 11:20 am. The nurse's notes documented that Resident 15 had two headaches during the day shift on [DATE], and a headache as well as two episodes of emesis during the night shift, and fever on [DATE]. At the start of the day shift on [DATE], Resident 15 was unresponsive. The physician was not notified of changes in Resident 15's condition until [DATE] at 6:15 am. This was more than 12 hours after Resident 15 first started complaining of headaches and eight hours after Resident 15 first had an episode of emesis.