Every finding on record at Arvin Post Acute

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of two sampled residents (Resident 2) when the care plan did not address the protection of Resident 2 from further physical harm after Resident 1's Family Member (FM) hit Resident 2 in the face with a pillow. This failure had the potential to result in Resident 2 experiencing additional physical assault and potential for injury. Findings:During a review of Resident 2's SBAR (Situation, Background, Appearance, Review and Notify) dated 6/22/26, the SBAR indicated, Struck in the face by a resident's family [Resident's 1 FM]. During a review of Resident 2's Progress Notes (PN) dated 6/23/26, the PN indicated, Resident [2] was identified wandering into another resident's room on 6/22/26 during the PM [afternoon] shift. During this occurrence, the spouse of the roommate [Resident 1's FM] struck the resident [2] in the face with a pillow while staff were intervening and redirecting the resident [2] from the room.During an observation on 6/30/26 at 9:55 a.m. in the hallway outside of Resident 2's room, Resident 2 was sitting in a wheelchair and was unable to respond to questions regarding being struck in the face with a pillow by Resident 1's FM.During an interview on 6/30/26 at 1:16 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated they (staff) observed Resident 1's FM visiting Resident 1 on multiple occasions following the incident with Resident 2.During a concurrent observation and interview on 6/30/26 at 1:39 p.m. with Resident 1, in Resident 1's room, Resident 1's FM was sitting in a chair by Resident 1's bed. Resident 1 stated Resident 1's FM hit Resident 2 with a pillow after Resident 2 entered her room. Resident 1 stated Resident 1's FM was asked to leave following the incident but was allowed to return to the facility the following day.During a concurrent interview and record review on 7/20/26 at 11:46 a.m. with Director of Nursing (DON), Resident 2's Care Plan (CP) dated 6/22/26 was reviewed. Resident 2's CP indicated, [Resident 2] received physical aggression by a visitor [Resident 1's FM] on AEB [As Evidenced By] being hit on the face with a pillow. DON stated the CP did not address the protection of Resident 2 from Resident 1's FM.During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. e. reflects currently recognized standards of practice for problem areas and conditions. 9. Care plan interventions are chosen after clinical assessment and consideration of the resident's problems and consideration of the resident's problems and their causes. 10. Interventions should address the underlying sources(s) of the problem, not just the symptoms.11. Care plans are revised as residents' conditions or circumstances change. 12. The interdisciplinary team reviews and updates the care plan: . a. when there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility:1. Failed to ensure the ice machine was sanitized (disinfected) according to manufacturer's instructions.2. Failed to ensure a visitor wore a hair net while in the kitchen. These failures placed residents at risk of consuming contaminated food and beverages. Findings: 1. During an interview on 3/24/26 at 10:02 a.m. with the Director of Maintenance (DM) in the kitchen, DM stated he was responsible for cleaning the ice machine. DM stated he cleaned the ice machine using a cleaner which he poured into the machine's water reservoir and let the cleaner to run through the machine's ice-making cycle. DM provided the cleaner he used which read Nickel-Safe Ice Machine Cleaner. DM stated this was the only product he used to clean the ice machine. During a concurrent interview and record review on 3/24/26 at 11:35 a.m. with DM, the ice machine's Installation, Use & Care Manual (Ice Machine Manual), dated 10/13 was reviewed. The Ice Machine Manual, under Section 4 Maintenance, indicated the cleaning of the ice machine should be followed by sanitizing it, which comprised running a sanitizer solution through the ice machine in the same way as the cleaner. The Ice Machine Manual indicated, Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime. DM stated he did not know he was supposed to sanitize the ice machine. DM stated he did not sanitize the ice machine. During an interview on 3/24/26 at 11:47 a.m. with the Dietary Director (DD), DD stated ice from the ice machine was placed in residents' water bottles, drinks, and used for food preparation for residents. During a review of facility policy and procedure (P&P) titled Ice Machines and Ice Storage Chests dated January 2012, the P&P indicated, Ice-making machines, ice storage chests/containers, and ice can all become contaminated by . colonization by microorganisms . Our facility has established procedures for cleaning and disinfecting ice machines . which adhere to manufacturer's instructions. 2. During observations on 3/24/26 at 10:33 a.m., 10:43 a.m., 10:46 a.m. and at 10:47 a.m., a haired food delivery worker entered the kitchen without a hair net and placed food boxes in front on the refrigerators. In each instance the food delivery worker passed a few feet away from trays of bread rolls and from a food preparation table where [NAME] 1 was preparing lunch for residents. During an interview on 3/24/26 at 4:20 p.m. with the Registered Dietician (RD), RD stated everyone entering the kitchen should wear a hair net, including non-staff and delivery people. During a review of facility policy and procedure (P&P) titled, Food Preparation and Service, dated November 2022, the P&P indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

Based on interview and record review, the facility failed to timely develop and implement a care plan for the prevention and treatment of pressure injuries (a localized injury to the skin and/or underlying issue usually over a bony prominence, as a result of pressure, or pressure in combination with a shear) for two of three sampled residents (Resident 6 and Resident 28). This failure placed Resident 6 and Resident 28 at risk for developing pressure injuries.Findings: RESIDENT 6 During a review of Resident 6's admission RECORD (AR), dated 3/23/19, the AR indicated, Resident 6's diagnosis includes Diabetes Mellitus (a group of disease that result in too much sugar in the blood), need for assistance with personal care, and vitamin deficiency. During a review of Resident 6's BRADEN SCALE [a tool used to assess a residents risk for skin breakdown] FOR PREDICTING PRESSURE SORE RISK (BSPS), dated 9/23/25 the BSPS indicated, Resident 6 had score of 13 (a score of 15 to 18 is a mild risk, 13 to 14 is a moderate risk, 10 to 12 is high risk, and any score less than 9 is considered a severe risk) which indicated Resident 6 was a moderate risk for pressure injury. During a concurrent interview and record review on 3/25/26 at 1:15 p.m. with Director of Nursing (DON), Resident 6's Weekly Summary (WS), dated 9/28/25 was reviewed. The WS indicated, Resident 6's skin assessment was blank. DON stated skin assessment is part of WS and should be completed with WS. DON stated on 9/28/26 skin assessment was not completed. During a review of Resident 6's Shower/Bed Bath Sheet (BBS), dated 9/29/25, the BBS indicated no wound on the left leg was documented. During a review of Resident 6's SBAR Communication Form (SBAR), dated 10/1/2025, the SBAR indicated, unstageable pressure wound to lateral left leg L [length] 1.5cm x W[width] 1.5 cm x D [depth] 0.1 cm w/ [with] mild serous drainage. During a review of Resident 6's Omni Wound Physician Progress Note (OMNIPN), dated 10/3/25, the OMNIPN indicated, Patient [Resident 6] and nursing staff were educated on the importance of adhering to the treatment plan, including offloading, repositioning every two hours, proper use of a low air-loss mattress, and maintaining an appropriate diet to support wound healing. During a review of Resident 6's Minimum Data Set (MDS- an assessment tool), dated 9/26/25, the MDS indicated, Resident 6's BIMS (Brief Interview for Mental Status) score was 9 (a score of 13 to 15 means resident is cognitively [mental process that involves knowledge and comprehension] intact, 8 to 12 suggest moderate impairment, 0 to 7 suggest severe impairment). During a review of Resident 6's MDS, dated [DATE], the MDS section GG indicated, Resident 6 required: A. Eating - Setup clean-up assistance (Helper sets up or clean up) B. Oral hygiene – Dependent (Helper does all the efforts) C. Toileting hygiene – Dependent F. Upper body dressing – Dependent G. Lower body dressing – Dependent H. Put on/taking off footwear – Dependent I. Personal Hygiene – Dependent During a concurrent interview and record review on 3/26/26 at 11:18 a.m. with Assistant Regional Director Clinical Services (ARDCS) Resident 6's Care Plan (CP), was reviewed. The ARDCS stated the left leg pressure wound was identified on 10/1/25 and there was no care plan initiated until 10/27/25. ARDSC stated CP's are created to direct the care for the resident and start the departmental communication and to reflect the current care and any changes in the resident's condition. ARDSC stated CP created on 10/27/25 did not address resident's needs. During a review of Resident 6's BSPS, dated 10/23/25 the BSPS indicated, Resident 6 had score of 10. During a review of facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated 4/2020, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered. RESIDENT 28 During a review of Resident 28's admission Record (AR), undated, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, hemiplegia (total paralysis of one side of the body) and hemiparesis (partial weakness in one side of the body) following cerebral infarction (when blood flow to part of the brain is blocked or a blood vessel bursts, starving brain cells of oxygen) affecting the right dominant side (the stronger side of the body), difficulty in walking, muscle spasms (abnormal involuntary movement of muscles) and fatigue. During a review of Resident 28's BSPS dated 12/26/25 at 5:16 p.m., the BSPS indicated Resident 28 had a MODERATE RISK for pressure injuries. The BSPS indicated Resident 28 had the following risk factors for pressure injuries: (1) SENSORY PERCEPTION (ability to respond meaningfully to pressure-related discomfort): Very Limited; (2) MOISTURE (degree to which skin is exposed to moisture): Occasionally Moist; (3) ACTIVITY (degree of physical activity): Chairfast (ability to walk severely limited or non-existent); (4) MOBILITY: Very Limited. [Resident]. unable to make frequent or significant changes independently); (5) NUTRITION (usual food intake pattern): probably inadequate; (6) FRICTION AND SHEAR (surface rubbing and internal deformation of skin when shifting in bed): Potential Problem. During a review of Resident 28's Care Plan Report (CPR) (a record of all care plans initiated for the resident), undated, the CPR indicated care plan titled, [Resident 28] has impaired skin integrity as evidenced by skin blister on his right thigh and multiple scratch on his both legs related to trauma, lower dryness legs and sever[e] dryness feet pt have old scabbed wound on his back bone and is at risk for other, pain or discomfort, dated 12/27/26. This care plan did not indicate Resident 28 was at risk for pressure injuries or contained interventions to mitigate the risk factor of limited mobility identified in the BSPS dated 12/26/25, such turning and repositioning Resident 28. During a review of Resident 28's SBAR Summary for Providers Note (SBAR Note) dated 12/27/25 at 9:10 p.m., the SBAR Note indicated Resident 28 was sent to the hospital on [DATE] for shortness of breath. During a review of Resident 28's Admission/re-admission Summary Note (ARSN) dated 1/1/26 at 6:16 p.m., the ARSN indicated Resident 28 was readmitted to the facility on [DATE]. During a review of Resident 28's BSPS dated 1/1/26 at 7:38 p.m., the BSPS indicated Resident 28 was at VERY HIGH RISK of pressure injuries. The BSPS indicated Resident 28 had the following risk factors for pressure injuries: (1) SENSORY PERCEPTION: Very Limited; (2) MOISTURE: Constantly Moist; (3) ACTIVITY: Bedfast (confined to bed); (4) MOBILITY: Very Limited, (5) NUTRITION: probably inadequate; (6) FRICTION AND SHEAR: Problem. During a review of Resident 28's CPR, the CPR indicated no care plan for the prevention of pressure injuries with interventions to mitigate the pressure injury risk factors identified in the BSPS dated 1/1/26. During a review of Resident 28's Nurse's Note (NN) dated 1/5/26 at 1:33 p.m., the NN indicated [Resident 28] found unresponsive in the dining room. 911 called. [Resident 28] sent to [hospital] for further evaluation. During a review of Resident 28's NN dated 1/8/26 at 8:06 p.m., the NN indicated, [Resident 28] re-admitted to facility today from hospital. During a review of Resident 28's BSPS dated 1/8/26 at 8:32 p.m., the BSPS indicated Resident 28 was at HIGH RISK of pressure injuries. The BSPS indicated Resident 28 had the following risk factors for pressure injuries: (1) SENSORY PERCEPTION (ability to respond meaningfully to pressure-related discomfort: Very Limited; (2) MOISTURE: Very Moist; (3) ACTIVITY: Bedfast; (4) MOBILITY: Very Limited; (5) NUTRITION: probably inadequate; (6) FRICTION AND SHEAR: Problem. During a review of Resident 28's CPR, the CPR indicated the care plan titled Resident is at risk for skin breakdown related to impaired mobility, wheelchair bound dated 1/10/26. This care plan contained the following interventions initiated on 1/10/26: (1) administer medications and treatments as ordered; (2) check skin during daily care provisions and notify the physician of abnormal findings; (3) diet and supplements as ordered and (4) educate on avoiding skin injuries and encourage fluids. This care plan did not contain interventions to address Resident 28's immobility, such as frequent turning and repositioning. During a review of Resident 28's CPR, the CPR indicated the care plan title Skin . Resident at risk for further breakdown . related to decreased mobility dated 1/12/26 with the intervention of Turning/repositioning program During a concurrent interview and record review on 3/26/26 at 8:15 a.m. with Director of Staff Development (DSD), the clinical record of Resident 28 was reviewed. DSD stated Resident 28 was at risk for pressure injuries as indicated in the BSPS dated 12/26/25, 1/1/26, and 1/8/26. DSD stated Resident 28 had very limited mobility and needed frequent turning and repositioning. DSD stated the first care plan for prevention of pressure injuries including the intervention of turning and repositioning for Resident 28 was developed on 1/12/26. During an interview on 3/26/26 at 11:28 a.m. with Regional Director of Clinical Services (RDCS), RDCS stated pressure injury prevention care plans should be created for all residents assessed to be at risk for pressure injuries and should contain interventions to address the risk factors identified in the BSPSs. RDCS stated pressure injury prevention care plans should be created as soon as residents are assessed to be at risk for pressure injuries. During a review of facility policy and procedure (P&P) titled Care Plans, Comprehensive Person Centered, dated March 2022, the P&P indicated, A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. During a review of facility's P&P titled Prevention of Pressure Injuries, dated 4/2020, the P&P indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered.

Based on observation, interview, and record review, the facility failed to ensure:1. Expired and opened sterile (processed to prevent infection) wound treatment supplies were removed from storage and disposed of. This failure had the potential to result in expired and opened wound treatment supplies being used for residents' care and preventing wound healing and causing infection.2. One of three sampled residents (Resident 28) at risk of falls had fall risk assessments completed after falls. This failure placed Resident 28 at risk of falls and injuries. Findings: 1. During a concurrent observation and interview on [DATE] at 11:03 a.m. with Licensed Vocational Nurse (LVN) 1, in the medication storage room cabinet, there were two expired sterile wound treatment supply packages and one opened sterile wound treatment supply. LVN 1 stated the sterile foam dressing expired on [DATE] (one year ago). LVN 1 stated the sterile canister supply expired on [DATE] (approximately four months ago). LVN 1 stated the opened cannister supply package was no longer sterile and needed to be thrown away. LVN 1 stated the supplies were used in the treatment of resident wounds. During an interview on [DATE] at 3:26 p.m. with Administrator, Administrator stated expired and opened wound treatment supplies should be disposed of and if used for care of residents could cause an infection or delayed wound healing. On [DATE] at 3:42 p.m. policy and procedure for storage of sterile supplies was requested, none was provided. 2. During a review of Resident 28's admission Record (AR), undated, the AR indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including need for assistance with personal care, hemiplegia (total paralysis of one side of the body) and hemiparesis (partial weakness in one side of the body) following cerebral infarction (when blood flow to part of the brain is blocked or a blood vessel bursts, starving brain cells of oxygen) affecting the right dominant side (the stronger side of the body), difficulty in walking, muscle spasms (abnormal involuntary movement of muscles) and fatigue. During a review of Resident 28's Nursing – Fall Risk Observation/Assessment (Fall Risk Assessment), dated [DATE] at 6:07 p.m., the Fall Risk Assessment indicated Resident 28 was at a HIGH RISK for falls. During a review of Resident 28's SBAR (Situation Background Assessment and Recommendation) Note (SBAR Note) dated [DATE] at 2:50 p.m., the SBAR Note indicated Resident 28 had a fall. During a review of Resident 28's clinical record, there was no fall risk assessment completed for Resident 28 after his fall on [DATE]. During a review of Resident 28's SBAR Note dated [DATE] at 2:30 p.m., the SBAR Note indicated Resident 28 had another fall. During a review of Resident 28's clinical record, there was no fall risk assessment completed for Resident 28 after his fall on [DATE]. During a concurrent interview and record review on [DATE] at 8:15 a.m. with the Director of Staff Development (DSD), the clinical record of Resident 28 was reviewed. DSD stated Resident 28 did not have fall risk assessments completed after the falls on [DATE] and [DATE]. DSD stated there were only three fall risk assessments completed for Resident 28, on [DATE], [DATE] and [DATE]. During an interview on [DATE] at 11:28 a.m. with Regional Director of Clinical Services (RDCS), RDCS stated fall risk assessments should be completed for residents after each fall. During a review of facility P&P titled, Falls Risk Assessment dated [DATE], the P&P indicated, The nursing staff, in conjunction with the attending physician, consulting pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 56 and Resident 43) were provided care using Enhanced Barrier Precautions (EBP - use of gowns and gloves to reduce transmission of multi-drug resistant organisms). This failure had the potential to result in Resident 56 and Resident 43 developing an infection. Findings: During an observation on 3/23/26 at 8:57 a.m. in the doorway of Resident 56's room, Certified Nursing Assistant (CNA) 6 was at Resident 56's bedside wearing gloves (no gown) while giving care to Resident 56. A sign on the name plate outside of Resident 56's room indicated Resident 56 was on EBP. During a concurrent observation and interview on 3/23/26 at 9:03 a.m. in the doorway of Resident 56's room, CNA 6 was at Resident 56's bedside wearing gloves (no gown) tying a trash bag then exited the room. CNA 6 stated Resident 56 had a wound on his groin but was not sure what EBP means. CNA 6 stated she was only wearing gloves while providing care to Resident 56. During a review of Resident 56's Order Summary (OS) dated 2/24/26, the OS indicated, Resident [56] requires Enhanced Barrier Precautions (EBP) during high contact care activities r/t [related/to]: Surgical Wound RT [right] groin. During an observation on 3/25/26 at 9:16 a.m. with Licensed Vocational Nurse (LVN) 1 at Resident 43's bedside, LVN 1 donned gloves (no gown) and checked Resident 43's gastrostomy tube (g-tube - a tube inserted into the stomach through the abdominal wall used to administer medications and nutrition) placement and residual (how much liquid was in the stomach). LVN 1 attached a syringe to the g-tube and flushed with 30 milliliters of water. During a concurrent observation and interview on 3/25/26 at 10:03 a.m. with LVN 1 outside of Resident 43's room, a sign on the nameplate indicated Resident 43 was on EBP. LVN 1 was unable to verbalize what EBP meant and why Resident 43 was on EBP. LVN 1 stated she only wore gloves while caring for Resident 43's g-tube but because Resident 43 was on EBP she also needed to wear a gown when providing care. During a review of Resident 43's OS, dated 12/4/25, the OS indicated, Resident [43] requires Enhanced Barrier Precautions (EBP) during high contact care activities r/t: G-Tube. During an interview on 3/26/26 at 2:13 p.m. with Infection Preventionist (IP), IP stated residents who have been colonized (presence of germs without causing disease symptoms) with MDRO (Multi Drug Resistant Organisms - germs immune to antibiotic drugs), have an indwelling device (medical instruments inserted into the body including g-tube), or have an open wound will be placed on EBP. IP stated staff have to wear a gown and gloves when providing care and touching the environment of residents on EBP to help prevent infections. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 2/2025, the P&P indicated, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. a. Gloves and gown are applied prior to performing the high contact resident care activity.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, for one of two sampled residents (Resident 12) when his informed consent for psychotropic (medication to treat mental disorders) medication was not completed. This failure had the potential for Resident 12 to receive psychotropic medication without knowing the risks and benefits of the medication.Findings:During a concurrent interview and record review on 3/25/26 at 1:37 p.m. with Assistant Regional Director Clinical Services (ARDCS), Resident 12's admission Record (AR), [undated] was reviewed. Resident 12 was on Prozac (used to treat mental disorder) 20 mg by mouth every day started on 1/9/26. ARDCS stated there was no informed consent obtained prior to administering this medication.During a review of facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, [undated], the P&P indicated, The prescribing clinician will obtain informed consent from the resident (or, as appropriate, the resident representative) for use of a psychotropic medication.1. General Guidelines: .g. Prior to administration of a psychotropic medication, the prescribing clinician will obtain informed consent from the resident (or as appropriate, the resident representative), and document the consent in the medical record.

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 34) was provided enough electrical outlets when Resident 34 was unable to plug in her television and refrigerator at the same time. This failure resulted in Resident 34 not being able to use her television. Findings:During a concurrent observation and interview on 3/23/26 at 9:53 a.m. with Resident 34 in Resident 34's room, a small refrigerator was plugged into an electrical outlet on the wall at the foot of Resident 34's bed. The cord for the television was unplugged. Resident 34 stated the facility would not allow her to have an extension cord with multiple outlets. Resident 34 stated she had only two single outlet plugs to use to charge her phone, use a lamp, plug in her refrigerator and use the television. Resident 34 stated she had to ask staff for assistance for plugging and unplugging her devices. Resident 34 stated she has not been able to watch television for a while since there were not enough outlets. During a review of Resident 34's Minimum Data Set (MDS - a comprehensive assessment tool), Section C, dated 6/2/25, the MDS indicated Resident 34's BIMS (Brief Interview for Mental Status) score was 14 (score of 13-15 means cognition is intact). During an interview on 3/26/26 at 11:45 a.m. with Administrator, Administrator stated the facility leadership team did rounds in resident rooms and remove items not allowed such as extension cords with concern for fire hazard. Administrator stated the expectation was that if an extension cord was removed, staff would replace it with a facility approved electrical outlet device. During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Accommodation of Needs, (undated), the P&P indicated, 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis as needed.

Based on interview and record review, the facility failed to inform and/or obtain Advance Directive (AD - written statement of person's wishes regarding medical treatment and end of life decisions, made to ensure those wishes are carried out should the person become unable to communicate their wishes) options for three of 24 sampled residents (Resident 11, Resident 72, and Resident 6). This failure had the potential for residents' end of life wishes to not be honored.Findings:During a review of Resident 11's Medical Record (MR), the MR contained no documentation the facility provided written information showing whether Resident 11 had formulated an advance directive, whether Resident 11 wished to do so, or if assistance was offered.During a review of Resident 72's MR, the MR contained no documentation the facility provided written information showing whether Resident 72 had formulated an AD, whether Resident 72 wished to do so, or if assistance was offered.During a review of Resident 6's MR, the MR contained no documentation the facility provided written information showing whether Resident 6 had formulated an AD, whether Resident 6 wished to do so, or if assistance was offered.During an interview on 3/25/26 at 12:40 p.m. with Director of Regional Clinical Services (DRCS), DRCS stated there were no Advance Directive Acknowledgement forms completed for Resident 11, Resident 72, and Resident 6.During a review of facility's Policy and Procedure (P&P) titled, Advance Directives dated 9/2022, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on interview and record review, the facility failed to notify ombudsman (representatives who assist residents in long-term care facilities with issues related to day-day care, health, safety, and personal preferences) of four of four sampled residents (Resident 11, Resident 12, Resident 6, and Resident 80) planned transfers and discharges. This failure had the potential to result in Resident 11, Resident 12, Resident 6, and Resident 80 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.Findings:During a concurrent interview and record review on 3/25/26 at 9:47 a.m. with Assistant Regional Director Clinical Services (ARDCS), Resident 11's Medical Record (MR), [undated] was reviewed. ARDCS stated Resident 11 was transferred to hospital on 3/21/25, 8/26/25, and 3/15/26. ARDCS stated there was no ombudsman notification completed for 3/21/25, 8/26/25, and 3/15/26. ARDCS stated Ombudsman should have been notified after each transfer out to hospital.During a review of Resident 6's MR, [undated], the MR indicated Resident 6 was transferred to hospital on 9/10/25 and 10/3/25. There was no indication in Resident 6's MR that Ombudsman was notified.During a review of Resident 80's MR, [undated], the MR indicated Resident 80 was transferred to hospital on 3/15/25 and 3/2/26. There was no indication in Resident 80's MR that Ombudsman was notified.During an interview on 3/25/26 at 11:19 a.m. with Director of Regional Clinical services (DRCS), DRCS stated Ombudsman notifications for Resident 80 and Resident 6 were not completed. DRCS stated Ombudsman should be notified when transfer to hospital. DRCS stated Ombudsman is only being notified when residents were being discharged to home.During a concurrent interview and record review on 3/25/26 at 1:47 p.m. with ARDCS, Resident 12's MR [undated] was reviewed. ARDCS stated Resident 12 was transferred to hospital 1/3/26 and 2/19/26. ARDCS stated there was no Ombudsman notification completed for 1/3/26 and 2/19/26.During a review of facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, dated 3/2021, the P&P indicated, Residents and/or representatives are notified in writing, and in language and format they understand, at least thirty (30) days prior to a transfer or discharge.

Based on interview and record review, the facility failed to provide the complete Baseline Care Plan (BCP- initial instructions for care of the residents) for two of six sampled residents (Resident 3 and Resident 11). This failure had the potential to result in staff being unaware of residents' needs.Findings:During a concurrent interview and record review on 3/25/26 at 9:31 a.m. with Assistant Regional Director Clinical Services (ARDCS), Resident 3's Medical Record (MR), [undated] was reviewed. Resident 3 was admitted on [DATE]. ARDSC was unable to find documentation for BCP. ARDSC stated BCP should be initiated within 48 hours. During a concurrent interview and record review on 3/25/26 at 9:47 a.m. with ARDCS, Resident 11's MR, [undated] was reviewed. Resident 11 was admitted on [DATE]. ARDSC stated she was unable to find documentation for BCP.During a review of facility's policy and procedure (P&P) titled, Care Plans - Baseline, dated 5/2024, the P&P indicated, A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission.

Based on interview and interview, the facility failed to ensure one of three residents (Resident 105) was offered and provided showers when requested. This failure resulted in Resident 105 only showering once during a seven day period. Findings: During a review of Resident 105's admission Record (AR), undated, the AR indicated Resident 105 was admitted on [DATE]. During an interview on 3/23/26 at 3:32 p.m. with Resident 105, Resident 105 stated she was not receiving enough showers. Resident 105 stated she wanted more showers. Resident 105 stated she requested a shower yesterday but was denied. During a concurrent interview and record review on 3/25/26 at 10:05 a.m. with the Director of Staff Development (DSD), Resident 105's shower flowsheets were reviewed. DSD opened Resident 105's Bathing log in the computer which indicated Resident 105 had a total of four showers since admission, on 3/17/26, 3/19/26, 3/20/26 and 3/24/26. DSD stated there were no shower refusals documented in Resident 105's Bathing log. DSD stated the facility's policy was for residents to be offered showers twice a week but residents could have showers as frequently as they wanted. DSD stated Resident 105's shower days were Tuesday and Thursdays. During an interview on 3/25/26 at 10:20 a.m. with Resident 105, Resident 105 stated she wanted showers every other day not only twice a week. During a review of facility policy and procedure (P&P) titled Shower/Tub Bath, dated October 2010, the P&P indicated showers/tub baths promote cleanliness, provided comfort to the resident and to observe the condition of the resident's skin.

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 43) receiving tube feedings was kept with his head elevated at least 30 degrees while receiving tube feedings. This failure placed Resident 43 at risk of aspiration (food or liquid going into the lungs causing disease and respiratory problems). Findings: During a concurrent observation and interview on 3/23/26 at 12:37 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 43's room, Resident 43 was receiving tube feedings while lying flat in his bed. LVN 1 stated Resident 43's head of bed should be elevated 45 degrees when receiving tube feedings. During a concurrent observation and interview on 3/25/26 at 3:35 p.m. with the Director of Nursing (DON) in Resident 43's room, Resident 43 was receiving tube feedings while lying flat in his bed. DON stated Resident 43's head of bed should be elevated 30 degrees when receiving tube feedings. During a review of Resident 43's care plan (CP) titled Resident requires tube feeding ., dated 3/20/26 with the objective, Resident will remain free of side effects or complications related to tube feeding . the CP indicated, Resident's HOB [head of bed] elevated 45 degrees during and thirty minutes after tube feed. During an interview on 3/26/26 at 11:28 a.m. with Regional Director of Clinical Services (RDCS), RDCS stated residents receiving tube feeding should be kept with their heads elevated at 45 degrees to prevent aspiration. During a review of facility policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions dated 2001, the P&P indicated, Elevate the head of bed (HOB) at least 30 degrees during tube feeding .

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.Findings:During a concurrent interview and record review on 3/24/26 at 3:18 p.m. with Director of Staff Development (DSD), the Detail Time and Job (clock in log) dated 1/10/26, 2/22/26, 3/14/26, and 3/15/26 was reviewed. DSD stated there was no RN present in the building for 8 hours a day during those days.During a review of facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent nursing, dated 8/2022, the P&P indicated, 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview and record review, the facility failed to ensure Performance Evaluation (PE - a process to give employees feedback on their job performance) for five of five sampled employees (Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3, CNA 4, CNA 5) were completed. This failure had the potential for the staff not to be aware of their need for improvement in certain areas, which could affect resident care.Findings:During a concurrent interview and record review on 3/25/26 at 8:13 a.m. with Director of Staff Development (DSD), CNA 1's Personnel File (PF) was reviewed. The PF indicated CNA 1 was hired on 2/1/18 and last PE was done on 7/5/24 and there was no PE found after 7/5/24. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:27 a.m. with DSD, CNA 2's PF was reviewed. The PF indicated CNA 2 was hired on 5/7/24 and there was no PE found in their PF. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:29 a.m. with DSD, CNA 3's PF was reviewed. The PF indicated CNA 3 was hired on 5/22/24 and there was no PE found in their employee file. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:33 a.m. with DSD, CNA 4's PF was reviewed. The PF indicated CNA 4 was hired on 4/28/22 and there was no PE found in their employee file. DSD stated PE should be completed annually.During a concurrent interview and record review on 3/25/26 at 8:37 a.m. with DSD, CNA 5's PF was reviewed. The PF indicated CNA 5 was hired on 4/12/22 and annual PE was completed on 6/25/24 and there was no PE found in their employee file. DSD stated PE should be completed annually.During a review of facility's policy and procedure (P&P) titled, Performance Evaluations, dated 9/2020, the P&P indicated, The job performance of each employee shall be reviewed and evaluated at least annually.

Based on observation, interview, and record review, the facility failed to ensure the safe administration of medications when medications were found at Resident 33's bedside table without a medication self- administration assessment or a physician order for one of 24 sampled resident (Resident 33). This failure had the potential for medications to be administered incorrectly and unsafely.Findings:During a concurrent observation and interview on 3/23/26 at 9:20 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 33's room, Resident 33 had a medication cup on the bedside table with five pills and three capsules in the medication cup and no nurse was present in the room. LVN 2 stated in the medication cup there were pantoprazole (medication used for stomach acid), aspirin (to prevent blood clots), cresemba (medication to treat fungal infections), metformin (medication used to treat high blood sugar), multi-vitamin, vitamin C, Vitamin B12 (used for vitamin deficiency) and senna (stool softener). LVN 2 stated nurses should wait and watch until residents swallow all the medications.During a concurrent interview and record review on 3/26/26 at 1:49 p.m. with Assistant Regional Director Clinical Services (ARDCS), Resident 33's Medical Record (MR), [undated] was reviewed. ARDCS stated there was no physician order to keep medications at bedside. ARDCS stated there was no self-administer assessment in Resident 33's MR. ARDCS stated there was no care plan to keep medications at bedside. ARDCS stated nurses should ensure Resident 33 swallowed the medication before leaving the room.During a review of facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on interview and record review, the facility failed to send one of three sampled residents (Resident 1) to the hospital promptly for evaluation and treatment of a left leg injury after Resident 1 reported she had injured her left leg and requested to be taken out to the hospital for X-rays (medical imaging to visualize the inside of the body, particularly bones and dense tissues) and treatment, delayed for six days until Resident 1 was taken to the hospital for evaluation and treatment for the left leg fracture (broken bone). This failure resulted in Resident 1 experiencing continued severe pain in her left leg which required hospitalization and surgical intervention.Findings:During a review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of abnormal posture and need assistance with personal care.During a review of Resident 1's Minimum Data Set (MDS) (a comprehensive assessment tool) dated 11/14/25, the MDS indicated Resident 1had a Brief Interview for Mental Status (BIMS - a mental capacity assessment) score of 15 (score of 13-15 means intact cognition). The MDS indicated Resident 1 used a wheelchair and needed assistance with movement and activities of daily living (eating, dressing, hygiene).During a review of Resident 1's Nurse's Note (NN) dated 1/3/26 at 6:21 p.m., the NN indicated Resident 1 had been out of the facility on 1/3/26 on a family outing and returned at 5 p.m. The NN indicated, [Resident 1] came back to facility with family at 5 p.m. VS [vital signs-clinical measurements, specifically pulse rate (the number of times your heart beats per minute as it pumps blood through your body), temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions] obtained were normal. No pain or discomfort noted.During a review of Resident 1's SBAR Communication Form (Situation, Background, Assessment and Recommendations - a standard form used to document change in conditions of residents) (SBAR), dated 1/3/26 at 8:05 p.m. (three hours later), the SBAR indicated [Resident 1] reported PAIN to nurse, pt [patient/Resident 1] reported while she was with family, on wheel chair her left leg got twisted, nurse assessed, mild swelling noted on left knee and provided PRN [as needed] pain medication for pain, vitals were recorded within normal range. Family/RP [Responsible Party] DR [Doctor] made aware, dr [Doctor] prescribed 5% lidocaine patch [a topical pain medication] for moderate pain and Norco 5mg [milligrams] [a narcotic pain medication] every 6 [hours] as needed. There was no documentation of physician's order to send resident to the hospital.During a review of Resident 1's Care Plan titled Pain (Pain Care Plan), dated 1/3/26, the Pain Care Plan indicated the intervention of, Assess pain every shift and as indicated.During a review of Resident 1's Medication Administration Record (MAR), dated January 2026, the MAR indicated order dated 7/14/25 indicating, Monitor and Record pain assessment level Q [every] shift, -No pain, 1-3 Mild pain, 4-6 Moderate pain, 7-10 Severe pain. 1/4/26: Pain Level of 7. The MAR also contained order dated 12/2/25 for Hydrocodone-Acetaminophen [a pain medication] Oral Tablet 5-325 mg [milligrams]. Give 1 tablet as needed for pain. The pain medication was given on:1/3/26: Pain Level of 81/4/26: Pain Level of 71/5/26: Pain Level of 71/6/26: Pain Level of 71/7/26: Pain Level of 81/8/26: Pain Level of 7 During a review of Resident 1's NN dated 1/6/26 at 1:36 p.m., the NN indicated, [Resident 1] is complaining of pain left knee. During a review of Resident 1's Radiology Results Report (RR), dated 1/8/26 at 4:31 p.m. (five days later), RR indicated, KNEE EXAM. LEFT. Reason for Study: PAIN IN LEFT KNEE. Conclusion: Nondisplaced [a stable break where the bone cracks but remains properly aligned] distal [away from body center] femur [the longest bone in the leg] fracture appears acute [happened recently] . Medical Doctor (MD) 1 sent a text message to Registered Nurse (RN) 1 on 1/3/26 (five days ago) with a thumbs up emoji to order X-Ray.During a review of Resident 1's SBAR, dated 1/9/26 at 10:44 a.m., the SBAR indicated, X-Ray results came, [Resident 1] has nondisplaced [a bone break where the fragments remain in their proper alignment] distal femur fracture appears acute. notified dr [doctor]/rp [responsible party/family], [Resident 1's son] told his dad was rolling the wheel chair while [Resident 1] got twisted her leg underneath the wheelchair. [Resident 1 sent out to hospital].During a review of Resident 1's hospital record History and Physical (H&P), dated 1/9/26 at 9:53 p.m. (six days later), the H&P indicated, Pt [patient] BIB [[NAME] in by ambulance] EMS [emergency medical services] from [facility] complaining of left knee pain for x6 [six] days. Complains of moderate pain and swelling. XR [r-ray] and CT [computerized tomography, diagnostic imaging procedure that uses rotating X-rays and computer technology to produce detailed, cross-sectional, 3D slices of bones, blood vessels, and soft tissues] scan of the left knee performed on arrival to ED [emergency department] showing new nondisplaced fracture of distal femur. Assessment/Plan: Fracture of the distal [farther] end of left femur [thigh]. occurred six days ago. Ortho surgical repair [procedure performed by specialists to fix, reconstruct, or replace damaged components of the bones].During an interview on 2/4/26 at 11:57 a.m. with RN 1, RN 1 stated he was the charge nurse on 1/3/26 during the afternoon shift (3 p.m. to 11 p.m.). RN 1 stated Resident 1 was out of the facility on a day pass on 1/3/26 and returned around 5-6 p.m. RN 1 stated at around 8 p.m. he went to Resident 1's room to check on her. RN 1 stated Resident 1 reported pain in her left knee. RN 1 stated he assessed Resident 1's left knee and noticed it was swollen. RN 1 stated he took pictures of Resident 1's knees using the Nursing Phone and sent the pictures via a text message to MD 1. RN 1 stated the Nursing Phone was a facility cell phone used to communicate with physicians. RN 1 showed the text message and pictures he sent MD 1. RN 1 showed a text message sent to MD 1 on 1/3/26 at 8:05 p.m. as follows, Hey dr, [Resident 1], her left knee hurts and its little swollen. Because she said her leg got twisted on wheelchair when she was out with her family. She didn't report anything after coming back but she is in pain now. She also requesting for X-ray for her knee. Attached to this text message were pictures of Resident 1's knees, showing swelling of her left knee. RN 1 said MD 1 replied with a thumbs up emoji and the following text message, We can do a lidocaine patch [patch with medication for pain] too, 5% q [every] 24 prn [as needed] . if severe can give Norco 5 [mg/milligram] q [every] 6 [hours] prn. RN 1 stated MD 1's response was for him to enter the two pain medication orders and treat Resident 1's pain. RN 1 stated that MD 1 did not order x-rays or for Resident 1 to be sent out to the hospital for evaluation of her leg.During an interview on 2/4/26 at 1:25 p.m. with Resident 1, Resident 1 was alert and oriented and stated she broke her left leg in the facility on 1/3/26 at around 6 p.m. Resident 1 stated on 1/3/26 at around 6 p.m. she was in her room and was going to the bathroom in her wheelchair when she accidently twisted her left leg and felt her left knee pop. Resident 1 stated she felt a sharp pain in her left knee and reported it to her nurse. Resident 1 stated thereafter she had a constant, sharp, moderate intensity pain in her left knee daily until she was taken to the hospital six days later on 1/9/26. Resident 1 asked why it took so long to take her to the hospital to check on her leg. Resident 1 stated she should have been taken to the hospital the same day she had injured her leg on 1/3/26.During an interview on 2/4/26 at 2:40 p.m. with MD 1, MD 1 stated she was contacted by RN 1 on 1/3/26 at night via text message. MD 1 stated RN 1 sent her a text message on 1/3/26 at 8:05 p.m. reporting Resident 1 had left knee pain and requesting an x-ray of her left knee. MD 1 stated she replied to RN 1's text message with a thumbs up emoji and a text message with pain medication orders. MD 1 stated the thumbs up emoji meant she approved of Resident 1's request for a left knee x-ray. MD 1 stated her expectation was for RN 1 to send Resident 1 out to the ER that night or the next morning for evaluation and treatment of her left leg pain and swelling. During an interview on 2/4/26 at 3 p.m. with Director of Nursing (DON), DON stated there was a miscommunication between RN 1 and MD 1 on 1/3/26 regarding Resident 1's left leg injury. DON stated emojis were not a professional way for MD 1 to communicate with RN 1 concerning the care of Resident 1. DON stated emojis had the potential for confusion and misunderstanding. DON stated the fact Resident 1 was Spanish speaking only may have contributed to a misunderstanding amongst nursing staff about how Resident 1 injured her leg. DON stated Resident 1 should have been sent earlier to the hospital for evaluation and treatment of her leg pain and injury. DON stated the facility had no policy and procedure on proper communication between the licensed nurse and the doctor.During a review of facility policy and procedure (P&P) titled Quality of Care/Accommodation of Needs, Revised March 2021, the P&P indicated, Our facility's environment and staff behavior are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences are accommodated to the extent possible.During a review of facility P&P titled Pain Assessment and Management, dated October 2022, the P&P indicated, .to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain.During a review of facility P&P titled Change in a Resident's Condition or Status, Revised February 2021, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an):.(a) accident or incident involving the resident. (g) need to transfer the resident to a hospital/treatment center.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when: 1. The facility did not complete a follow-up investigation report (FIR) after a resident-to-resident altercation (RRA) within five days for two of seven sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have another altercation, and to develop distress and injuries. 2. The facility did not report an allegation of financial abuse to California Department of Public Health (CDPH) within 24 hours of an allegation for one of seven sampled residents (Resident 3). This failure had the potential for emotional distress for Resident 3. Findings: 1. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 5/20/25, the SBAR indicated, Resident (1) states he woke up and saw (Resident 2) sitting on the end of the bed, (Resident 2) grabbed (Resident 1's) pillow from behind his head and starting to hit him with the pillow multiple times, then (Resident 2) proceeded to go around the bed, grabbed the water pitcher threatening to hit (Resident 1). During a review of Resident 2's Brief Interview for Mental Status (BIMS), dated 5/16/25, the BIMS indicated Resident 2 had a score of 3 (score 0-7 indicates severe cognitive impairment). During a review of Resident 1's BIMS, dated 5/17/25, the BIMS indicated Resident 1 had a score of 15 (score of 13-15 indicates cognitively intact). During an interview on 6/4/25 at 12:48 p.m. with Resident 1, Resident 1 stated Resident 2 went to his room while he was asleep and hit him with a pillow. During a concurrent interview and record review on 6/4/25 at 2:55 p.m. with the Administrator, the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022 was reviewed. The P&P indicated, Findings of all investigations are documented and reported. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. The Administrator stated he did not complete the FIR after Resident 1 and Resident 2's RRA on 5/20/25 and the P&P was not followed. The Administrator stated the FIR should have been submitted to CDPH by 5/25/25. 2. During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 6/2/25, the SOC-341 indicated, REPORTED TYPES OF ABUSE. Financial. On 5/15 (Family Member [FM] 1) contacted Social Services via phone call. She stated she was worried about paperwork that was signed by (Resident 3). (FM 2) had brought in paperwork and had (Resident 3) sign without notifying any family. On the same day Social Services went to talk to (Resident 3). (Resident 3) was asked what paperwork she signed and she stated (FM 2) had her sign financial paperwork so he is able to help pay her bills. (Resident 3) did not know much about the paperwork. (Resident 3) stated if she needs to she will get authorities involved. On 6/2/25 Social Services talked to (FM 2) via phone call. (FM 2) stated (Resident 3) did sign POA (Power of Attorney - legal document that grants one person the authority to act on behalf of another person) paperwork. (FM 1) does not want (FM 2) to have any authority over (Resident 3) . Other neighbors have told (FM 1) they do not trust (FM 2) and he may have ill intention. During a review of Resident 3's admission Record (AR), dated 6/4/25, the AR indicated FM 1 was Resident 3's Responsible Party (RP). During a review of Resident 3's BIMS, dated 3/5/25, the BIMS indicated Resident 3 had a score of 13 (score of 13-15 indicates cognitively intact). During an interview on 6/4/25 at 1:11 p.m. with Resident 3, Resident 3 stated FM 1 was her granddaughter and FM 2 was her neighbor. Resident 3 stated she may have given FM 2 the POA after she signed a paperwork he brought. Resident 3 stated she was not sure what the paperwork was about. Resident 3 stated the inheritance should go to FM 1 and that the POA for FM 2 needed to be revoked. During a concurrent interview and record review on 6/4/25 at 2:55 p.m. with the Administrator, Resident 3's Communication Note (CN), dated 5/15/25 was reviewed. The CN indicated FM 1 told the facility she did not agree with FM 2 managing Resident 3's finances and requested to be informed if Resident 3 was asked to sign any further documents. The Administrator stated since FM 1 raised the concern about Resident 3's finances, she maybe is also trying to get Resident 3's assets. The Administrator stated the facility should have notified the California Department of Public Health (CDPH) about the allegation of financial abuse by 5/16/25. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. 'immediately' is defined as. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the potential for Resident 2's RP not to be aware of Resident 2's COC. Findings: During a concurrent interview and record review, on 4/23/25 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's Change in Condition, (COC) dated 4/9/25 was reviewed. The COC indicated Resident 2 had a witnessed fall. Resident 2's Admission Record, (AR) indicated Resident 2 had RP. Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 1/31/25 was reviewed. The MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) score was 6 (a score of 0-7 points severely impaired cognition). LVN 1 reviewed Resident 2's progress notes and confirmed no RP notification was documented. LVN 1 stated Resident 2's RP should have been notified regarding Resident 2's fall on 4/9/25. During a review of the facility's policy and procedure (P&P) titled, Change of Resident's Condition or Status, revised February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental conditions or status.

Based on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen with known infestation of cockroaches as evidenced by: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. These failures had the potential to place 70 of 72 highly susceptible residents at risk for food borne illnesses in the facility infested with multi-generational German cockroaches which are known to spread 33 kinds of bacteria, six kinds of parasitic worms as well as other kind of human diseases. On 12/18/24 at 11:54 AM, an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has cause, or it is likely to cause, serious injury, harm, impairment, or death to a resident) under Federal tag 812 was declared with the Administrator, Administrator for Bakersfield Post Acute, Director of Nursing (DON), and Nursing Consultant regarding the following identified concerns: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. These failures had the potential to place 70 of 72 highly susceptible residents at risk for food-borne illnesses in the facility infested with multi-generational cockroaches. On 12/19/24 at 6:12 PM, the California Department of Public Health (CDPH) notified the Administrator, Administrator for Bakersfield Post Acute, DON, Nursing Consultant, and Registered Dietician (RD), the IJ was abated after verifying and confirming on-site the facility had implemented an acceptable written plan of correction. Findings: During a concurrent observation and interview on 12/16/24 at 8:15 a.m. with Dietary Manager (DM) in the kitchen, there were nine dead cockroaches in a floor drain above the sink where food was prepared. DM stated, those are bugs [dead cockroaches in the drain]. During an interview on 12/16/24 at 8:16 a.m. with DM, DM stated she had seen ants, pincher bugs, and cockroaches in the kitchen. DM stated she noticed them (ants, pincher bugs, and cockroaches) during the renovation of the kitchen approximately March 2024. During an observation on 12/17/24 a.m. at 11:19 a.m. in the kitchen, there was peeling paint and a hole under the skink near the dish washer. During a concurrent observation and interview on 12/17/24 at 11:20 a.m. with DM, in the staff bathroom, there was a hole in the staff bathroom. DM stated there was a leak in the ceiling of the staff bathroom in the kitchen in September 2024. DM stated the Maintenance Director (MD) was aware of the hole and was supposed to fix it but did not make the kitchen department a priority. DM stated she had put in a maintenance request to the maintenance department about the peeling paint and the hole on the ceiling of the staff bathroom in the kitchen. During a review of the facility's [NAME] COUNTY PUBLIC HEALTH SAFE DINER-Inspection Violations Report (KCPHSDIVR) dated 5/24/24, the KCPHSDIVR indicated, OBSERVED A HOLE IN THE CEILING IN THE RESTROOM LOCATED IN KITCHEN DIE [SIC] TO A WATER LEAK. PLEASE REPAIR TO PREVENT VERMIN INFESTATION. During an observation on 12/17/24 at 11:25 a.m. in the kitchen, there was a live cockroach crawling on the wall above the dishwasher. During an interview on 12/17/24 at 11:26 a.m. with Dietary Aide (DA) 1, DA 1 stated that looks like a cockroach. DA 1 stepped on it and killed the live cockroach. DA 1 stated, I've only been seeing pests since the facility's renovation. During a concurrent observation and interview on 12/17/24 at 11:28 a.m. with Administrator, in the kitchen, Administrator stated he was aware of the hole in the kitchen staff bathroom and the hole on the wall under the sink in the kitchen. Administrator stated they have Pest Control Company come every month. Administrator stated the holes were entrance for pests to come into the kitchen. Administrator saw a cockroach crawling on top of the counter near the dishwashing machine and a small brown cockroach crawling on the wall above the handwashing sink. During an interview on 12/17/24 at 2:44 p.m. with DA (2), DA 2 stated he had seen two cockroaches in the kitchen near the dish washer floor today. During an observation on 12/18/24 at 8:34 a.m. in the kitchen staff bathroom, the hole on the ceiling got bigger. During an observation on 12/18/24 at 8:42 a.m. in the kitchen, was a glue trap with one dead cockroach under the sink of the food preparation counter. During an observation on12/18/24 at 8:43 a.m. in the kitchen, a cabinet lined with a silicone-type material where assortment of food utensils was stored, there was one small dead cockroach under the lining. During an observation on 12/18/24 at 8:44 a.m. in the kitchen, across the counter where food preparation is done, there was a hole in a pipe connected to the sink used for cleaning. During an interview on 12/18/24 at 8:45 a.m. with DM, DM stated, I saw live roaches [cockroaches] yesterday crawling from the ceiling down to the bulletin board. The bulletin board was hanging on the wall by the entrance wall in the kitchen. DM stated pest control did the treatment last week due to ''live roaches[cockroaches]. DM stated, they were dark brown, little ones. DM stated she saw 2-4 live roaches[cockroaches], little one's crawling. DM stated she saw bigger in size, dark brown in color yesterday. DM stated she saw more roaches (cockroaches) on Monday (12/16/24) morning. DM stated she came to the dining room; she saw more dead cockroaches. DM stated sometime in November, I saw live roaches (cockroaches) little ones, in the dish area. DM stated, I mentioned to the Administrator and Maintenance about the live and dead roaches in the kitchen every week. I gave verbal report during the stand-up meeting. During an observation on 12/18/24 at 8:47 a.m. in the kitchen behind the oven, there was one glue trap with one tiny (unable to determine size) dead cockroach and one live, dark brown cockroach. During an interview on 12/18/24 at 8:57 a.m. with Cook, [NAME] stated she came in to work at 4:30 a.m. today. When she turned the light on, she saw one live small cockroach as she opened the door. [NAME] stated, I have noticed cockroaches the first two days I've worked. [NAME] stated alive small black and small brown cockroaches. [NAME] stated in the cabinet under the food preparation counter she saw a live cockroach in the morning, last week. During an observation on 12/18/24 at 8:59 a.m. at the kitchen sink beverage station, there was a large hole in the wall near the sink drainage under the sink. There was a dead cockroach under the kitchen beverage sink. During a concurrent observation and interview on 12/18/24 at 9 a.m. with DA 3 in the Janitorial Closet, there was one live medium dark brown cockroach, one dead medium brown cockroach in the hole near mop sink, two cockroach carcasses on the mop sink, one dead cockroach medium brown behind the janitorial door. DA 3 stated she saw a live roach on the preparation counter last weekend on 12/14/24 and 12/15/24 around 5:45 a.m. and she saw dead roaches in the janitorial room last month. During an observation on 12/18/24 at 9:05 a.m. in the kitchen, there was one small live brown cockroach crawling on the ceiling above the dishwasher sink. During an observation on 12/18/24 at 9:07 a.m. in the kitchen, there was a glue trap with five dead medium dark brown cockroaches behind a rack with plate covers. During an observation on 12/18/24 at 9:09 a.m. in the kitchen, there was a mesh-like metal material on the hole with a small dead cockroach under the sink near the dishwasher. During an interview on 12/18/24 at 9:10 a.m. with DA 1, DA 1 stated she saw roaches, one alive and two dead five days ago around the area where staff wash the dishes and saw three dark brown live roaches in the kitchen dishwashing area. During an observation on 12/18/24 at 9:11 a.m. in the kitchen, there was a leaking water pipe connected to the dishwasher found underneath the dishwashing counter. During an observation on 12/18/24 at 9:13 a.m. in the dry storage room, there was a glue trap behind the refrigerator with 7 small brown dead cockroaches and one small dead cockroach on the floor. During a concurrent observation and interview on 12/18/24 at 9:35 a.m. with Activities Assistant (AA) in the dining room, there was two dead roaches on the floor. AA stated she saw one small, brown, dead roach in the dining floor. During an interview on 12/18/24 at 9:38 a.m. with Housekeeper (HK), HK stated she saw roaches in the dining room, some dead, some alive last week. During an observation on 12/18/24 at 9:40 a.m. in the dining room, there was 10 dead cockroaches in a cabinet under the sink. During an interview on 12/18/2024 at 9:50 a.m. with Environmental Specialist (ES), ES stated because of the different sizes of roaches described, the facility has a problem with multi-generational infestation. During the day, so many of them in hiding places to scavenge for food. ES stated even if they (facility) had sprayed they still have live infestation of roaches. During a concurrent observation and interview on 12/18/24 at 9:58 a.m. with DM in the dry storage room, a live brown cockroach was inside a bin which contained sponges. DM stated that is a live cockroach and killed it with a sponge. There was a dead tiny cockroach in a bin with approximately a dozen scoopers. There was a live small cockroach crawling into a silver rectangular tin box, one dead cockroach under a rack with pitchers, and a small dead cockroach under an empty rack. During an interview on 12/18/24 at 10:30 a.m. with Pest Control Company Owner (PCCO), PCCO stated he was aware of the situation. PCCO stated he went out at night and made a thorough inspection of the kitchen on Wednesday [12/11/24]. PCCO stated he found infestation of German Cockroaches. On 12/18/24 at 11:54 AM, an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has cause, or it is likely to cause, serious injury, harm, impairment, or death to a resident) under Federal tag 812 was declared with the Administrator, Administrator for Bakersfield Post Acute, Director of Nursing (DON), and Nursing Consultant regarding the following identified concerns: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. These failures had the potential to place 70 of 72 highly susceptible residents at risk for food-borne illnesses in the facility infested with multi-generational cockroaches. During an interview on 12/19/24 at 2:01 p.m. with Infection Preventionist Nurse Consultant (IPNC), IPNC stated kitchen staff does not have a designated kitchen sanitation schedule or kitchen sanitation log. According to Dr. [NAME], an advisor for the National Pest Management Association, German cockroaches can spread 33 kinds of bacteria, six kinds of parasitic worms, as well as other kind of human diseases. Https://www.pestworld.org/news-hub/pest-articles/german-cockroaches-101/#:~:text=These%20germs%20are%20then%20transferred,least%20seven%20other%20human%20pathogens. Accessed 12.26.24 On 12/19/24 at 6:12 PM, the California Department of Public Health (CDPH) notified the Administrator, Administrator for Bakersfield Post Acute, DON, Nursing Consultant, and Registered Dietician (RD), the IJ was abated after verifying and confirming on-site the facility had implemented an acceptable written plan of correction. During a review of the facility's Pest Control Invoice (PCI), dated 12/3/24, the PCI indicated, INSPECTION FOR GERMAN ROACHES. During a review of the facility's PCI, dated 12/9/24, the PCI indicated, SERVICE FOR ROACHES IN THE KITCHEN. During a review of the facility's MAINTANENCE REQUEST (MR), dated 12/18/24, the MR request by DM, Pipe (black) from garbage disposal leaking. During a review of the facility's policy and procedure (P&P) titled, GENERAL CLEANING OF FOOD & NUTRITION SERVICES DEPARTMENT, dated 2023, the P&P indicated, Drains.1. FNS staff should remove large debris as it accumulates and are encouraged to clean drains weekly. During a review of the facility's P&P titled, WALLS, CEILINGS, AND LIGHT FIXTURES, dated 2023, the P&P indicated, Walls and ceilings must be free of chipped and/or peeling paint. During a review of the facility's P&P titled, JANITOR'S CLOSET, dated 2023, the P&P indicated, The janitor's closet must be kept clean and orderly. 4. Cleaning of the janitor's closet must be done on a scheduled routine. During a review of the facility's P&P titled, SANITATION, dated 2023, the P&P indicated, 1.The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. 11. All utensils, counters, shelves, and equipment shall be kept clean .

Based on interview and record review, the facility failed to ensure advance directives (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) were offered and completed for 15 of 27 sampled residents (Resident 6, Resident 7, Resident 10, Resident 11, Resident 12, Resident 21, Resident 25, Resident 26, Resident 28, Resident 30, Resident 33, Resident 41, Resident 49, Resident 59, and Resident 64). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 12/16/24 at 3:05 p.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC), MDSC was unable to provide documentation that Resident 33 was offered an AD. MDSC stated, I do not see anything on him [Resident 33]. There is no advance directive and there is no acknowledgment. During a concurrent interview and record review on 12/16/24 at 3:07 p.m. with MDSC, MDSC was unable to provide documentation of an AD for Resident 12. MDSC stated Resident 12 did not have an AD. During a concurrent interview and record review on 12/16/24 at 3:52 p.m. with MDSC, MDSC stated, I do not see an advance directive only POLST (physician order for life sustaining treatment). During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated, Determining Existence of Advance Directives: 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. 32946 During a concurrent interview and record review on 12/17/24 at 2:48 p.m. with SSD, Resident 28's medical record (MR) was reviewed. SSD stated, No [Resident 28] does not have one [an AD]. During a concurrent interview and record review on 12/17/24 at 2:49 p.m. with SSD, Resident 6's MR was reviewed. SSD stated, There is no AD in the chart [medical record]. During a concurrent interview and record review on 12/17/24 at 2:53 p.m. with SSD, Resident 41's MR was reviewed. SSD stated, No AD, I don't see it, it's not uploaded. During a concurrent interview and record review on 12/17/24 at 2:55 p.m. with SSD, Resident 11's MR was reviewed. SSD stated, No AD in the chart. During a concurrent interview and record review on 12/17/24 at 2:56 p.m. with SSD, Resident 21's MR was reviewed. SSD stated, No AD found. During a concurrent interview and record review on 12/17/24 at 2:57 p.m. with SSD, Resident 7's MR was reviewed. SSD stated, No AD in the medical record. During a concurrent interview and record review on 12/17/24 at 2:58 p.m. with SSD, Resident 10's MR was reviewed. SSD stated, No AD in the medical record. SSD stated, I handed them [AD form] out to resident families, but none of the families have returned them. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 9/2022, the P&P indicated, Determining Existence of Advance Directives: 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative. 50939 During a concurrent interview and record review on 12/17/24 at 10:39 a.m. with Nurse Consultant (NC) 1, Resident 30's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 30. During a concurrent interview and record review on 12/17/24 at 10:40 a.m. with NC 1, Resident 59's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 59. During a concurrent interview and record review on 12/17/24 at 10:42 a.m. with NC 1, Resident 64's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 64. During a review of the facility's P&P titled, Advance Directives, dated 9/2022, the P&P indicated,1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. A. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from sexual abuse. This resulted in Resident 1 being the victim of sexual assault from Resident 2. Findings: During an interview on 11/8/22, at 10:55 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, that on 11/1/22, she saw Resident 1 sitting in wheelchair in the Activity Room with her hands folded together front of her on her lap, and Resident 2 was lifting Resident 1's shirt up and was putting Resident 1's breast in his mouth. CNA 1 stated this happened between 3:30 PM and 4 PM. CNA 1 stated, Resident 1 was in her wheelchair and Resident 2 was in his wheelchair. CNA 1 stated she said to Resident 2, what are you doing? Go away from [Resident 1]! and then Resident 2 stopped. CNA 1 stated that Resident 2 acted surprised and Resident 2 moved away from Resident 1. CNA 1 brought Resident 1 in her wheelchair to licensed nurses at the nurse's station. During an interview on 11/8/22, at 12:15 PM, with Registered Nurse (RN) 1, RN 1 stated, she has been working at this facility for a month and she knows Resident 1. RN 1 stated Resident 1 is unable to make her own decisions. During an interview on 11/8/22, at 12:30 PM with RN 2, RN 2 stated, she has been working here for couple months and she knows both Resident 1 and Resident 2. RN 2 stated, Resident 1 cannot make her own decisions. RN 2 stated, Resident 2 cannot make his own decisions. RN 2 stated after the incident of Resident 2 that he had stated to her, I am sorry and won't do it again. During a review of Resident 1's History and Physical (H&P), dated 2/22, the H &P indicated, Resident 1 does not have capacity to understand choices and make healthcare decisions. The H&P was signed by Resident 1's physician. During a review of Resident 1's Minimum Data Set (MDS, standardized assessment tool), dated 9/12/22, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 had diagnoses that included dementia (a progressive brain disease that effects memory, thinking, and personality change). During a review of Resident 1's Progress Note, dated 11/1/22, at 3:56 PM, the Progress Note indicated Resident 1 was found in dinning [sic] room beside [Resident 2] CNA [CNA 1] observed [Resident 1]'s shirt put up and mouth is on her breast. During a review of Resident 2's H&P, dated 5/22, the H&P indicated, Resident 2 does not have capacity to make decisions. Resident 2's H&P was signed by his physician. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS is 12 which indicates a moderate cognitive impairment. During a review of Resident 2's Admission Record, the Admission Record indicated, Resident 2 had diagnoses that included dementia, and schizoaffective disorder (a serious mental condition disrupting thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, and a withdrawal from reality). During a review of Resident 2's Progress Note, dated 11/1/22, at 9:49 PM, the Progress Note indicated, [CNA 1] was walking by at [3:30 PM] dinning [sic] room and saw this resident touching inappropriately to another female resident [Resident 1]. [CNA 1] noticed this resident rouching female resident's breast. Residents were separated immediately. No physical injury noted. On asking [Resident 2] stated A girl outside shouting at me. In dining room I touched her but I won't do it again. Progress Note was written by RN 2. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition & Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime Policy and Procedure, dated 8/22, the P&P indicated, This facility prohibits and prevents abuse, neglect, exploitation, misappropriation of property, and mistreatment. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, and any other individuals. It is presumed that instances of abuse for all residents, even those in a coma, can cause physical harm, pain, and/or mental anguish. 46958 The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Facility Reported Incident: 809907 Representing the Department: 46958, HFEN 47444, HFEN 27137, HFES The inspection was limited to the specific facility reported incident and does not represent the findings of a full inspection of the facility. One deficiency was written for facility reported incident 809907. Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was free from sexual abuse. This resulted in Resident 1 being the victim of sexual assault from Resident 2. Findings: During an interview on 11/8/22, at 10:55 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, that on 11/1/22, she saw Resident 1 sitting in wheelchair in the Activity Room with her hands folded together front of her on her lap, and Resident 2 was lifting Resident 1's shirt up and was putting Resident 1's breast in his mouth. CNA 1 stated this happened between 3:30 PM and 4 PM. CNA 1 stated, Resident 1 was in her wheelchair and Resident 2 was in his wheelchair. CNA 1 stated she said to Resident 2, what are you doing? Go away from [Resident 1]! and then Resident 2 stopped. CNA 1 stated that Resident 2 acted surprised and Resident 2 moved away from Resident 1. CNA 1 brought Resident 1 in her wheelchair to licensed nurses at the nurse's station. During an interview on 11/8/22, at 12:15 PM, with Registered Nurse (RN) 1, RN 1 stated, she has been working at this facility for a month and she knows Resident 1. RN 1 stated Resident 1 is unable to make her own decisions. During an interview on 11/8/22, at 12:30 PM with RN 2, RN 2 stated, she has been working here for couple months and she knows both Resident 1 and Resident 2. RN 2 stated, Resident 1 cannot make her own decisions. RN 2 stated, Resident 2 cannot make his own decisions. RN 2 stated after the incident of Resident 2 that he had stated to her, I am sorry and won't do it again. During a review of Resident 1's History and Physical (H&P), dated 2/22, the H &P indicated, Resident 1 does not have capacity to understand choices and make healthcare decisions. The H&P was signed by Resident 1's physician. During a review of Resident 1's Minimum Data Set (MDS, standardized assessment tool), dated 9/12/22, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status) indicated severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 had diagnoses that included dementia (a progressive brain disease that effects memory, thinking, and personality change). During a review of Resident 1's Progress Note, dated 11/1/22, at 3:56 PM, the Progress Note indicated Resident 1 was found in dinning [sic] room beside [Resident 2] CNA [CNA 1] observed [Resident 1]'s shirt put up and mouth is on her breast. During a review of Resident 2's H&P, dated 5/22, the H&P indicated, Resident 2 does not have capacity to make decisions. Resident 2's H&P was signed by his physician. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS is 12 which indicates a moderate cognitive impairment. During a review of Resident 2's Admission Record, the Admission Record indicated, Resident 2 had diagnoses that included dementia, and schizoaffective disorder (a serious mental condition disrupting thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, and a withdrawal from reality). During a review of Resident 2's Progress Note, dated 11/1/22, at 9:49 PM, the Progress Note indicated, [CNA 1] was walking by at [3:30 PM] dinning [sic] room and saw this resident touching inappropriately to another female resident [Resident 1]. [CNA 1] noticed this resident rouching female resident's breast. Residents were separated immediately. No physical injury noted. On asking [Resident 2] stated A girl outside shouting at me. In dining room I touched her but I won't do it again. Progress Note was written by RN 2. During a review of the facility's policy and procedure (P&P) titled, Abuse Prohibition & Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime Policy and Procedure, dated 8/22, the P&P indicated, This facility prohibits and prevents abuse, neglect, exploitation, misappropriation of property, and mistreatment. Each resident has the right to be free from abuse, neglect, exploitation, misappropriation of property, and mistreatment. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends, and any other individuals. It is presumed that instances of abuse for all residents, even those in a coma, can cause physical harm, pain, and/or mental anguish.

Based on observation, interview, and record review, the facility failed to protect one of one sampled residents (Resident 1) from physical abuse when Resident 9 struck Resident 1 in the face with a soup can. This failure resulted in Resident 1 experiencing a broken bone, lacerations (cuts in the skin) to his face and hand, and pain. Findings: During a review of a letter sent to the Department, dated 6/17/21, the letter indicated there was a Resident to resident altercation, on 6/15/21, at approximately 9 AM. The letter indicated that on 6/15/21, at approximately 9 AM, Resident 1 entered Resident 9's room by mistake. Resident 9 yelled at Resident 1 to get out, and when he did not, Resident 9 hit Resident 1 in the face with a soup can. The letter indicated staff provided first aid to Resident 1, then transferred him to an Emergency Department. The letter indicated Resident 1 did sustain cuts and abrasions [scrapes] to his face and hand, some which required sutures [stitches]. Additionally, he sustained a nasal [nose area] bone fracture. Police interviewed [Resident 9] and asked him about right versus wrong. He admitted to assaulting [Resident 1]. Police ran a search and [Resident 9] had other warrants for his arrest. Police arrested [Resident 9] for the assault and the outstanding warrants. [Resident 9] is discharged to police custody and will not be returning. During an observation on 6/16/21, at 2 PM, Resident 1 was noted with swelling and lacerations to his face. During an interview on 6/16/21, at 1:35 PM, with DON (Director of Nursing), DON stated the incident happened the previous day. The DON stated Resident 1 was found in Resident 9's room with lacerations to Resident 1's face. Resident 1 was sent to the hospital and diagnosed with a broken nose and multiple face lacerations and a wrist laceration. DON stated Resident 9 had told her that he had hit Resident 1 at least three times with an unopened can of soup because Resident 1 was in his room. The DON stated Resident 9 was arrested later that day by local police. During a review of Resident 1's Admission Record, it indicated he was 91-years-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 9's Admission Record, it indicated he was 37-years-old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Progress Notes, dated 6/15/21, at 12:03 PM, the Progress Notes indicated, .[Resident 1] was hit in the face with a can at least 3 times by [Resident 9] causing injuries to nose, face and right hand. [Resident 1] had gone into [Resident 9's] room by mistake and [Resident 9] had yelled at him to get out or he will hit him. [Resident 1]. was then hit in the face, he attempted to put up his hands to protect himself and sustained a cut to the hand. The Progress Note was written by the Director of Nursing. During a review of Resident 1's Computed Tomography (a type of x-ray), dated 6/15/21, at 1:09 PM, it indicated, right nasal bone fracture with regional soft tissue swelling. During a review of Resident 1's Progress Notes, dated 6/15/21, at 1:57 PM, the Progress Notes indicated, Resident [9] hit the male peer [Resident 1] with a food can on his face. Victim had swelling and bleeding on the right eye and bridge of nose. On asking resident (suspect) [Resident 9] reported that he hit the victim [Resident 1] with a food can because victim was into his room and touching his stuff. On asking if suspect have any injury on his hands suspect stated I have not punched him with my hands, I hit him with the food can. He was not going out of my room and was touching my stuff. The Progress Note was written by Licensed Vocational Nurse (LVN) 1. During a review of Resident 1's Progress Notes, dated 6/16/21, at 6:34 AM, the Progress Notes indicated, [Resident 1] sustained injuries to the nose, face and hands. Pain meds given to relieve his pain and discomfort. The Progress Note was written by LVN 2. During a review of Resident 1's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Care Plan, dated 6/15/21, the Care Plan indicated Resident 1 had a laceration to his wrist measuring 1 centimeter (cm) x 1 cm; a nose laceration measuring 1 cm; a right eye laceration measuring 1 cm x 1 cm; and a superficial scratch to his lower right eye/upper cheek. During an interview with LVN 1, on 8/30/21, at 3:55 PM, LVN 1 stated she recalled the incident on 6/15/21, when she saw Resident 1 sitting outside Resident 9's room, in his wheelchair, crying, with blood on his face. LVN 1 stated Resident 1 was saying 'can of food, can of food.' LVN 1 stated she looked in Resident 9's room and saw blood on the floor and asked Resident 9 what had happened. LVN 1 stated Resident 9 had stated to her 'he was touching my stuff so I hit him with a can of food.' LVN 1 stated she noted a can of food on the floor with a dent in it. LVN 1 stated first aid was given to Resident 1 and emergency services were called.

Based on observation, interview, and record review, the facility failed to provide adequate nutrition for one of 44 sampled residents (Resident 44) when: 1. The nursing staff did not notify the Primary Care Physician (PCP) and the Family Member (FM) 2 of Resident 44's unplanned weight loss. 2. A care plan addressing unplanned weight loss was not developed and implemented. 3. Ensure the Interdisciplinary Team (IDT - a group of healthcare professionals who work together to provide beneficial care to the residents) addressed the significant weight loss. 4. Dietary recommendations by the Registered Dietician (RD) were not implemented. These failures resulted in Resident 44's unplanned total weight loss of 39 lbs (Pounds-unit of measure) (-15.4%) in 45 days. Findings: 1. During a review of Resident 44's Admission Record (AR), undated, the AR indicated, Resident 44 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 44's Weights and Vitals Summary (WVS), the WVS indicated: 5/1/21: 255.8 lbs 5/8/21: 248.4 lbs 5/16/21: 242.2 lbs 6/1/21: 241.4 lbs (weight loss of 14.4 lbs [-5.6%] in 30 days) 6/13/21: 216.4 lbs (weight loss of 39.4 lbs [-15.4%] in 45 days). During a concurrent interview and record review on 6/23/21, at 8:01 AM, with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), Resident 44's Progress Notes (PN), dated 5/1/21 to 6/15/21 was reviewed. ADON/IP was unable to find documentation the PCP and FM 2 were notified of Resident 44's weight loss. During a concurrent observation and interview on 6/23/21, at 11:37 AM, in Resident 44's room, Resident 44 was observed lying in bed with FM 2 sitting at bedside. Resident 44 and FM 2 stated they were unaware of the weight loss. FM 2 stated, Nobody has talked to us about her [Resident 44] diet or food preference. I'm here every day and I haven't spoken to any dietician [Registered Dietician (RD) a food and nutrition expert]. During an interview on 6/24/21, at 8:53 AM, with Director of Nursing (DON), DON stated the PCP and family should have been notified of Resident 44's significant weight loss. During a review of facility's policy and procedure (P&P) titled, CHANGE OF CONDITION, RESIDENT, dated 11/17, the P&P indicated, It is the policy of this facility to identify, inform the physician and resident or resident representative, and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. 2. During a concurrent interview and record review on 6/23/21, at 8:40 AM, with the Director of Staff Development/Infection Preventionist (DSD/IP), Resident 44's Care Plan (CP) was reviewed. DSD/IP was unable to provide a weight loss prevention CP for Resident 44. DSD/IP stated a CP should have been developed by the IDT when the 14 lbs weight loss was noted. During an interview on 6/24/21, at 8:53 AM, with DON, DON stated a CP should be in place for Resident 44's weight loss. During a review of the facility's P&P titled, WEIGHT MANAGEMENT SYSTEM, dated 11/12, the P&P indicated, Residents with poor intake, significant weight loss. or other risk factors placing the resident at risk, will have appropriate measures implemented in their plan of care to promote weight gain and increase food and fluid consumption. 3. During a concurrent interview and record review on 6/23/21, at 8:40 AM, with ADON/IP, Resident 44's IDT was reviewed. ADON/IP was unable to provide documentation of an IDT meeting addressing Resident 44's weight loss of 14.4 lbs (-5.6%) in 30 days. During an interview on 6/24/21, at 8:40 AM, with DON, DON stated, We [Social Service Director, DSD/IP, ADON/IP, RD] meet weekly for skin and weight variance every Monday. I was unaware of her 14.4 lbs weight loss on [6/1/21]. We should have caught that on our weekly meeting. During a review of the facility's P&P titled, WEIGHT MANAGEMENT SYSTEM, dated 11/12, the P&P indicated, 8. Significant weight gain or desired weight loss will be reviewed by the IDT to determine clinical appropriateness, and have plans of care established with measurable goals to meet each resident's individual needs. 9. The Interdisciplinary Team will meet weekly to review new admissions, residents with significant weight changes, and residents with significant changes in eating patterns. 4. During a concurrent interview and record review on 6/23/21, at 8:01 AM, with ADON/IP, Resident 44's Nutritional Assessment (NA), dated 4/30/21 was reviewed. The NA indicated, Recommend to add NEM [Nutritional Enhanced Meal] and small portions to current diet, House supplements 120 milliliters [ml - a unit of measurement] TID [three times a day] with meals, & Medpass (fortified nutritional shake) 90 mls QID [four times a day] between meals. ADON/IP verified the NA was completed by the RD on 4/30/21. ADON/IP was unable to provide documentation that the RD's NA dietary recommendations were implemented for Resident 44.

Based on interview and record review, the facility failed to take necessary actions for one of one sampled resident (1), who verbalized suicidal ideation (thoughts). This resulted in Resident 1 attempting suicide and then emergently transferred to an acute hospital. Findings: During a review of the clinical record for Resident 1, he was admitted on [DATE], with [DIAGNOSES REDACTED]. The QUALITY OF LIFE INITIAL ASSESSMENT, dated 9/4/15, indicated under Significant Life Accomplishments: Son passed away [AGE] years ago. The Interdisciplinary (IDT-group of people organized to do a task together) Progress Notes, dated 9/11/15, indicated Resident is also on [MEDICATION NAME] (anti-depressant) 25 mg (milligrams) at bedtime for feeling sad. IDT agrees to clarify medication prescription of manifested by crying secondary to resident exhibiting behaviors of crying since admission .the loss of his son triggers crying behavior . A physician order, dated 11/23/15, indicated, [MEDICATION NAME] (anti-depressant) 10 mg by mouth daily at 1830 (6:30 PM) for [MEDICAL CONDITION] manifested by crying. The Minimum Data Set (MDS- a comprehensive assessment tool) dated 12/10/15, indicated under Brief Interview for Mental Status (BIMS) a score of 15 (cognitively intact). The Resident Mood Interview indicated under B. Feeling down, depressed, or hopeless a score of 1/1 (meaning the symptoms were present and with 2-6 days frequency in the last two weeks look back period). The BEHAVIOR MONITORING FLOWSHEET dated 1/2016, indicated under Crying Resident 1 had two episodes of crying on 1/10/16. On 1/11/16, Resident 1 had one episode of crying and also one episode of crying on 1/12/16. The NURSE'S NOTES dated 1/12/16, at 9:20 AM, indicated .Resident did not eat breakfast today. When asked why aren't you eating he said I'm not hungry. CNA (Certified Nursing Assistant) left tray in room just in case resident changed his mind. Dietary Supervisor went and spoke with resident and asked him why he isn't eating. Resident said to her I don't like this place, I don't want to be here, Go to Hell. At 1820 (6:20 PM) Resident sister found the resident with a tied plastic bag over his head. During an interview with the Administrator, on 1/13/16, at 12:01 PM, he stated the incident happened on 1/12/16, at approximately 6 PM, when the resident's sister came in, she saw the resident with a trash can plastic bag on the resident's head and tied on his neck. The sister tried to remove the plastic bag and called for help. CNA 1 came and ripped open the plastic bag. The Administrator also stated the resident said, He doesn't wanna live, he doesn't like this place, he wanted to die and will find a way. The resident's physician ordered to send the resident to the hospital for psychiatric evaluation. During an interview with CNA 1, on 1/13/16, at 12:28 PM, she stated yesterday (1/12/15), at approximately 5 PM, she had a meal tray to pass and she saw the resident's sister by the door of Resident 1's room saying the resident had a plastic bag on his head. She immediately put the meal tray down and ran to the resident. The resident had a plastic bag over his head and tied on his neck. CNA 1 ripped the plastic bag between the resident's mouth and nose so the resident could breathe. When CNA 1 was asked if the resident was verbalizing suicidal ideation before this incident happened (1/12/15) she stated, Oh yes, two weeks ago the resident stated he would get a gun and shoot his head off. CNA 1 stated they (CNA's) told the CEO (Chief Executive Officer) and the afternoon shift nurse about the resident verbalizing suicidal ideation but they (nurses) did not do anything. CNA 1 also stated the resident was very depressed. He was just crying and upset most of the time. He was upset with the Administrator because the resident was saying the Administrator took away his therapy (physical therapy), they (staff) were trying to explain to the resident Maybe it's the insurance. During an interview with CNA 2, on 1/13/16, at 1:40 PM, he stated the resident would always say Please and thank you. But because of I guess insurance, he's not getting therapy anymore. When the resident stops his therapy he started to refuse to get up and he was also refusing the RNA (Restorative Nursing Assistant) program. The resident was always saying I'm done. CNA 2 also stated, two weeks ago he knew the resident had an increased depression because the resident started saying he would get a gun and shoot his head. CNA 2 also stated the resident was also refusing to eat, 12 hours without food just milk. Resident 1 started to refuse using the urinal and just wet his bed. CNA 2 also stated he told Licensed Vocational Nurse (LVN) 1 about it. But did not know if the nurse (LVN 1) did the documentation. During an interview with LVN 1, on 1/14/16, at 8:25 AM, she stated on 1/11/16, the CNA's told her Resident 1 was refusing his meal tray, and Resident 1 was saying He doesn't care and also saying profanity words. During a review of the clinical record for Resident 1, there was no documented evidence found in the nurses notes regarding the resident's verbalizing suicidal ideation. The care plan was also reviewed and found no plan and interventions regarding the resident's suicidal ideation. There was also no IDT review regarding the resident's suicidal ideation. During an interview with the Social Services Director (SSD), on 1/13/16, at 1:58 PM, she was informed regarding CNA 1 and CNA 2's saying Resident 1 had been verbalizing suicidal ideation. The SSD stated she was not informed the resident had suicidal ideation. The SSD was also informed there was no documented evidence in the clinical record regarding the resident's verbalizing suicidal ideation. The SSD reviewed the clinical record and again stated, she was not informed of the resident's suicidal ideation. During an interview with the Administrator, on 1/13/16, at 3:08 PM, he stated the facility had no policy and procedures on Suicidal Ideation. The Administrator provided a document dated 7/31/15. The document indicated under Suicidal Ideation- When a resident states they want to die or complete self-harm, regardless if they have a plan or not, you must treat this as real and planned attempt. The following occurs: The resident becomes 1:1 with another staff member watching them at all times. Their assignment is to only be with this resident. We do not do 15 minute checks at any time. MD/family are notified immediately. Preferably a psych (psychiatry) eval (evaluation) is ordered to rollout psychoses. The resident is put on alert charting Q (every) shift for a minimum of 24 hours. Social Services counsels the resident and a care plan is develop. The IDT meets, at a minimum, 24 hours later and determines, as a team, whether precautions should continue. All documentation is documented in the NN (Nurses Notes)/IDT notes and is read at daily in the clinical meeting. It is imperative staff take these comment seriously, whether this is a common occurrence or not. It only takes one time for the resident to follow through.

Based on observation, interview, and record review, the facility failed to: 1. Monitor and document pain management for one of one sampled resident (1) when facility had no evidence of pain management for Resident 1 with a fractured pelvis for 11 days. 2. Administer routine pain medication for one of one sampled resident (1) when Resident 1 did not receive his routinely ordered pain medication for 12 hours. 3. Notify the doctor for one of one sampled resident's (1) unrelieved pain. These failures resulted in Resident 1 suffering from unrelieved pain due to a fractured pelvis. Findings: 1. During a concurrent observation and interview with Resident 1, on 7/15/15, at 1:40 PM, in Resident 1's room, Resident 1 was lying in his bed. A forward wheeled walker was at bedside. Resident 1 stated, I have hard time getting in and out of the bed. When asked how his fall happened, he stated, After I used the bathroom, I tried to reach for the door knob to hold on to but the door opened wide and I missed the knob so I fell down to the floor landed on my right side. My hip cracked. When asked if he called for assistance before going to the bathroom, he stated, No, I did not ask for help. It's my fault. When asked if he had concerns with the care he was receiving from the facility, he stated, I think I don't have enough pain medicine. My pain medication is not working. When asked if he reported to the nursing staff, he stated, Yes, I did several times but they said, I am already taking [MEDICATION NAME] (strong narcotic pain medication) every 4 hours. During a review of the clinical record for Resident 1, the SBAR (Situation, Background, Assessment and Request) Communication Form, dated 7/4/15, indicated, Resident (1) fell to right side complaining of increased pain to right hip. Transfer to the hospital was check marked. The hospital Patient Visit Information, dated 7/4/15, indicated, Pelvic fracture. During an interview with the Director of Nursing (DON), on 7/15/15, at 2:52 PM, she reviewed the clinical record and was unable to find documentation of pain management from 7/4/15 to 7/15/15 (for 11 days). She stated, I can't find any. It is not done. The facility policy and procedure titled, Pain Management, dated 7/2014, read The Pain Management Flowsheet is initiated. The LN (Licensed Nurse) documents the pain evaluation for their shift on the Flowsheet until appropriate pain management has been achieved. 2. During a review of the clinical record for Resident 1, the July 2015 Medications, dated 7/2015, indicated, [MEDICATION NAME] 10/325 mg (milligram) tab (tablet) PO (by mouth) q (every) 4 hours (for pain). On 7/14/15, Licensed Nurses' initials were circled at 4 AM, 8 AM, 12 PM and 4 PM. The PRN (as needed) Notes, dated 7/14/15, indicated, [MEDICATION NAME] unavailable pharmacy awaiting. The DON confirmed the finding and stated those were four missed doses of [MEDICATION NAME] because the pharmacy did not refill. During an interview with the DON, on 7/15/15, at 2:52 PM, she reviewed the clinical record and was unable to find documentation of reasons for the missed doses at 8 AM and 12 PM. The DON stated, Nothing in the Nurses' notes. During an interview with the Licensed Vocational Nurse, on 7/15/15, at 3:26 PM, he stated he was the afternoon shift and he received a report from morning shift that resident's (1) [MEDICATION NAME] ran out. He stated, Resident (1) missed 4 doses of [MEDICATION NAME]. Resident (1) complained of pain so I gave the PRN (if needed) Tylenol (medication for mild pain). During an interview with Resident 1, on 7/15/15, at 4:12 PM, when asked if he remembered he did not receive [MEDICATION NAME] for 12 hours yesterday (7/14/15), he stated, Yes, I was in pain yesterday and I refused to do my therapy. When asked about his pain level (10 will be the worst), he stated, 9 out of 10. They said I ran out of pills. During an interview with the Registered Nurse, on 7/20/15, at 10:54 AM, she stated, Resident (1) had no supply of [MEDICATION NAME] so he (Resident 1) did not receive a dose for 8 AM and 12 PM (in her shift). When asked if she notified the doctor, she stated, I called the doctor, no new order. I told the Therapist and resident (1) to call me if he (Resident 1) needed a pain medication. When asked if she went to reassess Resident 1's pain, she stated, The Therapist and Resident (1) did not let me know. The facility policy and procedure titled, Pain Management, dated 7/2014, read When there is a change in pain level, or if there is newly identified pain, the LN (Licensed Nurse) contacts the physician for appropriate treatment orders. 3. During a review of the clinical record for Resident 1, the Nurse's Notes, dated 7/8/15, at 2:45 AM, indicated, Resident c/o (complained of) pain 6/10 scale (10 is worst pain). Resident taking [MEDICATION NAME]. The Nurse's Notes, dated 7/9/15, at 1:20 AM, indicated in part .Continue to experience pain due to fracture of R (right) hip on routine [MEDICATION NAME]. There was no indication the nurse notified the treating physician of Resident 1's continued pain. The DON verified the findings. During an interview with the DON, on 7/15/15, at 2:52 PM, when asked what were the interventions done for the unrelieved pain, she stated, I totally agree, there should be non-pharmacological interventions (things done to relieve pain other than giving medication). The facility policy and procedure titled Pain Management dated 7/2014, read The information on the Pain Evaluation Record is used in conjunction with the Center's other evaluation and data collection tools to develop an individualized care plan, including non-pharmacological interventions, if appropriate.

Based on observation, interview, and record review, the facility staff failed to protect three of 15 sampled residents' (8, 9 and 10) dignity when: 1. Nursing staff failed to respond to the call lights for two residents (8 and 10) that activated their lights to obtain help with toileting in a timely manner. This failure caused the residents to sit for long periods of time in urine and feces. 2. Nursing staff exposed one resident's (9) body from waist down during a 25-minute treatment. This practice had the potential to cause Resident 9's embarrassment. Findings: 1. During a review of the clinical record for Resident 10, on 9/18/13, the Minimum Data Set assessment (MDS is a comprehensive assessment tool) completed on 6/22/13 was reviewed. A brief interview was conducted on 6/22/13 to determine the resident's mental status, the resident scored 14 out of 15 possible points. Based on the coding criteria, a score between 13-15 indicated the resident had intact thought process. The MDS assessment also indicated the resident was totally dependant on staff to assist her in and out of the wheelchair and was totally continent of bowel and bladder. The MDS also indicated the resident had left sided weakness. During an interview with Resident 10 on 9/18/13, at 1:45 PM, she indicated this past Sunday (9/15/13), the Certified Nursing Assistants (CNAs) took over 45 minutes to answer her call light when she needed to go to the bathroom. She stated because she could not transfer herself onto the toilet and because she was having problems with loose bowel movements, she did not receive help quickly enough which resulted in her having "an accident". When the CNAs arrived they had to clean her up and she stated the staff had to shower her the next day. During an interview with the MDS Nurse and Director of Nursing (DON), on 9/18/13, at 2:45 PM, the MDS Nurse was asked about Resident 10's continence. The MDS Nurse indicated the resident was totally continent of bowel and bladder but wore a brief "just in case". When she was asked if the resident had an incontinent bowel episode this past Sunday (9/15/13) based on documentation, she stated she did not know because the CNAs did not need to document if residents have a continent or incontinent bowel movement. The DON was asked to provide the call light policy. The MDS Nurse did indicate Resident 10 was oriented and able to carry conversation with others. No further documentation was provided. 2. During an observation of Resident 8's room on 9/16/13, at 3:50 PM, many pages of paper and notebooks were noted on her bedside table. Resident 8 stated she had been asking staff to write down when they provided incontinent care. Resident 8 stated this was an effort on her part to document how long it took staff to provide this care, and how often she was changed. Resident 8 indicated due to severe contractures in her hands, it was difficult for her to write this information down herself, and had asked staff to do it. Resident 8 indicated that the DON had told staff not to write this information down, upon learning about Resident 8's request. During an interview with Resident 8 on 9/16/13 at 3:50 PM, she stated she had been a resident of the facility for about a year. Resident 8 stated she is incontinent of bowel and bladder, and often has to wait "1 to 2 hours" after activating her call light before staff assist her with incontinent care, which makes her "feel lousy." Resident 8 stated the longest she had to wait was 6 hours, but waiting 1 or 2 hours was normal, and that she does not like to "sit in my own urine, or worse" for the 1 or 2 hours it takes for staff to help her. Resident 8 stated she had been told by staff the reason for the delays is because there is a staffing shortage, or someone was on break, or there was a shift change and staff were busy in 'report'. Resident 8 stated these delays did not occur during a specific shift or day. Resident 8 indicated during the time of the survey, however, while surveyors were onsite, the staff had responded to her call lights immediately. During a review of the clinical record for Resident 8, the MDS, dated [DATE] indicated she had competent in making sound decisions, had no issues with memory, no signs or symptoms of [MEDICAL CONDITION], had no negative behavioral symptoms. The MDS also indicated Resident 8 required "extensive assistance" and "one person to physically assist" her with toileting. The MDS also indicated Resident 8 was "always incontinent" of bowel and bladder (has no control of these functions). During an interview with the DON on 9/18/13, at 11 AM, she stated she did instruct staff to not write this information down for Resident 8. The DON stated nursing staff had come to her, concerned about this request from Resident 8. The DON indicated Resident 8 had asked staff to document their name, date, and time procedures were done on paper, 'like when I changed you, times medications were given.' The DON indicated Resident 8 stated the reason was so she "knows when things are done." The DON stated she told Resident 8 to use her call light to ask for help, and after doing so, she can "make an appointment" with the Medical Records Department to see her clinical record whenever she wished, to review when procedures were done and when medications were given. The DON stated she told Resident 8 staff would not be writing this information down for her. The DON did not state that she had addressed the reason Resident 8 was requesting staff to write the information down. 3. During an observation on 9/17/13, beginning at 9:05 AM, at the bedside of Resident 9, and ending at 10 AM, a series of complex treatments were observed. Present at bedside for the observation included the DON, the Treatment Nurse (TN), CNA 1, and a Health Facilities Evaluator Nurse (HFEN ). The treatments involved dressing changes to the following areas: 1) A tube was inserted through the lower abdominal wall into the bladder; 2) Wound to the left great toe, the ankle, left buttock, coccyx, and the right buttock. After each dressing change, the TN removed her gloves and left the bedside to go into the resident's bathroom to wash her hands, dry them, and apply new gloves for the next dressing change. During the observation of the treatment, between 9:35 AM to 10 AM, the TN, CNA 1, and DON never covered Resident 9. The resident was exposed during the 25-minute duration. The resident was alert, oriented, and making eye contact with all observers in the room. During a review of the clinical record for Resident 9, the MDS, dated [DATE], indicated Resident 9 was dependent on staff for his daily needs. His admitting [DIAGNOSES REDACTED]. During an interview with the TN on 9/18/13, at 10:45 AM, she stated Resident 9's body should have been covered.

Based on observation and interview, the facility failed to keep Random Resident 27's indwelling catheter (a flexible tube that can be inserted into the bladder for a long period) drainage bag covered. This had the potential to cause embarrassment to Resident 27. Findings: During a concurrent observation and interview with the Director of Staff Development (DSD) on 12/4/13, at 11:15 AM, Random Resident 1 was lying in bed with an exposed indwelling drainage bag containing 300 milliliter (ml) of yellow liquid hanging underneath her bed facing the door. The DSD confirmed and verified the findings and stated, "There should be a dignity bag (a bag used to conceal the catheter drainage bag)."

Based on interview and record review, the facility failed to protect one of one sampled resident (1) from physical and verbal abuse, when a staff member hit the resident's leg with a closed fist while providing care. This had the potential for injury to the resident's leg and emotional distress. Findings: During an interview with Licensed Vocation Nurse (LVN) 1 on 7/12/13, at 2:15 PM, she stated Certified Nursing Assistant (CNA) 1 was assisting her with Resident 1's wound care. LVN 1 described they had finished changing Resident 1 and CNA 1 was applying an antiseptic cream to his scrotal area. Resident 1 struck out at CNA 1 and she stepped back and let him calm down. CNA 1 again attempted to apply the cream and Resident 1 struck out hitting CNA 1. LVN 1 stated "she (CNA 1) struck back with a closed fist hitting Resident 1's thigh. There was a verbal confrontation between the Resident and CNA using the "F" word, and I immediately said 'No stop that'." During an interview with Resident 1 on 7/12/13, at 3:45 PM, he denied any verbal or physical encounters with staff. Resident 1 did not respond to many of the questions asked. During an interview with the Administrator on 7/12/13, at 2 PM, he described during his investigation it was determined CNA 1 did strike Resident 1 with her fist. The incident was witnessed by LVN 1. During attempts to interview CNA 1 messages were left to her known telephone number on 7/19/13, at 4 PM, and 7/22/13, at 2 PM. CNA 1 did not return the telephone calls. During a review of the clinical record for Resident 1, the "Face Sheet" dated 2/14/13 indicated Resident 1 was [AGE] years of age, was admitted to the facility on [DATE], with the following medical conditions: [MEDICAL CONDITION], pressure ulcers (A pressure ulcer is an area of skin that breaks down when something keeps rubbing or pressing against the skin,) dementia, (Dementia is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.) and chronic pain. The "Interdisciplinary Progress Notes" (IDT) dated 6/27/13, stated "...today during treatment rt (resident) became agitated and was swinging at CNA and cursing at her. Rt turned and hit CNA ...the CNA hit rt back on his thigh ...rt altercation witnessed by treatment nurse ...". No injuries were noted on the resident. The facility policy and procedure titled "Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy" dated October 2010; read "each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Nursing Center implements policies and process so that residents are not subjected to abuse by staff...."

Based on observation, interview, and record review, the facility failed to ensure privacy during care for two of 16 sampled resident (5 and 8) and one random residents (19), which had the potential to decrease their self esteem and self worth. Findings: 1. During an observation on 8/7/12 at 10:15 AM in Resident 19"s room Certified Nursing Assistant (CNA) 1 was changing the resident's brief with the privacy curtain half open. The resident was visible from the door way. The Roster Sample Matrix (form with resident assessment information on it) was reviewed on 8/7/12. The form indicates Resident 19 is cognitively impaired (affects the residents ability to think concentrate and formulate ideas) and incontinent of urine. 2. During concurrent observation and interview with the Director of Nursing (DON), on 8/9/12 at 6:45 AM, of Resident 8"s room CNA 3 was giving care to Resident 8 with the privacy curtain partially open. Resident 8's lower body was exposed and could be seen from the door way. At that time the DON indicated the privacy curtain should be closed when staff is giving care. The clinical record for Resident 8 was reviewed on 8/7/12, the Quarterly Minimum Data Set (resident assessment tool) dated 7/8/12 indicated Resident 8 was rarely able to make himself understood, and was dependent on staff for his hygiene needs. 3. During an interview with Resident 5, on 8/7/12 at 1:30 PM, she stated "Well, some of the male nurses tend to barge in on me... I yell at them 'Get out and don't do that again.' But I've had to do that several times. It happens more on the 'night shift'. Resident 5 also indicated she prefers to have female staff care for her. She stated she has told staff of her preference but still continues to receive care from male staff. During an interview with the Social Service Director (SSD), on 8/9/12, at 10:15 AM, she stated, "This is the first time I have ever heard of a complaint from Resident 5 concerning lack of privacy or of staff preferences." During a concurrent interview with Charge Nurse 1(PM Shift) and Resident 5, on 8/9/12, at 3:15 PM, the Charge Nurse stated she was not aware of a gender preference request from Resident 5. Resident 5 stated, "I let them (staff) all know, all of them. I yell at them. They (staff) know and the women know, too. I don't want men nurses changing me... I know I'm heavy and maybe it doesn't make any difference. But, still! And, no I don't remember who I told or names (of staff)."

Based on observation, record review, and interview, the facility failed to maintain the wheel and/or caster brakes of 17 out of 73 resident beds in safe, working order. This had the potential to cause significant injury to many residents in the facility if their beds moved during transfers. Findings: A condition of Immediate Jeopardy (IJ) was identified by the survey team due to the facility's failure to maintain the brakes on the wheels of 17 out of 73 resident beds in a safe, working order. This had the potential to cause significant injury to a resident if he/she were attempting a transfer to or from a bed, and the bed moved unexpectedly due to the wheel brakes were faulty or non-existent. The IJ was called on 9/29/11 at 5 PM by the survey team coordinator and one additional Health Facilities Evaluator Nurse. In addition to the survey team members, the following facility staff were present at the time the IJ was called: the Administrator, two Corporate Registered Nurses, and the facility Director of Nursing. On 9/30/11 at 2:05 PM, the Administrator presented a Plan of Correction (POC) to the survey team. The POC addressed the following issues of faulty or non-existent bed brakes for many of the resident beds: 1) non-slip pads were installed under the wheels under the casters (small wheels on a swivel, usually found under heavy furniture to make them easier to move) that wouldn't lock; 2) new castors have been ordered; 3) inservices have started for staff regarding the above; 4) the bed brakes will be monitored by the maintenance staff during daily rounds and whose reporting log will in turn be monitored daily by the Administrator and Maintenance Supervisor. The survey team verified inservices had begun for staff and inspected all the beds in use in the facility. The survey team then met with the Administrator and Director of Nursing and the IJ was abated on 9/30/11 at 2:50 PM. During an observation of Resident 4's room on 9/26/11 at 1:35 PM, two unpainted, wooden blocks were noted nailed to the wall near the headboard of her bed. During an interview with Resident 4 on 9/26/11 at 1:35 PM, she was asked why the wooden blocks were there, nailed to the wall. Resident 4 stated her bed moves if the bed's headboard isn't pushed flush against the wall, between the two wooden blocks. Resident 4 stated her bed "moves when I try to get out of it. (The facility) put those (blocks) there to try and stop it." At the time of the interview and observation, the bed's headboard was not pushed up against the wall between the two blocks, and could be easily moved in all directions with slight knee pressure against the mattress. The facility document titled "Maintenance (sic) Log" was reviewed on 9/29/11 at 3 PM, and it contained the following entries: 1) 9/29/11 at 9:12 AM, "brakes on bed 7A & 6B not working" 2) an undated entry reading "brakes on bed 14A, 16A, 16B please check", and 3) 7/19/11 "18A bed break (sic) not good." During an interview with Random Resident 21 on 9/29/11 at 9:45 AM, she stated her bed brakes don't work, and she wakes up in the morning on occasion with her bed very out of place in the room, "sometimes it's diagonal." Random Resident 21 also stated on 9/29/11 at 4:05 PM, "I've been lucky not to have fallen." The clinical record for Random Resident 22 was reviewed on 9/29/11 at 3:30 PM. The nurse's notes dated 7/31/11 at 11:05 AM read, "Upon assessment Resident was on sitting position attempting (sic) to get up and asking for help... stated he attempted to go to bed and bed was unlocked and he slid down to floor." During an observation on 9/29/11 between the hours of 9:07 AM and 10:47 AM, the bed brakes on all of the facility's 73 beds in use were checked with facility staff. The following beds were noted to have faulty bed brakes (identified by room number), and could be moved across the floor with slight pressure against the side of the bed, or on the footboard: Beds observed with, and verified as faulty, with Licensed Vocational Nurse 1: 1) 33A 2) 34A 3) 36A 4) 41A 5) 42A 6) 38A Beds observed with, and verified as faulty, with Certified Nurse Assistant 2: 7) 24B 8) 25A 9) 26B 10) 28A 11) 29B 12) 30A 13) 30B 14) 42B 15) 7B 16) 6B 17) 24A