Every finding on record at Bay View Rehabilitation Hospital, LLC

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received dialysis consistent with professional standards of practice, the comprehensive person-centered care plans, and residents' goals and preferences when Resident 1 had refused and missed dialysis treatment six times within the last six months (since January).There was no care plan for the refusals of dialysis for Resident 1 and no notification of the Medical Doctor (MD) four out of the six times that dialysis treatment was refused and no notification of Responsible Party (RP) five times. These failures placed Resident 1 at increased risk for complications including high potassium build up which can lead to heart problems, heart attack, and death.A review of Resident 1's admission record (AR) indicated that Resident 1 was admitted to the facility originally on 1/27/17 with diagnoses that included end stage kidney disease, dependence on kidney dialysis, diabetes, and stroke and was readmitted [DATE].A review of the physician progress note dated 6/17/26 indicated Resident 1 had limited capacity to make medical decisions and had medical history of vascular dementia.During a concurrent interview and record review on 7/8/26 at 3:37 p.m. with Social Services Director (SSD), SSD stated Resident 1's dialysis days are Monday, Wednesday, and Friday. SSD acknowledged that Resident 1 had been missing dialysis treatments. SSD stated they had a care conference with Resident's RP on 6/1/26, and on 6/23/26 and family wanted to be informed about the health status and condition of the Resident. The RP wanted to be informed on days when Resident 1 refused to go to dialysis so that the RP could convince Resident 1 to go for the dialysis treatments. The RP also wanted psychiatrist referral. When asked for the care plan for Resident 1's dialysis refusals, SSD searched the electronic record under care plan but could not find it. SSD stated SSD could not find any care plan for dialysis refusals. SSD stated it is important for them to have a care plan for missing dialysis so they can plan and identify the root cause of not going to dialysis and address it. SSD stated it is important for the residents to have dialysis to clear the toxins from their blood. SSD stated missing several consecutive dialysis treatments could lead to complications and sometimes even death. SSD stated Resident 1 used to be alert and oriented, but is now getting confused.During a concurrent interview and record review on 7/8/26 at 4:32 p.m. with the Director of Nursing (DON), DON was trying to review Resident 1's records for missed dialysis days. DON stated when a resident refuses dialysis they monitor them and if need be, send them to acute care. When asked, DON stated they need to call the doctor to report missed dialysis treatments, and the doctor would decide the next medical approach to prevent complications. When asked, DON stated they need to communicate the refusals to the family too. DON searched for the missed dialysis dates for Resident 1 but was unable to locate them. DON then called for MRD at 4:43 pm to help search for Resident 's care plan and confirmed they have no care plan for Resident 1' s dialysis refusals.During an interview on 7/9/26 at 9:23 a.m. with DON, DON stated care plan is important. DON stated refusal of dialysis leads to build up of waste materials in the blood so they need dialysis to clean that out. DON stated the nurse needs to monitor the resident.During a review of the hospital Discharge (DC) Summary dated 6/14/26, the DC summary indicated Resident 1 presented to the hospital because of missed hemodialysis (HD) and had acute encephalopathy (any disease, damage, or malfunction that affects the brain's structure of function) and hyperkalemia (potassium level in the blood that is higher than is healthy).During an extensive review of the progress notes for Resident 1's missed dialysis due to refusals from January 2026, the progress notes dated 1/9/26, 3/13/26, 3/27/26, 4/3/26, 5/8/26, 5/25/26 indicated Resident 1 refused dialysis during those days, and the Medical Doctor (MD) and the RP were not notified for the dialysis refusals of 1/9/26, 3/13/26, 3/27/26, 4/3/26; there was no indication that RP was notified on 5/8/26.During a review of the facility's policy and procedure (P&P) titled Policy and Procedure on Dialysis Care, revised October 2019, the P&P indicated, It is the facility's policy to provide standards of care to residents receiving dialysis care.Physician shall also be notified if resident misses his/her dialysis treatment for whatever expressed reason; plan of care addressing renal dialysis care shall be developed and updated promptly by members of the interdisciplinary team to reflect any changes.During a review of the facility's P&P titled, Care Plans, Comprehensive, revised 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional need is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.The Interdisciplinary Team must review and update the care plan: When there has been a significant change in the resident's condition; when the desired outcome is not met.

Based on interview and record review, for one sampled resident (Resident 1), the facility failed to provide Resident 1's Responsible party (RP) copies of the requested medical records within the required timeframe according to the faxed requests on 2/4/26.This failure resulted in a delay in obtaining Resident 1's medical records for the RP/family's desired purpose.A review of Resident 1's admission record (AR) indicated that Resident 1 was admitted to the facility originally on 1/27/17 and readmitted [DATE].During a telephone interview on 7/7/26 at 5:20 p.m. with RP, RP expressed concern that it took a while for the facility to send them Resident 1's medical records to start the process of moving Resident 1 to a facility closer to the family's home.During an interview on 7/9/26 at 3:15 p.m. with Medical Records Director (MRD), MRD stated MRD was trying to go through E-fax to retrieve RP's messages, and instructions as to where the medical records of Resident 1 should have been sent for the purpose of screening prior to admission by the receiving facility. MRD stated that on 3/30/26, RP came to the facility (from out of state) to inquire about the status of the medical records of Resident 1 which RP repeatedly requested via facsimile transmission. MRD stated they sent Resident 1's medical records to addresses that were provided by RP, and they received receipts of successful transmittals each time.During a review of the documents provided by MRD via email on 7/10/26 at 2:38 p.m. the documents indicated multiple emails sent to Director of Nursing (DON) and Social Services Director (SSD) by Resident 1's care advocate designated by RP. The emails were pertaining to medical records' requests; and there was also a faxed request to the facility from the care advocate dated 1/27/26 with confirmation date 2/4/26 and a release form signed dated 1/23/26 by RP. However, there was no proof to show that the records were sent by the facility to the recipients requested by the care advocate.During an interview on 7/10/26 at 4:20 p.m. with MRD, MRD stated MRD was not aware of the emails sent to the DON and SSD regarding the requests for Resident 1's medical records. MRD stated the facility's policy is such that medical records must be released at least 48 hours after the request has been made in writing. During a concurrent interview and record review on 7/10/26 at 4:28 p.m. with DON, the emails from the care advocate for Resident 1 sent on behalf of RP to facility were reviewed - email dated 4/6/26 sent to DON and MRD, email dated 2/20/26 sent to DON and SSD, email dated 2/11/26 sent to DON and SSD, email dated 2/9/26 sent to SSD, and email dated 1/27/26 sent to DON. DON acknowledged receiving the emails and admitted speaking to RP on 2/4/26 informing RP that the HIPAA (U.S. federal law to protect health data) Authorization Disclosure form must be signed by RP before medical records' release to the care advocate. Also reviewed was the fax document dated 1/27/26 with a list of requests from the care advocate with an attached HIPAA medical release form signed dated 1/23/26 by RP. The documents were with a fax confirmation on top dated 2/4/26. DON stated DON did not see or know about that 2/4/26 fax request.During an interview on 7/10/26 at around 4:45 p.m., DON placed a telephone call to MRD to find out if they honored the medical records request of 2/4/26 sent by the care advocate. DON then placed MRD on the speaker. MRD stated they needed to retrieve the fax confirmation for 2/4/26 but was unable to and unsure if the medical records were sent. DON and MRD acknowledged there was no evidence of the medical records requests on 2/24/26 having been carried out.During an interview on 7/10/26 at 5:02 p.m. with DON, DON acknowledged that Resident 1's RP had the right to receive Resident 1's medical records and in a timely manner.During a review of the facility's policy and procedure (P&P) titled, Release of Information, revised November 2024, the P&P indicated, The resident may initiate a request to release such information contained in his/her records and charts to anyone he/she wishes.A responsible party may have access to his or her records within 15 days (excluding weekends or holidays) of the written or oral request.A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request.

Based on interview and record review, the facility failed to ensure Resident 2 was provided a room and bed in a timely manner when he spent around 12 hours sitting in their wheelchair in the hallway from around 12 midnight until 1:30 p.m.This failure had the potential for increased risk of Resident 2 developing pressure ulcers; deep vein thrombosis ( DVT- a serious medical condition that occurs when a blood clot forms in a deep vein, usually in the leg or thigh), muscle stiffness and contractures (an involuntary, persistent shortening of muscle fibers), and skin problems such as pressure ulcers.A review of Resident 2's admission record (AR) indicated that Resident 2 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (the heart muscle does not pump blood as well as it should), acute respiratory failure ( the lungs fail to oxygenate the blood), diabetes (the body cannot properly process glucose(sugar) leading to high blood sugar levels), muscle weakness, and depression.A review of Resident 2's Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/25/26, indicated a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 14 indicating no cognitive impairment. The MDS indicated Resident 2 required substantial/maximal assistance from staff for Roll left and right; Sit to lying; Lying to sitting on side of bed; Sit to stand; and Chair/bed-to-chair transfer.During an interview on 7/8/26 at 11:55 a.m. with Resident 2, Resident 2 stated on the night of the incident (6/27- 6/28/26), Resident 2 had a disagreement with roommate and staff separated them. Resident 2 stated they said they were going to move them and Resident 2 sat there in the wheelchair (W/C) in the hallway from 12 midnight (MN) to 1 p.m. the following day. Resident 2 stated their scrotum and everything had swollen up and they couldn't move and was told they have not got a room for them. Resident 2 stated the next shift did not even know the reason they were there in the hallway.During an interview on 7/9/26 at 10:25 a.m. with Registered Nurse Supervisor (RNS), RNS stated Resident 2 had an argument with his roommate and staff separated them and was left along the hallway. RNS stated Resident 2 was siting in their regular W/C. RNS stated Resident 2 was in the hallway in the W/C from MN, around 1 a.m., and was moved to a room around 1:30 p.m. When asked, RNS stated it was 12 hours. RNS acknowledged they should have found a room faster than 12 hours. RNS stated the risks of sitting in the W/C for prolonged period of time for Resident 2 was edema (swelling in the body's tissues), and there was a chance there could be a wound.During a telephone interview on 7/9/26 at 12:42 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated they had separated the two residents when they had verbal altercation as both residents did not get along. LVN 1 stated they brought Resident 2 out with them to be at the nursing station and was there till endorsed to the charge nurse the following day. LVN 1 stated the incident was about 12 MN and 1 a.m. LVN 1 stated they called and informed DON that night and assured them they would move Resident 2.During a record review of the nursing progress note (PN) dated 6/28/26 2 p.m. PN indicated Resident 2 was moved to another room, belongings and commode transferred, oriented to room, assisted resident to bed with feet elevatedDuring an interview on 7/9/26 at 4:30 p.m. with Director of Nursing (DON), DON stated that night he had told staff there was a room and to move Resident 2 to that available room. DON stated DON was perplexed about the fact that the resident was not moved promptly. DON stated Resident 1 came in for swollen leg. DON stated Resident 2 needed assistance for W/C mobility - W/C to bed and bed to W/C. DON stated there is a lot of risks for Resident 2 such as pain, discomfort, and swelling could worsen.

Based on observation, interview and record review the facility failed to protect two of ten sampled residents (Resident 2 and Resident 3), and one visitor (Visitor 1, family member of Resident 7), from abuse when:Resident 1 fondled the genitals of Resident 2 on 5/24/26.Resident 1 hit the arm of Resident 3 on 6/4/26.The facility relocated Resident 1 to the same unit as Resident 2 after an alleged sexual assault by Resident 1 to Resident 2 on 6/5/26.The facility placed Resident 1 in a room with two vulnerable residents (Resident 9 and Resident 10) on 6/10/26.Additionally, R1 displayed physical aggression towards an unrelated Visitor on 6/4/26. This failure resulted in emotional harm to Resident 2, Resident 3 after Resident 1 abused them and had the potential to render physical and/or emotional harm to Resident 9 and Resident 10 and other vulnerable residents in the facility.An Immediate Jeopardy situation (Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death), was identified and called due to the failure of the facility to protect Resident 2, Resident 3, Visitor 1 and all other vulnerable residents from physical, emotional and sexual abuse beginning on 5/24/26.The Administrator (ADM) was notified verbally and in writing of the IJ situation on 6/10/26 at 6:40 p.m.During a visit to the facility on 6/11/26 the facility provided an acceptable plan of action and the IJ was removed at 5:10 p.m.Non-compliance of F0600 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate jeopardy. During a review of the admission Record (AR) for Resident 1 printed on 6/10/26, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a disease of the brain caused by a buildup of certain proteins resulting in the brain shrinking affecting memory, thinking and behavior), diabetes (long term disease in which the body cannot regulate the amount of sugar in the blood), anxiety disorder (a long term mental health condition involving persistent excessive and uncontrolled worry that interferes with daily activities), restlessness (being unable to rest, relax or remain still, due to many different forms of discomfort), and agitation (state of extreme restlessness, excitement or disturbance).During a review of the Minimum Data Set Assessment: Section C: Cognitive Patterns (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 4/15/26, the record indicated the Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score for Resident 1 was six out of fifteen indicating severe cognitive impairment (significant, irreversible, loss of intellectual capacity that prevents an individual from living independently).During a review of Change of Condition Evaluation dated 4/12/26, the record stated Resident 1 became extremely agitated and aggressive towards staff when being redirected toward Resident 1's room. The record stated Resident 1 was threatening staff and ramming them with a wheelchair and was also throwing food and ice at others in the hallway. The record stated since being admitted , Resident 1 has frequently shown hostility toward staff and other residents. This includes arguing and physical aggression, such as grabbing at others. As a result, staff must continuously monitor the resident's location and mood.Record review of Change of Condition Evaluation dated 5/2/26, the record indicated Resident 1 had baseline confusion and was observed to be agitated, restless and wandering around the facility going in and out of other resident rooms. The record stated Resident 1 was combative towards staff when being redirected. During a review of SNF [Skilled Nursing Facility] Visit Note (physician note) dated 4/27/26, the record indicated Resident 1 was noted to hallucinate (sensory perception of something that is not actually present), responding to internal stimuli (any physical or psychological signals originating inside an organism that trigger a response or conscious awareness), exhibiting unsafe and intrusive behaviors. The record indicated Resident 1 .lacks capacity to understand choices and make healthcare decisions.During a review of Attentive Cognitive Mental Health: Psychology Initial Evaluation Note dated 5/19/26, the record indicated Resident 1 had diagnoses of unspecified mood [affective] disorder (a mental health condition that primarily affects your emotional state, causing persistent and intense feelings of sadness, elation, or anger), psychotic disorder due to another medical condition with delusions (severe mental illnesses that disrupt a person's thoughts and perceptions, causing them to lose touch with reality), unspecified depressive disorder (a diagnosis used when a person exhibits symptoms of depression that cause significant distress but does not meet the full, exact criteria for other recognized categories, such as Major Depressive Disorder), and unspecified anxiety disorder (when a person experiences prominent symptoms of anxiety or panic that cause clinically significant distress, but the clinical picture does not fully meet the strict criteria for any other specific anxiety condition). The record states The severity of the patient's neurocognitive deficits (a significant, measurable decline in one or more areas of brain function that manage information processing), likely preclude the patient from being able to benefit from psychological services. The patient (Resident 1), continues to demonstrate significant neuropsychiatric symptoms (behavioral, emotional, and psychological changes that occur as a direct result of underlying diseases, injuries, or structural disruptions in the brain and central nervous system), despite pharmacotherapy (the medical treatment of diseases, disorders, or symptoms using medications), hence, psychiatric follow-up is recommended to determine an optimal treatment regimen. The record stated the patient shows poor insight secondary to anosognosia (a neurological condition where a person is completely unaware of their own medical condition or disability), and level of cognitive impairment. During a review of the AR for Resident 2 printed on 6/9/26, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), anxiety, encephalopathy (any brain disease that alters brain function or structure, manifested by declining ability to reason and concentrate, memory loss, personality change, seizures, and twitching are common symptoms), and a developmental delay (when a child fails to reach age appropriate milestones in one or more areas of growth and development). During a record review of MDS Section C: Cognitive Patterns for Resident 2 dated 3/16/26, the record indicated Resident 2 had a BIMS of 12 out of 15 indicating moderate cognitive impairment (stage of neurological decline where symptoms clearly interfere with daily independence and complex tasks, though basic self-care remains intact). During a review of the AR for Resident 3 printed on 6/9/26, the record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease ( a long term condition where the kidneys are damaged and cannot filter blood as well as they should), anxiety, depression (mood disorder that causes persistent feelings of sadness and hopelessness), and cancer of the kidney (uncontrolled growth and spread of abnormal cells in the kidney) with nephrectomy (surgical removal of the kidney). During a review of MDS Section C: Cognitive Patterns for Resident 3 dated 3/30/26, the record indicated Resident 3 had a BIMS score of 15 of 15 indicating no cognitive impairment. During a review of the AR for Resident 7 printed on 6/9/26, the record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain (progressive loss of brain cells, tissue volume and cognitive function that occurs with advanced age), anxiety and depression. Resident 7 is non-English speaking and MDS Section C: Cognitive Patterns dated 4/12/2026 indicated the BIMS score was incomplete and Visitor 1 is the responsible party for Resident 7. During a review of the AR for Resident 8 printed 6/19/26, the record indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (occurs when blood flow to part of the brain is blocked), and paraplegia (partial or complete loss of voluntary movement of the lower half of the body). During a review of MDS Section C: Cognitive Patterns dated 5/6/26, the report indicated Resident 8 had a BIMS score of 13 of 15 indicating no cognitive impairment. During a review of the AR for Resident 9 printed 6/19/26, the record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of end stage renal disease (final, permanent stage of kidney failure), and dementia. During a review of MDS Section C: Cognitive Patterns for Resident 9 dated 5/14/26, the report indicated Resident 9 had a BIMS score of 0 out of fifteen indicating severe cognitive impairment (significant loss of intellectual capacity that disrupts a person's ability to live independently). During a review of the AR for Resident 10 printed on 6/19/26, the record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (chronic mental health condition that combines symptoms of schizophrenia ( like hallucinations{a false sensory perception that occurs in the absence of an external stimuli} or delusions {a firmly held false belief that persists despite clear, undeniable evidence to the contrary} ) with a mood disorder (such as depression or bipolar disorder), and diabetes. During a review of MDS Section C: Cognitive Patterns for Resident 10 dated 4/22/26, the record indicated Resident 10 had a BIMS score of four out of 15 indicating severe cognitive impairment (significant loss of intellectual capacity that disrupts a person's ability to live independently). 1. During an interview on 6/9/26 at 4:15 p.m. with Resident 2, Resident 2 recalled walking in the hallway and stopping in front of Resident 1. Resident 2 stated Resident 1 reached out and touched Resident 2's genitals. Resident 2 stated staff saw the incident, called out to Resident 1 to stop, as Resident 2 stepped away from Resident 1 and went back to Resident 2's room. During an interview on 6/11/26 at 11:00 a.m. with Licensed Vocational Nurse 1 (LVN1), LVN1 stated on 5/24/26, an incident involving Resident 1 touching Resident 2's genitals was reported to LVN1 by Certified Nursing Assistant 1, (CNA1). LVN1 stated CNA1 reported upon seeing Resident 1 touching Resident 2, CNA1 called out to Residents 1 and 2 and immediately separated them. LVN1 stated she assessed Resident 1 and Resident 2 after the incident. LVN1 stated Resident 2 did not say anything about the incident during the assessment. LVN1 stated Resident 1 could not be understood during the assessment. LVN1 stated there were no injuries on either resident. LVN1 stated the incident was immediately reported to the charge nurse. During an interview on 6/11/26 at 11:20 a.m. with Registered Nurse 1 (RN1), RN1 stated the incident between Resident 1 and Resident 2 was reported to RN1 on 5/24/26 by LVN1. The residents were assessed by LVN1 and found to have no injuries. RN1 stated the DON (Director or Nursing) was notified of the incident between Resident 1 and Resident 2 immediately. RN1 stated the process for abuse reporting is that the staff reports all incidents to the Administrator (ADM) for investigation and reporting. RN1 stated at the time of the incident the residents lived on different units with Resident 1 at the 500 hallway and Resident 2 at the 400 hallway. RN1 stated at the time of the incident the residents went back to their respective rooms on different units. RN1 stated training about abuse prevention, recognition and reporting is important for all staff to protect the residents from abuse. During a review of Change of Condition Evaluation for Resident 1 dated 5/24/26, the record indicated CNA1 saw Resident 1's hand under the pants of Resident 2. CNA1 separated both residents and redirected the residents to their separate areas (Resident 1 to the 500 hallway and Resident 2 to the adjacent 400 hallway), to maintain a safe distance and prevent further inappropriate contact. 2.During a telephone interview on 6/8/26 at 2:15 p.m. with Visitor 1, Visitor 1 stated on 6/4/26 at lunchtime, Visitor 1 went to Resident 7's room and saw Resident 1 standing over Resident 7 with a closed fist poised to hit Resident 7. Visitor 1 immediately called for assistance. Visitor 1 stated as Visitor 1 was leaving Resident 7's room, Resident 1 hit Visitor 1's left shoulder. Visitor 1 notified the ADM, and called 911.During an interview on 6/8/26 at 2:30 p.m. with Resident 8, Resident 8 stated Resident 8 occupied the bed next to Resident 7. Resident 8 stated Resident 1 has wandered in and out of their room several times since Resident 1's arrival. Resident 8 stated Resident 8 did not see the incident with Resident 1, but Resident 8 heard Visitor 1 call for assistance and tell the staff Resident 1 was standing over Resident 7 as if to hit Resident 7.3. During an interview on 6/9/26 at 1:00 p.m. with Resident 3, Resident 3 stated on or about 6/4/26 Resident 3 heard Visitor 1 yelling from the hallway outside Resident 7's room for help. Resident 3 stated as Resident 3 was approaching the doorway to Resident 7's room, Resident 3 saw Resident 1's hand graze over Visitor 1's left arm. Resident 3 stated that as Resident 3 arrived at Resident 7's room, Resident 3 saw Visitor 1 heading away from Resident 7's room as Resident 1 proceeded to hit Resident 3 on the arms. Resident 3 stated fearing being hit on the head and face. Resident 3 stated the staff intervened and escorted Resident 1 back to Resident 1's room. Resident 3 stated Resident 1 was allowed to wander in and out of other resident's rooms without supervision. Resident 3 stated Resident 3 has observed Resident 1 being physically aggressive with staff and other residents. Resident 3 stated I do not feel safe when Resident 1 is wandering in the facility unattended. Resident 3 reported the incident and concerns to the ADM.During an interview on 6/9/26 at 10:05 a.m. with CNA2, CNA2 stated on 6/4/26, CNA2 saw Resident 1 hit Visitor 1 with an open hand on Visitor 1's left arm.During a review of Change of Condition Evaluation for Resident 1 dated 6/4/26, the record indicated @1230 Noted physical aggressiveness with another resident (Resident 3 & with a visitor (Visitor 1).Administrator made aware of the incident. Incident report completed. Resident on monitoring & visual check for safety. 4. During an interview on 6/9/26 at 4:15 p.m. Resident 2 stated several days after Resident 1 groped Resident2, Resident 1 was moved to a room on the same unit and two rooms down from Resident 2. Resident 2 stated Resident 1 would follow Resident 2 on the unit and into Resident 2's room. Resident 2 was very upset to have Resident 1 nearby going in and out of Resident 2's room. Resident 2 stated Resident 2 felt violated and unsafe in the facility. 5. During an interview with Licensed Vocational Nurse (LVN1) on 6/9/26 at 4:00 p.m., LVN1 stated after an altercation on 6/4/26 with a resident and visitor, Resident 1 was moved from the 500 hallway to the 400 hallway. LVN1 stated LVN1 was concerned because of a sexual abuse allegation that Resident 1 had sexually abused Resident 2. LVN1 was concerned for Resident 2's safety because Resident 1 was placed two rooms away from Resident 2's room.During a review of Progress Notes-Administration Note for Resident 1, dated 6/8/26, the record indicated Resident 1 kept following Resident 2 into Resident 2's room. The record stated staff kept separating Resident 1 and Resident 2, despite Resident 1 being aggressive and combative when redirected.During a review of Facility Census dated 6/10/26, the census indicated Resident 1 was placed in a room with two vulnerable roommates (Resident 9 and Resident 10), while on the 400 hallway.During a review of Nurses Progress Note for Resident 1 dated 6/10/26, the record indicated Resident 1 was transferred from the 400 hallway to the 200 hallway and a sitter was assigned to Resident 1.During a concurrent observation and interview on 6/11/26 at 10:20 a.m. with CNA 3 in the 200 hallway, Resident 1 was observed to have moved into a private room. CNA 3 stated CNA 3 was the sitter for the day.During an interview on 6/15/26 at 3:00 p.m. with the DON, the DON stated the incident between Resident 1 and Resident 2 was reported to the DON on the day it occurred. The DON stated the ADM is the assigned abuse coordinator and has the responsibility to investigate and report abuse cases. When the DON was asked if the incident of 5/24/26 was reported to the ADM, the DON had no answer. The DON stated residents involved in abuse investigations should be separated to protect victims from further abuse. The DON could not articulate expectations of the staff regarding abuse prevention, recognition, intervention and reporting. The DON stated staff is trained annually for abuse and refreshed after any incidents. The DON stated staff training and monitoring are important to protect residents from abuse.Review of the facility's policy and procedure titled, Resident Rights, dated 12/2016, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the right to be.free of abuse, neglect, misappropriation of property and exploitation.Review of the facility's policy and procedure titled, Policy and Procedure on Patient Abuse and Prevention dated 10/2010 indicated .If the suspected perpetrator is another resident separate the residents immediately to avoid any further contacts.

Based on interview and record review, the facility failed to identify, investigate, and report one sexual assault allegation within two hours of incident notification and one abuse allegation within 24 hours of incident notification to the California Department of Public Health (CDPH), and the Ombudsman for two of ten sampled residents (Resident 2 and Resident 3).This failure resulted in one allegation of physical abuse and one allegation of sexual abuse going uninvestigated and unreported resulting in emotional harm to Resident 2 and Resident 3, in addition to the potential for physical and/or emotional harm to other vulnerable residents.During a review of the AR for Resident 1 printed on 6/10/26, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a disease of the brain caused by a buildup of certain proteins that results in brain shrinkage affecting memory, thinking, and behavior), diabetes (a long term disease in which the body cannot regulate the amount of sugar in the blood), anxiety disorder (a long term mental health condition involving persistent, excessive, and uncontrollable worry that interferes with daily activities), restlessness (being unable to rest, relax, or remain still due to various forms of discomfort), and agitation (a state of extreme restlessness, excitement, or disturbance). During a review of the Minimum Data Set Assessment: admission Section C: Cognitive Patterns (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 4/15/26, the record stated the Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and the ability to register and recall information) score for Resident 1 was six out of 15, indicating severe cognitive impairment. During a review of the AR for Resident 2 printed on 6/9/26, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), anxiety and encephalopathy (any brain disease that alters brain function or structure, manifested by declining ability to reason and concentrate, memory loss, personality change, seizures, and twitching are common symptoms). During a record review of MDS Section C: Cognitive Patterns for Resident 2 dated 3/16/26, the record indicated Resident 2 had a BIMS of 12 out of 15 indicating moderate cognitive impairment.During a review of the AR for Resident 3 printed on 6/9/26, the record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease ( a long term condition where the kidneys are damaged and cannot filter blood as well as they should), anxiety, depression (mood disorder that causes persistent feelings of sadness and hopelessness), and cancer of the kidney (uncontrolled growth and spread of abnormal cells in the kidney) with nephrectomy (surgical removal of the kidney). During a review of the MDS Section C: Cognitive Patterns for Resident 3 dated 3/30/26, the record indicated Resident 3 had a BIMS score of 15 out of 15 indicating no cognitive impairment. During an interview on 6/11/26 at 11:20 a.m. with Registered Nurse (RN1), RN1 stated the incident between Resident 1 and Resident 2 was witnessed by CNA1 and reported to RN1 on 5/24/26 by LVN1. RN1 stated the Director of Nursing (DON) was notified of the incident between Resident 1 and Resident 2 immediately. RN1 stated the process for abuse reporting is the staff reports all incidents to the Abuse Coordinator for investigation and reporting. RN1 stated the Administrator (ADM) acts as the Abuse Coordinator for the facility. RN1 stated training in abuse prevention, recognition, response and reporting is important to protect the residents from abuse.During an interview on 6/9/26 at 4:15 p.m. with Resident 2, Resident 2 stated Resident 2 was walking along the hallway when Resident 2 stopped in front of Resident 1, and Resident 1 touched Resident 2's genitals. Resident 2 stated the incident made Resident 2 feel vulnerable and unsafe.During a record review of Care Plan Report for Resident 2 dated 5/24/26, the report indicated the incident of sexual abuse between Resident 1 and Resident 2 was reported to the DON on 5/24/26.During an interview on 6/9/26 at 1:00 p.m. with Resident 3, Resident 3 stated on or about 6/4/26, Resident 3 heard Visitor 1 yelling from the hallway outside Resident 7's room for help. Resident 3 stated as Resident 3 was approaching the doorway to Resident 7's room, Resident 3 saw Resident 1's hand graze over Visitor 1's left arm. Resident 3 stated as he arrived at Resident 7's room, he saw Visitor 1 heading away from Resident 7's room and Resident 1 began hitting Resident 3 on the arms. Resident 3 stated Resident 3's arms were up around the face and head for protection. Resident 3 stated the staff intervened and escorted Resident 1 back to Resident 1's room. Resident 3 stated Resident 1 was allowed to wander in and out of other residents' rooms without supervision. Resident 3 stated Resident 3 has observed Resident 1 being physically aggressive with staff and other residents. Resident 3 stated he did not feel safe when Resident 1 was wandering around the facility unattended. Resident 3 reported the incident and concerns to the ADM.During an interview on 6/15/26 at 3:00 p.m. with the DON, the DON stated the DON was aware of the incident between Resident 1 and Resident 2. The DON stated the ADM is the designated abuse coordinator responsible for investigating and reporting abuse allegations. When the DON was asked if the incident between Resident 1 and Resident 2 was reported to the ADM, the DON had no response. When the DON was asked about reporting responsibilities, the DON could not articulate expectations of the staff regarding abuse prevention, recognition, intervention and reporting. The DON stated staff are trained annually for abuse and refreshed after any incidents. The DON stated abuse reporting and staff training and monitoring are important to protect residents from abuse.During a concurrent interview and record review on 6/11/26 at 10:45 a.m. with the ADM, the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) for the allegation of sexual abuse involving Resident 1 and Resident 2 that occurred on 5/24/26, and the SOC 341 for the allegation of abuse between Resident 1 and Resident 3 that occurred on 6/4/26 were reviewed. During a review of the submission receipts for the SOC 341 submitted for the incident on 5/24/26 and the SOC 341 submitted for the incident on 6/4/26, the receipts indicated the reports were submitted to the California Department of Public Health (CDPH), and to the Ombudsman simultaneously on 6/10/26 at 8:50 p.m. The ADM stated the SOC 341 for the incident between Resident 1 and Resident 2 dated 5/24/26 was due 2 hours after notification of the incident and the SOC 341 for the incident between Resident 1 and Resident 3 dated 6/4/26 was due to be reported within 24 hours of the incident. The ADM stated incident investigation summaries are due within five days of each incident, and the incidents were not reported or investigated as required.During a review of the facility's policy and procedure titled, Policy and Procedure on Patient Abuse and Prevention dated 10/2010 indicated: The facility shall ensure reporting of all alleged and/or substantiated violation to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation.Facility shall report the incident by calling DHS within 24 hours of the knowledge of such an incident followed by a letter explaining the circumstances surrounding the incident.The Administrator and Director of Nurses in the order written, shall report incidents of suspected abuse to the following agencies within 24 hours of occurrenceDepartment of Health-Licensing and CertificationLTC Ombudsman or designee orLocal law enforcement or Police DepartmentManaging physician for treatment orders as requiredFamily Members/Responsible Parties or Guardians.Facility Administrator shall report findings of investigation to the Department within five working days of the incident.The facility Administrator is the duly appointed Abuse Prevention Coordinator. In the absence of the Administrator the designated alternate or Assistant Administrator, if any, will take over the responsibilities.

Based on interview and record review, the facility failed to follow the physician's order for interventions/treatment for one of three sampled residents (Resident 1) pressure injury to sacrococcyx (tailbone).This failure resulted in slow healing of Resident 1's pressure injury and had the potential for infection. During a review of Resident 1's admission record, dated 4/10/26, the admission record indicated Resident 1 was admitted to the facility on [DATE].During a review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 1/30/26, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11. A score of 11 indicated Resident 1 had moderate cognitive impairment. MDS also revealed, Resident 1 had multiple diagnoses that included malnutrition, Diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing) and Cerebrovascular Disease (CVA - stroke). MDS further revealed, Resident 1 had hemiplegia (complete loss of muscle control or paralysis on one side) or hemiparesis (partial weakness on one side of the body). MDS showed, Resident 1 had Stage 3 pressure ulcer that was present upon admission. MDS also showed, Resident 1 required application of nonsurgical dressings (with or without topical medications). During a review of Resident 1's, Discharge Summary Notes from acute care hospital dated 1/23/26, the notes indicated under Wound Care: .1. Cover sacrum (bony structure in lower back) with optiview hydrogel dressing (clear medical patches designed to protect vulnerable skin and heal wounds). 2. Assess every shift. 3. Change as needed. Do not leave dressing on for more than 7 days. 4. Reconsult wound care for any worsening of sacral wound.During a review of Resident 1's admission notes, dated 1/23/26, under B. Narrative note, Resident 1 had sacrococcyx redness 0.3 cm by 0.2 cm (cm-centimeter, a unit of measurement).During a review of Resident 1's January 2026 TREATMENT RECORD, the record showed Resident 1 did not receive hydrogel dressing to the sacrum on multiple days (1/24/26, 1/25/26, 1/26/26 and 1/27/26) as ordered by the physician.During a review of Resident 1's Skin Condition Reassessment, dated 1/23/26, the document indicated, Resident 1 had Stage III (full thickness tissue loss or a deep crater-like bedsore) pressure ulcer on sacrococcyx.During a review of Resident 1's Surgical Consult, dated 1/27/26, the document indicated under reason for visit, consultation and evaluation of wounds that included sacrococcyx. Under assessment and plan, Resident 1 had multitude of wounds that included sacrococcyx. Surgical consult also showed Resident 1 had risk factors including limited mobility and diabetes which might exacerbate the worsening of the pressure injury. Furthermore, Resident 1 required continued topical wound dressing therapy on sacrococcyx. During a telephone interview on 4/28/26 at 11:42 a.m. with the Treatment Licensed Nurse (TLN) 1, TLN 1 stated, treatment record showed Resident 1 did not receive treatment on sacrum on 1/24/26, 1/25/26, 1/26/26 and 1/27/26. TLN 1 also added, she does not recall providing wound treatment on Resident 1's sacrum on the dates with missing signature. TLN 1 further stated, if wound treatment record was not signed, it was not done. During a telephone interview on 4/28/26 at 11:59 a.m. with Wound Care Physician (WCP), WCP stated, the expectation from TLN 1 was to follow Resident 1's wound treatment regimen to prevent the pressure injury worsening. During a telephone interview on 4/28/26 at 1:29 p.m., with the Director of Nursing (DON), DON stated, Resident 1 had state 3 pressure ulcer. DON added, Resident 1 had a physician order for hydrogel dressing to Resident 1's sacrum but did not receive it on multiple days. DON also stated, it was important for the TLN 1 to provide wound treatment to Resident 1 within 24 hours of admission to prevent pressure injury from worsening. DON further stated, the expectation was for TLN 1 to follow doctor's order.During a review of Resident 1's care plan (personalized treatment plan that outlines patient's needs), dated 1/24/26, indicated Resident 1 had a pressure ulcer . The care plan also indicated one of the interventions were: .Treatment as ordered and evaluate effectiveness. During a review of facility's policy and procedures (P&P) titled, POLICY AND PROCEDURE ON PHYSICIAN ORDERS, dated 10/2014, indicated under Policy: It shall be this facility's policy to provide care and services to the resident in accordance with physician orders. Under Procedure: 1. All aspect of resident's care, including but not limited to the following shall only be provided if ordered by the physician: .treatments .During a review of facility's P&P titled, POLICY AND PROCEDURE ON PRESSURE ULCERS, dated 10/2010, indicated under policy: The facility shall ensure that a resident who enters the facility with pressure ulcer and/or develops unavoidable pressure ulcers while being in the facility, must receive treatment and services necessary to promote healing, prevent infection and prevent new ulcers from developing. Under procedures: .2. Assessment of pressure ulcers shall be done at least once every week or as wound condition changes. 3. Document general findings in the weekly skin and would progress report. 4.c. Pressure ulcer treatment orders shall be evaluated for effectiveness every 21 days and as needed.P&P titled, POLICY AND PROCEDURE ON NURSING admission ASSESSMENT, dated 10/2019, indicated under Procedures.7. Verify orders with physician and communicate with other disciplines necessary treatment and/or services to meet resident's needs.

Based on interview and record review the facility failed to ensure resident-directed care for one of three sampled residents, (Resident 1), when Resident 1 attended a medical appointment without physician ordered x-rays.During a review of Resident 1's admission Record printed on 5/13/26, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, (lungs fail to provide adequate oxygen to the bloodstream, leading to dangerously low levels of oxygen in the body), pneumonia, (infection of the lungs), cerebral infarction, (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain), metabolic encephalopathy, (any brain disease that alters brain function or structure, manifested by declining ability to reason and concentrate, memory loss, personality change, seizures, and twitching are common symptoms),alcohol abuse, (when a person drinks alcohol in a way that causes harm to themselves or others), stimulant abuse, (when a person repeatedly uses central nervous system stimulants in excessive doses, without a prescription, or for purposes other than their intended medical use), anxiety, (the body's response to stress, characterized by feelings of fear, dread or uneasiness), and delusional disorder, (mental health condition where a person experiences persistent, unshakable false beliefs [delusions] that are not rooted in reality).During a review of Resident 1's Minimum Data Set assessment, ([MDS] a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), Section C Cognitive Patterns dated 12/15/25, the assessment indicated Resident 1's Brief Interview for Mental Status, ([BIMS] a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information), score was of seven out of fifteen indicating severe cognitive impairment.During an interview on 5/12/26 at 1:30 p.m. with Registered Nurse (RN), RN stated the facility is responsible for ordering tests through an external vendor that comes to the facility.During a review of Resident 1's MD Order Summary printed on 5/12/26, the record indicated an x-ray was ordered for Resident 1 to be completed on 4/20/26.During a review of Resident 1's medical office visit notes dated 4/29/26, the record indicated pelvis and left hip x-rays were not available despite multiple requests by the office to the facility.During a concurrent interview and record review on 5/13/26 at 2:30 p.m. with Licensed Vocational Nurse (LVN), Resident 1's medical record was reviewed. The record indicated there were no x-ray results for Resident 1 in April 2026. LVN stated the x-ray was not performed.During an interview on 5/13/26 at 3:00 p.m. with the Director of Nursing (DON), the DON stated that missing ordered tests can compromise care and lead to negative outcomes.During a review of the facility's policy and procedure titled, Nursing admission Assessment dated 10/2019, indicated, the licensed nursing staff will verify orders with the physician and communicate with other disciplines necessary treatment and/or services to meet resident's needs.

Based on observation, interview and record review, the facility failed to ensure the resident and/or responsible party (RP or legal guardian) for one of one sampled resident (Resident 1) received a written notification about the room change when Resident 1 was moved to another room. This failure violated Resident 1 and Resident 1's RP ' s rights to receive written notice of the room change, including the reason for the change, before the resident's room in the facility was changed. Findings: During a review of Resident 1 ' s undated Admission Record printed on 12/17/24, the Admission Record indicated, Resident 1 was admitted in the facility on 7/29/21 with an admission diagnosis of dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). The Admission Record indicated, Resident 1 had a RP. During a record review of Resident 1 ' s Minimum Data Set (MDS- an assessment used to guide plan of care) dated 8/7/24, indicated Resident 1 ' s Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information) score was 6 out of 15, indicating severe cognitive impairment. During a phone interview on 12/4/24 at 9:48am with the Resident 1 ' s RP, the RP stated, he was not informed of the reason for Resident 1 ' s room change. During a concurrent observation and interview, on 12/17/24 at 2:01 p.m. with Social Services Assistant (SSA), the SSA flipped through a blue binder with Notification of Room Change forms. The SSA stated, they kept the filled-out forms in the binder. The SSA stated, the form was used to document the reason for the room change and who was notified. The SSA stated, Resident 1 ' s 7/17/24 Notification of Room Change form was not in the binder. During a follow up concurrent interview and record review on 12/17/24 at 3:15 p.m. with the SSA, Resident 1 ' s Admin Census dated 7/17/24 was reviewed. The Admin Census indicated, Resident 1 had an action code of RC. The SSA stated, the action code RC means room change. The SSD stated Resident 1 had a room change from room [ROOM NUMBER]-C to room [ROOM NUMBER]-B on 7/17/24. The SSD stated she was not aware that a written notice should be provided to the resident or RP for a room change. The SSA stated, she only called resident ' s RP on the phone to notify of room change. During an interview on 12/17/24 at 3:39 p.m. with Registered Nurse Supervisor (RNS), the RNS stated, they only provide verbal notification of room change to RP either personally when in the facility or via phone call. During a review of the facility ' s policy and procedure (P&P) titled Room Change/Roommate Assignment dated 5/17, indicated, 2. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., resident and their representatives) will be given advance notice of such change.; 3. Advance notice of a roommate change will include why the change is being made and any information that will assist with the roommate in becoming acquainted with his or her new roommate.

Based observation, interview, and record review, the facility failed to provide a comfortable and safe room temperature for three of 158 sampled residents (Residents 1, 2, and 3) when the room temperature for these residents was less than 71 degrees for over six hours. This failure resulted in an unhomelike environment and placed Resident 1, 2, and 3 at risk for loss of body heat and hypothermia (body's temperature drops dangerously low, usually due to prolonged exposure to cold temperatures). Findings: During a review of Resident 1 ' s Admission Record dated 12/4/24, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1 ' s Minimum Data Set( MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/4/2024, the MDS indicated Resident 1 had a Brief Interview of Mental Status (BIMS, a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15 ( A BIMS score of 15 is an indication of an intact cognitive status). During a concurrent observation and interview on 11/20/24, at 10:53 a.m., with Maintenance Director (MD), the MD conducted temperature check for Resident 1 ' s room. The surveyor observed the MD ' s digital infrared thermometer display indicate Resident 1 ' s room temperature was 67 degrees. Resident 1 stated, It ' s freezing. During a review of Resident 2 ' s Admission Record dated 12/4/24, the Admission Record indicated Resident 2 was admitted to the facility on [DATE]. During a review of Resident 2 ' s MDS assessment dated [DATE], the MDS assessment indicated Resident 3 had a BIMS score of 15. During a concurrent observation and interview on 11/20/24, at 10:55 a.m., with MD, the MD conducted temperature check for Resident 2 ' s room. The surveyor observed the MD ' s digital infrared thermometer display indicate Resident 2 ' s room temperature was 67 degrees. Resident 2 stated, It is very cold here; they give me blankets. During a review of Resident 3 ' s Admission Record dated 12/4/24, the Admission Record indicated Resident 3 was admitted to the facility on [DATE]. During a review of Resident 3 ' s MDS assessment dated [DATE], the MDS assessment indicated Resident 3 had a BIMS score of 15. During a concurrent observation and interview on 11/20/24, at 10:59 a.m., with MD, the MD conducted temperature check for Resident 3 ' s room. The surveyor observed the MD ' s digital infrared thermometer display indicate Resident 3 ' s room temperature was 66 degrees. Resident 3 stated she was freezing and had comforters brought in by family. Surveyor observed Resident 3 was covered in three layers of thick blankets. The MD stated resident rooms did not have hot air circulation outlets, and that the hot air circulation outlets were in the hallways. During an interview on 11/20/24, at 2:10 p.m., with the Administrator (ADMIN), Admin confirmed none of the resident rooms had hot air circulation outlets in the room, and that the hot air circulation outlets were located in every hallway. Admin stated he had asked the MD to raise the temperature and it would take more than a few hours to get the Resident room temperature between 71 and 81 degrees. During an interview on 11/20/24 at 2:20 p.m., with the Director of Staff Development (DSD), DSD stated she was aware of Resident ' s reports of being cold, and that the facility had provided Residents with extra blankets. DSD stated room temperature below 71 degrees could cause blood circulation issues and an uncomfortable environment. During an interview on 11/20/24 at 2:30 p.m., with the Director of Nursing (DON), DON stated many residents at the facility were older with multiple medical issues. DON stated cold room temperature could put residents at risk for hypothermia, hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). During a concurrent record review and interview on 11/20/24 at 2:40 p.m., with MD, the facility ' s temperature log titled Internal Building Temperature, dated 11/03/24 was reviewed, the log indicated eight of the 30 resident room had a recorded temperature of less than 71 degree. MD stated he was aware of the low temperature on the log and had not followed up on it. During a review of the facility ' s undated Policy and Procedure (P&P) titled, Internal Temperature of the facility, the P&P indicated, It is the policy of this facility to maintain the temperature of environment at the level that residents feel comfortable at all times. More Specifically, the facility maintains the temperature from 71 degree to 81 degree .

Based on interview, record review, document review, and facility policy review, the facility failed to complete a Level I preadmission screening and resident review (PASARR) for residents that remained in the facility on the 31st day of admission to the facility for two (Resident 116 and Resident 152) of six sampled residents reviewed for PASARR. The facility further failed to ensure a Level I Screening was accurate for one (Resident 96) of six sampled residents reviewed for PASARR. Findings included: 1. An Admission Record revealed the facility admitted Resident 116 on 09/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of anxiety disorder, schizoaffective disorder and post-traumatic stress disorder (PTSD). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/2024, revealed Resident 116 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident 116's care plan, included a problem statement initiated 09/30/2024, that indicated the resident admitted to the facility for short-term rehabilitation and had diagnoses to include anxiety, PTSD, gastroesophageal reflux disease, schizophrenia, hypothyroidism, and obesity. A letter from the California Department of Health Care Services dated 09/27/2024, revealed If the individual [Resident 116] remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day. Resident 116's medical record revealed no evidence to indicate a new Level I Screening was submitted on day 31 of the resident's admission to the facility. 2. An Admission Record revealed the facility admitted Resident 152 on 08/15/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of schizoaffective disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2024, revealed Resident 152 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident 152's care plan, included a problem statement initiated 08/15/2024, that indicated the resident had a condition of schizoaffective disorder. A letter from the California Department of Health Care Services dated 08/15/2024, revealed If the individual [Resident 152] remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day. Resident 152's medical record revealed no evidence to indicate a new Level I Screening was submitted on day 31 of the resident's admission to the facility. During a concurrent record review and interview on 10/31/2024 at 9:26 AM, the Administrator stated the Director of Nursing was responsible for ensuring the Level I PASARRs were completed, if required. The Administrator reviewed the medical record of Resident 116 and Resident 152 and stated he was unable to locate any further information of a new Level I Screening being completed after the residents remained in the nursing facility on the 31st day. The Administrator stated he was not aware of the requirement or the letter which indicated the PASARR was required. 39714 3. An Admission Record indicated the facility admitted Resident 96 on 08/11/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of schizophrenia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/20/2024, revealed Resident 96 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. S Resident 96's care plan, included a problem statement initiated 12/2023, that indicated the resident had a condition of schizophrenia. Resident 96's Preadmission Screening and Resident Review Level I Screening, dated 12/05/2023, revealed the resident did not have a serious diagnoses mental disorder such as depression disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. During an interview on 10/31/2024 at 9:24 AM, the Admission Director stated she made sure residents had a PASARR upon admission, but the nursing staff was responsible for reviewing the PASARR for accuracy. During an interview on 10/31/2024 at 9:40 AM, the Administrator confirmed that Resident 96's Level I Screening from 12/05/2023 was inaccurate as the resident had the diagnosis of schizophrenia prior to the Level I Screening. The Administrator stated it was the responsibility of the Director of Nursing to ensure the accuracy of PASARRs. A facility policy titled, Pre-Admission Screening and Resident Review (PASARR), revised 12/2006, revealed, Policy Statement All new admission and readmission are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review process. Policy Interpretation and Implementation 1. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD, unless the individual is admitted directly to the facility from a hospital where he or she received acute care, and Level I had been completed.

Based on interview, record review, and document review, the facility failed to ensure a significant change in status assessment (SCSA) Minimum Data Set (MDS) assessment was completed for one (Resident 78) of one sampled resident reviewed for hospice. Findings included: An Admission Record revealed the facility admitted Resident 78 on 06/14/2024. According to the Admission Record, the resident had a medical history that included diagnoses of cerebral infarction and Parkinson's disease. Resident 78's Order Summary Report that contained active orders as of 10/30/2024, revealed an order dated 10/15/2024, to admit the resident to hospice care. Resident 78's care plan, included a problem initiated 10/15/2024, that revealed the resident had limited life expectancy due to a terminal illness of cerebrovascular accident. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10//2024, specified, 03. Significant Change in Status Assessment (SCSA) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. Per the manual, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for six (Residents 13, 17, 60, 116, 148, and 157) of 32 sampled residents. Finding included: 1. An Admission Record revealed the facility admitted Resident 116 on 09/29/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of presence of cardiac pacemaker. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/2024, revealed Resident 116 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. According to the MDS, Resident 116 took an anticoagulant medication during the last seven days. Resident 116's Order Summary Report for the timeframe 09/29/2024 to 10/31/2024, revealed no evidence to indicate the resident had been prescribed an anticoagulant medication. During an interview on 10/31/2024 at 10:46 AM, the MDS Resource stated that after review of Resident 116's physician orders, he was unable to locate a physician order for an anticoagulant medication. The MDS Resource stated Resident 116's MDS was inaccurate. During an interview on 10/31/2024 at 12:56 PM, the Administrator stated a resident's MDS should be accurate and the MDS Resource was responsible for ensuring the accuracy of the MDS. 46258 2. An Admission Record revealed the facility admitted Resident 13 on 06/17/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/2024, revealed Resident 13 was not considered by the state level II preadmission screening and resident review process (PASARR) to have a serious mental illness and/or intellectual disability or a related condition. Per the MDS, the resident had active diagnoses to include anxiety disorder, depression, and bipolar disorder. During an interview on 10/31/2024 at 12:25 PM, the MDS Resource stated the level II PASARR should have triggered on the resident's MDS. During an interview on 10/31/2024 at 1:11 PM, the Administrator stated the level II PASARR should have been triggered on the MDS. The Administrator stated if the MDS was not correct, the facility would not know if they were providing the correct interventions. 3. An Admission Record revealed the facility admitted Resident 17 on 12/10/2010. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/05/2024, revealed Resident 17 was not considered by the state level II preadmission screening and resident review process (PASARR) to have a serious mental illness and/or intellectual disability or a related condition. Per the MDS, the resident had active diagnoses to include depression, bipolar disorder, and psychotic disorder. During an interview on 10/31/2024 at 12:25 PM, the MDS Resource stated the level II PASARR should have triggered on the resident's MDS. During an interview on 10/31/2024 at 1:11 PM, the Administrator stated the level II PASARR should have been triggered on the MDS. The Administrator stated if the MDS was not correct, the facility would not know if they were providing the correct interventions. 4. An Admission Record revealed the facility admitted Resident 148 on 06/06/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/13/2024, revealed Resident 148 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident 148 had an active diagnosis to include post-traumatic stress disorder (PTSD). A quarterly MDS, with an ARD of 09/13/2024, revealed Resident 148 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated Resident 148 did not have an active diagnosis of PTSD. During an interview on 10/31/2024 at 12:25 PM, the MDS Resource stated if Resident 148's PTSD was still active, it should be listed on the MDS. 5. An Admission Record revealed the facility admitted Resident 157 on 04/02/2024. According to the Admission Record, the resident had a medical history that included diagnoses of metabolic encephalopathy and sepsis. Resident 157's physician's order dated 07/25/2024, indicated the resident would discharge home on 08/02/2024. Resident 157's Nurses Notes, dated 08/02/2024, revealed the resident discharged home. A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/2024, revealed Resident 157 discharged to a short-term general hospital on 08/02/2024. During an interview on 10/31/2024 at 12:25 PM, the MDS Resource stated the MDS was not coded accurately. During an interview on 10/31/2024 at 1:11 PM, the Administrator stated he expected all MDS assessments to be accurate. 40141 6. An Admission Record indicated the facility admitted Resident 60 on 04/08/2020. According to the Admission Record, the resident had a medical history that included a diagnosis of paraplegia (the inability to voluntarily move the lower parts of the body). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/21/2024, revealed Resident 60 had no functional limitations in range of motion in their upper or lower extremities. During an interview on 10/31/2024 at 12:25 PM, the MDS Resource stated that according to the definition of paraplegia, the coding on the MDS did not make sense and it was either an inaccurate diagnosis or it was an inaccurate assessment. During a concurrent record review and interview on 10/31/2024 at 1:11 PM, the Administrator stated Resident 60 was paraplegic. The Administrator reviewed Resident 60's MDS and stated the MDS was not accurate because the resident was paraplegic. The Administrator stated he expected the MDS to be coded accurately. A facility policy titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, indicated, Any person completing a portion of the Minimum Data Set/MDS must sign and certify the accuracy of that portion of the assessment. The policy specified, 3. The information captured on the assessment reflects the status of the resident during the observation period for that assessment. Different items on the MDS may have different observation periods.

Based on interview, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed for one (Resident 148) of two sampled residents reviewed for mood/behavior. Findings included: An Admission Record revealed the facility admitted Resident 148 on 06/06/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of anxiety disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/13/2024, revealed Resident 148 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident 148 had an active diagnosis to include post-traumatic stress disorder (PTSD). Resident 148's comprehensive care plan, revealed no evidence of goals or approaches/interventions to manage the resident's diagnosis of PTSD. During an interview on 10/30/2024 at 2:47 PM, the Social Services (SS) staff person stated care plans were done by nursing and the social services department. She added it was her responsibility to create a care plan for Resident 148's diagnosis of PTSD. According to the SS staff person, the care plan would help staff know what Resident 148 needed to feel safe. During an interview on 10/31/2024 at 9:34 AM, the Administrator stated social services was responsible for care plans related to PTSD. The Administrator stated a care plan should have been created. The Administrator added that care plans were in place to help staff understand what a resident needed. A facility policy titled, Care Plans, Comprehensive, revised 12/2016, specified, 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.

Based on interview and record review, the facility failed to prevent medical device related pressure injury (injury to the skin and underlying tissues that results from prolonged pressure on the skin) from developing for one of one sampled resident (Resident 1) when Resident 1 ' s nephrostomy tube (a thin catheter that drains urine from the kidney into a bag) pressed onto Resident 1 ' s upper back skin. This failure resulted in Resident 1 developing pressure injury to the left upper back. Findings: During a review of undated Admission Record, printed on 8/22/24, the Admission Record indicated, Resident 1 was admitted in the facility on 5/21/24 with multiple diagnoses that included quadriplegia (symptom of paralysis that affects all four limbs and body from the neck down.) and hydronephrosis (swelling of one or both kidneys.). During a review of Resident 1's Minimum Data Set (MDS - an assessment tool used to direct resident care), dated 5/28/24, the MDS Section GG indicated Resident 1 was dependent (helper does all the effort. Resident does none of the effort to complete the activity.) with staff assistance to roll left and right on the bed. During a review of Resident 1 ' s Non-Pressure Sore Skin Problem Report, dated 5/21/24, the Non-Pressure Sore Skin Problem Report indicated, Resident 1 had a nephrostomy (an opening between the kidney and the skin.) located at the left lower back. During a review of Resident 1 ' s Situation, Background, Assessment, Recommendation (SBAR) record, dated 7/16/24, the SBAR indicated, Resident 1 was noted with redness on left upper back measuring 3.3 by 1.3 by 0 centimeters (cm) due to trauma lying on nephrostomy tube. The SBAR did not indicate the time the trauma was discovered. During a phone interview on 8/22/24 at 12:39 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 had a shear wound on the upper back but was unsure of the exact side. LVN 1 stated Resident 1 had a nephrostomy tube on the left lower back. LVN 1 stated Resident 1 was lying on the nephrostomy tubing which caused the wound. During a follow up interview on 9/24/24 at 2:39 p.m. with LVN 1, LVN 1 stated Resident 1 ' s skin on the left upper back had a mark of the plastic piece from the nephrostomy tubing when the skin injury was discovered. LVN 1 stated Certified Nursing Assistant (CNA) 2 was assisting her when the pressure injury was discovered. LVN 1 stated the injury could have been prevented by making sure Resident 1 was not lying on the nephrostomy tube. During an interview on 9/24/24 at 3:01 p.m. with CNA 1, CNA 1 stated taking care of Resident 1 on 7/15/24 but did not see the pressure injury. CNA 1 stated she wraps Resident 1 ' s nephrostomy tube with a towel or a pillowcase to prevent the tube from hanging on the side of the bed. During an interview on 9/24/24 at 3:12 p.m. with CNA 2, CNA 2 stated, she did not see Resident 1 ' s nephrostomy tube when she came in at 7:00 a.m. on 7/16/24 because she served resident ' s breakfast. CNA 2 stated she could not recall the time the pressure injury was discovered but thinks it was sometime before 12:00 p.m. because LVN 1 usually does her treatments before 12:00 p.m. During a review of Resident 1 ' s Non-Pressure Sore Skin Problem Report, dated 7/16/24, the Non-Pressure Sore Skin Problem Report indicated, preventive measure for Resident 1 ' s trauma on the left upper back was to monitor. During a review of Resident 1 ' s Skin Alteration-Non-Pressure Wound Care Plan, dated 7/16/24, the care plan indicated, preventive approach to make sure Resident 1 was not lying on the nephrostomy tube was not included in the plan of care.

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the facility Administrator and to California Department of Public Health (CDPH) within 2 hours, for one of three sampled residents (Resident 1), when Resident 1 alleged Certified Nursing Assistant 1 (CNA 1) slapped them in the face. This failure had the potential to cause a delay in investigations and affect physical and psychological well-being of Resident 1. A review of Resident 1's Admission Record printed 7/27/24, indicated Resident 1 was admitted to the facility in 2020 with multiple diagnosis including: Major Depressive Disorder, Single Episode (a serious mood disorder that can affect how a person feels, thinks, and behaves). During an interview on 7/9/24, at 2:35 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 4/7/24 at around 10:00 a.m., Resident 1 told them CNA 1 hit them in the face in the morning. LVN 1 stated Resident 1 had redness on their face. LVN 1 stated they did not report the alleged abuse or complete and submit a Report of Suspected Dependent Adult/Elder Abuse (SOC 341), to the Administrator, CDPH, the ombudsman or law enforcement. LVN 1 stated they completed the SOC 341 sometime after 3:00 p.m. and gave it the nurse on the next shift. LVN 1 stated their policy was to report abuse allegations immediately and within 2 hours to the Administrator, CDPH, ombudsman, law enforcement, physician, and family so the allegations could be investigated immediately. During an interview on 7/9/24, at 4:20 p.m. with Director of Nursing (DON), DON stated Resident 1's SOC 341 was done late. DON stated their policy was to report alleged abuse to the Administrator, CDPH, the ombudsman and to law enforcement, immediately or within 2 hours and it was important so the alleged abuse could be investigated right away, residents could be assessed and for resident safety. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 4/7/24, the SBAR indicated, Per Resident interview at around 10:00 a.m. while administering medications to the resident, she stated that CNA assigned to her ' Slapped me in my face.' During a review of Resident 1's SOC 341, dated 4/7/24, the SOC 341 indicated it was completed and faxed on 4/7/24 at 6:10 p.m. During a review of the facility's policy and procedure (P&P) titled, Abuse Allegation/Incident Reporting, updated 2/10/19, the P&P indicated, Please note that as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . to the Administrator/Abuse Coordinator or designee and to other officials (including to the State Survey Agency, local law enforcement entity, local Ombudsman, and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .

Based on observation, interview and record review, the facility failed to protect residents in the facility from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked one resident (Resident 1) in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing Resident 1 to cry out. The facility failed to protect 16 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) assigned to CNA1, from possible physical abuse when the Administrator (ADM) returned CNA1 to direct care duty before completion of a thorough abuse investigation, including interviewing all witnesses. CNA1 was permitted to have access to Resident 1 and continued to work with other vulnerable residents. This failure resulted in Resident 1 crying out in pain, hyperventilating (breathing rapidly) and visibly shaking, and had the potential to result in further physical abuse towards Resident 1 and/or other vulnerable residents under CNA1's care. An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) was identified and called due to the failure of the facility to protect residents from further abuse by returning CNA1 to direct care duty before completion of a thorough abuse investigation. The ADM was verbally notified of the IJ situation on 5/14/24 at 6:09 p.m. During a visit to the facility on [DATE], the facility provided an acceptable plan of action and the IJ was removed at 12:59 p.m. Findings: During an interview with the Director of Nursing (DON) on 5/13/24 at 3:33 p.m., DON stated the alleged abuse towards Resident 1 occurred on 5/8/24 at approximately 6:00 p.m. in the hallway outside of room [ROOM NUMBER], which is located at Nursing Unit 1. DON stated CNA1 allegedly sat Resident 1 down forcefully in her wheelchair. DON stated Licensed Vocation Nurse 1 (LVN1) witnessed the incident and felt that CNA1 handled Resident 1 roughly. DON stated LVN1 reported the alleged abuse to ADM on 5/8/24. DON stated CNA1 was suspended by ADM on 5/8/24 and returned to duty on 5/10/24 after the facility completed an abuse investigation. DON stated the abuse allegation towards Resident 1 was unsubstantiated. During a concurrent interview and record review on 5/13/24 at 3:35 p.m. with the DON and Assistant Administrator (AA), the facility's undated Investigative Summary document, pertaining to Resident 1's abuse investigation, was reviewed. The Investigative Summary showed .upon completion of investigation, she [CNA1] was re-educated by D.S.D. [Director of Staff Development] and is returning to her PM shift today following her suspension. DON and AA confirmed the Investigative Summary was completed on 5/10/24 at 2:32 p.m. During an interview with the DSD on 5/13/24 at 3:58 p.m., DSD stated CNA1 reported to work on 5/10/24 and worked both the AM and PM shifts on Nursing Unit 1. DSD also stated CNA1 is scheduled to work on Nursing Unit 1 today. During a concurrent interview and record review on 5/13/24 at 5:33 p.m. with the DON, the facility's undated Investigative Summary document and Resident 1's Interdisciplinary Team [IDT] Conference Record document dated 5/9/24 were reviewed. The Investigative summary showed .Interventions: 7. IDT performed post-incident 72 hour assessment . The Interdisciplinary Team Conference Record did not show that an IDT post-incident 72 hour assessment had been completed. The DON confirmed that the Interdisciplinary Team Conference Record did not show that an IDT post-incident 72 hour assessment had been completed. During a concurrent interview and record review on 5/13/24 at 5:38 p.m. with the DON, CNA1's timecard dated 5/13/24, was reviewed. The DON confirmed the timecard showed CNA1 worked at the facility on 5/10/24 from 6:58 a.m. until 11:28 p.m. During an interview with ADM on 5/13/24 at 5:40 p.m., ADM stated on 5/8/24, around 6:30 p.m., LVN1 called him to report that she had witnessed CNA1 poke Resident 1 in the cheek and then CNA1 forcefully sat Resident 1 down in her wheelchair. ADM stated that he spoke with CNA1 on 5/8/24 around 6:40 p.m. about the alleged abuse toward Resident 1. ADM stated CNA1 told him that she helped Resident 1 sit down in her wheelchair because she was falling. ADM stated CNA1 told him she had applied A&D ointment (Vitamin A&D ointment, a medicated ointment used to protect skin) to Resident 1's face after she was seated in her wheelchair. ADM stated CNA1 was suspended on 5/8/24 and returned to duty on 5/10/24 after the he completed Resident 1's abuse investigation. ADM then stated Resident 1's abuse allegation was unsubstantiated. During an interview with LVN1 in the Medication Room located at Nursing Unit 2 on 5/14/23 at 4:19 p.m., LVN1 stated she was working at Nursing Unit 1 on 5/8/24 during the PM shift. LVN1 stated she was doing her medication pass around 6:00 p.m. at room [ROOM NUMBER]. LVN1 stated CNA1 was sitting in a chair next to Resident 1, who was sitting in her wheelchair in the hallway outside of room [ROOM NUMBER]. LVN1 stated CNA1 got up to help pass out dinner trays to the Nursing Unit 1 residents. LVN1 stated Resident 1 then stood up. LVN1 stated CNA1 helped Resident 1 sit back down in her wheelchair. LVN1 stated Resident 1 stood up again and CNA1 yanked Resident 1 down into her wheelchair. LVN1 stated CNA1 began yelling at Resident 1 in Tagalog (a language spoken by people of Filipino decent) and CNA1 then poked Resident 1 in the right cheek. LVN1 stated Resident 1 then swatted CNA1's hand away from her face. LVN1 stated CNA1 then smacked Resident 1 in the hand. LVN1 stated she also heard the smack to Resident 1's hand. LVN1 stated Resident 1 stood up again and CNA1 then grabbed Resident 1 by her pants and slammed her back down in her wheelchair. LVN1 stated Resident 1 yelped out in pain after being slammed down in her wheelchair by CNA1. LVN1 stated she told CNA1 to stop because her actions were abusive. LVN1 stated she then calmed Resident 1 down and assessed her condition. LVN1 stated she then called the Nurse Consultant (NC) and ADM to report the abuse she had witnessed. During a record review on 5/14/24 at 4:34 p.m. at Nursing Unit 1, the facility's document titled [NAME] Work Assignment dated 5/14/24 showed CNA1 was assigned to care for 10 residents (Residents 4, 5, 8, 9, 10, 11, 13, 14, 15,16) during the AM shift and 10 residents (Residents 6, 7, 10, 11, 12, 13, 14, 15, 16) including Resident 1 during the PM shift. During an interview with CNA1 at Nursing Unit 1 on 5/14/23 at 4:36 p.m., CNA1 stated on 5/8/24 around 6:00 p.m., she was sitting next to Resident 1 in the hallway outside of room [ROOM NUMBER]. CNA1 stated Resident 1 got up from her wheelchair and attempted to sit in her chair. CNA1 stated she then helped Resident 1 sit back down in her wheelchair. CNA1 stated once Resident 1 was seated in her wheelchair, she applied A&D ointment to Resident 1's face because she had dry skin. CNA1 stated no other physical contact was made with Resident 1 other than to apply the A&D ointment to her face. During an observation on 5/14/24 at 6:24 p.m. at Nursing Unit 1, CNA1 was observed entering Resident 13 and Resident 14's room and performed patient care. During an observation on 5/14/24 at 7:18 p.m. at Nursing Unit 1, the DON was observed interviewing 11 residents (Residents 2, 3, 6, 7, 10, 12, 13, 14, 16, 17, 18) about the abuse incident that occurred on 5/8/24 towards Resident 1. During a concurrent interview and record review on 5/16/24 at 2:50 p.m. with the Medical Records Director (MRD), CNA1's timecard dated 5/15/24, was reviewed. The MRD confirmed the timecard indicated CNA1 worked at the facility on 5/14/24 until 6:49 p.m. During a telephone interview with LVN2 on 5/17/24 at 11:30 a.m., LVN2 stated she was using restroom [ROOM NUMBER] located adjacent to Nursing Unit 1 on 5/8/24 at approximately 6:00 p.m. LVN2 stated she heard two screams that sounded gut-wrenching, fearful and painful coming from Nursing Unit 1. LVN2 stated she exited the restroom and ran to Nursing Unit 1. LVN2 stated Resident 1 was standing in the hallway outside of room [ROOM NUMBER] hyperventilating (breathing rapidly) and visibly shaking. LVN2 stated she then asked LVN1 what had happened. LVN2 stated LVN1 told her that she witnessed CNA1 poke Resident 1 in the right cheek, smack Resident 1 in the hand and slam Resident 1 down into her wheelchair. LVN2 stated she called NC at 6:15 p.m. to report the screams she heard. During review of an additional undated document titled Summary of Investigation received on 5/15/24 at 6:57 p.m., the Summary of Investigation showed .Interventions/Plan of Action: .The facility completed their preliminary summary of investigation and continued their investigation and decided to bring back the certified nursing assistant . During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure on Patient Abuse Allegation Investigation dated October 2019, the P&P showed, .Policy: .The facility shall ensure thorough and extensive investigation of different types of incidents including but not limited to those that may constitute abuse .e: Thorough investigation shall include: .Suspend staff if he/she is the alleged perpetrator pending final and thorough investigation .

Based on observation, interview, and record review, the facility failed to keep one of three residents (Resident 1) free from physical abuse when Certified Nursing Assistant 1 (CNA1) deliberately poked Resident 1 in the right cheek, smacked Resident 1 in the hand and then forced Resident 1 down in her wheelchair causing her to cry out. This abuse resulted in Resident 1 crying out in pain, hyperventilating (breathing rapidly) and visibly shaking, and had the potential to instill fear in Resident 1 which could result in psychosocial harm. This abuse also had the potential to result in further physical abuse towards Resident 1 and/or other vulnerable residents under CNA1 ' s care. (Cross Reference F610) Findings: During a review of Resident 1's Admission Record dated 5/13/24, the Admission Record showed Resident 1 was admitted to the facility on [DATE] and primarily spoke Tagalog (a language spoken by people of Filipino descent) for communication. During a record review of Resident 1's Admission Minimum Data Set (MDS- An assessment tool to guide care) assessment dated [DATE], MDS assessment showed Resident 1 required partial assistance from another person when walking from room to room. The MDS assessment showed Resident 1 had active diagnoses of Alzheimer's Disease (a disease that affects memory, thinking and behavior), Non-Alzheimer ' s Dementia (memory loss) and difficulty walking. During an interview with the Director of Nursing (DON) on 5/13/24 at 3:33 p.m., DON stated the alleged abuse towards Resident 1 occurred on 5/8/24 at approximately 6:00 p.m. in the hallway outside of room [ROOM NUMBER], which is located at Nursing Unit 1. DON stated CNA1 allegedly sat Resident 1 down forcefully in her wheelchair. DON stated Licensed Vocation Nurse 1 (LVN1) witnessed the incident and felt that CNA1 handled Resident 1 roughly. During an interview with the Administrator (ADM) on 5/13/24 at 5:40 p.m., ADM stated on 5/8/24, around 6:30 p.m., LVN1 called him to report that she had witnessed CNA1 poke Resident 1 in the cheek, smack Resident 1 in the hand and then forcefully sit Resident 1 down in her wheelchair. ADM stated that he spoke with CNA1 on 5/8/24 around 6:40 p.m. about the alleged abuse toward Resident 1. ADM stated CNA1 told him that she helped Resident 1 sit down in her wheelchair because she was falling. ADM stated CNA1 told him she had applied A&D ointment (Vitamin A&D ointment, a medicated ointment used to protect skin) to Resident 1 ' s face after she was seated in her wheelchair. During an interview with LVN1 in the Medication Room located at Nursing Unit 2 on 5/14/23 at 4:19 p.m., LVN1 stated she was working at Nursing Unit 1 on 5/8/24 during the PM shift. LVN1 stated she was doing her medication pass around 6:00 p.m. at room [ROOM NUMBER]. LVN1 stated CNA1 was sitting in a chair next to Resident 1, who was sitting in her wheelchair in the hallway outside of room [ROOM NUMBER]. LVN1 stated CNA1 got up to help pass out dinner trays to the Nursing Unit 1 residents. LVN1 stated Resident 1 then stood up. LVN1 stated CNA1 helped Resident 1 sit back down in her wheelchair. LVN1 stated Resident 1 stood up again and CNA1 yanked Resident 1 down into her wheelchair. LVN1 stated CNA1 began yelling at Resident 1 in Tagalog (a language spoken by people of Filipino decent) and CNA1 then poked Resident 1 in the right cheek. LVN1 stated Resident 1 then swatted CNA1 ' s hand away from her face. LVN1 stated CNA1 then smacked Resident 1 in the hand. LVN1 stated she also heard the smack to Resident 1 ' s hand. LVN1 stated Resident 1 stood up again and CNA1 then grabbed Resident 1 by her pants and slammed her back down in her wheelchair. LVN1 stated Resident 1 yelped out in pain after being slammed down in her wheelchair by CNA1. LVN1 stated she told CNA1 to stop because her actions were abusive. LVN1 stated she then calmed Resident 1 down and assessed her condition. LVN1 stated she then called the Nurse Consultant (NC) and ADM to report the abuse she had witnessed. LVN1 stated she submitted a written statement to ADM about the abuse incident toward Resident 1 that she had witnessed. LVN1 stated ADM told her to take out the part where CNA1 poked Resident 1 in the cheek and smacked her in the hand because it made CNA1 look bad. LVN1 stated she then re-wrote her statement because she was afraid of being retaliated against by ADM. During an interview with CNA1 at Nursing Unit 1 on 5/14/23 at 4:36 p.m., CNA1 stated on 5/8/24 around 6:00 p.m., she was sitting next to Resident 1 in the hallway outside of room [ROOM NUMBER]. CNA1 stated Resident 1 got up from her wheelchair and attempted to sit in her chair. CNA1 stated she then helped Resident 1 sit back down in her wheelchair. CNA1 stated once Resident 1 was seated in her wheelchair, she applied A&D ointment to Resident 1 ' s face because she had dry skin. CNA1 stated no other physical contact was made with Resident 1 other than to apply the A&D ointment to her face. During a review of Resident 1's Order Summary Report dated 5/15/24, the Order Summary Report did not show that there was an active doctor ' s order to apply A&D ointment to Resident 1 ' s face. During a telephone interview with the Police Officer (PO) on 5/16/24 at 2:24 p.m., PO stated he received a call for service from police dispatch (a team that works together to take emergent and non-emergent calls) on 5/8/24 around 6:00 p.m. to take a report regarding an alleged abuse incident that had occurred at the nursing facility. PO stated he arrived at the nursing facility on 5/8/24 at around 11:00 p.m. and proceeded to Nursing Unit 1. PO stated he spoke with LVN1 who witnessed the alleged abuse incident. PO stated LVN1 told him that she had called CNA1 over to watch Resident 1 because Resident 1 is a fall risk and she has severe dementia. PO stated LVN1 told him Resident 1 got up from her wheelchair and CNA1 helped Resident 1 sit back down. PO stated LVN1 told him that Resident 1 then stood up again and CNA1 forcefully sat Resident 1 back down in her wheelchair. PO stated LVN1 told him that CNA1 began speaking to Resident 1 in Tagalog. PO stated LVN1 told him that CNA1 then poked Resident 1 in the face. PO stated LVN1 told him Resident 1 then swatted CNA1's hand away from her face. PO stated LVN1 told him CNA1 then smacked Resident 1 ' s hand and Resident 1 yelped. PO stated LVN1 told him Resident 1 then stood up again. PO stated LVN1 told him CNA1 then stood in front of Resident 1 and slammed her back down into her wheelchair causing Resident 1 to yelp out in pain. PO stated LVN1 told him that she sent CNA1 off Nursing Unit 1 after the incident. PO stated after writing down LVN1 ' s statement, he attempted to call ADM three times, but the calls were not answered. PO stated he also interviewed LVN2 on 5/8/24. PO stated LVN2 stated she was using a restroom adjacent to Nursing Unit 1 at the time of the alleged abuse. PO stated LVN2 told him that she heard a gut-wrenching scream coming from Nursing Unit 1. PO stated LVN2 told him that she ran to Nursing Unit 1 after hearing the scream. PO stated he returned to the nursing facility the next morning on 5/9/24 at around 9:00 a.m. to finish interviewing witnesses and to check on Resident 1. PO stated he then spoke with ADM about the alleged abuse incident that occurred the previous night on 5/8/24. PO stated ADM gave him LVN1 ' s written witness statement from 5/8/24 regarding Resident 1 ' s alleged abuse. PO stated that he read LVN1 ' s written statement, but it was vague (not clear) and different than the verbal statement she had given him previously. PO stated he then re-interviewed LVN1. PO stated LVN1 admitted that ADM told her to rewrite her statement because it looks bad. PO stated LVN2 ' s statement corroborated (confirmed) LVN1 ' s original verbal statement. During a telephone interview with LVN2 on 5/17/24 at 11:30 a.m., LVN2 stated she was using restroom [ROOM NUMBER] located adjacent to Nursing Unit 1 on 5/8/24 at approximately 6:00 p.m. LVN2 stated she heard two screams that sounded gut-wrenching, fearful and painful coming from Nursing Unit 1. LVN2 stated she exited the restroom and ran to Nursing Unit 1. LVN2 stated Resident 1 was standing in the hallway outside of room [ROOM NUMBER] hyperventilating (breathing rapidly) and visibly shaking. LVN2 stated she then asked LVN1 what had happened. LVN2 stated LVN1 told her that she witnessed CNA1 poke Resident 1 in the right cheek, smack Resident 1 in the hand and slam Resident 1 down into her wheelchair. During a review of the facility ' s P&P titled, Policy and Procedure on Patient Abuse Allegation Investigation dated October 2019, the P&P showed, .Policy: The facility shall uphold resident ' s right to be free from any form of verbal, sexual, physical, and mental abuse . During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights dated April 2019, the P&P showed, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation: .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .c: be free from abuse, neglect, misappropriation of property, and exploitation . During a review of the facility ' s document titled Resignation dated 5/14/24, the Resignation document showed, Effective today May 14, 2024 I am resigning as CNA. The Resignation document was signed by CNA1.

Based on observation, interview, and record review, the facility failed to ensure a safe and functional environment for residents and staff when: 1. Sliding doors in multiple residents' rooms did not have a working lock. 2. Screen doors in all resident's rooms did not have locks. This failure had the potential to result in residents and staff being unsafe from neighborhood crimes such as theft and physical assault because of unlocked doors. Findings: During an observation and concurrent interview on 5/1/24 at 10:59 a.m. with Resident 1 in Resident 1's room, Resident 1 stated the screen door did not have a lock. Resident 1's sliding door was left ajar, there were multiple personal items at the bedside that included a motorized scooter and a big manual wheelchair that was placed inside the closet. During an observation and concurrent interview on 5/1/24 at 11:31 a.m. with Maintenance Director (MD), the sliding doors in the residents' rooms were inspected. MD stated all screen doors inside all residents' rooms did not have a locking mechanism. MD stated screen doors need to have locks so that residents could feel safe leaving the sliding door open for fresh air during the summer. There were six (room [ROOM NUMBER], 214, 217, 218, 219, 221) out of 20 resident rooms in the Fernside Station that did not have locks or had malfunctioning locks on the sliding doors. Multiple rooms in Fernside Station had sliding doors that led to a public parking lot and a commercial shopping center. During an interview on 5/1/24 at 11:55 a.m. with Resident 2, who was one of the occupants of the above-mentioned rooms, Resident 2 stated having mentioned this concern to one of the facility management staff who simply brushed off the concern. Resident 2 stated she wanted to make sure the sliding door was locked, especially at night. During an interview on 5/2/24 at 1:35 p.m. with Resident 3, Resident 3 stated asking the staff to make sure the sliding door was always locked especially at night. Resident 3 also stated it would be very scary if the sliding door was not locked. During a review of the three residents' clinical record, the clinical records indicated: 1. Resident 1 was admitted to the facility in January 2024 with diagnoses that included difficulty walking, seizures (episodes of uncontrolled and abnormal firing of brain cells that can cause physical changes in attention or behavior such as uncontrollable shaking with rapid and rhythmic body movements), dyspnea, and depression (persistent feeling of sadness and loss of interest). Resident 1's Minimum Data Set (MDS,a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 2/1/24, indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score of 14 out of 15 indicating an intact cognitive status. 2. Resident 2 was admitted to the facility in September 2023 with diagnoses that included morbid obesity, muscle weakness, and need for assistance with personal care. Resident 2's MDS, dated [DATE], indicated a BIMS score of 15. 3. Resident 3 was admitted to the facility in January 2022 with diagnoses that included anxiety disorder (excessive feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), osteoporosis (condition in which bones become weak and brittle) and history of falling. Resident 3's MDS, dated [DATE], indicated a BIMS score of 9, indicating moderate cognitive impairment. During an interview on 5/1/24 at 1:32 p.m. with Licensed Vocational Nurse (LVN), LVN stated sometimes the sliding doors were very hard to close and open because they would get stuck on the runners. When asked how the staff would ensure residents' safety with sliding doors that were not locked, LVN stated That is a very good question. During an interview and concurrent record review on 5/1/24 at 1:49 p.m. with MD, MD stated he did not have a record that regular inspection of all the resident rooms and doors were done for maintenance. MD stated inspection of resident rooms, making sure door locks were working and in good working condition should have been made the priority when MD started working for the facility in February 2024. MD stated it was not safe for the residents to be in the room that were not locked from the inside especially at night. During a review of the facility's policy and procedure (P&P) titled General Maintenance, last revised 2/1/11, the P&P indicated under Daily Inspections, All resident rooms will be checked on, at least, a monthly basis to assure that equipment is in proper operating condition. A portion of resident rooms shall be checked on a daily basis to assure each room has been checked at least once a month. Checks of resident rooms shall include: .Window Screens. All the screen doors and screens on windows shall be checked to see that they are not torn, bent or off their runners, and that a protective barrier is maintained .Doors and Closets. Checked to assure in proper operating condition and latch securely.

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report an alleged abuse allegation to the California Department of Public Health (CDPH) within two hours, for two of three sampled residents (Resident 1 and 2), when Resident 1 and Resident 3 allegedly hit each other, and Resident 2 alleged Certified Nursing Assistant 1 (CNA 1) hit him on the side of his stomach. These failures had the potential to cause a delay in investigations and affect physical and psychological well-being of residents. Findings: A review of Resident 1's Admission Record printed 1/16/24, indicated Resident 1 was admitted to the facility in 2021 with a diagnosis of Pneumonia (lung inflammation caused by bacterial or viral infection). A review of Resident 2's Admission Record printed 2/23/24, indicated Resident 2 was admitted to the facility in 2023 with a diagnosis of End Stage Renal Disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body's needs). During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR), dated 12/12/23, the SBAR indicated, Resident 1 had a physical altercation with Resident 3 at 10:40 a.m., on 12/12/23. During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR), dated 2/11/24, 6:20 p.m., the SBAR indicated, CNA 1 allegedly hit Resident 2. During a concurrent interview and record review on 3/28/24, at 1:16 p.m., with Director of Nursing (DON), Resident 1's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 12/12/23 and Resident 2's Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 2/12/24 were reviewed. Resident 1's SOC 341 indicated, Resident 1 and Resident 3 were hitting each other this morning. Resident 1's SOC 341 indicated it was faxed to CDPH at 4:25 p.m., on 12/12/23. DON stated Resident 1's SOC 341 was reported hours late. Resident 2's SOC 341 indicated, Resident 2 was hit on the side of their stomach by CNA 1. Resident 2's SOC 341 indicated it was faxed to CDPH at 12:33 p.m., on 2/12/24. DON stated Resident 2's SOC 341 was reported a day late. DON stated all abuse incidents should have been reported immediately and within two hours of the incident. DON stated all staff are mandated reporters and staff should have turned in the SOC 341. DON stated it was important to turn in the SOC 341 on time to prevent future abuse incidents. During a review of the facility's policy and procedure (P&P) titled, Abuse Allegation/Incident Reporting, updated 2/10/19, the P&P indicated, Please note that as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made . to the Administrator/Abuse Coordinator or designee and to other officials (including to the State Survey Agency, local law enforcement entity, local Ombudsman, and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .

Based on observation, interview, and record review, the facility failed to ensure a licensed nurse (LVN) monitored one of three residents (Resident 1) to ensure all the resident ' s prescribed medications were ingested. This failure had the potential for Resident 1 to not receive the medications as prescribed and had the potential to result in the ingestion of the medications by an unauthorized person. Findings: During a review of the Admission Record, dated April 6, 2023, it indicated Resident 1 had a diagnosis to include gout (painful form of arthritis, swollen joint). During an observation and interview on 4/6/23 at 10:15 A.M., Resident 1 was sitting up in her bed under the covers with the head of bed elevated. On Resident 1 ' s bedside table there was a medication cup with multiple tablets. Resident 1 stated the nurse left the pills for her to take after the medication under her tongue dissolved. Resident 1 stated she took her pills without help. Resident 1 stated there were nine pills in the medication cup. During an interview on 4/6/23 at 11:08 A.M., with the Licensed Vocational Nurse (LVN), LVN stated she had given Resident 1 suboxone-a pain medication that needed to dissolve slowly under the tongue. The LVN stated she left the pills because Resident 1 preferred to wait for the suboxone to dissolve before taking the rest of her medications. LVN stated Resident 1 preferred to wait until her pain medication (suboxone- an opioid, film taken under the tongue that dissolves in 4-8 minutes) had dissolved. LVN stated Resident 1 was allowed to self-administer her own medications. LVN stated Resident 1 ' s assessment for self administration was in Resident 1 ' s medical record. During a review of the Medication Administration Record (MAR), Resident 1's oral prescription medications, scheduled on 4/6/23 for 9:00 a.m. were: two capsules of Duloxetine (a medication given for depression), and one tablet of allopurinol (for treatment of gout). During an interview on 4/6/23 at 11:53 A.M., with the Director of Nursing (DON), the DON stated she had reviewed the medical record for Resident 1. The DON stated Resident 1 had not been assessed for self-administration of medications, nor did Resident 1 have a physician order to self-administer medications. The DON stated Resident 1 did not meet the facility criteria for self-administration of medications. Review of the facility policy and procedure (PNP) titled, Preparation and General Guidelines for Medication Administration, undated, the PNP indicated, 4. Medications are administered at the time they are prepared . 5. Administered without interruptions . 6. The person who prepares the dose for administration is the person who administers the dose . 11. Residents allowed to self-administer when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications, and . 15. The resident is always observed after administration to ensure that the dose was completely ingested .

Based on observation, interview, and record review the skilled nursing facility (SNF) failed to establish a policy and procedure that permits residents to return to the SNF after a stay in the acute care hospital (ACH). The SNF's policy stated it would discharge residents after 30 days. Resident 1 was not permitted to return to the SNF from the ACH when a bed became available. Resident 1 was ready to return to the facility on [DATE]. Resident 1 has been in the ACH for over 30 days. This failure resulted in psychological harm and distress to Resident 1 who has lived in the SNF for over eight years and called it his home. Resident 1 made repeated phone calls to the State Agency upset and request information on when he would be returning to the SNF. Findings: The Department received a complaint on 9/16/20 regarding the SNF refusing to readmit Resident 1 from the ACH. Resident 1 called the Department on 9/18/20 stating he wanted to know when he could go back to his SNF. On 9/22/20 at 12:56 p.m. Resident 1 called again, he was upset and demanded to know when he could go back. Resident 1 called on 9/23/20 at 11:34 a.m. wanting to know dates when he was going back to the SNF. During a phone conversation with Resident 1 on 10/12/20 at 2:25 p.m. Resident 1 wanted to know what was happening with his appeal (Resident 1 requested a hearing with the State's appeal unit). A review of Resident 1's medical record, the Minimum Data Set, (MDS, an assessment tool), dated 7/30/20, indicated Resident 1 was originally admitted to the SNF 3/9/12. During a review of Section C 0500 of the MDS, it indicated Resident 1 has a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) of 15, cognitively intact. Review of Sections D and E indicated Resident 1 did not exhibit mood or behavioral problems. According to Section I of the MDS, Resident 1 has [DIAGNOSES REDACTED]. Review of Section G Functional Status of the MDS indicated Resident 1 is totally dependent needing two persons to assist to transfer, and one person assist for dressing, eating, toilet use, and personal hygiene. Resident 1 is able to independently move around with the use of a motorized wheelchair. During a review of the nurse's note dated 9/8/20, Resident 1 was transported to the ACH due to unresponsiveness and low blood pressure. During an interview with the Administrator (ADM), on 9/17/20 at 11:00 a.m., ADM stated there were no available beds for Resident 1. ADM stated the ACH had been advised and Resident 1 would be readmitted to the SNF on 9/22/20. During an interview with the DON on 9/17/20 at 11:05 a.m., DON stated the facility had not initiated a discharge and Resident 1 was eligible for a seven-day bed hold. DON stated Resident 1's admission had been greater that seven days so he would get the first available bed. During a review of Resident 1's Admission Agreement at the SNF dated 4/8/12, Resident 1 was eligible for a seven-day bed hold. The document indicated, .If you are away from out facility for more than seven days due to hospitalization or other medical treatment we will readmit you to the first available bed in a semi-private room if you need the care provided by our facility and wish to be readmitted . During a telephone interview with Resident 1 on 9/21/20 at 4:11 p.m., Resident 1 stated he had been told he was not going back to the facility on [DATE]. During a telephone interview with DON on 9/21/20 at 4:20 p.m., DON stated they would take Resident 1 back on 9/25/20. During a telephone interview with DON on 9/28/20 at 10:53 a.m., DON stated Resident 1 had not returned to the facility. During an onsite visit and observation on 9/28/20 at 3:00 p.m., observed room [ROOM NUMBER] was unoccupied with two beds available. Empty male beds were noted in rooms 103B, 105A, 108A, 112A, 114B, 115A, 305A and 305B. During an interview with Resident 1 on 9/29/20 at 1:15 p.m., Resident 1 stated it has been very difficult for him not being home. Resident 1 stated he is unable to have visitors in the hospital and there is no one to even have a conversation with. Resident stated he felt very isolated. During an interview with ADM on 9/29/20 at 3:19 p.m., ADM stated Resident 1 had not returned to the facility because there was no bed. ADM stated, It's a very complicated situation. During a review of the IDT Discharge Planning Notes dated 9/30/20 at 1:00 p.m., the Interdisciplinary Team (IDT) noted the SNF has gone out of it's way to provide for all his needs despite his being verbally abusive, threatening behavior, and multiple complaints against staff members, but it appears it is never enough as he continues to call the state repeatedly with complaints and to complain about the care given by staff who have provided excellent care to our residents over the course of many years. The IDT expressed that his demands are beyond the capacity of any nursing home and the IDT believes that this facility cannot meet his needs and should not be readmitted to the facility. During a phone interview between the District Manager (DM) in the State Agency local office and the DON on 9/30/20 at 1:23 p.m., DON stated We told ACH today that we will not readmit Resident 1 due to his non-compliance with our rules. His behavior is consistently threatening with the staff. He threatens to have their licenses taken away by the State. During an interview with Patient Care Coordinator (PCC), at ACH on 9/30/20 at 3:00 p.m., PCC stated the SNF has continued to refuse to readmit Resident 1. PCC stated her staff has documented in his chart and she has made multiple phone calls herself. PCC attempted to call on the following dates and times: Friday 9/25/20: 10:30 AM Friday 9/25/20: 12:08 PM Friday 9/25/20: 12:21 PM Friday 9/25/20: 3:17 PM Monday 9/28/20: 8:37 AM Tuesday 9/29/20: 1:20 PM Wednesday 9/30/20: 2:21 PM PCC stated the ADM and DON have not returned her calls. During a review of the Discharge Planner notes from ACH dated 9/16/20, 9/18/20, 9/19/20, 9/20/20, 9/21/20, 9/23/20, 9/25/20, 9/26/20, 9/27/20, 9/28/20 and 9/30/20, the notes indicated Resident 1 is medically cleared with a discharge order since 9/14/20 and unable to return to the facility due to no available bed. During a review of the Acute Care Psychology consult dated 10/7/20, the Psychologist (PsyD) noted that Resident 1 was experiencing distress due to not previous facility not taking him back. PsyD discussed coping strategies and planned to follow up and continue to provide treatment for [REDACTED]. During an interview with Admissions Coordinator (AC) on 10/6/20 at 11:00 a.m., the AC stated the SNF issued a discharge notice dated 10/2/20 to Resident 1. The AC stated since Resident 1 is still in the ACH, it was mailed to him there. During a review of the discharge notice dated 10/2/20, it indicated Resident 1 was discharged because it was necessary for his welfare and his needs could not be met in the SNF; and the safety of individuals in the SNF was endangered due to the clinical or behavioral status of Resident 1. During a review of the Readmission to the Facility Policy, dated 3/2017, the policy indicated, A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident: a. Requires the services provided by the facility; b. Meets the admission criteria as outlined in facility policy; c. Was not discharged for any reason outlined in the Transfer or Discharge Notice policy; and d. Is eligible for Medicaid nursing facility services. It further indicated that if it is determined that a resident who was transferred with an expectation that he or she will return cannot return to the facility, he or she will be discharged according to the discharge policy. During a review of the Transfer or Discharge Notice Policy, dated 3/2017, the policy indicated that a resident will be given a 30-day advance notice of an impending transfer or discharge. It further indicated that under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; f. An immediate transfer or discharge is required by the resident's urgent medical needs; g. The resident has not resided in the facility for 30 days; and/or h. The facility ceases to operate.

Based on interview and record review, the facility failed to provide one of four residents (Resident 1) with enough fluids to avoid dehydration (a condition of decreased body water that results in weight loss, body chemical imbalance, and can lead to organ failure and death if not corrected). For Resident 1, this failure resulted in a five day hospitalization to treat [MEDICAL CONDITION] (high sodium in the blood) and acute kidney injury (kidneys were unable to adequately filter waste products from the blood) due to dehydration. Findings: A review of the clinical record of Resident 1 indicated she was admitted to the facility on [DATE], with the short term need for wound care of the right palm and rehabilitation. Resident 1 had a history of [REDACTED].The Minimum Data Set (MDS, a resident assessment tool used to guide care), dated 3/25/15, reflected that Resident 1 required total to extensive assistance from at least one person for all activities of daily living (ADL). Review of the care plan, Self Care Deficit: ADL's, dated 3/15/15, indicated Resident 1 required extensive assistance for eating, and staff should offer fluids. A review of the care plan, Dehydration Risk Assessment, dated 3/18/15, indicated Resident 1 was at high risk for dehydration. A review of the care plan, Risk for Fluid Volume Deficit, dated 3/18/15, reflected, assist with meals and fluid intake, encourage, offer and cue to drink more as tolerated .Monitor meal and fluid intake. A review of the facility's, Nutritional Assessment Screening ., dated 3/23/15, indicated Resident 1 had estimated fluid needs of 1.5 quarts to 1.7 quarts per day. The assessment also indicated Resident 1 had a history of [REDACTED]. A review of the physician's orders [REDACTED]. The Risk for Fluid Volume Deficit was updated on 3/23/15, to reflect the physician's orders [REDACTED]. During a telephone interview, 4/18/16, the responsible party (RP) 1 for Resident 1, said Resident 1 went home on a four hour pass on 4/5/15, and was unable to eat or drink anything during the visit; Resident 1 just drooled and slept. RP 1 said she also noticed Resident 1's tongue seemed dry, and RP 1 voiced her concerns to the facility staff and the physician upon return to the facility. RP 1 said Resident 1 continued to lose weight over the next few days. RP 1 insisted Resident 1 go to the emergency room , on 4/11/15, when Resident 1 acted like a zombie, and continued to lose weight. Follow-up review of the care plans showed no further updates or additional interventions dated after 3/23/15, when Resident 1 became less alert and continued to lose weight. A review of Resident 1's weights on the facility's, Vital Sign Flow Sheet, reflected Resident 1 weighed 114.3 pounds when admitted on [DATE]; and 100 pounds on 4/10/15, representing a 14 pound weight loss over 24 days. A review of the Nurses' Notes, dated 4/7/15 at 1 p.m., indicated Resident 1 was drooling, not eating loosing(sic) wt (weight). A Condition Change Form, dated 4/11/15 at 2 p.m., reflected Resident (1) observed with poor appetite, decreased meal, fluids intake, lost weight, total 14 pounds since 3/18/15. The Condition Change Form, dated 4/11/15 at 5:50 p.m., reflected Refusing to eat or drink for some days now. At 8:40 p.m., Resident 1 was admitted to the hospital. A review of the facility's Meal Intake Record, dated April 2015, indicated 32 meals were consumed during Resident 1's admission in April. Percentage intake of the 32 meals was as follows: 100%=5 meals; 75%=2 meals; 50 %=4 meals; 25%=6 meals; less than 25%=9 meals. A review of the Medication Administration Record, for April 2015, indicated Resident 1's intake for all but one snack, and one liquid supplement was 50% or lower, from 4/7/15 to 4/11/15. During an interview, on 6/8/16 at 3:25 p.m., Licensed Vocational Nurse (LVN) 1 said certified nursing assistants recorded meal and fluid intake, which should then be reviewed by the resident's licensed nurse. LVN 1 said she noticed Resident 1 was not drinking and was losing weight, so she was not surprised when Resident 1 went to the emergency room . A review of the acute care hospital discharge summary, dated 4/16/15, indicated Resident 1 was admitted , on 4/11/15, for drowsiness and weakness, altered mental state, acute kidney injury, and high blood sodium levels due to profound dehydration, with no indication of any source of infection. The records also reflected the high blood sodium level required slow correction over three days, with discharge from the acute care hospital on [DATE]. A review of routine laboratory blood testing for kidney health, collected at the facility, on 3/20/15 at 6:20 a.m., showed the following normal values: Sodium = 143 mEq/L (milliequivalents/Liter- how substances in the blood are measured), within the normal range of 136-145 mEq/L; Creatinine (a waste product in blood; an increased value indicates decreased kidney function) = 1.2 mg/dL (milligrams/deciliter), within the normal range of 0.6-1.3 mg/dL; Blood Urea Nitrogen (a blood waste product; an increased value indicates decreased kidney function) = 21 mg/dL, within the normal range of 7-25 mg/dL; There was one abnormal value: Glomerular filtration rate (a measurement of rate of kidney blood filtration; a decreased value indicates slower clearance of toxins) = 49.61 mL/min (milliliters/minute), below the normal range of 60-499 mL/min. A review of the emergency room blood tests obtained, on 4/11/15 at 5:15 p.m., indicated the following values: Sodium = 174 mEq/L, above the normal range of 133-145 mEq/L; Creatinine = 5.04 mg/dL, above the normal range of 0-1.11 mg/dL; Blood Urea Nitrogen = 91mg/ dL, above the normal range of 7-27 mg/dL; Glomerular Filtration Rate = 10, below the normal range of greater than 60 mL/min. A review of the Merck Manual, Professional Version, reflected The major signs of [MEDICAL CONDITION] result from central nervous system dysfunction due to brain cell shrinkage. Confusion, neuromuscular excitability, hyperreflexia, [MEDICAL CONDITION], or coma may result. (Reviewed/revised April 2016 by(NAME)L.(NAME) III, MD.) (http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/[MEDICAL CONDITION])

Based on observation, interviews and record review, the facility failed to follow their policy and procedure and Federal regulations for providing discharge preparation with information concerning continuing care post- discharge for three (1, 2, 3) of three sampled residents. These three residents were discharged to an unsafe situation and were turned away at the accepting facility due to their medical needs. Since the facility refused to readmit the residents, all 3 had to be sent to the hospital for treatment of [REDACTED]. As a result of the inappropriate transfer, all three residents resided in the hospital for four nights. Findings: On 7/2/14 at 8:00 a.m., during a phone interview, the hospital social worker (SW 2) stated, "The three residents (1, 2, 3) arrived via ambulance from Agency 2 (an unlicensed transitional housing unit for homeless men and veterans) and we couldn't turn them away." The Social worker said she contacted the facility where they resided prior to going to the transitional housing place. The Social Worker said "The facility refused to take them back, they (residents 1, 2, 3) were admitted to the observation unit on 6/28/14. None needed medical care. They were weak and hadn't eaten. I called the facility again on the following Monday and left messages. No one called back. On 6/30/14, I spoke to the ADM (administrator) and assistant social worker and they refused to re-admit." 1. On 7/4/14, review of the medical record showed Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. The Post Discharge Plan of Care, dated 6/27/14, showed date of admission and date of discharge, name and address of accepting agency; name and phone number of home health agency for PT (physical therapy); "follow up with primary physician, equipment needs: wheelchair." The accompanying form, titled "Release of Responsibility for Medications" showed a list of twelve medications with administration directions. The column "Time to be Taken" and "Amount of Medication Leaving" were blank. One of the medications listed was [MEDICATION NAME] for [MEDICAL CONDITION] prevention. It required blood levels to be drawn to maintain a therapeutic level in the body. Resident 1 was sent to agency 2(boarding house type facility)but was never admitted and according to the ambulance staff's documentation, dated 6/27/14, "Responded code 2 (not emergency) as the third ambulance for a group of patients with unknown problems. The patient designated to me first was a [AGE] year old male (Resident 1) with a headache. On scene sitting in a wheelchair out side of (receiving facility)...Patient was kicked out of (Facility A) along with 2 other patients stating that their time for rehab is over....When patients arrived at the accepting facility(Agency 2) , they realized that none of the patients were ambulatory. Staff refused intaking them due to the fact that they are not equipped to handle patients of this nature. Paramedic supervisor notified of abandonment situation ...Taken to hospital." According to the hospital emergency department report, dated 6/27/14, "Patient (Resident 1) complained of headache for three days getting worse. Patient discharged from (Facility A) this morning to board and care facility with two other individuals. All three were deemed unacceptable for admission after arriving due to medical complaints and 911 was subsequently called with patients transferred here. (Faciltiy A) has been called and they refuse to take the patient back into their facility." During interview on 7/1/14 at 10:35 a.m., the Director of Nurses (DON) stated, "The physician did not document lower level of care was needed. We got a telephone order only." When asked how the interdisciplinary team (IDT) planned discharges, DON stated, "We need to get together on planning discharges." DON confirmed that there were no IDT notes about discharge planning. During interview on 7/1/14 at 11:15 a.m., RN 1 was asked what medications were sent with the resident and what arrangements were made for laboratory tests. RN 1 stated, "We don't know what meds were sent. There's nothing written about where to go for lab work. He should have blood drawn for [MEDICATION NAME] level (an anti- [MEDICAL CONDITION] medication)." During interview on 7/1/14 at 3:15 p.m., the Rehabilitation Director stated, "He (Resident 1) was wheelchair- bound. We loaned him a wheelchair when he was discharged . We should all be getting together about discharge planning." 2. According to the medical record at Facility A, Resident 2 was admitted to the facility on [DATE] and discharged on [DATE]. His [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A form titled "Certification and Recertification", dated 5/29/14, showed, "Speech therapy 5x/ week for 12 weeks for cognitive and communication deficit. PT for difficulty walking 5x/ week for 12 weeks. Due date- 7/1/14." Social Service Notes, dated 6/26/14, showed that a staff person from the accepting facility (Agency 2) visited the resident..."and was accepted into their facility. SSD met with resident who agreed to be transported the the facility. 6/27/14- Resident was discharged with home health, PT (physical therapy), OT (occupational therapy), front wheel walker and commode. Orders were given to ... home health agency." 6/28/14- Was informed that resident is at the hospital." The "Post Discharge Plan of Care, dated 6/27/14, " showed a blank area under "Special Training/ Instructions." There was a list of twelve medications with blank spaces under the headings "Time to be Taken," and Amount of Medication on Leaving." The headings, "Special Training/ Instructions," and "Accuchecks (finger stick blood sugar checks) and "Blood pressure 'How to take'" were blank. The medication list showed "Check FSBS (fingerstick blood glucose) every four hours around the clock; and [MEDICATION NAME] (medication to lower blood pressure) 10 mg (milligrams) one tab orally daily hold is SBP less than 100." According to the ambulance staff's documentation, dated, 6/27/14, "Dispatched code three for 'dehydrated patient, possibly multiple patients.' Arrived on scene to find three patients sitting in front of address in no acute distress. Patient is currently complaining of shortness of breath. Patient was admitted to Bay View on 5/19/14 with [DIAGNOSES REDACTED]. Patient has been on home oxygen and prescribed [MEDICATION NAME] (diuretic)... He cannot get up the stairs. Also, patient has no spare oxygen tanks. Patient states, "I'm supposed to be in an in-home care facility and states he wants to go back to Bay View or another facility that can take care of him properly." The hospital emergency department documentation, dated 6/27/14, showed, "Presenting problem: Shortness of breath due to [MEDICAL CONDITION], primary lung disease,...anxiety. History: [AGE] year old male brought to ER by paramedics. Patient was transferred to accepting facility with two other patients, but found to be inappropriate for the facility. 911 was called and paramedics arrived on the scene. Bay View has been called and they refuse to take patients back. Primary impression: nursing home abandonment." During interview on 7/1/14 at 9:25 a.m., Social Worker 1 (SW 1) stated, "Resident 2 was here for [MEDICAL CONDITION] 6/27/14 at 2:00 p.m., he was picked up by the accepting facility. At 7:00 p.m., I got a call that he was in the hospital. I called the accepting facility and asked why we were not called. I was told that he ran out of oxygen and they called 911. The other two went along in the ambulance. All three are still at the hospital." During interview on 7/1/14 at 9:35 a.m., Social Service Designee (SSD) stated, "I guess we should have taken them there to make sure they liked it. None of us have seen the facility." During further interview and concurrent record review on 7/1/14 at 2:00 p.m., the SSD was asked about the physician's orders [REDACTED]." SSD stated, "You should ask nursing. We never had an IDT meeting to discuss his discharge." During interview on 7/14/14, at 11:20 a.m., SSD stated , "I expected they (receiving facility) would take care of the oxygen, showering, dressing. He (Resident 2) was on oxygen with a tank attached to his wheelchair. Their staff told me they could get oxygen across the street at a medical supply." During observation and interview on 7/14/14 at 1:00 p.m., Resident 2 was sitting in a wheelchair, dressed in street clothes, in his room. He had used the urinal and the front of his pants was wet. One eye was glazed over and a few teeth were noted in his lower jaw. When asked about being discharged and being brought back to the facility, Resident 2 stated, "They didn't check the place out and tell them I needed care. When I got there, the owner sent me by ambulance and then I came back here. I need a care home." 3. According to the medical record, Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Social Services Notes, dated 6/23/14, showed "Resident stated he is homeless and would need a place to live on discharge. ...SS to assist with resources and placement. 6/26/14- Resident spoke with receiving agency staff and agreed to go there. 6/27/14- Spoke with receiving agency and they stated they can pick him up today." According to federal regulations, a "post-discharge plan of care" means the discharge planning process which includes: assessing continuing care needs and developing a plan designed to ensure the individual's needs will be met after discharge from the facility into the community. According to the facility's policy and procedure, titled "Discharge Summary and Plan," revised 12/12, "When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/ her new environment." The list of items included in the discharge policy summary were "sensory and physical impairments; nutritional status and requirements, special treatments or procedures; and mental and psychosocial status." The section titled "Content of Post Discharge Plan," showed "the post- discharge plan will be developed by the Care Planning/ Interdisciplinary Team with the assistance of the resident...and will contain, as a minimum: a description of the resident's preference for care; a description of how the resident will access such services; a description of how care should be coordinated if continuing treatment involves multiple caregivers; the identity of specific resident needs after discharge and a description of how the resident should prepare for discharge. The representative (sponsor) should provide the facility with a minimum of 72 hours notice of a discharge to assure that an adequate discharge plan can be developed. The social service department will review the plan with the resident...twenty-four hours before the discharge is to take place." This facility policy defined documentation requirements as, "Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: The reason for the transfer or discharge; that an appropriate notice was provided to the resident; that the resident...participated in a pre-discharge orientation program; the new location; the mode of transportation, a summary of the resident's overall medical, physical, and mental condition; and disposition of medications. The attending physician must document that the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility." During interview on 7/1/14 at 8:50 a.m., the facility administrator (ADM) stated, "These three residents no longer needed skilled care. Our social workers contacted the receiving facility and their staff came here and assessed the residents and accepted them. They were transferred there on 6/27/14. The following day, the hospital called and said 'We have your three residents here and need to send them back to you.' We refused and all three remain at the hospital." The medical record contained a copy of the Post Discharge Plan of Care, dated 6/27/14. It showed that Resident 3 was discharged "home" and to "transitional housing," The areas for post discharge plans/ community agencies, equipment needs, special training/ instructions were blank. Medications were listed with medical abbreviations, not in common language. There was no notation of quantity given or instruction for re-fills. The "Controlled Drug Record" showed that an unknown number of [MEDICATION NAME] 10 mg (milligrams) (an opiate pain control drug) with Tylenol 325 mg was given to the resident with no written instructions. According to the ambulance staff's documentation, dated 6/27/14, "Dispatched code 3 as the second unit for multiple patients with unknown problems. Upon arrival, this patient complained of 6 out of 10 chest pain upon inspiration and palpitations. The patient states he was discharged from a SNF...and was supposed to be taken to a transitional housing facility that could facilitate his medical needs and rehabilitation. Upon arrival at the facility, was informed that they could not accommodate his needs and activated 911 due to concern over his health needs." Hospital emergency department (ED) records, dated, 6/27/14, showed, "discharged from another hospital with [DIAGNOSES REDACTED]. Presents today, per emergency medical technicians, with complaint of SOB, pneumonia and chest pain. History: ...a [AGE] year old male who was brought to the ED by paramedics. Patient was transferred from (Facility B) to a board and care center with two other patients, but found to be inappropriate for the facility as he is on oxygen. 911 was called ...(Facility B) has been called and they refuse to take the patient back." During phone interview on 7/8/14 at 10:30 a.m, Staff A at Community Care Licensing stated that the accepting facility was not a board and care. "They are not licensed for care. "

Based on observation, interview, and record review, the facility failed to acknowledge a resident's crying out in discomfort, failed to assess for the need of additional pain medication, failed to reposition the resident for comfort during wound care, and failed to implement facility's plan of care for pain related to pressure ulcer for one (Resident 1 ) of 24 sampled residents. Resident 1 was observed displaying verbal, physical and emotional signs of pain and distress during wound care. Definition of terms: a. Sacral - above the tail bone. b. pressure ulcer - any wound caused by unrelieved pressure that resulted in damage to the underlying tissues. c. Stage IV pressure ulcer - full thickness of tissue loss with exposed bone, tendon or muscle Findings: 1. Review of the clinical record for Resident 1 indicated a [AGE] year old admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The care plan dated 1/2/14 for pain problem related to pressure ulcer had the goal that Resident 1 will be comfortable as evidenced by calm effect, no moaning, no restlessness, no complaints of pain. Some of the interventions were: a. administer [MEDICATION NAME]. b. monitor for behavior changes indicating pain. c. position for comfort. On 2/25/14 at 2:00 p.m., during observation of pressure ulcer wound care, CNA 2 (Certified Nurse Assistant) and LVN 1 (Licensed Vocational Nurse) were both in attendance, standing by Resident 1's back, while the resident was turned to his left side. CNA 2 was holding and keeping Resident 1 to his left side, close against the bed railing. Resident 1 was screaming loudly stating, " One more push and you will break my bones". CNA 2 did not let go of her hold on Resident 1, instead CNA 2 kept hold of Resident 1 on his side while the resident stated in a loud scream, "Stop, you are killing me." It was loud and repetitive and the Nursing Supervisor (NS) came and checked what was going on. NS saw the two staffs and left the room. CNA 2 again pushed Resident 1 and held him on the left side position for the LVN 2 to have a better view of the sacral pressure ulcer as she continued with the dressing changes. Again Resident 1 screamed, "Stop you are killing me." The procedure went on from 2 p.m. and finished at 2:10 p.m., while Resident 1 continuously said to LVN 1 and CNA 2, "Stop you are killing me". The staff did not delay the treatment nor stop and reposition Resident 1 but instead told him "It's almost done." Staff did not ask the resident if he had pain and did not assess Resident 1 for discomfort and needed pain medication. Resident 1 refused to be interviewed after the procedure. CNA 2 was interviewed at 2:25 p.m. she stated that she was sorry that she did not stop and gave Resident 1 a break and keep him in a comfortable position. LVN 2 was interviewed at 2:30 p.m. on that same date and stated that she worked with Resident 1 before and she had not heard him scream that way. During an interview on 2/25/14 at 2:35 p.m., Nursing Supervisor stated that she heard Resident 1's screams but after she saw the LVN 1 and CNA 2 with the Resident 1 she just left. NS stated "I should have stopped both of them." During an interview on 2/25/14 at 2:40 p.m. LVN 1 stated that she gave Resident 1 one [MEDICATION NAME] tablet at 1:00 p.m. for generalized body pain. She did not assess Resident 1 for an additional pain medication prior to or during the procedure of pressure ulcer dressing change.

Based on observation, interview and record review for one of 24 sampled residents (Resident 2), the facility failed to revise the care plan as the resident's functional ability changed. Resident 2, due to the lack of assistive equipment, was unable to move himself about the facility independently and he no longer participated in his favored activity. This lack of planning resulted in Resident 2's loss of independence and freedom of movement as well as his loss of diversional activity. Findings: 1. On 8/22/11 at 8:44 a.m., during the initial tour of the facility, Resident 2 was lying in his bed, on his back. When asked what had brought him to live in the facility, Resident 2 stated, I had a stroke, "I can't move my left side." Resident 2's speech was clear and he was articulate as he spoke. When asked to, with his right hand, he turned back the blanket that covered his left arm. With his right hand, he pulled his left arm to his chest. The left hand and wrist were deformed by changes in his joints; the fingers curled into his palm and the wrist was flexed. He demonstrated that he could move his right leg, but could not move the left leg. The left leg and foot turned inward. When asked how he would spend this day, Resident 2 stated, "I just lay here." In further interview, Resident 2 stated that he once had a hand crank wheelchair that he used to propel himself to the lobby to use the Wi-Fi for his laptop computer to access the Internet. But the wheelchair had been taken for repair and never returned. He could no longer use his laptop for the Internet as there was no access in his room. Review of the medical record, on 8/23/11, showed that Resident 2 was a long term resident of the facility. Resident 2 had multiple medical [DIAGNOSES REDACTED]. A facility document titled, "Abilities-Focused Activities Assessment," that was dated 3/10/10, indicated that Resident 2's past occupation was, "computer." In a section of the assessment titled, "cognitive skills," use of a computer was checked as a, "life-long interest and strength." Also under the heading of cognitive skills the attribute, "likes to be in control," was listed as, "observed, a life-long interest and a present strength." Under the heading, "Pleasant and Meaningful Activities," the facility had indicated that, "computer work/game," was, "enjoyed throughout life and enjoys now." The facility's goal for Resident 2's activity program was to, "continue to maintain high functioning level of independent leisure." The facility's comprehensive assessment of Resident 2's condition (Minimum Data Set, MDS), dated [DATE], indicated that Resident 2 had loss of function of an arm and leg on one side of his body and he used a wheelchair for mobility. An, "Activity Note," dated 3/14/11, recorded that Resident 2 enjoyed, "browsing the Internet," on his laptop computer. Review of the facility's care plan for impaired physical mobility, originally dated 3/20/10 and reviewed on 3/20/11, showed no mention of an adaptive wheelchair for independent mobility. The facility indicated that they would, "encourage independence in mobility and function, but there was no explanation as to how that would be accomplished. A care plan entry for self-care deficit, originally dated 3/20/10 and reviewed on "3/2011," showed that Resident 2 was wheelchair, "independent." Review of the facility's care plan, originally dated 4/5/10 and updated on "4/11," for diversional activities showed no entry at all for how the facility would support Resident 2's preferred activity, computer use. The most recent MDS, dated [DATE], showed that Resident 2 had declined in his functional ability. He no longer used a wheelchair and he did not move about within his room and adjacent hallway nor did he leave this immediate area to go to other parts of the facility. There were no revisions to the care plans to reflect Resident 2's functional status. In an interview and concurrent record review with Registered Nurse (RN) 2 on 8/23/11 at 1:50 p.m., he confirmed that there was no care plan for rehabilitation services to address Resident 2's lack of independent mobility. In an interview with the Activities Director (AD), on 8/23/11 at 3:10 p.m., he stated that he was familiar with Resident 2 and visited him in his room. AD stated that Resident 2 was, "very alert." AD stated that Resident 2 was very active, coming to activities and he would see him about in the facility; "but he stopped about six months ago." When asked the reason why Resident 2 had stopped his participation in activities, AD stated that he thought Resident 2 had become more ill and could no longer do so. When asked if he was aware that Resident 2 no longer had a wheelchair that he could use independently, the AD stated that he did not know of the loss of the equipment. In an interview with AD on 8/24/11 at 11:30 a.m., he stated that Resident 2 had used his laptop, "yesterday." AD stated that Resident 2 had watched a DVD (movie) using his laptop. In concurrent interview and record review with RN 2 on 8/24/11 at 11:35 a.m., he confirmed that there was no revision to the activity care plan to show interventions due to a decline in Resident 2's decline in mobility. In an interview with the Maintenance Supervisor (MS), on 8/24/11 at 12:20 p.m., he stated regarding Resident 2's hand crank wheelchair, "that wheelchair just disappeared." MS stated that the wheelchair had not actually been the property of Resident 2 and perhaps it had been removed from the facility by the real owner or family. MS stated that using the hand crank wheelchair that Resident 2 would go to the facility's lobby everyday, "I would connect his computer to the Wi-Fi." MS was unable to say how long Resident 2 had been without the hand crank wheelchair; "it's been a long time, he is only in bed now." When asked about facility's Wi-Fi for Internet access for Resident 2, MS stated that in the past a resident with a laptop could only use the Internet while in the lobby. However, since, "mid-June," Wi-Fi was available throughout the facility and that would include Resident 2's room. MS asked, "Oh, didn't he know?" 1a. Please refer to F 248 1b. Please refer to F 310

Based on observation, interview and record review the facility failed to provide services to ensure that one of 24 sampled residents (Resident 2) did not lose his abilities in activities of daily living. Resident 2 was not provided equipment or services to ensure that he did not decline in his ability to transfer from bed and move about the facility independently. This failure resulted in Resident 2's self-isolation in his room, feelings of frustration, disappointment and anger. Resident 2 had declined significantly in his ability to transfer from bed and he was no longer independent for mobility because of a lack of adaptive equipment. Findings: 1. On 8/22/11 at 8:44 a.m., during the initial tour of the facility, Resident 2 was lying in his bed, on his back. When asked what had brought him to live in the facility, Resident 2 stated, I had a stroke, "I can't move my left side." Resident 2's speech was clear and he was articulate as he spoke. When asked to, with his right hand, he turned back the blanket that covered his left arm. With his right hand, he pulled his left arm to his chest. The left hand and wrist were deformed by changes in his joints; the fingers curled into his palm and the wrist was flexed. He demonstrated that he could move his right leg, but could not move the left leg. The left leg and foot turned inward. When asked how he would spend this day, Resident 2 stated, "I just lay here. They don't do anything for me here but feed me." When asked if he received any rehabilitation services or exercises, Resident 2 stated that he had received therapy when first admitted to the facility and, with assistance, he had gained the ability to stand on his right leg and transfer into a wheelchair. He stated that all of the services had stopped and, "I lost all that (ability)...I can't do it anymore." Resident 2 stated that he had a wheelchair with a, "hand crank," that he could use to propel himself about the facility but, "they lost it." Resident 2 stated that the wheelchair had broken and that staff took it to the maintenance staff for repair, but the wheelchair was never returned. On 8/22/11, review of the medical record showed that Resident 2 a [AGE] year old was a long term resident of the facility. Resident 2 had multiple medical [DIAGNOSES REDACTED]. An, "Activity Note," dated 3/14/11, recorded that Resident 2 enjoyed, "browsing the Internet," on his laptop computer. Wireless Internet access was available in the facility's lobby at that time. The facility's comprehensive assessment of Resident 2's condition, dated 3/14/11, indicated that Resident 2 was unsteady when he moved from a seated to a standing position and unsteady during a surface to surface transfer. He was dependent upon the support of one staff person to transfer out of bed. He used a wheelchair for mobility. According to the facility's most recent assessment of Resident 2's condition and functional ability, dated 6/6/11, he did not transfer from his bed at all, and he did not move about in his room or other areas of the facility using a wheelchair. This was a significant change in Resident 2's functional status. For the assessment of balance, the facility had indicated that Resident 2 did not transfer and did not move from a seated to standing position. For the assessment of mobility devices, the facility indicated that Resident 2 used no devices including no manual or electric wheelchair. Also according to the assessment, the facility had provided no Occupational Therapy, no Physical Therapy, and no Restorative Nursing Program. The facility had developed a Care Plan for the problem of, "self care deficit." The Care Plan had a most recent review date of, "6/2011," and was originally dated 3/30/10. According to this Care Plan, Resident 2 was totally dependent on staff for his personal care, including transfers from bed that were accomplished by use of a, "sling/standing." According to this care plan, Resident 2 was able to use a wheelchair without help, he was, "(wheelchair) independent." There was no information regarding a, "lost," wheelchair or confinement to bed. Also according to this care plan, the facility would refer Resident 2 to Occupational or Physical Therapy services as needed. However, there was no planning by Rehabilitation services for Resident 2. During an interview with Resident 2 ,on 8/23/11 at 8:55 a.m., he was lying in his bed. In discussion of the use of a wheel chair, he explained that the wheelchair that he had used for independent locomotion, "had a crank." The wheelchair had a device that he could use with his right hand and arm to turn the wheel and move as well as steer the chair, "I could get around." Resident 2 stated that the wheelchair had been taken for repair and never returned to him. He stated that in a non-adapted wheelchair, "I just go in a circle." He stated, "I would love to get up, I would love to go to the lobby." Resident 2 stated that he felt, "trapped," in his bed. He stated that there was no point in getting out of bed only to be in a wheelchair that he could not maneuver and someone would have to push him. His independence for mobility was taken away. When asked if there were devices that would make him more able to do things for himself, he enumerated numerous items and wrote some on paper. Review of Resident 2's written wishes for devices to assist him showed that he had written that he wished for items that included, "wheel chair (with a) crank," and a power wheel chair. In an interview with the Activities Director (AD) on 8/23/11 at 3:10 p.m., he stated that he was very familiar with Resident 2. AD stated that Resident 2 was, "very alert." AD stated that Resident 2 was very active, coming to activities and he would see him about in the facility; "but he stopped about six months ago." When asked the reason why Resident 2 had stopped his participation in activities, AD stated that he thought Resident 2 had become more ill and could no longer do so. When asked if he was aware that Resident 2 no longer had a wheelchair that he could use independently, the AD stated that he did not know of the loss of the equipment. In an interview with Certified Nurse Aide (CNA) 5 on 8/23/11 at noon, he stated that he did not work regularly at the facility, but he was familiar with Resident 2. CNA 5 stated that Resident 2 did not want to get out of bed today. When asked about Resident 2's wheelchair, CNA 5 stated that he did not know what had happened to Resident 2's wheelchair. On 8/23/11 at 12:10 p.m., in concurrent medical record review and staff interview with RN 2 and RN 5, review of physician's orders [REDACTED]." To the side of the order, someone had written, ... "clarify the writing cannot read." Registered Nurse (RN) 2 was asked what this entry meant. RN 2 stated that the person who had made the written comment worked on night shift, RN 6, and should have communicated with a day shift nurse for clarification of the physician's orders [REDACTED]." When the order and additional entry were reviewed by RN 5, she stated that the order had not been carried out. There had been no referral to Rehabilitation services for an evaluation of Resident 2 for a wheelchair after three weeks. In an interview with Occupational Therapist (OT) 1, on 8/23/11 at 1:05 p.m., she stated that she was not aware of a referral of Resident 2 to the Rehabilitation services for a wheelchair. When asked, she stated that if one used only one hand and arm to move a non-adaptive wheelchair that the wheelchair would, "move in a circle." In an interview with the Maintenance Supervisor (MS), on 8/24/11 at 12:20 p.m., he stated regarding Resident 2's hand crank wheelchair, "that wheelchair just disappeared." MS stated that the wheelchair had not actually been the property of Resident 2 and perhaps it had been removed from the facility by the real owner or family. MS stated that using the hand crank wheelchair that Resident 2 would go to the facility's lobby everyday, "I would connect his computer to the wi-fi." MS was unable to say how long Resident 2 had been without the hand crank wheelchair; "it's been a long time, he is only in bed now." On 8/23/11, review of physician's orders [REDACTED]. In an Occupational Therapy Evaluation, dated 8/23/11, a therapist documented Resident 2's functional ability on this date and a comparison with the last record of evaluation on 3/22/09. For the functional category, transfers, Resident 2, on 3/22/09, was assessed as, "3.0," he required moderate assistance. On 8/23/11, the therapist assessed Resident 2 as, "1.0," total dependence. On 8/25/11 at 4 p.m., in Resident 2's room and across from the foot of his bed, there sat a wheelchair with a high back and a table that was attached to the left side of the wheelchair. The table could be raised or lowered for use. When asked regarding the wheelchair, Resident 2 stated, "they brought me that but I can't use it, someone will have to take me wherever I want to go." Resident 2 stated that he was hoping for a wheelchair that he could maneuver on his own. 1a. Please refer to F 275 1b. Please refer to F 279 1c. Please refer to F 248 1d. Please refer to F 250

The facility failed to provide services to ensure Resident 1's highest practical physical condition when the facility did not provide care when Resident 1 was bleeding which resulted in Resident 1 bleeding to death.Record review on [DATE] showed that the facility admitted Resident 1, a [AGE] year old, on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. Resident 1 had an arteriovenous fistula (AVF) in his upper left arm. The AVF had been created by a surgeon. In the upper arm, under the skin, a large artery had been connected to a large vein so that a large amount of blood flowed rapidly. The AVF was necessary to perform [MEDICAL TREATMENT] treatments. According to radiological studies of AVF fistulas and success for [MEDICAL TREATMENT] treatments, "successful fistulas," had an average blood flow rate in AVF of, "780," milliliters (ml) every minute." (Blood flowed at a rate of approximately 1.6 pints every minute.) (Reference: Radiology, [DATE], [MEDICAL TREATMENT] Arteriovenous Fistula Maturity: US Evaluation, pages 59 - 63) Blood flow rates in mature devices typically may reach up to 2000 ml/min. but more typically they are [PHONE NUMBER] ml/min. (Reference: "Clinical [MEDICAL TREATMENT]" 4th edition; 2005 Nissenson, Fine). "If an AVF bleeds, apply direct pressure until the bleeding stops. Rationale: Bleeding can be a life threatening emergency." Reference: "Textbook of Basic Nursing," 9th edition, 2008 Lippincott Williams & Wilkins.Resident 1's nursing care plan, titled, "Kidney [MEDICAL TREATMENT]: Potential Problems," dated [DATE], instructed that the nurse was to monitor and check the AVF every shift. There were no interventions for bleeding included in the plan.Review of nurse's progress notes, dated [DATE] at 12:30 a.m., showed an entry that recorded RN A's assessment of Resident 1's condition; he was pale and weak. RN A gave Resident 1 a breathing treatment and recorded his blood pressure as ,[DATE], pulse=70, temperature=96.4 and respirations=24. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s, "chest, (left AVF) shunt and abdomen." Resident 1, "was breathing," but RN A was unable to measure his blood pressure or an oxygen saturation level (amount of circulating oxygen in the blood). Facility staff made a, "911," telephone call to transfer Resident 1 to a hospital emergency department and RN A documented in the nurse's notes the administration of another breathing treatment to Resident 1.RN A did not record any information as to the cause of blood on Resident 1's body, nor was there any information recorded as to any attempt to stop bleeding. Review of the ambulance emergency response team report, dated [DATE], indicated the emergency response team arrived at the bedside of Resident 1 at 2:56 a.m. Paramedic A recorded that the response team found Resident 1 with, "blood on the bed and his bandages. "Paramedic A recorded that a CNA had told him that there was, "blood everywhere..." Resident 1 went by ambulance to the hospital emergency department (ED) and arrived at 3:12 a.m. A review of hospital ED records, dated [DATE], showed that on arrival Resident 1 was, "pulseless," and not breathing. "...the patient (Resident 1) was pronounced dead at 3:22 a.m." The death of Resident 1 was referred to the Alameda County Coroner. Coroner Autopsy Examination Findings, dated [DATE], included examination of Resident 1's AVF. "There is an (oval shaped opening) defect, measuring ,[DATE] inch in length..." "The opening leads into the (vessel)...no other abnormalities are noted." There was a hole in Resident 1's AVF.During an interview on [DATE] at 11:00 a.m. Paramedic A stated a call was received from the facility on [DATE] concerning a resident, "who was vomiting blood." Paramedic A stated he found Resident 1 lying in bed, looking pale, skin cool to touch, sweating and with an abnormal breathing pattern. Paramedic A stated "...there was no blood in (Resident 1's) mouth which is not consistent with vomiting blood." Resident 1's left arm bandage was soaked in blood.On [DATE] at 11:a.m. during an interview, Emergency and Fire Response Captain H stated that (Resident 1) was all cleaned up but had a blood soaked bandage on his left arm where the shunt was. He noted that the bed sheets were clean but there were blood soaked sheets on the bathroom floor. A bandage on Resident 1's left arm was blood soaked. The nurses were, "vague," about what happened and the story kept changing about when the resident was last seen by facility staff. The Coroner stated in an interview on [DATE] at 8:08 a.m., that his preliminary report indicated that Resident 1 died on [DATE] from shock due to hemorrhaging (excessive bleeding). During an interview on [DATE] at 2:23 p.m., Police Officer 1 stated he did an investigation because Resident 1 was dead on arrival to the hospital. Review of Police Officer 1's investigative report of the interview with RN A dated [DATE], indicated that RN A stated that she failed to identify the source of Resident 1' s bleeding and had not lifted, changed, removed or touched any portion of the access shunt device dressing. Digital photographs taken by the Police Officer showed several blood soaked linens and a bloody bandage from Resident 1's left upper arm where the access device was located. In an interview on [DATE] at 2:19 p.m. RN A confirmed that she did not apply direct pressure to the bleeding AVF and that she did not check Resident 1's AVF during her work shift or contact the physician regarding the observed change in Resident 1's condition. She stated "I was exhausted. I made up the vital signs and did not give a breathing treatment as documented at 1 a.m. I didn't know where the blood was coming from." RN A was unable to identify the signs/symptoms of hemorrhaging and stated, "I don't know ...I am blank."During an interview on [DATE] at 3:54 p.m., CNA 1 said she took a break at 2:00 a.m. and returned at 2:30 a.m. to check on Resident 1 and found a lot of blood around the left side of his body. CNA 1 stated she noted Resident 1 was, "breathing big breaths," so she immediately called RN A. She said RN A came into the room, took one look at Resident 1 and left to call 911. During this time, CNA 1 said she observed RN A walking back and forth in front of Resident 1's room and returning to the nurses' station to check the chart or use the phone at least three times while she (CNA 1) cleaned Resident 1 of the blood.Facility staff did not assess Resident 1 for bleeding from the AVF and did not apply pressure to the bleeding AVF. During an interview on [DATE] at 1:53 p.m., the facility's Executive Director stated that the facility had a Policy and Procedure (P& P) titled "Bleeding Control" dated [DATE], which indicated that firm direct pressure was to be applied to the site of the injury and pressure was to be maintained until the bleeding stops. In an interview on [DATE] at 3:09 p.m., Resident 1's attending physician stated she would expect the staff to do a full assessment of Resident 1's pale and weak condition, notify the physician and apply a gloved hand or use a towel to control the bleeding. The nephrologist, (a physician specializing in kidney disorders) during an interview on [DATE] at 9:56 a.m., stated he would expect the staff to put pressure if there was bleeding at the AVF.In an interview on [DATE] at 3:00 p.m. the Staff Developer Coordinator (SDC) who was responsible for staff training, confirmed there was no training for care of a [MEDICAL TREATMENT] dependent resident during RN A's orientation. The SDC stated that she eventually gave staff a mandatory [MEDICAL TREATMENT] in-service, but RN A was always too busy to attend the meeting. The SDC was unable to provide any documentation which validated a staff in-service training of care of the [MEDICAL TREATMENT] dependent resident prior to [DATE].Therefore:The facility failed to assess the condition of Resident 1 to determine the cause of bleeding and did not apply pressure to the hemorrhaging AVF thus allowing Resident 1 to bleed to death.