Every finding on record at Blythe Post Acute LLC

Based on interviews and record review, the facility failed to ensure an allegation of verbal abuse was reported immediately, but not later than two hours after the allegation was witnessed, for one of three residents reviewed for abuse (Resident 1).This failure delayed initiation of the facility's investigation and implementation of timely measures to ensure resident safety, placing Resident 1 at risk for potential ongoing abuse.Findings:On April 3, 2026, at 10:46am, the California Department of Public Health received a call from the facility reporting an allegation of abuse involving a resident and a Certified Nurse Assistant (CNA).On April 15, 2026, at 9:15 a.m., an unannounced visit was conducted to investigate an allegation of verbal abuse. A review of Resident 1's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (a decline in cognitive function).A review of Resident 1's Minimum Data Set (an assessment tool) dated January 30, 2026, indicated a Brief Interview for Mental Status (a cognitive assessment) score of 11 indicating moderate cognitive impairment.A review of Resident 1's Change of Condition dated April 3, 2026, indicated the facility completed an assessment related to an allegation of verbal abuse involving a CNA. Further review of Resident 1's record indicated the facility did not submit the required report to the state agency within two hours. On April 15, 2026, at 11:12 a.m., an interview was conducted with the LA. The LA stated on April 3, 2026, at approximately 5:45 a.m., she heard the CNA yelling, What the f**k (expletive) did I say to do? Do what the f**k (expletive) I said, toward Resident 1 while in Resident 1's room. The LA stated she did not report the incident to her supervisor until approximately 8:45 a.m. (three hours after the incident). The LA stated allegations of abuse should be reported immediately to supervisor and the administrator. The LA further stated timely reporting was important to ensure resident safety and allow the facility to conduct a timely investigation while details of the incident could still be recalled. On April 15, 2026, at 12:26 p.m., an interview was conducted with the Licensed Vocational Nurs (LVN) 1. LVN 1 stated allegations of abuse involving Resident 1 should have been reported immediately after it was witnessed, within two hours to state agency. On April 15, 2026, at 1:50 p.m., an interview was conducted with the Administrator. The Administrator stated the incident was considered verbal abuse. The Administrator stated the incident occurred between approximately 5:15 a.m. and 5:30 a.m. and was not reported to him until approximately 9:15 a.m. to 9:30 a.m., by the Maintenance Supervisor. The Administrator stated the allegation of verbal abuse was not reported within the required two-hour timeframe to the state agency and should have been. The Administrator further stated timely reporting of abuse allegations was important to ensure resident safety and allow the facility to promptly initiate an investigation. A review of the facility policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .An alleged violation of abuse.will be reported immediately, but not later than.Two (2) hours if the violation involves abuse.

Based on interview and record review, the facility failed to ensure one of three residents reviewed for abuse (Resident 1) was free from verbal abuse when a Certified Nurse Assistant (CNA) yelled profanity toward Resident 1.This failure had the potential to cause psychosocial distress, fear, humiliation, loss of trust, emotional harm, behavioral symptoms, and decline in psychosocial well-being.Findings:A review of Resident 1's record was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (decline in cognitive function).A review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated January 30, 2026, indicated a Brief Interview for Mental Status (BIMS - cognitive assessment) score of 11, indicating moderate cognitive impairment.A review of Resident 1's Change of Condition dated April 3, 2026, indicated the facility completed an assessment related to an allegation of verbal abuse involving a CNA.On April 15, 2026, at 11:12 a.m., an interview was conducted with the Laundry Aide (LA). The LA stated on April 3, 2026, at around 5:45 a.m., she heard CNA yelling, What the f**** (expletive) did I say to do? Do what the f***k (expletive) I said, toward Resident 1 while passing by Resident 1's room. The LA stated the CNA should not have spoken to Resident 1, or any resident, in that manner.On April 15, 2026, at 4:10 p.m., an interview with the Administrator was conducted. The Administrator stated this incident was considered verbal abuse. The Administrator stated the CNA's use of profanity and yelling toward Resident 1 was unacceptable and did not promote the resident's right to be free from verbal abuse. The Administrator stated the resident has the right to be treated with dignity and respect and to be free from verbal abuse to prevent feelings of fear, voicelessness, depression, and other negative psychosocial outcomes. The Administrator further stated during the facility's investigation, Resident 1's roommate reported hearing the CNA use profanity toward Resident 1. The Administrator stated the CNA was terminated on April 10, 2026.A review of the facility policy and procedure titled, Abuse Prevention Program, dated December 2016, indicated, .residents have the right to be free from abuse.This includes but is not limited to.verbal.A review of the facility policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, indicated, .If the investigation reveals that the allegation(s) of abuse are founded, the employee(s) will be terminated.

Based on interview and record review, the facility failed to provide a convenient venue to both parties in the Arbitration Agreement to four of 23 sample residents (Residents 16, 26, 41, and 55).This deficient practice had the potential to prevent residents from resolving their dispute with the facility in a proper and convenient location.Findings:1. A review of Resident 16's admission Record indicated Resident 16 was admitted to facility on 3/6/25, with diagnoses which included major depressive disorder (severe loss of interest in activities) and anxiety (feeling of fear and worry).A review of Resident 16's History and Physical (H&P), dated 6/29/25, indicated Resident 16 had the capacity to understand and make decisions.A review of Resident 16's quarterly Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/24/26, Section C- Cognitive Pattern, indicated Resident 16's Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated Resident 16 had no memory impairment.A review of the facility contract titled Resident-Facility Arbitration Agreement entered between the facility and Resident 16 on 3/6/25, indicated the venue was not provided in the contract to settle the dispute between the facility and Resident 16.During an interview on 2/10/26, at 10:35 AM, with Resident 16, Resident 16 confirmed he voluntarily signed the agreement on 3/6/25.2. A review of Resident 26's admission Record indicated Resident 26 was admitted on [DATE], with diagnoses which included cerebral infarction (disruptive blood flow to the brain).A review of Resident 26's H&P, dated 3/1/23, indicated Resident 26 had the capacity to understand and make decisions.A review of Resident 26's quarterly MDS, dated [DATE], Section C- Cognitive Pattern, indicated Resident 26's BIMS score was 15 out of 15 which indicated Resident 26 had no memory impairment.A review of the facility contract titled Resident-Facility Arbitration Agreement entered between the facility and Resident 26 on 1/9/23, indicated the venue was not provided in the contract to settle the dispute between the facility and Resident 26.During an interview on 2/10/26 at 10:31 AM with Resident 26, Resident 26 confirmed that he voluntarily signed the agreement on 1/9/23.3. A review of Resident 41's admission Record indicated Resident 41 was admitted on [DATE], with diagnoses which included major depressive disorder.A review of Resident 41's H&P, dated 7/1/25, indicated Resident 41 had the capacity to understand and make decisions.A review of Resident 41's quarterly MDS, dated [DATE], Section C- Cognitive Pattern, indicated Resident 41's BIMS score was 15 out of 15 which indicated Resident 41 had no memory impairment.A review of the facility contract titled Resident-Facility Arbitration Agreement entered between the facility and Resident 41 on 6/14/25, indicated no venue was provided in the contract to settle the dispute between the facility and Resident 41.During an interview on 2/10/26 at 10:34 AM with Resident 41, Resident 41 confirmed that he voluntarily signed the agreement on 6/14/25.4. A review of Resident 55's admission Record indicated Resident 55 was admitted on [DATE], with diagnoses which included adult failure to thrive (a syndrome of physical decline).A review of Resident 55's H&P, dated 2/8/26, indicated Resident 55 had fluctuating capacity to understand and make decisions.A review of Resident 55's comprehensive MDS, dated [DATE], Section C- Cognitive Pattern, indicated Resident 55's BIMS score was 13 out of 15 which indicated Resident 55 had mild memory impairment.A review of the facility contract titled Resident-Facility Arbitration Agreement entered between the facility and Resident 55 on 2/10/26, indicated no venue was provided in the contract to settle the dispute between the facility and Resident 55.During an interview on 2/10/26, at 11:00 AM, with Resident 55, Resident 55 confirmed he voluntarily signed the agreement on 2/10/26.During an interview on 2/10/26, at 11:04 AM, with the Administrator (ADM), ADM confirmed the arbitration agreement of Residents 16, 26, 41 and 55 did not contain the venue in the event of a dispute between the facility and the residents. ADM also confirmed that it would be disadvantageous for the residents if the dispute was resolved in a place that was not convenient for them.A review of the facility's policy and procedure titled Arbitration Agreement revised 4/2021 indicated, .4. The facility will ensure that the agreement provides for the selection of a venue that is convenient to both parties.

Based on observation, interview, and record review, the facility failed to ensure the safe use of medications when:Controlled substance (controlled medications, those with high potential for abuse and addiction) waste procedures were not implemented for five of seven randomly selected residents (Resident 50, 2, 5, 29, and 24);The Controlled Substance Records (CSR, accountability records) for two of four randomly selected residents (Residents 24 and 2) did not reconcile with the Medication Administration Records (MAR, daily documentation record used by nurses to document medications and treatments given to a resident); andPrescription medications were used for multiple residents when one medication at one of one reviewed medication carts was shared between two residents (Residents 10 and 16).These failures resulted in inaccurate accountability of controlled medications and the potential for duplicate doses and possible abuse or diversion of controlled medications. In addition, the failure to ensure prescription medications were only used for the ordered resident had the potential for medication errors. Findings: 1a. A review of Resident 50's MAR, dated December 2025, indicated Resident 50 had orders for hydrocodone with acetaminophen (generic for Norco, a controlled narcotic medication for pain) 5-325 milligrams (mg), dated 10/26/25, Give 1 tablet by mouth every 6 hours as needed.A review of Resident 50's Norco controlled substance record (CSR), dated 11/15/25, indicated a tablet of Norco was wasted on the following dates and times: - 12/11/25 at 6:00 AM - 12/11/25 at 12:00 PM - 12/12/25 at 4:00 AM - 12/12/25 at 6:00 PM - 12/13/25 at 12:00 AMThere were no witnesses documented for the Norco waste.1b. A review of Resident 2's Order Summary Report, dated 2/1/26, indicated Resident 2 had a physician's order, dated 12/10/25, for lacosamide (generic for Vimpat, controlled medication for seizures) 50 mg, Give 1 tablet by mouth two times a day for anticonvulsant [seizure prevention].A review of Resident 2's lacosamide CSR, dated 1/20/26, indicated a tablet of lacosamide was wasted on 2/5/26 at 5:50 PM with no witness documented.During a concurrent interview and record review on 2/10/26 at 10:38 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 50's Norco CSR, dated 11/15/25, and Resident 2's lacosamide CSR, dated 1/20/26, were reviewed. LVN 1 stated only one nurse worked the overnight shift so no one was available to witness controlled substance (CS) waste during those hours. LVN 1 stated there would be a witness to waste Norco during the day shifts and the witness was never documented. LVN 1 stated a witness was not required to waste doses of lacosamide.1c. A review of Resident 5's physician's orders, dated 12/14/25, indicated Resident 5 had orders for Norco 5-325 mg, Give 1 tablet by mouth every 6 hours as needed for L Hip [left hip] pain.A review of Resident 5's Norco CSR, dated 12/16/25, indicated a tablet of Norco was wasted on the following dates and times: - 12/21/25 at 9:00 PM - 1/8/26 at 12:00 AMThere were no witnesses documented for the Norco waste.1d. A review of Resident 29's physician's orders, dated 12/31/25, indicated Resident 29 had orders for Norco 5-325 mg, Give 1 tablet by mouth every 6 hours as needed for Severe pain.A review of Resident 29's Norco CSR, dated 12/31/25, indicated a tablet of Norco was wasted on the following dates and times: - 1/7/26, time not documented - 1/8/26, time not documentedThere were no witnesses documented for the Norco waste.During a concurrent interview and record review on 2/10/26 at 11:26 AM with LVN 2, Resident 5's Norco CSR, dated 12/16/25, and Resident 29's Norco CSR, dated 12/31/25, were reviewed. LVN 2 stated there were no witnesses documented for the wasted CS. LVN 2 verified it would be impossible to know who witnessed the waste without initials. LVN 2 stated there was supposed to be a witness documented in the CSR when wasting CS.1e. A review of Resident 24's Order Summary Report, dated 2/10/26, indicated Resident 24 had an active physician's order, dated 1/24/26, for Norco 5-325 mg, Give 1 tablet by mouth every 6 hours for Severe chronic pain.A review of Resident 24's Norco CSR, dated 1/24/26, indicated a tablet of Norco was wasted on 1/28/26 at 6:00 PM with no witness documented.During an interview on 2/10/26 at 3:15 PM with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC), the DON-MDSC stated the nurse needed to waste CS with another nurse. The DON-MDSC stated the waste and witness needed to be documented on the CSR. The DON-MDSC stated a witness was needed because of drug abuse and to ensure nobody's taking medications.A review of the facility's policy and procedure (P&P) titled, Proper Wasting and Documentation of Narcotic Medication, dated May 2017, indicated, Wasting Process.A second licensed staff member must be physically present. and Required documentation.Date and time.Medication name, strength, and amount wasted.Reason for waste.Signatures of both licensed staff.2a. A review of Resident 24's Order Summary Report, dated 2/10/26, indicated Resident 24 had an active physician's order, dated 1/24/26, for Norco 5-325 mg, Give 1 tablet by mouth every 6 hours for Severe chronic pain.During a concurrent interview and record review on 2/10/26 at 3:49 PM with the DON-MDSC, Resident 24's MAR, dated January 2026, and Norco CSR, dated 1/25/26, were reviewed. The DON-MDSC confirmed the nursing staff documented Norco administration in the MAR but did not sign out the medication on the CSR on 1/24/26 at 6:00 PM and 1/25/26 at 12:00 AM. The DON-MDSC acknowledged the records did not account for two doses of Resident 24's Norco.2b. A review of Resident 2's Order Summary Report, dated 2/1/26, indicated Resident 2 had an active physician's order, dated 12/10/25, for lacosamide 50 mg, Give 1 tablet by mouth two times a day for anticonvulsant [seizure prevention].During a concurrent interview and record review on 2/10/26 at 3:30 PM with the DON-MDSC, Resident 2's MAR, dated January 2026, and lacosamide CDR, dated 1/20/26, were reviewed. The DON-MDSC confirmed the nursing staff documented lacosamide administration in the MAR but did not sign out the medication on the CSR on the following dates and times: - 1/22/26 at 9:00 AM - 1/23/26 at 9:00 AM and 5:00 PM - 1/24/26 at 9:00 AM - 1/25/26 at 9:00 AM - 1/26/26 at 5:00 PM - 1/28/26 at 9:00 AM and 5:00 PM - 1/30/26 at 5:00 PMA total of nine lacosamide doses were not accounted for in Resident 2's records.During an interview on 2/10/26 at 11:26 AM with LVN 2, LVN 2 stated the nurse was supposed to check the MAR and CSR before giving narcotic medications to the resident to make sure the right amount of time had passed between doses. LVN 2 verified the nurse was supposed to fill out both the MAR and CSR when giving CS to residents.During an interview on 2/10/26 at 3:15 PM with the DON-MDSC, the DON-MDSC stated the expectation was for the nurse to document the CS was given on both the CSR and MAR. The DON-MDSC stated the residents' MAR and CSR should match. The DON-MDSC stated if the MAR and CSR didn't match, it meant the medication wasn't given.A review of the facility's P&P titled, Charting and Documentation, dated July 2017, indicated, The following information is be documented in the resident medical record.Medications administered. and Documentation in the medical record will be.complete, and accurate.A review of the facility's P&P titled, Controlled Substances, dated December 2012, indicated, The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation.3. During a concurrent observation and interview on 2/10/26 at 10:06 AM with LVN 1 at Medication Cart 1, the cart contained an empty box of lactulose (generic for Enulose, a liquid medication to treat constipation) labeled for Resident 10. LVN 1 stated the box was empty because she gave the medication to LVN 2 to use for a different resident.During an interview on 2/10/26 at 11:33 AM with LVN 2, LVN 2 stated she requested a refill of Resident 16's lactulose from the pharmacy on 2/9/26. LVN 2 stated she gave Resident 10's lactulose to Resident 16 during the morning medication pass on 2/9/26 and 2/10/26 because Resident 16 needed the medication. LVN 2 stated she did not know when Resident 16 first ran out of lactulose. During an interview on 2/10/26 at 3:59 PM with the DON-MDSC, the DON-MDSC stated it was definitely not facility practice to use one resident's medications for another resident. The DON-MDSC stated the expectation was prescription medication was only used for one specific resident.A review of Resident 10's physician's orders, dated 1/9/26, indicated Resident 10 had orders for lactulose solution 10 grams (gm) per 15 milliliters (ml), Give 30 ml by mouth four times a day for ESRD [end stage renal disease, longstanding kidney failure].A review of Resident 16's Order Summary Report, dated 2/11/26, indicated Resident 16 had an active physician's order, dated 1/17/26, for lactulose, strength not indicated, Give 30 ml by mouth two times a day for Cirrhosis [liver damage].A review of Resident 16's MAR, dated February 2026, indicated Resident 16 received lactulose on 2/9/26 at 9:00 AM and 5:00 PM, and on 2/10/26 at 9:00 AM, after the facility ran out of the medication.A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated, Medications ordered for a particular resident may not be administered to another resident.

Based on observation, interview and record review the facility failed to ensure food items were stored in a sanitary manner in two of two refrigerators (Refrigerator 1 and Resident's Refrigerator), three of four freezers (Freezers 1, 2, and 3), and the kitchen counter by failing to:a. Label received food items,b. Indicate the use by date (the last date recommended for the use of the product) and/ or the open date,c. Discard food beyond the use by date.These deficient practices had the potential to cause food-borne diseases to 47 residents receiving food from the kitchen.Findings:During an initial observation tour of the kitchen and utility room, and interview, on 2/9/26, at 7:53 AM, with the Kitchen Staff (KS), the following were observed:a. One (1) opened whipped topping with no opened date in Refrigerator 1.b. One (1) opened container of canola oil with no opened date on the kitchen counter.c. One (1) opened can of thickener with no opened date on the kitchen counter.d. One (1) box French toast with no use by date inside Freezer 1.e. One (1) plastic bag of hashbrowns with no date labeled inside Freezer 2.f. One (1) plastic bag of chicken patties with no date labeled inside Freezer 3.g. Two (2) bags of chicken strips with no date labeled inside Freezer 3.h. Three (3) plastic bags of sandwiches were found beyond use by date in the Resident's Refrigerator.KS confirmed that all food in the kitchen needed to be labeled and all food in the refrigerators and freezers needed to have date opened and use by date labeled. KS also confirmed that all food not labeled and food beyond use by date or no date opened needed to be discarded.A review of the facility diet log, titled Diets/Nourishments, dated 2/7/25, indicated 47 residents were receiving food from the kitchen.A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage revised 10/2017, indicated . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).A review of the facility's P&P titled, Refrigerators and Freezers revised 10/2017, indicated, .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.A review of the facility's P&P titled, Foods Brought by Family/Visitors revised 10/2017 indicated, .5.b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.

Based on observation, interview, and record review, the facility had a medication error rate of 11.67% when seven medication errors occurred out of 60 opportunities during the medication administration observation for five of ten residents (Residents 44, 42, 3, 13, and 2). These failures resulted in medications not given according to the physician's orders and had the potential for residents to experience side effects such as loose stools or inadequate management of conditions.Findings: 1. During a medication pass observation on 2/9/26 at 8:16 AM at Resident 44's bedside, Licensed Vocational Nurse 2 (LVN 2) was observed administering two medications to Resident 44. The medications included one tablet of enteric coated (EC, coating to protect medications from stomach acid and allow absorption from the intestines) aspirin (blood thinner) 81 milligrams (mg). A review of Resident 44's Order Summary Report, dated 2/10/26, indicated Resident 44 had a physician's order, dated 7/25/25, for aspirin 81 mg capsule, Give 1 capsule by mouth one time a day related to CEREBRAL INFARCTION [type of stroke].During an interview on 2/9/26 at 3:00 PM with LVN 2, LVN 2 stated she gave EC aspirin tablets to residents during the morning medication pass. LVN 2 stated they didn't have any aspirin capsules at the facility.2. During a medication pass observation on 2/9/26 at 8:33 AM at Resident 42's bedside, LVN 2 was observed administering six medications to Resident 42. The medications included one 81 mg tablet of EC aspirin.A review of Resident 42's Order Summary Report, dated 2/10/26, indicated Resident 42 had a physician's order, dated 9/19/25, for Aspirin 81 Oral [by mouth] Tablet Chewable, Give 1 tablet by mouth one time a day for CAD [coronary artery disease, buildup of plaque in the heart's arteries that could lead to heart attack or stroke].During an interview on 2/9/26 at 3:00 PM with LVN 2, LVN 2 stated she did not give chewable aspirin to any residents during medication pass. LVN 2 stated she gave EC aspirin to Resident 42 and acknowledged Resident 42's orders were for chewable aspirin.3. During a medication pass observation on 2/9/26 at 8:38 AM at Resident 3's bedside, LVN 2 was observed administering seven medications to Resident 3. The medications included one 81 mg tablet of EC aspirin and one 100 mg tablet of docusate (generic for Colace, a medication to treat constipation). LVN 2 crushed Resident 3's tablets before giving the medications to Resident 3.A review of Resident 3's Order Summary Report, dated 2/10/26, indicated Resident 3 had a physician's order, dated 5/23/24, for docusate 100 mg capsule, Give 1 capsule by mouth two times a day for constipation. The record further indicated Resident 3 had orders, dated 5/23/24, May crush medication if not contraindicated.A review of Resident 3's February 2026 Medication Administration Record (MAR, daily documentation record used by nurse to document medications), dated 2/10/26, indicated Resident 3 had a physician's order, dated 12/29/25, for aspirin EC 81 mg tablet, Give 1 tablet by mouth one time a day for cva [cerebrovascular accident, type of stroke].During an interview on 2/9/26 at 3:00 PM with LVN 2, LVN 2 stated she was not supposed to crush EC aspirin tablets. LVN 2 stated Resident 3 needed orders for chewable aspirin so the medication could be crushed. LVN 2 also stated she gave a docusate tablet to Resident 3 instead of the ordered docusate capsule.During a telephone interview on 2/11/26 at 2:18 PM with the Consultant Pharmacist (CP), the CP stated EC aspirin needed to be swallowed whole, can't be crushed.4. During a medication pass observation on 2/9/26 at 8:57 AM at Resident 13's bedside, LVN 3 was observed administering seven medications to Resident 13. The medications included one tablet of daily multivitamin.During a concurrent interview and record review on 2/9/26 at 3:22 PM with LVN 3, Resident 13's February 2026 MAR, dated 2/9/26, was reviewed. LVN 3 stated Resident 13 did not have orders for multivitamin tablets.During an interview on 2/10/26 at 4:06 PM with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC), the DON-MDSC stated physician's orders were required to administer a multivitamin tablet to a resident.A review of the facility's policy and procedure (P&P) titled, Policy and Procedure on Physician Orders, dated December 2025, indicated, All aspect of resident's care, including.the following shall only be provided if ordered by the physician.Medications.5a. During a medication pass observation on 2/9/26 at 9:03 AM in the dining room, LVN 3 was observed administering five medications to Resident 2. The medications included one 100mg tablet of docusate. LVN 3 stated she could not administer Resident 2's lacosamide (generic for Vimpat, seizure medication) because the facility was out of the medication.A review of Resident 2's Order Summary Report, dated 2/1/26, indicated Resident 2 had an active physician's order, dated 12/10/25, for lacosamide 50 mg tablet, Give 1 tablet by mouth two times a day for anticonvulsant [seizure prevention].A review of Resident 2's Progress Notes, dated 2/9/26 at 9:14 AM, indicated Lacosamide Oral Tablet 50 MG.drug unavailable at this time will call pharmacy to check on medication.During an interview on 2/10/26 at 3:39 PM with the DON-MDSC, the DON-MDSC stated facility staff did not know where lacosamide was stored in the medication cart. The DON-MDSC stated this did not excuse Resident 2's missed dose of lacosamide. The DON-MDSC acknowledged Resident 2's lacosamide was available for the morning medication pass on 2/9/26.During a telephone interview on 2/11/26 at 2:09 PM with the CP, the CP stated it was important to take lacosamide doses as ordered to avoid any risk of seizures.5b. A review of Resident 2's Order Summary Report, dated 2/1/26, indicated Resident 2 had an active physician's order, dated 12/9/25, for Docusate Sodium Oral Capsule 50 MG, Give 1 capsule by mouth two times a day for constipation prevention.During a concurrent interview and record review on 2/9/26 at 3:27 PM with LVN 3, Resident 2's February 2026 MAR, dated 2/9/26, was reviewed. LVN 3 stated she gave Resident 2 one tablet of docusate 100 mg. LVN 3 stated she was supposed to give Resident 2 one capsule of docusate 50 mg.During an interview on 2/10/26 at 4:06 PM with the DON-MDSC, the DON-MDSC stated nurses needed to identify the right resident, dose, and route of administration when giving medications to residents. The DON-MDSC stated it was not acceptable to switch capsules and tablets without a physician's order.During a telephone interview on 2/11/26 at 2:18 PM with the CP, the CP stated nurses needed to follow the physician's orders. The CP stated nurses were supposed to make sure they were following the physician's orders. The CP stated EC aspirin and chewable aspirin were not interchangeable.A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, Medications are administered in accordance with prescriber orders, and The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.A review of the facility's P&P titled, Policy and Procedure on Physician Orders, dated December 2025, indicated, It shall be this facility's policy to provide care and services to the resident in accordance with physician orders.

Based on interview and record review, the facility failed to ensure the Comprehensive admission Minimum Data Set (MDS - a federally mandated resident assessment tool) Assessment was not completed more than 14 days after admission for one of 18 sampled residents (Resident 24).This deficient practice had the potential to delay the care planning process to meet Resident 24's comprehensive and individualized care needs. Findings:A review of Resident 24's admission Record (document which contains demographic and medical information) indicated she was admitted to the facility on [DATE].During a concurrent interview and record review with the Director of Nursing/Minimum Data Set Coordinator (DON-MDSC) on 2/9/26, at 2:48 PM, the DON-MDSC reviewed Resident 24's Comprehensive admission MDS Assessment with an Assessment Reference Date (ARD) of 2/6/26 and stated it should be completed and signed today.A review of Resident 24's Comprehensive admission MDS Assessment, with an ARD of 2/6/26, indicated Section Z0500B. Date RN Assessment Coordinator signed assessment as complete 02-09-2026.During a concurrent interview and record review with the DON-MDSC, on 2/12/26, at 10:24 AM, the DON-MDSC reviewed Resident 24's Comprehensive admission Assessment and acknowledged that it was not completed timely. DON-MDSC also stated the Comprehensive admission MDS Assessment should have been completed within 14 days of admission. DON-MDSC stated in this situation the facility did not follow its policy and procedure on Resident Assessment and the RAI (Resident Assessment Instrument- comprehensive assessment and care planning process used by nursing home) guidelines. DON-MDSC also stated it was important for the Comprehensive admission Assessment to be completed in a timely manner to identify care areas that need to be addressed in the care plan. The DON-MDSC stated she missed signing the assessment on 2/6/26. The DON-MDSC stated the facility's policy and procedure, and RAI guidelines were not followed.A review of the facility's policy titled, Resident Assessment, revised November 2019, indicated, 1. The Resident Assessment Coordinator is responsible for ensuring .timely and appropriate resident assessment. a. (1) Initial Assessment (Comprehensive) conducted within fourteen (14) days of the resident admission to the facility.The Centers for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025, indicated Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred.01. admission Assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed on the end of day 14, counting the date of admission to the nursing home as day 1.The MDS completion date (item Z0500B) must be no later than day 14 days.

Based on observation, interview, and record review, the facility failed to develop an individualized care plan for one of three residents (Resident 50), to address the behavior of removing the nasal cannula (NC-flexible tube to deliver oxygen into the nose) used for oxygen therapy.This failure had the potential to place Resident 50 at risk for ineffective oxygen therapy and potential respiratory compromise. Findings:A review of Resident 50's admission Record (contains demographic and medical information), indicated Resident 50 was admitted to the facility on [DATE], with diagnoses which included, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), Type 2 diabetes mellitus (a long term condition that causes high blood sugar levels), and muscle weakness (a reduced ability to move or exert force).During an observation on 2/10/26, at 10:18 AM., in Resident 50's room, Resident 50 was observed asleep in bed with audible wheezing sounds noted. NC tubing was lying beside her face and not in her nares (openings of the nose), while the oxygen concentrator (medical device used to deliver oxygen) was on at 2 Liters Per Minute (LPM- unit of measurement).A review of Resident 50's Order Summary Report dated 4/27/25, indicated, O2 [oxygen] on 2L per NC PRN [as needed] for shortness of breath.During an interview with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC) on 2/11/26, at 11:23 AM, DON-MDSC stated Resident 50 had been residing in the facility for some time and had a habitual behavior of removing her NC tubing. The DON-MDSC further stated that although this behavior was common for Resident 50, there was no prohibition on the action as it was the resident's right. When asked whether this behavior was addressed in Resident 50's care plan, the DON-MDSC confirmed that it was not.During a follow-up observation on 2/11/26, at 11:39 AM., in Resident 50's room, Resident 50 was observed gasping for breath while talking. The NC tubing was next to her in the bed and the oxygen concentrator was on.During an interview with the DON-MDSC on 2/12/26, at 9:43 AM, the DON-MDSC stated Resident 50's behavior of removing her NC tubing should be addressed in the care plan to ensure effective oxygen therapy.During a concurrent interview and record review on 2/12/26, at 10:06 AM, with the DON-MDSC, the facility's policy and procedure (P&P) titled, Care Planning, revised September 2013, was reviewed. The P&P indicated, .facility's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.1. A comprehensive care plan for each resident is developed within seven (14) days of completion of the resident assessment.2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team. The DON-MDSC stated that the facility did not follow the policy.

Based on interview and record review, the facility failed to meet professional standards when one of five sampled residents (Resident 8) did not have documentation to support a diagnosis of schizophrenia (a mental illness characterized by disturbances in thought) in a resident with dementia (memory loss that gets worse over time).This failure had the potential for unnecessary use of antipsychotic medications (medications to treat mental illness like schizophrenia).Findings: A review of Resident 8's admission Record, dated 2/11/26, indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. The admission record further indicated diagnoses of dementia and schizophrenia with an Onset Date of 9/21/24.A review of Resident 8's Preadmission Screening and Resident Review (PASARR) Level I Screening [federal assessment requirement to ensure individuals with mental disorder or intellectual disabilities are placed in facilities that can provide appropriate care], dated 2/20/24, completed by the facility, indicated Resident 8 did not have a serious diagnosed mental disorder such as.Schizophrenia.A review of Resident 8's History and Physical Examination, dated 2/26/24, indicated a diagnosis of Dementia [with] psychosis and did not include schizophrenia.A review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 11/28/25, indicated Resident 8's active diagnoses included schizophrenia.During a concurrent interview and record review on 2/11/26 at 4:24 PM with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC), Resident 8's hospital Discharge Summary Note, dated 9/21/24, was reviewed. The record indicated Resident 8's past medical history included dementia and schizophrenia. The DON-MDSC stated the schizophrenia diagnosis was added to the medical record after Resident 8 was discharged from the hospital on 9/21/24. The DON-MDSC stated she was unable to confirm whether there was clinical documentation in the medical record supporting Resident 8's schizophrenia diagnosis on 9/21/24.During an interview on 2/11/26 at 4:22 PM with the DON-MDSC, the DON-MDSC stated the facility did not have a policy addressing clinical or documentation requirements for diagnosis of schizophrenia.A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, indicated, .any changes in the resident's medical.condition, shall be documented in the resident's medical record. and Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered as ordered for one of three sampled residents (Resident 50), when the nasal cannula (NC- flexible tube to deliver oxygen into the nose) tubing was not positioned in the resident's nares (openings of the nose).This failure had the potential to result in ineffective oxygen therapy and potential respiratory compromise for Resident 50. Findings:A review of Resident 50's admission Record (demographic clinical information), indicated Resident 50 was admitted to the facility on [DATE], with diagnoses which included, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), Type 2 diabetes (a long term condition that causes high blood sugar levels), and muscle weakness (a reduced ability to move or exert force).A review of Resident 50's Order Summary Report dated 4/27/25, indicated, O2 [oxygen] at 2L per NC PRN [as needed] for shortness of breath.During an observation on 2/10/26, at 10:18 AM., in Resident 50's room, Resident 50 was observed asleep in bed with audible wheezing sounds noted. NC tubing was lying beside her face and not in her nares, while the oxygen concentrator (medical device used to deliver oxygen) was on at 2 Liters Per Minute (LPM- unit of measurement).During a follow-up observation on 2/11/26, at 9:00 AM., in Resident 50's room, the Licensed Vocational Nurse (LVN 1) was observed leaving Resident 50's room. Resident 50 was observed gasping for breath while talking. The NC tubing was next to her in the bed and the oxygen concentrator was on.During an interview with LVN 1 on 2/11/26, at 9:11AM., LVN 1 stated Resident 50 removed her NC tubing at times. LVN 1 stated she did not check if Resident 50's NC tubing was in place and properly positioned in the nares. LVN 1 acknowledged that the NC tubing placement should have been checked prior to leaving the room to ensure the resident was receiving ordered oxygen therapy.During an interview with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC) on 2/12/26, at 10:39 AM., the DON-MDSC stated the oxygen NC tubing should be positioned in Resident 50's nares to ensure the resident received ordered oxygen therapy.A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, revised January 2019, indicated, .Oxygen therapy shall be administered as ordered by the physician.1. Administration of oxygen shall be with physician's order .6. Licensed nurse should check and ensure that correct oxygen flow rate is administered in accordance with physician's order.

Based on observation, interview, and record review, the facility failed to ensure one of ten residents (Resident 2) was free of a significant medication error when the facility did not give lacosamide (generic for Vimpat, seizure medication) doses to Resident 2 as ordered on four of 10 days. This failure had the potential for Resident 2 to experience worsening of her medical conditions, including seizures.Findings: During a medication pass observation on 2/9/26 at 9:03 AM in the dining room, Licensed Vocational Nurse 3 (LVN 3) was observed administering five medications to Resident 2. LVN 3 stated she could not administer Resident 2's lacosamide because the facility was out of the medication.A review of Resident 2's Order Summary Report, dated 2/1/26, indicated Resident 2 had an active physician's order, dated 12/10/25, for lacosamide 50 milligram (mg) tablet, Give 1 tablet by mouth two times a day for anticonvulsant [seizure prevention].During an observation on 2/10/26 at 10:20 AM at Medication Cart 1, the Medication Cart 1 locked narcotic drawer was opened with LVN 1. The drawer contained one opened blister pack (a card that packages doses of medication within small plastic bubbles or blisters) of Resident 2's lacosamide 50 mg tablets, labeled 1/20/26 by pharmacy, with one lacosamide tablet remaining. The drawer also contained one additional opened blister pack of Resident 2's lacosamide, labeled 1/7/26 by pharmacy, with 14 lacosamide tablets remaining. The drawer contained two unopened blister packs, labeled 2/2/26 by pharmacy, each with 15 lacosamide tablets. During an interview on 2/10/26 at 2:17 PM with LVN 1, LVN 1 stated the facility had enough supply of Resident 2's lacosamide for at least the past two weeks based on the contents on Medication Cart 1. LVN 1 stated two of Resident 2's lacosamide blister packs were sent to the facility on 2/2/26 and the other two blister packs were in the medication cart since January 2026.During a concurrent interview and record review on 2/10/26 at 3:30 PM with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC), Resident 2's Medication Administration Record (MAR, daily documentation record used by nurses to document medications and treatments given to a resident), dated January 2026, was reviewed. The January 2026 MAR indicated Resident 2 did not receive the evening dose of lacosamide on 1/31/26. The DON-MDSC stated the record indicated the medication was not given because lacosamide was not available. During a continued concurrent interview and record review on 2/10/26 at 3:30 PM with the DON-MDSC, Resident 2's MAR, dated February 2026, was reviewed. The February 2026 MAR indicated Resident 2 did not receive the morning dose of lacosamide on 2/3/26, 2/4/26, or 2/9/26. The DON-MDSC stated the record indicated the medication was not given because lacosamide was not available.During an interview on 2/10/26 at 3:39 PM with the DON-MDSC, the DON-MDSC stated facility staff did not know where lacosamide was stored in the medication cart. The DON-MDSC stated this did not excuse Resident 2's missed doses of lacosamide. The DON-MDSC acknowledged Resident 2's lacosamide was available in January and February 2026.During an interview on 2/11/26 at 12:11 PM with the DON-MDSC, the DON-MDSC stated the risk of missed lacosamide doses was seizures.During a telephone interview on 2/11/26 at 2:09 PM with the CP, the CP stated it was important to take lacosamide doses to avoid any risk of seizures. The CP stated lacosamide was a medication that shouldn't be missed or skipped.A review of Resident 2's Progress Notes, dated 2/3/26 at 9:40 AM, indicated Lacosamide Oral [by mouth] Tablet.awaiting delivery from pharmacy.A review of Resident 2's Progress Notes, dated 2/4/26 at 9:43 AM, indicated Lacosamide Oral Tablet.awaiting pharmacy.A review of Resident 2's Progress Notes, dated 2/9/26 at 9:14 AM, indicated Lacosamide Oral Tablet.drug unavailable at this time will call pharmacy to check on medication.A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.A review of the facility's P&P titled, Policy and Procedure on Physician Orders, dated December 2025, indicated, It shall be this facility's policy to provide care and services to the resident in accordance with physician orders.

Based on observation, interview and record review, the facility failed to properly close one of four metal dumpsters which exposed the overflowing trash inside.This deficient practice had the potential to attract pests which could spread disease to residents and staff in the facility.Findings:During a concurrent observation tour and interview, on 2/9/26, at 7:53 AM, with the Kitchen Staff (KS) at the facility's outside garbage area, one metal dumpster was not completely closed and had trash piled above the top of the container. KS confirmed the metal dumpster was partially opened with trash exposed. KS also stated the dumpsters must always be closed to prevent harboring rodents.A review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, revised 10/2017, indicated, . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) was free from unnecessary psychotropic medications (medications that affect brain activities associated with mental processes and behavior) when:One resident (Resident 2) received an as needed (PRN) antipsychotic medication (type of psychotropic medication to treat mental illness) without required documentation of behavior or attempted non-pharmacological interventions (treatment or method used to improve symptoms without taking medication); and One resident (Resident 2) received an antipsychotic medication without specific targeted behavior.These failures resulted in one resident (Resident 2) with dementia (memory loss that gets worse over time) receiving unnecessary psychotropic medications with Black Box Warnings (required drug labeling indicating the medication has a significant risk of serious or life-threatening adverse events) and had the potential for medication side effects, such as sedation and falls.Findings: 1. A review of Resident 2's admission Record, dated 2/10/26, indicated Resident 2 was initially admitted to the facility on [DATE]. The admission record further indicated diagnoses of dementia and psychosis [symptoms caused by loss of contact with reality] with an Onset Date of 11/6/25.A review of Resident 2's physician's orders, dated 11/19/25, indicated Resident 2 had orders for haloperidol lactate (generic for Haldol, an injectable antipsychotic), to inject 5 milligrams (mg) into the muscle every 24 hours as needed [PRN] for Angry outburst towards staff and other residents for 14 days.A review of Resident 2's Psychotropic Medication Assessment, dated 11/19/25, indicated Resident 2 had a Behavior Problem of Angry outbursts. The record indicated the physician ordered haloperidol 5 mg injection as needed.A review of Resident 2's Medication Administration Record (MAR, daily documentation record used by nurses to document medications and treatments given to a resident), dated November 2025 indicated Resident 2 received a haloperidol 5 mg injection on 11/27/25 at 1:49 AM.During a concurrent interview and record review on 2/11/26 at 11:37 AM with the Director of Nursing-Minimum Data Set Coordinator (DON-MDSC), Resident 2's Licensed Progress Notes, dated November 2025, and PRN [as needed] Non-Pharmacological Intervention and Medication Flowsheet, dated November 2025, were reviewed. The DON-MDSC stated non-pharmacologic behavioral interventions were attempted before giving PRN antipsychotics like haloperidol and supposed to be documented. The DON-MDSC further stated the resident's behavior before giving PRN antipsychotics also needed to be documented. The DON-MDSC verified Resident 2's records did not include the required documentation related to the PRN haloperidol injection on 11/27/25.A review of the Prescribing Information (PI, detailed description of a medication available to clinicians) for haloperidol lactate injection, dated 1/25/22, retrieved from DailyMed, indicated a Black Box Warning, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.Haloperidol Injection.is not approved for the treatment of patients with dementia-related psychosis.A review of the facility's policy and procedure (P&P) titled, Psychotropic Drug Treatment, dated December 2016, indicated, Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The record also indicated, Facility staff will document episodes of behavior.the impact of medication on behavior, and Other non-pharmacological interventions will be identified and implemented. 2. A review of Resident 2's physician's orders, dated 11/13/25, indicated Resident 2 had orders for quetiapine (generic for Seroquel, an antipsychotic medication) 50 mg, to give one tablet by mouth two times a day for psychosis manifested by delusional (having false or unrealistic beliefs) behaviors.During an interview on 2/11/26 at 10:13 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2's psychosis behaviors included acting out, sundowning (increased confusion and agitation in the evening for people with dementia), trying to get out of her wheelchair, falls, and talking to people who weren't there.During a concurrent interview and record review on 2/11/26 at 11:05 AM with the DON-MDSC, Resident 2's Psychotropic Medication Assessment, dated 11/12/25, was reviewed. The record indicated Resident 2 had a Behavior Problem of Delusional bx [behaviors]. The record indicated the physician ordered quetiapine 50 mg two times a day. The DON-MDSC stated delusional behaviors meant the resident was out of touch with reality and was a non-specific behavior.During a concurrent interview and record review on 2/11/26 at 11:39 AM with the DON-MDSC, Resident 2's MAR, dated November 2025, was reviewed. The November 2025 MAR indicated orders, dated 11/6/25, to monitor episodes of psychosis manifested by delusional behaviors every shift, three shifts per day, for Resident 2. The MAR indicated zero episodes of delusional behaviors in November 2025. The DON-MDSC stated I know how it looks. The DON-MDSC acknowledged Resident 2's records did not include evidence of psychosis behaviors requiring quetiapine in November 2025.During a telephone interview on 2/11/26 at 2:11 PM with the Consultant Pharmacist (CP), the CP stated indications for antipsychotic medications needed to include specific, measurable, detectable, observable behaviors. The CP stated delusional behaviors meant the resident could be harming others and he didn't know too much else. The CP stated delusional behaviors needed to be a little more clarified to be more specific. A review of the PI for quetiapine tablets, dated 5/28/25, retrieved from DailyMed, indicated the following Black Box Warning, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.Quetiapine is not approved for the treatment of patients with dementia-related psychosis. The quetiapine PI further indicated the following adverse reactions (side effects) associated with quetiapine: Falls, Somnolence [sleepiness], and Dizziness. A review of the facility's P&P titled, Psychotropic Drug Treatment, dated December 2016, indicated, The purpose.is to provide psychotropic drug treatment for a resident with a specific condition as diagnosed and documented in the clinical record.

Based on observation, interview and record review, the facility failed to ensure multi-resident bedrooms provided the required minimum of 80 square feet of livable space per resident in eight of 18 rooms (room [ROOM NUMBER], 6, 7, 8, 9, 10, 11, 12).This failure limited residents' available personal space and had the potential to affect residents' ability to move safely and freely within the room. Findings:During a concurrent interview and record review with the Administrator (ADM), on 2/10/26, at 9:16 AM, the facility's room waiver request approval letter, dated 4/24/25 was reviewed. The ADM stated the facility had a room waiver for Rooms 5, 6, 8, 9, 10, 11 and 12. The ADM stated the facility submitted a letter requesting re-approval of the room waiver on 1/5/26, for the 2026 waiver period.During an observation on 2/10/26, at 8:44 AM, in room [ROOM NUMBER], three beds were observed in the room and two were occupied with residents. During an environmental observation tour with the Maintenance Supervisor (MS), on 2/12/26, at 2:38 PM, seven resident rooms had three beds each. The residents' rooms and their measurements of livable space were noted as follows:I. room [ROOM NUMBER] (3 beds) measured: 238 sq. ft. [square feet] (79.33 sq. ft. per resident)II. room [ROOM NUMBER] (3 beds) measured: 239 sq. ft. [square feet] (79.66 sq. ft. per resident)III. room [ROOM NUMBER] (3 beds) measured: 239 sq. ft [square feet] (79.66 sq. ft. per resident)IV. room [ROOM NUMBER] (3 beds) measured: 239 sq. ft [square feet] (79.66 sq. ft. per resident)V. room [ROOM NUMBER] (3 beds) measured: 239 sq. ft [square feet] (79.66 sq. ft. per resident)VI. room [ROOM NUMBER] (3 beds) measured: 239 sq. ft [square feet] (79.66 sq. ft. per resident)VII. room [ROOM NUMBER] (3 beds) measured: 239 sq. ft [square feet] (79.66 sq. ft. per resident)The rooms were not crowded with furniture and no safety hazards were observed.During a follow-up interview with the ADM, on 2/12/26, at 3:05 PM, the ADM confirmed the measurements for Rooms 5, 6, 8, 9, 10, 11, and 12 did not meet the accommodation requirement per room.During the survey days from 2/9/26 to 2/12/26, no negative impacts on the health, safety, and comfort of the residents were observed. Residents residing in Rooms 5, 6, 7, 8, 9, 10, 11, and 12 who were interviewed stated they were comfortable in their rooms. There were no complaints about space or room issues from the residents occupying these rooms.A review of the room waiver approval letter, dated 12/3/24, indicated Currently, Rooms 5,6,7,8,9,10,11, and 12 are less than 80 square feet per resident in a three bed room. These rooms can be approved for the room waiver.The survey team recommends the approval of the room waiver request for the rooms listed in this deficiency.

Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of one resident reviewed for tobacco use (Resident 1) following her re-admission to the facility, despite a documented history of marijuana use. This failure had the potential to place the resident at risk for adverse health effects related to medical diagnoses, unsafe use or storage of marijuana, and smoke-related safety hazards. Findings:On June 10, 2025, Resident 1's admission record was reviewed. Resident 1 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included heart failure (when the heart doesn't pump blood effectively), chronic obstructive pulmonary disease (lung disease) and nicotine dependence (smoker). Resident 1 had a history of marijuana use while in the facility.A review of Resident 1's History and Physical, dated June 22, 2025, indicated Resident 1 had the capacity to understand and make decisions.A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated June 24, 2025, indicated Resident 1 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15 (intact cognitive response).A review of Resident 1's previous Short Term Goals care plans, dated October 31, 2024, indicated resident had a positive test for THC (Tetrahydrocannabinol ingredient in marijuana).A further review of Resident 1's care plan indicated no interventions addressing marijuana use being identified in the admission history. On July 10, 2025, at 11:06 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was sitting in her wheelchair in her room and was receiving 2L (liters) of oxygen via nasal canula (tubing that delivers oxygen into nostril). Resident 1 stated she was a smoker and did not need supervision. Resident 1 stated she needed oxygen sometimes because she had difficulty breathing. On July 10, 2025, at 2:12 p.m., a concurrent interview and record review of Resident 1's care plans were conducted with the Registered Nurse (RN). The RN stated Resident 1 was re-admitted to the facility on [DATE] and should have new set of care plans developed for her specific needs and should be available in her records. The RN stated Resident 1 was a smoker and had previous history of testing positive for THC. The RN verified and stated there was no smoking care plan available in Resident 1's current records. The RN stated Resident 1 should have a care plan to ensure she remained safe and was not continuing to smoke marijuana to prevent any health risks due to her health history.On July 10, 2025, at 3:35 p.m., a concurrent interview and record review of Resident 1's care plans were conducted with the Director of Nursing (DON). The DON stated she was responsible for conducting assessments and developing care plans for residents. The DON stated for newly or re-admitted residents, a set of new care plans should be implemented to address their conditions and specific needs. The DON stated Resident 1 was sent out to the hospital and returned back to facility on June 17, 2025. The DON verified and stated Resident 1 did not have a smoking care plan in her current records. The DON stated Resident 1 was a smoker and had previously tested positive for THC. The DON stated, Resident 1 should have a smoking care plan to avoid safety related risks and ensure the resident was following facility rules of not continuing to smoke marijuana and further compromise her health.A review of the facility's policy and procedure titled, Care Plans, Comprehensive, dated 2016, indicated .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident.the comprehensive, person-centered care plan is developed within seven (7) days of the completion of required comprehensive assessment (MDS).assessment of residents are ongoing and care plans are revised as information about the residents and residents' conditions change.the Interdisciplinary Team must review and update the care plan.when the resident has been readmitted to the facility from a hospital stay.

Based on interview and record review, the facility failed to ensure one of four Certified Nursing Assistants reviewed (CNA 1) maintained an active State-approved CNA certification and current CPR certification (cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating) before providing direct care to residents. This failure had the potential to result in unsafe and inadequate care to residents. Findings:A review of CNA 1's Employee file indicated, CNA 1's license was issued on [DATE], and expired on [DATE].A further review of CNA 1's employee file indicated no documentation of a current CPR certificate. A review of facility's Staffing Assignment dated [DATE] and [DATE], indicated CNA 1 was scheduled to work on both dates.On [DATE], at 3:50 p.m., a concurrent interview and record review of staffing schedule and employee personnel file was conducted with the Director of Staff Development (DSD). The DSD stated she assists with the facility's hiring process and is responsible for verifying staff employment requirements, including current and active licenses and CPR certificates. The DSD stated, CNA 1 worked the morning shift on [DATE], and the night shift on [DATE], and stated she should not have been scheduled. The DSD further stated, CNA 1 should not have been placed on the schedule without an active license and CPR certification, as this created the potential for not being able to provide adequate care to residents. On [DATE], at 4:31 p.m., a concurrent interview and record review of staffing schedule and CNA 1's employee personnel file was conducted with the DON. The DON stated CNAs are required to have an active license and CPR certification to provide direct care to residents. The DON stated, CNA 1 was on the schedule on [DATE], and [DATE], despite her expired CNA license and lacking a CPR certificate. The DON stated her expectations was for all staff to keep their licenses up to date and for the DSD to follow up. The DON stated it was an oversight and CNA 1 should not have been allowed to work without a current license due to a potential in not being able to deliver safe and adequate care to residents.A review of facility's policy and procedure titled Hiring, dated [DATE], indicated, .This facility provides an equal employment opportunity to all person qualified to perform the essential functions of the position that is to be filled.the following criteria will be considered in determining whether an applicant is qualified for a particular job positions.skill, knowledge, training, efficiency, etc.; and certification and licenses.A review of the facility's job description, titled Position Description: Certified Nursing Assistant, dated [DATE], indicated, .minimum qualification requirements.education.current, active, California Nursing Assistant Certification.A review of the facility's job description, titled Position Description: Director of Staff Development, dated [DATE], indicated, .detailed duties and responsibilities, essential functions.assist and tracks CNA staff in renewal of required State certification.

Based on interview and record review, the facility failed to ensure a safe water system was in place for 44 residents when: 1. The high temperature alarm (a mechanism to alert the staff when water temperatures exceed 120 degrees Fahrenheit [°F]) was not working. This failure had the potential to place the residents at risk of scalding from high temperature water. 2. The facility did not monitor hot water temperature for three out of 12 days for the month of June 2025. This failure had the potential to contribute to unsafe conditions without timely staff awareness. Findings: 1. On July 3, 2025, at 10:30 a.m., during an interview with the Maintenance Supervisor (MS). The MS stated, the facility's procedure was to monitor hot water temperatures daily. The MS stated, the high temperature alarm was used to ensure that water used by residents did not exceed 120°F. The MS further stated, the high temperature alarm at the nurses station was currently not working. On July 3, 2025, at 1:30 p.m., during an interview with the Administrator (ADM), the ADM stated to ensure resident safety, the MS was responsible for daily hot water monitoring and the high temperature alarm should be functioning. 2. A review of facility document titled, Daily Hot Water Temperature Record, Month of June 2025, indicated blank entries on the following dates: - June 1, 2025; - June 6, 2025; and - June 7, 2025. On July 3, 2025, at 10:30 a.m., during a concurrent interview and record review with the Maintenance Supervisor (MS), the MS stated no hot water temperature checks were performed on June 1, June 6, and June 7, 2025. The MS stated, it should have been checked, since it's a risk not knowing if the water may be too hot, which may place residents at risk of burning themselves. A review of facility's policy and procedure titled, Water Supply, revised November 2009, indicated, .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no less than 105°F and no more than 120°F . Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log .

Based on interview and record review, the facility failed to assess and document residents' vital signs (an assessment of resident's physiological stability, including a blood pressure, pulse, temperature and oxygen saturations) prior to non-emergent transport to a general acute care hospital (GACH) for two of three sampled residents (Residents 1 and 2). This failure had the potential to result in unrecognized changes in condition and adverse outcomes during transport. Findings: On May 8, 2025, at 10:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. A review of Resident 1's, Personal Information, dated May 8, 2025, indicated, resident was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (a lung disease that cause airflow obstruction). Further review indicated Resident 1 had a Brief Interview for Mental Status (short structured tool to assess cognitive function) score of 15 (intact cognition). On May 8, 2025, at 1:40 p.m., an interview was conducted with Resident 1, who verified, she was recently transferred out of the facility for further evaluation at GACH (from April 23 - 27, 2025). A review of Resident 1's, Progress Notes, dated, April 23, 2025, at 7:30 a.m., indicated, . (Resident 1) (complained of) increased difficulty breathing and . edema (swelling caused by excess fluid buildup in tissue) to (both lower legs). Requesting to go to GACH for evaluation. Taken via wheelchair . (new orders) received for transfer . Further review indicated no documented vital signs were taken prior to the transfer to GACH on April 15, 2025. A review of Resident 1's, Notice of Transfer/Discharge, dated, April 23, 2025, untimed, indicated, resident was transferred to GACH on the same day on April 23, 2025. A review of Resident 1's vital signs, indicated, the last assessment of vital signs before transferring to GACH on April 23, 2025, were documented on April 22, 2025, between the hours of 2 p.m. and 10 p.m. and were as follows: - Blood pressure: 109/64 - Pulse: 78 - Temperature: 96.8 - Respirations: 20 - O2 (oxygen) Saturation: 93%. On May 8, 2025, at 3:07 p.m., an interview was conducted with the Director of Nursing (DON), who stated, a resident's vital signs provide a baseline of their over health status and are used to evaluate a resident's (physiological) stability, prior to transport. The DON stated, it is her expectations that nursing staff obtain and document a set of resident's vital signs prior to any transfer to GACH. The DON stated, if a residents' vital signs were not stable, they would be transported for evaluation via ambulance, not the facility van. On June 16, 2025, at 2:47 p.m., an interview was conducted with the DON, who stated, vital signs should be taken at least one hour prior to hospital transfer and documented in the medical record. 2. A review of Resident 2's medical records, titled, Resident Information, dated, May 8, 2025, at 10:53 a.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of heart failure, and muscle weakness. A review of Resident 2's BIMS indicated a score of 10 (Moderate impairment). On May 8, 2025, at 1:46 p.m., an interview was conducted with Resident 2, who verified, she had recently been transferred to a general acute hospital for further evaluation from April 30 to May 4, 2025. A review of Resident 2's, Nurses Progress Notes, dated, April 30, 2025, at 0800, indicated, . (Resident 2) (complained of) shortness of breath, increased weakness, not answering questions appropriately and lethargic . (New Orders) received for transfer to (General Acute Care Hospital {GACH}). Taken via (wheelchair) Van to (GACH) . Further review of Resident 2's record indicated no set of vital signs was documented prior to Resident 2's transfer to GACH on April 30, 2025. A review of Resident 2's, Notice of Transfer . , dated, April 30, 2025, untimed, indicated resident was transferred to GACH on April 30, 2025. A review of Resident 2's, vital signs documentation, indicated, the last recorded set of vital signs before transfer to GACH was from April 29, 2025, between the hours of 2 p.m., and 10 p.m.: - Blood Pressure: 134/75 - Temperature: 97.7 - Pulse: 62 - Respirations: 16 - O2 Saturation: 94%. On May 8, 2025, at 3:07 p.m., an interview was conducted with the Director of Nursing (DON), who stated, a resident's vital signs provide a baseline of their over health status and are taken to evaluate a resident's (physiological) stability, prior to transport. The DON stated, it is her expectations for nursing staff to take and document vital signs in the resident's medical record prior to transfer to GACH. The DON stated, if the residents' vital signs were not stable, the resident should be transported via an ambulance, not the facility VAN. On June 16, 2025, at 2:47 p.m., an interview was conducted with the DON, who stated, the nursing staff are expected to obtain and document a set of vital signs at least one hour prior to transport to the hospital for further evaluation. A facility Policy & Procedure, titled, Change in a Resident's Condition or Status, revised, May 2017, indicated, . 1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): . g. need to transfer the resident to a hospital/treatment center . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Based on interview and record review, the facility failed for one of three sampled residents (Resident 1) to conduct a thorough investigation into Resident 1's allegation of abuse involving Certified Nursing Assistant (CNA 1) before allowing the alleged perpetrator to return to work. This failure had the potential to expose Resident 1 to further abuse and compromised the integrity of the abuse investigation process. Findings: On March 28, 2025, at 10:50 a.m., an unannounced visit was made to the facility to investigate an allegation of abuse. On March 28, 2025, at 11:10 a.m., an interview was conducted with Resident 1, who stated, CNA 1 was rough while changing her brief, pushing her against the bed railing and causing pain and a bump on her left wrist on March 15, 2025. Resident 1 stated It upset me at the time. A Review of Resident 1's medical record, title, Resident Information, dated, March 18, 2025, at 11:50 a.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis (One-sided {Left} paralysis or weakness) following a stroke. A review of Resident 1's, Brief Interview for Mental Status (a cognitive assessment), indicated a score of 15 (cognitively intact). A review of Resident 1's, Change of Condition, (A deviation from baseline condition) note, dated, March 15, 2025, at 8:00 p.m., by Licensed Vocational Nurse (LVN) 1, indicated, . (Resident 1 . accusing {CNA 1} being rough while changing (resident), (Resident 1) complained of a bump (on) left wrist . (LVN 1 assessed Resident 1's left wrist) bone, no noted (injuries) skin intact, no discolorations . (CNA 1) stated she was not rough with (resident) and had . (CNA 2) with her, while changing Resident 1 . (LVN 1) . notified . Director of Nursing (DON) and Administrator ({Admin}-Abuse Coordinator) . DON informed all staff to take a second person at all times caring for (Resident 1) . Police officer arrived and spoke to (LVN 1) . (Resident 1) and (Admin). (Admin) called (the facility) and tried to speak to (Resident 1) twice and (resident) said No I'm not talking to (Admin) . On March 28, 2025, at 1:18 p.m., an interview was conducted with CNA 1, who stated, she worked double shift on March 15, 2025, and cared for Resident 1 in the morning without incident. CNA 1 stated she was informed on March 15, 2025, at 9:23 p.m. (one hour after the allegation was reported), that she could return to work the next morning, March 16, 2025 at 6:30 a.m. On March 28, 2025, at 1:37 p.m., an interview was conducted with the DON, who stated, she was informed of the allegation and spoke with Resident 1 by phone, then reported the incident to the Administrator. The DON stated, she did not participate further in the investigation, as she was off duty. On March 28, 2025, at 2:23 p.m., an interview was conducted with the Administrator (Abuse Coordinator), who stated, he was responsible for abuse investigations. The Administrator stated, he received the report from LVN 1, spoke with the police, and attempted to interview Resident 1, who declined. The Administrator stated, he interviewed staff who assisted with Resident 1's care but did not interview Resident 1 or any other residents assigned to CNA 1 prior to allowing the CNA to return to work. The Administrator stated, he believed he had enough information and permitted CNA 1 to return to her shift on March 16, 2025, even though the investigation was not complete. On April 1, 2025, at 10:29 a.m., an interview was conducted with LVN 1, who stated, Resident 1 reported the incident around 7:50 p.m. on March 15, 2025. LVN 1 stated she assessed the resident, notified the DON and Administrator. LVN 1 stated, the police arrived shortly afterward to interview Resident 1. LVN 1 stated CNA 1 was sent home around 8:45 p.m. that evening. On April 1, 2025, at 4:45 p.m., an interview was conducted with the Administrator, who stated, on March 17, 2025 (a day after the reported allegation of abuse), he presented to the facility to interview other residents who had received care from CNA 1 and conducted a follow-up with Resident 1, who decline to discuss the incident further. The Administrator stated, he allowed CNA 1 to return to work on March 16, 2025. A review of the facility Policy and Procedure, titled, Abuse Investigation and Reporting, revised, July 2017, indicated, . Policy Statement: All reports of resident abuse . shall be promptly . and thoroughly investigated by facility management. Policy Interpretation and Implementation: Role of the Administrator . 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Role of the investigator: 1. The individual conducting the investigation will, as a minimum: c. Interview the person(s) reporting the incident; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident . 2. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location . d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it .

Based on interview and record review, the facility failed to ensure a dietary staff was able to accurately verbalize the proper cool down process (proper method of cooling cooked foods to safe temperatures). This failure had the potential to expose a population of 44 residents to foodborne illnesses (illnesses resulting from eating contaminated food). Findings: On February 27, 2025, at 2:40 p.m., an interview was conducted with the [NAME] regarding the cool down process. The [NAME] stated the cooling process from hot food temperature of 135 degrees Fahrenheit ( F- unit of measurement) to ambient temperature of 70 F would take one hour and from 70 F to a cold temperature of 40 F, it would take less than an hour. The [NAME] further stated when she had questions about the cool-down process, she would refer to the cool down log. A review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019, indicated .Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees F to 70 degrees F within 2 hours and then to a temperature of 41 F or below within the next 4 hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours .

Based on observation, interview, and record review, the facility failed to ensure treatment were consistently provided. In addition, the facility failed to reassess and to monitor weekly the status of the open wound on the left side of the forehead for one of the three sampled resident (Resident 1). These failures resulted in the facility licensed nurses unaware on the changes in the resident's left forehead open wound causing a delay in the provision of an appropriate treatment. Resident 1's open wound on the left forehead was noticed with maggot infestation (parasitic skin infestation caused by the larvae [maggots]of certain fly species) on May 20, 2023; and the resident had to be transferred to the general acute care hospital (GACH) for evaluation. In addition, the resident was diagnosed with cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) to the left forehead open wound (the area infested with maggot) while at the GACH on May 20, 2023. Findings: On May 23, 2023, at 10:20 a.m., an unannounced visit was made to the facility to investigate a quality care issue. A review of Resident 1 ' s facility admission notes, dated October 6, 2022, at 12 p.m., indicated Resident 1 was admitted to the facility with a head wound measuring four x (by) six. The admission notes further indicated the resident was admitted with melanoma (skin cancer typically appears as a brown or black raised lump with dark, irregular colors and borders). A review of Resident 1's care plan titled, Actual Alteration in Skin: Related to squamous cell carcinoma (type of skin cancer), dated October 6, 2022, indicated, Interventions . Inspect skin weekly and PRN (As needed); Report lack of progress toward healing after two weeks to MD (medical doctor) & change treatment as ordered . Educate resident regarding consequences of non-compliance behavior . A review of Resident 1's a care plan titled, Refusal of Care/Demanding of Staff, dated, November 2, 2022, indicated, . Goal: Will not have a negative impact on medical status (related to) refusals of care . Interventions . Keep head wound clean and covered at all times .Educate resident related to the results of refusing . A review of Resident 1's progress notes dated March 8, 2023, indicated, Physician notified of worsening large skin lesion to left (L) side forehead. Wound is malodorous, yellow/brown with uneven boarders. New orders (N.O.) received to transfer resident to (name of GACH) emergency room (ER) for evaluation . A review of Resident 1's physician order dated March 8, 2023, indicated the physician gave an order for Resident 1 to be transferred to the GACH for non-healing forehead lesion (any damage or abnormal change in the tissue of an organism). A review of Resident 1 ' s consultation physician assessment from the GACH dated March 8, 2023, at 1:49 p.m., indicated, .brought in from the nursing home for a chronic draining wound (skin wound not healing) on the forehead. The patient states that it ' s been present for about a year and that he does not have a diagnosis as to the etiology . Physical Examination .on the forehead there is approximate 7 x (by) 4 cm. (centimeters) .exudative (has drainage seeping out of the wound) and not purulent (pus) .He has multiple other small lesions on his head . A review of the physician order dated April 4, 2023, indicated Resident 1 would have a surgery on April 5, 2023, for debridement (removal of damaged tissue from a wound) of the open wound located on the left side of the forehead. A review of the dermatologist ' s (medical practitioner specializingin the diagnosis and treatment of skin disorders) notes from the GACH dated April 5, 2023, indicated Resident 1 had his forehead wound assessed by the dermatologist, and came back with treatment orders for, . Saline (mixture of sodium chloride and water used to clean wounds) moist to dry 4 x (by) 4 gauze dressing (Twice a day) .Bacitracin/Neosporin (topical medication used to treat minor skin injuries, including cuts, scrapes, and burns) and Dry 4 x 4 after washing head, every (day) . (Follow-up dermatologist visit) next month . A review of Resident 1's skilled nursing facility progress notes titled, Skin Wound Progress Report, related to the resident's open wound on the left forehead indicated the following: a. April 6, 2023, .size: 4 x 4; color of drainage: yellow; wound bed: red; no undermining (separation of the wound edges from the surrounding healthy tissue) and no tunnelling (wound extends deeper into the tissue) . b. April 12, 2023, size: 4 x 5; color of drainage: yellow; wound bed: red; no undermining and no tunnelling .; and c. April 19, 2023, . 4 x 4 (cm); color of drainage: none, wound bed: Pink; No undermining/tunneling . Further review of Resident 1's skin/wound progress notes for April 2023, indicated no other wound assessment was conducted after April 19, 2023. A review of Resident 1 ' s Treatment Administration Record (TAR), dated April 2023, indicated Resident 1 received treatment of normal saline to the open wound on the left side of the forehead from April 5 to April 18, 2023; except on April 10 and 18, 2023. Further review of the TAR dated April 2023, indicated Resident 1 did not receive treatment of normal saline for his open wound on the left side of the forehead after April 18, 2023. A review of Resident 1's Nurses Treatment Notes, dated April 2023, indicated Resident 1 had refused treatment to the open wound on the left forehead on April 10 and 18, 2023. A review of Resident 1's Nurses Treatment Notes, dated May 2023, indicated Resident 1 had refused treatment to the open wound on the left forehead on May 2, 2023. A review of Resident 1 ' s dermatologist ' s follow-up notes dated May 4, 2023, at 2:30 p.m., indicated, . Per RN (Registered nurse), refusing wound care, dressing changes . (Diagnosis) Squamous Cell (Cancer) . Recommend wound care if resident agrees; plastic surgery (surgical specialty involving restoration of a body or tissue defect) consult should resident become compliant; this will not heal without treatment . A review of Resident 1 ' s Licensed Nurse Record, dated May 7 and 14, 2023; indicated, .Skin: Please refer to the skin assessment and/or Weekly Wound progress report, for size/location, staging . Open lesion . A review of Resident 1 ' s Skin Assessment and/Weekly Wound Record, for the month of May 2023, indicated no assessments on Resident 1 ' s forehead open wound was documented on May 7, and 14, 2023. A review of Resident 1's skin/wound progress report on a cellulitis on the left forehead open wound dated May 20, 2023, indicated the wound was measured 6 x 5.5 x .5. A record review of Resident 1 ' s progress note, dated May 20, 2023, at 6:30 a.m., indicated, . had maggots crawling on his head wound (open wound on the left forehead) . multiple maggots were crawling in resident's head . Resident to be sent out to acute care hospital for evaluation . A record review of Resident 1 ' s GACH Admission/discharge note, dated May 20, 2023, at 2:50 p.m., indicated, . Disheveled in appearance with large lesion on scalp oozing pus and has maggots crawling everywhere from his head . multiple scrapes and has large lesion on forehead with lots of maggots eating his flesh . Discharge (Diagnosis): Cellulitis (Skin infection) of scalp, Maggot infestation . A review of Resident 1 ' s Physician ' s orders dated May 21, 2023, indicated, Cleanse cellulitis with maggot infestation left forehead, cleanse with normal saline (NS) and H2O2 (hydrogen peroxide-mild antiseptic used on the skin to prevent infection) important disinfectant and bleach and is currently manage (treatment) 50/50 mix (half normal saline and half hydrogen peroxide mixture). apply clean dry dressing Q evening x 14 days until 6/2/2023. On May 23, 2023, at 10:50 a.m., Resident 1 was observed lying in bed inside his room, with a bandage partially covering the left side of his forehead. Resident 1's head was observed to have a loose-fitting gauze, covering the wound on the left side of the forehead. In addition to the forehead open wound, Resident 1 was observed to have an uncovered open wound on top of his head. On May 23, 2023, at 11:12 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed removing Resident 1 ' s bandage on the the resident's forehead, revealing a forehead open wound which appeared pink and granulated (roughened surface) with clear discharge. LVN 1 stated the weather had been hot and the inevitable happened. She stated Resident 1's forehead open wound got infested with maggots. LVN 1 further stated, Resident 1 went to the GACH on May 20, 2023, for wound debridement (removal of damaged tissue or foreign objects from a wound), after maggot infestation occurred on Resident 1's open wound on the left side of the forehead. On May 23, 2023, at 1:17 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was not receiving wound care treatments to the open wound on the forehead between the dates of April 19, 2023, and May 20, 2023, due to the resident's refusals of wound treatments. On May 24, 2023, at 1:45 p.m., during an interview with Certified Nursing Assistant (CNA)1, CNA 1 stated on May 20, 2023, at approximately 5:30 a.m., CNA 1 saw maggots on Resident 1's forehead. CNA 1 further stated she reported the situation to the LVN (LVN 3), and the licensed nurse (LVN 3) called 911 for transport to the GACH emergency room . On July 21, 2023, at 4:46 p.m., an interview was conducted with the DON. The DON stated LVN 2 discussed the dermatologist's recommendation on May 4, 2023, to Resident 1 and the family member. The DON stated the resident and the family member refused treatments and she stated at that point the wound treatment for the resident's head was just not being done until the maggot infestation was discovered on May 20, 2023. On August 25, 2023, at 4:03 p.m., during an interview, the DON was asked on how often the treatment nurse conducted wound assessment. She stated the wound would be assessed daily during wound treatment; and the Treatment (Tx) Nurse would measure the extent of the wounds weekly. The DON stated the Tx Nurse would document the measurement of the wound and would conduct an assessment if further treatment is needed during the weekly wound assessment. However, there was no consistent weekly wound assessment completed for April and May 2023, since the resident would sometimes refuse wound treatment. A review of the facility policy and procedure titled, Wound Care, revised December 2010, indicated, .6. Record in the resident's medical record the type of wound care given and the date and time the wound care was given. 7. Notify the supervisor if the resident refuses the wound care. 8. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer (an injury that breaks down the skin and underlying tissue) to the supervisor.

Based on observation, interview, and record review, the facility failed to ensure for five of seven residents reviewed for nutrition (Residents 6, 26, 34, 41, and 43), additional interventions such as fortified diet [adding nutrients to the food], feeding program, and other protein supplements were provided for resident's weight loss and the Registered Dietitian (RD) participated in the weight variance review meetings. These failures had the potential to result in the deterioration in overall residents' condition causing harm, impairment, and death. Findings: 1. On March 21, 2022, at 12:43 p.m., during observation in the dining room, Resident 26 was observed not drinking the milk and eating the lunch meal served. On March 22, 2022, at 9:42 a.m., Resident 26 was interviewed. She stated she had been losing a lot of weight. Resident 26 stated she could not take her food and felt like throwing up. Resident 26 stated she was trying to take the food but she felt nauseated. Resident 26's record was reviewed. Resident 26 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the document titled NUTRITIONAL SCREENING ASSESSMENT, dated January 6, 2021, indicated, .Registered Dietitian Assessment .Res (Resident 26) has poor appetite, wt (weight) loss .on comfort measures only. current wt 90 lb. last year ranges fr (from) 97 lb -135 lb. Rec (recommend) to offer food of Resident's choice as tolerated . A review of the physician order dated April 29, 2021, indicated, NAS (no added salt), LCS (low concentrated sweets) diet Mechanical Soft (foods that are soft and easy to chew) texture. Mighty shake TID (three times a day) with meals. A review of the document titled DIETARY PROGRESS NOTES, dated October 29, 2021, indicated, .Resident (Resident 26) Quarterly Review .Continue diet Mechanical Soft, LCS, NAS, plus Mighty Shakes eats 10-20% of most meals. Current Weight 79.2 .continue Monthly Weight . During review of Resident 26's record, there were no additional interventions provided for the resident when there was a progressive decline in Resident 26's weights. There were no other recommendations provided by the RD to improve the caloric intake of Resident 26. A review of the quarterly Minimum Data Set (an assessment tool) assessment dated [DATE], indicated Resident 26 was independent with eating and did not require staff oversight at any time. A review of the document titled MONTHLY RECORD OF V/S AND WTS (Vital signs and weights), indicated Resident 26 had an admission weight of 140 pounds (lbs) on June 25, 2018, and on: - January 3, 2021, 90 lbs; - February 7, 2021, 84.2 lbs.; - March 7, 2021, 80.4 lbs.; - April 4, 2021, 75.6 lbs.; - May 2, 2021, 81 lbs.; - June 6, 2021, 79.6 lbs.; - July 4, 2021, 76.4 lbs.; - August 1, 2021, 77.4 lbs.; - September 6, 2021, 76.2 lbs.; - October 3, 2021, 79.2 lbs.; - November 7, 2021, 83.8 lbs.; - December 5, 2021, 79.6 lbs.; - January 2, 2022, 71.2 lbs.; - February 2022, 74.6 lbs.; - March, 2022, 73.6 lbs. A review of the document titled, The Weight Variance Review, dated January 3, 2022, indicated, Resident 26 had 8 lbs. (11 percent) weight loss for one month, with recommendations to .Assist/Supervise at meals .Allow extra time to eat .Nurishments (sic) .cont. (continue) wkly (weekly) wt. until stable . During review of Resident 26's record, there was no participation of the RD during the weight variance review meeting and there was no notification of the RD or the MD for the continued decline in Resident 26's weight. On March 28, 2022, at 4:41 p.m., the RD was inerviewed. She stated for Resident 26, she was aware resident's weight was 79 lbs. last December 2021, but not the present weight of 73.6 lbs. She stated the staff should have informed her of the resident's weight. The RD stated even if there was no significant weight change, she should have been informed of resident's weight of 73.6 lbs. She stated she could have modified the diet to a fortified diet to provide more calories to the resident. On March 28, 2022, at 5:20 p.m., the Medical Director (MD) was interviewed. He stated he was not aware of Resident 26's weight loss. He stated he should have been notified by the staff and he should have evaluated the resident regarding the resident's weight loss. On March 29, 2022, at 10:02 a.m., an interview and record review was conducted with the DON and she stated they did not provide other interventions for Resident 26's weight loss when the other interventions were ineffective. 2. Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the document Nutritional Screening Assessment, dated August 16, 2021, indicated, .Ideal Body Weight Range: 122 -149 .Usual wt: 135 per res/family/chart .Weight: 101 .Body Mass Index (BMI) 16 (<20 underweight) Registered Dietitian Assessment .Vitamin D 50,000 po (per oral) every Wednesdays to promote bone health. Will cont (continue) to monitor po intake + wt. chg. (weight change) . During review of Resident 34's [NAME], there was no additional recommendation and other interventions from the RD to increase caloric intake of Resident 34. A review of the document titled, Weight Variance Review, dated February 7, 2022, indicated, Resident 34 had a weight of 96.6 lbs, 11 lbs. (10%) weight loss in one month, with recommendations to .Weight change is unintended .Assist/Supervise at meals .Allow extra time to eat .Nurishments (sic) .Other approaches .weekly wts . A review of the document titled, Follow-up weight Reviews, indicated: - Dated February 14, 2022, Weight: 91.7 .Change: - 5 lbs . -5% change in 1 (one) week . - Dated February 28, 2022, Weight: 86.4 Change: - 6lbs . -6% in 1 week .` During review of Resident 34's record, there was no documentation the physician was notified of the weight changes on February 14 and 28, 2022. There were no additional interventions in Resident 34's plan of care when Resident 34 had progressive decline in weight loss. There was no participation of the RD during the weight variance review. A review of Resident 34's care plan titled, Alteration in Nutrition, indicated: - Dated February 9, 2021, .Interventions .weekly wt. until stable .encourage Food & Fluid intake .Mighty Shake TID (three times a day) . - Dated Februray 10, 2022, .Interventions .wkly wts .Encourage Food & Fluid intake .Assist c (with) meals . A review of Resident 34's Minimum Data Set (an assessment tool) dated February 17, 2022, indicated, Resident 34 was independent with eating and did not require staff oversight at any time. A review of the document titled MOTHLY (sic) RECORD OF V/S AND WTS (Vital signs and weights), indicated Resident 34 had an admission weight of 122 pounds (lbs.) on August 18, 2020 and on: - January 3, 2021, 124 lbs.; - February 7, 2021, 116 lbs.; - March 7, 2021, 113.4 lbs.; - April 4, 2021, 111.8 lbs.; - May 2, 2021, 112.8 lbs.; - June 6, 2021, 114.2 lbs.; - July 4, 2021, 110.6 lbs.; - August 1, 2021, 113 lbs.; - September 6, 2021, 110.2 lbs.; - October 3, 2021, 105.6 lbs.; - November 7, 2021, 101.8 lbs.; - December 5, 2021, 98.8 lbs.; - January 2, 2022, 107.6 lbs.; - February 2022, 96.6 lbs.; - March, 2022, 93.6 lbs. On March 28, 2022, at 4:41 p.m., the RD was interviewed. The RD stated Resident 34 had gradually declining weight loss. She stated she was not aware Resident 34's weight was 93.6 lbs. The RD stated if Resident 34 had progressive weight loss, even if there were no significant changes in the weight, she should have been notified. She would assess Resident 34, evaluate the feeding ability of Resident 34, modify the diet to fortified diet. The RD stated the care plan should have been updated to provide new interventions for Resident 34's progressive weight loss. On March 28, 2022, at 5:20 p.m., the Medical Director (MD) was interviewed. He stated the licensed nurses would let him know if resident had significant weight changes. He was not aware Resident 34 had weight loss. The MD stated he should have been notifed and he should have evaluated the resident. 3. Resident 41's record was reviewed. Resident 41 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 41's physician order dated August 23, 2021, indicated, Regular diet Pureed texture, No dairy, Might Shake QAM (every morning). A review of Resident 41's Minimum Data Set (an assessment tool) dated January 29, 2022, indicated, Resident 41 was independent with eating and did not require staff oversight at any time. A review of the document MOTHLY (sic) RECORD OF V/S AND WTS, indicated, - January 3, 2021, 81.6 pounds (lbs); - February 7, 2021, 75.4 lbs.; - March 7, 2021, 82.6 lbs.; - April 4, 2021, 78.4 lbs.; - May 2, 2021, 77.4 lbs.; - June 6, 2021, 73.6 lbs.; - July 4, 2021, 73 lbs.; - August 1, 2021, 73.4 lbs.; - September 6, 2021, 74.2 lbs.; - October 3, 2021, 69.6 lbs.; - November 7, 2021, 69.4 lbs.; - December 5, 2021, 68.8 lbs.; - January 2, 2022, 70.8 lbs.; - February 6, 2022, 71 lbs.; - March 6, 2022, 69.8 lbs. A review of Resident 41's care plan titled, Alteration in Nurtition, indicated: - February 27, 2021, Promote comfort & (and) healthy wt (weight) .weekly wt until stable .Encourage & assist c (with) milk intake & fluids. - June 7, 2021, .wt. loss .continue Mighty Shake q AM .encourage meal intake .wkly (weekly wt (weight) until stable. - February 10, 2022, wt. loss .Promote healthy wt .Encourage food/fluid intake .wkly wt until stable. During review of Resident 41's record, there were no additional interventions provided to prevent progressive decline in Resident 41's weight loss. There was no documentation the Registered Dietitian was informed of the present weight of the resident. On March 29, 2022, at 3:11 p.m., a concurrent interview and record review was conducted with the DON, she stated Resident 41 was not provided with additional interventions to improve resident's nutritional status. The DON stated she did not ask the RD for other interventions and she did not inform the RD of Resident 41's present weight. On March 30, 2022, at 2:50 p.m., the MD was interviewed. He stated when a licensed nurse referred a resident with weight loss, the licensed nurse would tell him the pounds lost by the resident and not the actual weight of the resident. 4. In a review of Resident 6's record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 6's document titled, MONTHLY WEIGHT VARIANCE TRACKING MATRIX, indicated the following: September 2021= 130.8 lbs. (pounds) October 2021= 129.6 lbs. November 2021= 118.4 lbs. December 2021= 118.4 lbs. January 2022= 117.6 lbs. February 2022= 116.6 lbs. March 2022= 117.6 lbs. A review of Resident 6's Minimum Data Set (an assessment tool), dated December 16, 2021 .Section G .Functional Status .Eating .Self -Performance .4 (total dependence) .Section K .Swallowing/Nutritional Status, indicated, .Coughing or choking during meals or when swallowing medications . A review of Resident 6's Minimum Data Set, dated dated [DATE], .Section G .Functional Status .Eating .Self -Performance .4 (total dependence) .Section K .Swallowing/Nutritional Status, indicated, .Coughing or choking during meals or when swallowing medications . A review of facility document titled, Weight Variance Review, with a review date of November 7, 2021, indicated, Change .11 lbs .8.6 % change in 1 month .Unintended weight loss .Diet .Puree thickened liquid .Nourishment .mighty shake .Poor Meal Tolerance .Recommendations .Assist/Supervise at meals .Allow extra time to eat .Monitoring .Weekly weights .Other approaches .Encourage assist with meal intake . During review of Resident 6's record, there were no additional interventions provided to prevent progressive decline in Resident 6's weight loss and there was no documented evidence physician was notified. On March 28, 2022, at 1:47 p.m., in an interview with Licensed Vocational Nurse (LVN) 5, she stated when a resident had a significant weight loss the physician and the RD should be notified. In a concurrent review of Resident 6's record with LVN 5, LVN 5 stated was no documentation the physician and the registered dietician (RD) were notified. LVN 5 stated there should have been documentations of the COC (Change of Condition), notification of physician and RD in Resident 6's record. She stated swallow evaluation was not done because they do not have Speech Therapist in the facility. On March 28, 2022, at 4:50 p.m., in an interview with the RD, she stated she comes to the facility twice weekly mostly during the weekends. The RD stated for Resident 6 current weight falls below the BMI, and must be between 21- 25, to reach this goal the interventions needed to be revised, by fortifying her foods, like adding fortified peanut butter and protein fortified milk. 5. In a review of Resident 43 record, indicated Resident 43 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 43's History and Physical (H & P) dated June 10, 2021, indicated, Resident 43 does not have the capacity to understand and make decisions. A review of Resident 43's document titled, MONTHLY WEIGHT VARIANCE TRACKING MATRIX, indicated the following: September 2021= 120 lbs. October 2021= 116.4 lbs. November 2021= 116 lbs. December 2021= 91 lbs. January 2022= 83.2 lbs. February 2022= 90.2 lbs. March 2022= 90.4 lbs. A review of facility document titled, Weigh Variance Review, with a review date of December 6, 2021, indicated, .Change .25 lbs. 22% change in 1 month .Unintended weight loss .Diet .Regular NAS .Nourishment .MS (mighty shake) .TID (three times daily) with meals .Poor Meal Tolerance .Recommendations .Assist/Supervise at meals .Allow extra time to eat .Between meal snacks .Nourishment .Monitoring .Weekly weights .Other approaches .Encourage assist with meal intake .Add M.S. TID .promote healthy weight . During review of Resident 43's record, there were no other interventions added to meet the caloric needs of Resident 43 when the resident had a weight loss from September 2021 to December 2021. There were no additional interventions to increase caloric content of foods when the resident continue to loose another 7.8 lbs. from December 2021 to January 2022 On March 28, 2022, at 02:04 p.m., in an interview with the Director of Nursing (DON), the DON stated the facility conducted weight variance review meetings every month. She stated when there is significant weight loss (> 5% in a month; > 7.5 % in 3 months; or > 10% in 6 months) there will be a weight variance meeting review, the Dietary Service Supervisor (DSS), and herself will be in that meeting. The DON stated the RD will not be a part of the weight variance meeting, but will be consulted, when needed. She stated the physician was also not involved in the weight variance review meetings. The DON stated the interventions provided for the residents were monitoring of weight weekly until stable; nourishments like mighty shake 3x a day. The DON stated there were no additional interventions to ensure caloric intakes were able to meet the nutritional need of the resident. On March 28, 2022, at 4:41 p.m., the RD was interviewed. She stated she talked to the DSS regarding resident's weight loss. The RD stated if the interventions provided were not effective, the facility should have provided new interventions. She stated there are other interventions such as doing a calorie count, modifying the diet to a fortified diet, and provide other protein supplements. The RD stated for progressive weight loss, the resident should be assessed and provided new interventions to boost the caloric intake of the resident. On March 29, 2022, at 9:20 a.m., in an interview and record review with the DSS, she stated when a resident had significant weight loss, she would notify the RD. The DSS stated the RD was in the facility during the weekends and the DSS was not around. The DSS stated the RD was not present during the weight variance review meetings. She stated no other interventions were added to meet the caloric needs of the residents who had weight loss, like fortified foods. A review of the facility document titled, Weight Assessment and intervention, with date revised September 2008, indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Weight Assessment .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter .If no weight concerns are noted, weight will be measured monthly thereafter .Any weight change of 5% or more since last weight measure .nursing will notify the dietician .the dietician will respond within 24 hours of receipt of written notice .The threshold for significant unplanned and undesired weight loss .a. 1.month- 5% weight loss is significant; greater than 5% is severe; b. 3 months- 7.5% weight loss is significant; greater than 7.5 % is severe; 6 months- 10 % weight loss is significant; greater than 10 % is severe .Analysis .Assessment Information shall be analyzed by the multidisciplinary team .and conclusion shall be made regarding: Resident target weight range (including rationale if different from ideal body weight), Approximate calorie, protein and other nutrient needs compared with resident's current intake .the Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing risk of weight loss for example .Cognitive or functional decline .Chewing or swallowing abnormalities . A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated December 2016, indicated, .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change .The Interdisciplinary Team must review and update the care plan .when there has been a significant change in the resident's condition . In a review of facility document titled, Job Description, dated 2003, indicated, .Dietician .The primary purpose of your job position is to plan, organize, develop and direct overall operation of the Food Services Department .to assure that quality nutritional services are being provided on a daily basis .Meet with the food service personnel, on a regular basis and solicit advice from staff concerning the operation of the Food Service Department. Assist in identifying and correcting problem areas and/or the improvement of services .

Based on interview and record review, the facility failed to ensure the care plans were reviewed and revised to address the episodes of fall on (MONTH) 3, and (MONTH) 30, 2019, for one of one resident reviewed for fall (Resident 158). This failure resulted in Resident 158 to fall for the fifth time since admission, while at the facility. Resident 158 sustained [MEDICAL CONDITION] back. Findings: On (MONTH) 7, 2020, at 1:19 p.m., Resident 158's representative (RR) was interviewed. The RR stated Resident 158 had a fall last (MONTH) 2019, and sustained a broken back. The RR stated the resident had multiple falls while at the facility resulting in multiple injuries. Resident 158's record was reviewed. Resident 158 was admitted to the facility on (MONTH) 20, 2019, with [DIAGNOSES REDACTED]. Resident 158's Minimum Data Set (MDS - an assessment tool) dated (MONTH) 3, 2019, indicated Resident 158 had a BIMS (Brief Interview on Mental Status- an assessment of cognition level) score of 13 (meant cognitively intact). Resident 158's nursing progress notes indicated the following: a. On (MONTH) 20, 2019, at 19:00 (7 p.m.) (First fall), .Resident was found by CNA (Certified Nursing Assistant) while assisting another - resident to the bathroom she was laying on her left side - by bed C. resident's bed. She claimed she was trying to get back to her bed & slipped upon assessment there were no injury noted. Assisted with help of CNA to wheelchair. Vitals were taken wnl (within normal limits) .; b. On (MONTH) 21, 2019, at 12:00 p.m., .Taken via EMS (emergency medical services) to (name of acute care hospital) for x-ray (test which produces images of structures in the body) left hip r/t (related to) c/o (complaint of) pain . At 14:02 (2:02 p.m.) .resident had a fracture to left hip area. (Family member's name) was called & notified of the result per radiology, they were taking her in thru the ER at (name of acute care hospital) .; c. On (MONTH) 15, 2019, at 12:55 p.m., (Second fall) .Resident had a non injury fall during shower and CNA was trying to get clothes & resident stood up & slide to ground - an assessment was completed. No injuries to report @ (at) present .; d. On (MONTH) 3, 2019, at 00:20 (12:20 a.m.) (Third fall) .Resident was found on the floor at foot of the bed with a large amount of blood covering her shirt face, and arms. Due to patient's position and complaint of head & neck pain we did not move patient. 911 was called immediately. Upon waiting for (name of transport) resident remained awake, and notified us that she fell in the restroom. (Excessive amount of blood found in the restroom.) Resident was alert and normal to usual behavior. (Name of transport) arrived and took pt. (patient) to ER (emergency room ) for further evaluation .; e. On (MONTH) 3, 2019, at 17:30 (5:30 p.m.) .Resident returned back from (name of acute care hospital) ER. Resident arrived back to facility .with discharge Dx (diagnosis) of UTI (Urinary Tract Infection). However, resident sustained [REDACTED].and obtained a laceration (tear) to right forehead area. ER reports show a nondisplaced [MEDICAL CONDITION] proximal phalanx (finger) may be present to right hand, her hand also has a skin tear to top of wrist .shows bruising & swelling to area of fingers. Reports also show limited R (right) tibia/fibula (lower leg) trauma - with a nondisplaced vertical [MEDICAL CONDITION] tibial shaft (broken lower leg) . ; f. On (MONTH) 30, 2019, at 20:00 (8 p.m.) (Fourth fall) .Resident was observed to have gotten out of bed and was walking by her closet door attempting to reach the restroom & slipped on to ground. She hit the side of here R (right) head on closet wall. Was found in a sitting position .; g. On (MONTH) 8, 2019, at 7:40 a.m., (Fifth fall) .Pt (patient) found on floor in front of toilet. States she leaned forward to wipe and chair tilted forward. Denies pain. Body assessment no s/s (signs and symptoms) of injury noticed. B/P (blood pressure) 130/76 (normal range 120/80 - 140/80) R (respiration)-18 (normal range 16-20) P (pulse)-76 (normal range 60-100) T (temperature)-98.2 (normal range 96.8 - 99.9) Will cont. (continue) to monitor. h. On (MONTH) 8, 2019, at 12:30 p.m., New order r/t (related to) fall this am, Resident was in pain on L (left) side. Sent to (name of acute care hospital) for further eval (evaluation) . Resident 158's care plan titled, At risk for fall/injury, dated (MONTH) 20, 2019, indicated, .Goal .Be free of injury r/t (related to) falls .Interventions .Keep bed in low position. Assist with transfers. Educate resident how to call for assist and keep call bell within reach. Non slip footwear/shoes. Resident 158's care plan regarding fall incident dated (MONTH) 20, 2019, indicated .Assess and address injuries PRN (as needed). Notify MD and Family promptly. Attempt to determine reason for fall. Post falling star to alert continued fall risk. Add to toileting schedule PRN. Assess for possible pain. Teach resident and family regarding falls and safety. Monitor and document any skin tears, abrasions, lacerations, bruising, or c/o pain for 72 hours and evaluate for need to follow up. Fall Mat at bed side when in bed. Other: X-ray L (left) hip r/t c/o of pain. A review of the care plan for Resident 158's fall incident while at the shower on (MONTH) 15, 2019, indicated the same goal and interventions as the care plan on (MONTH) 20, 2019. There was no documented evidence that the care plan for fall was reevaluated and revised to address the fall incident which occured at the shower room while with the CNA on (MONTH) 15, 2019. On (MONTH) 8, 2020, at 4:11 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON verified there was no documented evidence Resident 158's plan of care was revised or updated after Resident 158's fall incident on (MONTH) 3, 2019 and (MONTH) 30, 2019. The DON stated there was no documented evidence an Interdisciplinary Team (IDT) meeting was conducted after the resident (Resident 158) fell on (MONTH) 3, 2019 and (MONTH) 30, 2019. On (MONTH) 8, 2020, at 10:32 a.m., CNA 1 was interviewed. CNA 1 stated Resident 158 likes to get up every hour, and would not let staff know if she wanted to use the bathroom. CNA 1 stated Resident 158 would grab the call light and throw it on her dresser. On (MONTH) 8, 2020, at 10:39 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated Resident 158 has confusion. LVN 1 stated the resident would get out of bed and would forget to use the call light. On (MONTH) 8, 2020, at 3:26 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated Resident 158 has dementia. She stated the resident would not listen and would not remember to call for help. On (MONTH) 9, 2020, at 2:42 p.m., the DON was interviewed. The DON stated when a resident falls, the licensed nurse should initiate an incident report and should update the resident's plan of care. A concurrent record review was conducted with the DON. The DON verified there was no documented evidence an incident report was conducted when Resident 158 fell on (MONTH) 3, 2019 and (MONTH) 30, 2019. The DON verified there was no documented evidence the facility staff completed a fall risk assessment or evaluation for Resident 158 after the fall incidents on (MONTH) 15, 2019, (MONTH) 3, 2019, and (MONTH) 30, 2019. In addition, the DON stated the licensed nurse should have made an incident report and updated the care plans for Resident 158. Resident 158's nursing progress notes dated (MONTH) 8, 2019, indicated Resident 158 had a fall and was sent to the acute care hospital. (This was Resident 158's fifth fall since she was admitted at the facility on (MONTH) 20, 2019.) A review of the x-ray result from the acute care hospital dated (MONTH) 8, 2019, indicated, .L1 vertebral infrapedical/lower endplate acute compression fracture (broken lower back) . A review of the undated facility policy titled, Falls: Post Assessment, indicated, .All residents are assessed post fall in order to identify any physical problems, medications or environmental issues related to the fall. A Post Fall Assessment and Fall Incident Report will be completed on all residents who have fallen .Document .Plan of Care accelerated/approaches updated . The undated facility policy titled, Falls and Fall Risk, Managing, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified .

Based on observation, interview, and record review, the facility failed to provide an environment free from sexual abuse, when Resident A, a victim of previous sexual abuse, was left out in the lobby with no staff supervision. This enabled Resident B, who had history of being sexually inappropriate to Resident A on three separate occasions (August 11, (MONTH) 25, and (MONTH) 9, (YEAR)), to sexual molest Resident A while out in the lobby. This failure to provide adequate supervision to Residents A and B resulted in Resident A to be a victim of sexual abuse for the fourth time by Resident B. Findings: On (MONTH) 20, (YEAR), Resident A's record was reviewed, the record indicated Resident A was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility form titled, history and physical examination [REDACTED].does NOT have the capacity to understand and make decisions . Review of Resident A's MDS (Minimum Data Set- an assessment tool) Section C (Cognitive Patterns), dated (MONTH) 15, (YEAR), indicated Resident A had short and long term memory problems. The assessment indicated that Resident A has severely impaired cognitive skills for daily decision making. Review of Resident A's progress notes indicated the following: a. On (MONTH) 11, (YEAR), at 18:00 (6 p.m.), . IT WAS ALLEGED THAT ANOTHER RESIDENT (Resident B) TOOK HER HAND AND WAS RUBBING HIS P_ _ _ _ (term for a male genital part) WITH HER HAND IN THE HALLWAY WHEN HE WAS INTERRUPTED BY ANOTHER RESIDENT .; b On (MONTH) 25, (YEAR), at 1540 (3:40 p.m.), . (Name of Resident C's family member) proceeded to tell us (Certified Nursing Assistant/CNA 1 and LVN /Licensed Vocational Nurse 3) that while sitting in the dining room, she observed (name of Resident B) had his hand up (name of Resident A) shirt .; and c. On (MONTH) 9, (YEAR), at 0745 (7:45 a.m.), Another resident (Resident B) was found touching pts (Resident A) breast in hallway . Review of Resident A's progress notes indicated Resident A had been subjected to sexual inappropriateness by Resident B, three times from (MONTH) 11 to (MONTH) 9, (YEAR). Resident A's care plans were reviewed. The care plans indicated the following: 1. On (MONTH) 11, (YEAR), Concerns & Problems: ALT (alteration) IN ALLEGED SEXUAL ASSAULT. a. Resident Goals: Will remain safe from potential harm; and b. Approach Plan: Keep individual away from alleged perpetrator, frequent visual checks while asleep, Notify M.D (medical doctor) of any signs and symptoms of trauma, and social service referral if ordered. 2. On (MONTH) 25, (YEAR), Concerns & Problems: Alt (alteration) by alleged sexual assault. a. Resident goals: Will remain safe from potential harm; and b. Approach Plan: Keep individual away from alleged perpetrator, frequent visual checks, Notify M.D. of any signs and symptoms of trauma, and social service referral if ordered. 3. On (MONTH) 10, (YEAR),Concerns & Problems: Altration (sic) in Alleged Sexuel (sic) assault. a. Resident goals: Resident will remain safe from potential harm; and b. Approach Plan: Keep resident away from alleged offender, keep resident near nurses' station when not asleep, frequent checks to room when pt. (patient) sleeping, notify M.D of any signs and symptoms of sexual assault. Resident B's record was reviewed. The record indicated Resident B was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of the facility form titled, history and physical examination [REDACTED].does NOT have the capacity to understand and make decisions. Review of Resident B's MDS (Minimum Data Set- an assessment tool), dated (MONTH) 16, (YEAR), indicated Resident B had a BIMS (Brief interview for Mental Status-used to assess cognition) score of 15. A BIMS score of 15 meant intact cognition (13-15 points= intact cognition, 8-12 points = moderately impaired, and 0-7 points= severely impaired cognition). Review of Resident B's progress notes indicated the following: a. On (MONTH) 11, (YEAR), at 1800 (6 p.m.), .rec (received) a complaint from a 3rd resident (Resident D) regarding alleged sexual abuse by this resident (Resident B), he was using her (Resident A) hand to rub his P _ _ _ _ (term for a male genital part) in the hallway . b. On (MONTH) 25, (YEAR), at 1540 (3:40 p.m.), . (Name of Resident C's family member) proceeded to tell us (CNA 1 and LVN 3) that while sitting in the dining room, she observed (name of Resident B) had his hand up (name of Resident A) shirt . c. On (MONTH) 9, (YEAR), at 0745 (7:45 a.m.,), Resident (Resident B) found .outside of room touching other residents (sic) (Resident A) breast . Review of Resident B's progress notes indicated Resident B had been sexually inappropriate towards Resident A on three separate incidents from (MONTH) 11 to (MONTH) 9, (YEAR). Resident B's care plans titled, SHORT TERM GOALS, were reviewed. The care plans indicated: 1. (MONTH) 11, (YEAR), Concerns & Problems: ALT. (alteration) IN Bx. (behavor) R/T (related to) ALLEGED INAPPROPRIATE CONTACT WITH ANOTHER RESIDENT. a. Resident goals: Keep other female residents safe, which allowing resident to move about the facility freely; and b. Approach plan: Provide as much visual contact as possible, engage resident with activities of choice, and notify social services for 1 x 1 activities. 2. (MONTH) 25, (YEAR),' Concerns & Problems: Alt (alteration) in behavior R/T alleged inappropriate contact with another resident. a. Resident Goals: Keep other female resident safe which allowing resident to move about the facility freely; and b. Approach Plan: Provide as much visual contact as possible, notify social service for 1 x 1 (one to one) activities, keep resident out of dining room unless supervised by staff member, supervise resident at any time he is out of his room with female residents. 3. (MONTH) 10, (YEAR), Concerns & Problems: Alteration in behavior r/t inappropriate contact with other resident. a. Resident Goals: Present advice effect and promote safety to self and other resident; and b. Approach plan: Keep out of dining room unless supervise, supervise pt. (patient) at all times, and Keep resident separated from female residents at all times unless supervised. On (MONTH) 20, (YEAR), at 10:16 a.m., Resident B was interviewed. Resident B acknowledged he fondled Resident A's breast. Resident B further stated, he did not have a reason why he touched Resident A's breast. On (MONTH) 20, (YEAR), at 10:36 a.m., Resident A was observed sitting in her wheelchair attending activities in the dining room. On (MONTH) 20, (YEAR), at 10:47 a.m., Medical Record Staff (MRS) 1, was interviewed. She stated while she was at the nurse's station by the window on (MONTH) 18, (YEAR), she saw Resident B caressing Resident A's right breast with his left hand. On (MONTH) 20, (YEAR), at 11:02 a.m., LVN 1 was interviewed. LVN 1 stated she was notified that Resident A was touched inappropriately by Resident B, on (MONTH) 18, (YEAR). On (MONTH) 20, (YEAR), at 12:05 p.m., LVN 2 was interviewed. LVN 2 stated Resident B had touched Resident A inappropriately before, about two months ago. On (MONTH) 20, (YEAR), at 12:13 p.m., CNA 3, was interviewed. CNA 3 stated there was an incident involving Residents A and B, two to three months ago. On (MONTH) 20, (YEAR), at 12:35 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated he (Resident B) did the same thing before. On (MONTH) 20, (YEAR), at 12:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated she was aware of the incident involving Resident A and Resident B. In addition, the DON stated Resident B admitted touching Resident A inappropriately. On (MONTH) 20, (YEAR), at 1:36 p.m., Resident A along with a Spanish interpreter was interviewed. Resident A was unable to respond to questions appropriately during the interview. On (MONTH) 23, 2019, at 8:11 a.m., CNA 2 was interviewed. CNA 2 stated she witnessed Resident B touching Resident A's breast in the hallway on (MONTH) 9, (YEAR). On (MONTH) 23, 2019, at 10:20 a.m., Registered Nurse (RN) 1 was interviewed. RN 1 stated there were multiple incidents of sexual abuse on Resident A by Resident B. On (MONTH) 7, 2019, at 1 p.m., CNA 4 was interviewed. CNA 4 stated Resident B would watch staff and when he sees the staff were busy that is when Resident B abuses the resident (Resident A). CNA 4 further stated, staff were told to keep an eye on him and keep him separated. On (MONTH) 6, 2019, at 8:57 a.m., MRS 1 was interviewed whether there was staff present when she saw the two residents (Residents A and B) in the lobby on (MONTH) 18, (YEAR). She stated there was no staff in the lobby, when Resident B was found with Resident A. On (MONTH) 7, 2019, at 11: 21 a.m., CNA 2 was interviewed. She stated it was hard for them to watch the residents all the time. CNA 2 stated they (the CNAs) have a lot of residents and they tend to get busy. She stated all the staff were supposed to watch the two residents (Residents A and B). Review of the facility's policy and procedure titled, Abuse Prevention Program, revised date of (MONTH) 2006 indicated, Policy Statement Our residents have the right to be free from abuse, neglect, . Policy Interpretation and Implementations 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: other residents . 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. a. Protocols for conducting employment background checks; b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc.; c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; e. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident to resident abuse and resident-to-staff abuse; f. Timely and thorough investigation of all reports and allegations of abuse; g. The reporting and filing of accurate documents relative to incidents of abuse; h. An ongoing review and analysis of abuse incidents; and i. The implementation of changes to prevent future occurrences of abuse .

Based on observation, interview and record review, the facility failed to identify, evaluate and implement interventions to ensure the environment was free from the potential of electrical fire hazards for a universe of 40 residents when: 1. A professional electrical engineer (PE) identified safety hazards in the main electrical service panel and notified the facility's owners/previous administrators in writing on December 23, 2016, of the hazards. The facility Administrative Staff had not taken any action to ensure the identified hazards had been addressed as of September 20, 2017. This failure had the potential to place all 40 facility residents (35 of which were wheelchair bound, four needed staff assistance, and one was independent with ambulation), visitors, and employees at risk for injuries up to death in case of an electrical fire. 2. Three water heaters were replaced without obtaining a Building Permit, and the hot water annunciator (an alarm to advise staff when hot water temperatures exceeds 125 degrees Fahrenheit (F) for the domestic hot water (hot water used by residents) was out of order. This failure had the potential to cause scald (burns caused by hot liquid or steam) injuries to residents if staff were not aware that the hot water exceeded 125 degrees F. Due to the facility's failure to ensure that the environment was free from potential electrical fire hazards, the Administrator (AD) and Administrator in Training (AIT) were verbally notified of an Immediate Jeopardy situation on September 20, 2017, at 2:06 p.m. On September 20, 2017, the facility presented CDPH with an acceptable plan of action that indicated the facility would have Fire watches, (a staff member who is tasked with going around the facility every 30 minutes to monitor, identify, and react to hazards such as smoke and/or fire) 24 hours a day seven days a week until the identified electrical fire hazard had been fixed. The AD would have an electrical engineer onsite on Friday, September 22, 2017, when OSHPD (Office of Statewide Health Planning and Development) would come to the facility to review the electrical concerns and to provide the necessary emergency permits to begin work on the electrical hazard. The Immediate Jeopardy was removed in the presence of the Administrator, Maintenance Supervisor and IOR (Inspector of Record) on October 10, 2017, at 10:45 a.m., after OSHPD had completed an inspection and determined the facility's electrical system had been corrected. Findings: On September 19, 2017, at 11:40 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding an environmental safety hazard. At 12 noon on September 19, 2017, an interview was conducted with Electrician 1. Electrician 1 stated the building was safe from fire hazards but would not certify in writing that the building was safe from fire hazards. At 2:30 p.m. on September 19, 2017, the facility could not provide any documentation to substantiate that the facility was safe from fire hazards. On September 20, 2017, at 12:01 p.m., a second visit was conducted at the facility to investigate the complaint regarding the physical environment. At 12:13 p.m., a tour of the facility was conducted with a certified nursing assistant (CNA) who was conducting the Fire watch for the day shift. While touring the exterior of the building, the AD was observed standing outside near the main electrical box with four men. At 12:50 p.m., an interview was conducted with the AD and the AIT. The AD stated that they had not been made aware of any electrical issues until the State (CDPH) had come out to the facility on Friday (September 15, 2017), to investigate the complaint. The AD further stated that she had not received a copy of the PE's report until it had been faxed to her by the (CDPH) District Office on Monday September 18, 2017. Review of the report by the PE dated December 23, 2016, addressed to the owner/previous administrator at the facility indicated, Subject: (Name of Facility in City, State). Report of existing conditions .but for some reason all the distribution circuit breakers at the bottom section have been removed. Because of this, we open (sic) the section below the main (electrical service panel) and found out all the circuit breakers were there at one point but for some reason they were removed .4. This is an unsafe condition because the power panels and feeders fed by this section are not protected . The report further indicated, .Once we open (sic) the bottom of the Main Service Switchboard, we noticed more non-code complaint issues .But the existing conditions of the main electrical service is in non-code compliant conditions that could be the cause of an electrical fire if an overload or short circuit condition presents itself . Review of the CONSTRUCTION ADVISORY REPORT, by OSHPD inspector dated September 22, 2017, indicated, Title or Scope of Project: MAIN ELECTRICAL SERVICE REPLACEMENT. The report further indicated, .The purpose of the visit is to observe and review the electrical main service panel board for hazardous conditions. These conditions were presented by email including photographs and narrative by (PE's name). The report indicated nine bullet points that addressed the main electrical service, temporary generator and related equipment. The report recommended five bullet points to be observed, tested and/or corrected ASAP to help reduce potential fire hazard . 2. On September 22, 2017, documentation of the inspection by the Fire Marshall with the OSHPD Inspector was reviewed. The documentation indicated the annunciator (alarm to warn the hot water was over the high limit of 125 degrees Fahrenheit) for the domestic water heater was out of order and three new water heaters had been installed without a permit. On [DATE], at 12 noon, an interview was conducted with Certified Nursing Assistant 1 (CNA 1). CNA 1 was asked what precautions were in place to deal with the non-working hot water heater alarm. CNA 1 stated that she had not been aware the alarm was not working. On September 23, 2017, at 12:02 p.m., an interview was conducted with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated that she was the licensed staff member for the facility for the day shift. LVN 2 was asked if she was aware of the non-working hot water alarm. LVN 2 stated that she had not been aware of the problem with the hot water alarm. On September 23, 2017, at 12:03 p.m., an interview was conducted with the Environmental Services Aide (EVA). The EVA was asked if she was aware of the non-working hot water alarm. The EVA stated that she had not been aware of any problem with the hot water alarm. The EVA further stated that they had checked the temperature of the hot water every afternoon in some of the facility rooms. The EVA stated that she had recorded the temperatures in a log. On September 23, 2017, the temperature log for the month of September was reviewed. The log indicated only a sampling of rooms that were checked each day, and that the same rooms were sampled each time. The log also indicated on the dates of September 14,15,17, and 22, 2017, no temperatures had been recorded. On September 23, 2017, at 12:05 p.m., the EVA was asked about the missing dates in the temperature log for September. The EVA stated that she usually had taken the temperatures in the afternoon, but probably had gotten too busy on those days and had not done it. On September 27, 2017, the OSHPD guide titled, Expedited Building Permit for Water Heater Replacement, dated December 2015, by OSHPD was reviewed. The OSHPD guide indicated, A water heater replacement requires a Building Permit. The OSHPD guide indicated one of the requirements was, .34. Temperature Control Valves .the high temperature alarm set at 125 degrees Fahrenheit and the audible/visual device for high temperature annunciating at a continuously occupied location (Section 613.5,2013 CPC)).

Based on observation, interviews, and record review, the facility failed to provide adequate supervision for Resident A when the resident had wheeled herself out of the facility and was not discovered for two hours and 55 minutes in temperatures of 100 degrees Fahrenheit (F). This failure to provide supervision of Resident A caused her to become unresponsive, require an endotracheal tube (insertion of a tube into the windpipe to provide artificial respiration by way of a ventilator), admission to the intensive care unit, and a burn to the right inner forearm. Findings: On June 5, 2014, at 8:20 a.m., an unannounced visit was made to the facility to investigate an entity reported incident that occurred on May 24, 2014, and indicated Resident A had wheeled herself outside the facility where the temperature reached at least 100 degrees F, developed altered level of consciousness, and was not discovered for two hours and 55 minutes. Resident A also developed a burn on her right inner arm. According to the "Weather History for Blythe, CA / Weather Underground," (an Internet weather history site) the recorded maximum temperature for May 25, 2014, was 100 degrees Fahrenheit. The record for Resident A was reviewed. Resident A, a [AGE] year old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On June 5, 2014, at 8:35 a.m., Resident A was observed sitting in her wheelchair in the main hallway. Further observation revealed a lap buddy (a removable cushion restraint) in place. In addition, a wheelchair alarm was applied to her sweater. On June 5, 2014, at 10:10 a.m., the Director of Nursing (DON) was interviewed. She stated that Resident A was more mobile after her Risperdal (a medication used off label to treat agitation associated with dementia; the medication is known to cause sedation) was changed to a lower dose. The DON stated they (IDT, interdisciplinary team) failed to recognize Resident A's increase in mobility after the medication dosage was reduced. The DON further stated Resident A was able to move from one location to another using her feet to propel her wheelchair. On June 5, 2014, at 10:45 a.m., a phone interview was conducted with CNA (Certified Nursing Assistant) 1. She stated she (CNA 1), received instructions from the charge nurse and off duty (morning) CNA prior to starting her duties on May 24, 2014. CNA 1 further stated that she had no shift report from the morning CNA and had no instructions about Resident A's behavior of wandering off. In addition, CNA 1 stated, "We are suppose to watch our patients every time. The last time I saw her, I can't pinpoint the time. I saw her at the beginning of the shift (2 p.m.). We were so busy that day. For the most part she's very alert. I never know she goes out the back door. It was really hot that day. I didn't realize she was not around. I know of her, she (Resident A) roaming around in the facility. Typical of her being inside." In an interview with Laundry Staff 1, on June 5, 2014, at 11:35 a.m., she stated that Resident A could open both doors that lead to the staff patio. In an interview with CNA 2 on June 5, 2014, at 11:52 a.m., she stated that she had seen Resident A open the north door with no assistance. CNA 2 further stated, "She (Resident A) can open the door sitting in her chair." In a phone interview with Licensed Nurse (LN) 1 on June 5, 2014, at 12:10 p.m., she stated, "She (Resident A) can scoot around pretty good in her wheelchair." LN 1 further stated, "All of us are responsible to watch patients." There were no wandering/elopement assessment and no nursing care plan to indicate Resident A was a wanderer. The "LICENSED NURSES PROGRESS NOTES," dated May 25, 2014, at 5:30 p.m., indicated, "Discovered patient sitting in w/c (wheelchair) in grass on west side of building was unresponsive to verbal stimuli & noted to have small emesis (vomit) & mucous on chin & chest aided into bed... O2 (oxygen) sats (saturation) 87% on room air (the amount of oxygen circulating in arterial blood; normal level is 96% or greater) ronchi (rhonchi) & wheezes (abnormal lung sounds) bilat. (bilateral - both lungs)..." Review of Resident A's physician telephone orders dated, May 25, 2014, at 5:50 p.m., indicated, "Send to (Hospital 1's name omitted) ER (emergency room ) for eval (evaluation)." On May 25, 2014, at 6:05 p.m., Resident A was transferred to Hospital 1's ER for evaluation. The Emergency Department record dated, May 25, 2014, at 6:23 p.m., indicated "CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: ...75 old F (female) that presented to the Emergency Department at 18:23 (6:23 p.m.) by AMB (ambulance) ... vital signs 99.6 (elevated temperature) PO (oral) 133 regular (heart rate), 28 (respirations) Unlabored. Chief Complaint-- ALTERED MENTAL STATUS...found outside, unknown time outside, altered , emesis on gown and possible aspirations... poorly responsive... She was in wheelchair at (facility name omitted). PHYSICAL EXAMINATION: ...Chest - rales ronchi bilaterally... CLINICAL IMPRESSION: 2. Aspiration pneumonia - intubation (insertion of a tube into the windpipe to provide artificial respirations by way of a ventilator)." Review of the facility's portable upright chest x-ray indicated there was "No significant acute abnormality." Review of the laboratory report dated May 25, 2014, at 7:10 p.m., indicated: "WBC (white blood count) 15.5 H (high) (4.6 - 10.2 normal) BUN (Blood Urea Nitrogen) 30 H (high) (.7 - 18 normal) CREATININE BLOOD 1.7 H (high) (0.6 - 1.5 normal)" (An elevated WBC is indicative of infection. Abnormal high results of the BUN and Creatinine could indicate dehydration and/or kidney disease.) At 11:16 p.m., on May 25, 2014, Resident A was transferred by air ambulance to another hospital (Hospital 2). Transfer was initiated for, "SPECIALIZED RESPIRATORY." Resident A's [DIAGNOSES REDACTED]. Review of the Hospital 2's emergency department (ED) report, dated May 25, 2014, at 1 a.m., indicated that Resident A remained intubated and had been placed on a ventilator. Further review of the ED report indicated that Resident A was on a cardiac (heart) monitor, received IV (intravenous) fluids, antibiotics and had a Foley catheter (a tube inserted into the bladder to drain urine). Resident A was transferred from the ED to the Intensive Care Unit in critical condition. Review of the nurses progress notes titled, "Site Management," from May 25, 2014 at 12:38 a.m., to June 3, 2014 at 4 a.m., indicated: "BLISTER (1) RIGHT INFERIOR) Side = RIGHT, Site ELBOW (...RN at 05/25/2014 10:36), Descriptors = INFERIOR (below) (... RN at 05/25/2014 10:36, Type = BLISTER ...Comments = looks like a blister that popped ... BLISTER (1) LEFT UPPER ARM Side = LEFT; Site = UPPER ARM (... RN at 05/27/2014 06:10); Type = BLISTER (...RN at 05/27/2014 06:10)" Review of the Hospital 2's form titled, "PHYSICIANS PROGRESS NOTES," dated "5/27/14 1500" (3 p.m.)indicated, "Wound care - Pt. (patient) has 2 unroofed (uncovered) blisters of (R) (right) inner arm that family member says may have been due to a burn from the metal of her wheelchair. Blisters measure 6 x 7 x 0.1 cm (centimeters) (distal) and 2 x 5 x 0.1 cm (proximal) ... " Review of the facility's investigation report, completed on June 5, 2014, indicated under "Conclusion: Considering the condition the pt. (patient) was found in (extremely hot skin, unresponsive, possible vomiting and questionable aspiration) and the fact that the pt. had not been seen by staff members after 2-2:20 p.m., and that even if the assigned CNA had actually seen her in the facility an hour prior to finding her behind the facility the least amount of time the resident (patient) would have been exposed to extreme heat outdoors was an hour. However, the security cameras recording shows a pt. (patient) exiting the facility at 2:20 p.m. by the back door, going around the building toward back of the facility and does not show pt. returning from behind facility until she was wheeled back into back door at approximately 5:15 p.m. This makes this incident a confirmed abuse in the form of neglect by the CNA assigned to care for her because she (the CNA) did not check her pt. at least every 2 hours." Review of the facility's policy titled, "Preventing Hot Weather Injuries," undated, indicated: "POLICY: To prevent sunburn, heat exhaustion, dehydration, heat stroke and other injuries to residents from exposure to sun and hot weather (above 85*F) the nursing staff will adopt guidelines recommended by the CDC (Center For Disease Control). PROCEDURE: D. Limit time outside to 1 hr (hour) if temperature is below 100 degrees and limit time to 30 min (minutes) if temp (temperature) exceeds 100. E. Place patient in shaded areas outside. DO NOT ALLOW EXPOSURE TO DIRECT SUNLIGHT." Review of the facility's form titled, "RESIDENT RIGHTS," undated, indicated under the section, "In Summary ...The main point to remember is that the resident rights are protected. You are responsible for assuring that your assigned residents are properly cared for."