Every finding on record at Brighton Place Spring Valley

Based on observation, interview and record review, the facility failed to implement the facility's abuse policy and procedure for an allegation of physical abuse of a resident (Resident 3) when the alleged perpetrator (person who inflicts harm) was not suspended pending outcome of the investigation. This deficient practice did not protect the resident and other residents for potential abuse by the alleged perpetrator.Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood causing confusion and memory loss) and respiratory failure (when lungs cannot get enough oxygen into the blood or remove waste gas) according to the facility's admission record. An observation and interview on 8/13/26 at 9:43 A.M. was conducted with Resident 3. Resident 3 was in sitting up in bed with oxygen on. Resident 3 stated he was slapped on the face, (pointing to left cheek) by a male nurse. Resident 3 stated a week ago from 8/13/26, he accidentally spilled juice or water on his legs and got wet, so he waved for the male nurse (LN1) who was passing by his room to come to this room. Resident 3 stated LN 1 told him his legs were not wet. Resident 3 then asked LN 1 to change his brief and the nurse refused to change him and slapped him on the face. Resident 3 stated LN 1 left the room after he told the nurse not to touch him. An interview on 8/13/26 at 11:17 A.M. was conducted with LN1. LN 1 stated on 8/4/26, the following day of the alleged incident, the social service director notified him of the allegation of physical abuse. LN 1 stated he was not sent home from work nor was he suspended pending outcome of the investigation. During review of care plans for Resident 3, the care plan dated 8/4/26 indicated, Resident at risk for emotional distress r/t reported an allegation of staff-to-resident abuse involving alleged contact to the left shoulder. The care plan further indicated, Interventions.Identified Staff member suspended until further notice / until investigations is completed. An interview on 8/13/26 at 2:55 P.M. was conducted with the facility's Administrator (ADMIN). The ADMIN stated that depending on the situation, the facility may or may not suspend an employee. A review of the facility's Alleged Staff-to-Resident Physical Abuse - 5-day Investigation Report, dated 8/9/26 was conducted. The 5-day Investigation Report indicated, .Facility determined suspension was not required at that time based on the investigation findings to date. During an interview on 8/26/26 at 11:05 A.M. with the Director of Nursing (DON), the DON stated it was important to suspend the alleged perpetrator (employee) to protect other residents and per facility policy. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/24 was conducted. The P&P indicated, Definitions. [Physical abuse] is defined as, but not limited to, hitting, slapping, punching, and/or kicking.6. Immediate Actions.ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies.

Based on interview and record review, the facility failed to report an allegation of financial abuse between a resident (Resident 1) and a Certified Nursing Assistant (CNA 1) to the California Department of Public Health (CDPH) within the 24 hour time requirement. This failure had the potential to delay investigation and affect the physical and psychosocial wellbeing of the resident.Findings:According to an undated Face Sheet, Resident 1 was readmitted to the facility on [DATE] with diagnoses to include paraplegia (the loss of function to both legs) and schizoaffective disorder (a complex mental health problem).According to the physician's History and Physical note, dated 5/5/26, Resident 1 could make his needs known, but could not make medical decisions.According to the Brief Interview for Mental Status (BIMS, an assessment tool), dated 5/22/26, Resident 1 had moderately impaired cognition.A complaint was received by the California Department of Public Health indicating Resident 1 had reported an unknown amount of money was missing from a personal bank account. Resident 1 had reported that a certified nurse assistant (CNA) had purchased food using his debit card number. An interview was conducted with Resident 1 on 6/9/26 at 10:55 A.M. Resident 1 stated he had asked CNA 1 to help order food from a food delivery application (app). Resident 1 stated CNA 1 had used her personal phone with his debit card number for payment to order food delivery for him. Resident 1 stated CNA 1 then went home, forgetting his debit card was on her phone, and her child had then ordered food using the same app and his debit card. Resident 1 stated CNA 1 had apologized and returned the money, and he did not want her to get in trouble. Resident 1 stated he had reported this information to the Social Services Director (SSD) at the facility.An interview was conducted with the SSD on 6/9/26 at 11:30 A.M. The SSD stated Resident 1 had asked to speak with her on 5/30/26. The SSD stated Resident 1 had told her about CNA 1 ordering the food with her phone using his debit card, and about the additional purchases made from CNA 1's home. The SSD stated Resident 1 had told her the money had been paid back to him. Per the SSD, she educated Resident 1 about not sharing his debit card information with anyone. The SSD stated she informed the Administrator (Admin) about the incident on the same day. An interview was conducted with the Admin on 6/9/26 at 11:45 A.M. The Admin stated he was the abuse coordinator for the facility. Per the Admin, he was aware of the incident reported by Resident 1. The Admin stated Resident 1 occasionally acted inappropriately due to his illness in order to get attention. The Admin stated he had not considered the incident to potentially be financial abuse, and he did not report the incident to CDPH. The Admin stated he should have reported the incident to CDPH as soon as it was reported to him, but he had not done so. A telephone interview was conducted with CNA 1 on 6/10/26 at 7:15 A.M. CNA 1 stated she had not been assigned to work with Resident 1 in a long time. CNA 1 stated she had never ordered food delivery for Resident 1 using her phone and had never assisted Resident 1 in ordering food from his phone or tablet. CNA 1 stated she had never paid money to Resident 1. CNA 1 stated she had not been disciplined for the reported incident, but she and her coworkers had been educated on identifying and preventing abuse. A follow up telephone interview was conducted with the Admin on 6/10/26 at 8:30 A.M. The Admin stated CNA 1 had provided access to her phone, including the food delivery app and payments. Per the Admin, there were no purchases made using Resident 1's debit card number. The Admin stated Resident 1 had admitted he was trying to get the SSD's attention by reporting the incident. The Admin stated he should have identified the situation as potentially being financial abuse, and reported the incident to CDPH, but he had not done so. A follow up interview and document review was conducted with the SSD on 6/15/26 at 2:30 P.M. The SSD stated rather than educating Resident 1 regarding giving his debit card information to staff, she should have immediately reported the incident to the Admin who was the Abuse Coordinator for the facility. The SSD reviewed the facility's Abuse Prevention and Management policy and stated she had not identified the situation as abuse and had not reported the incident to the Admin as a possible abuse allegation. According to a facility policy, revised 5/30/24 and titled Abuse Prevention and Management, .The facility will report all allegations of abuse.as required by law and regulations to the appropriate agencies.Reports of resident abuse.are promptly reported.

Based on interview and record review, the facility failed to investigate an allegation of financial abuse for one of two residents reviewed for abuse (Resident 1). This failure had the potential to place residents at risk for abuse. Findings:According to an undated Face Sheet, Resident 1 was readmitted to the facility on [DATE] with diagnoses to include paraplegia (the loss of function to both legs) and schizoaffective disorder (a complex mental health problem).According to the physician's History and Physical note, dated 5/5/26, Resident 1 could make his needs known, but could not make medical decisions.According to the Brief Interview for Mental Status (BIMS, an assessment tool), dated 5/22/26, Resident 1 had moderately impaired cognition.A complaint was received by the California Department of Public Health indicating Resident 1 had reported missing money from a personal bank account. Resident 1 had reported that a CNA had purchased food using his debit card number. An interview was conducted with Resident 1 on 6/9/26 at 10:55 A.M. Resident 1 stated he had asked certified nurse assistant (CNA) 1 to help order food from a food delivery application (app). Resident 1 stated CNA 1 had used her personal phone with his debit card number for payment to order food delivery for him. Resident 1 stated CNA 1 then went home, forgetting his debit card was on her phone, and her child had then ordered food using the same app and his debit card. Resident 1 stated CNA 1 had apologized and returned the money, and he did not want her to get in trouble. Resident 1 stated he had reported this information to the Social Services Director (SSD) at the facility, who advised him not to share his debit card information with anyone. Resident 1 stated nobody else from the facility had discussed this with him. An interview was conducted with the SSD on 6/9/26 at 11:30 A.M. The SSD stated Resident 1 had asked to speak with her on 5/30/26. The SSD stated Resident 1 had told her about CNA 1 ordering the food with her phone using his debit card, and about the additional purchases made from CNA 1's home. The SSD stated Resident 1 had told her the money had been paid back to him. Per the SSD, she educated Resident 1 about not sharing his debit card information with anyone. The SSD stated she informed the Administrator (Admin) about the incident, but she had not spoken to CNA 1 or conducted an investigation. An interview was conducted with the Admin on 6/9/26 at 11:45 A.M. The Admin stated he was the abuse coordinator for the facility. Per the Admin, he was aware of the incident reported by Resident 1. The Admin stated Resident 1 occasionally acted inappropriately due to his illness to get attention. The Admin stated he had not considered the incident to potentially be financial abuse, and he had not spoken to Resident 1 or asked CNA 1 any questions about her involvement. The Admin stated he should have conducted an investigation to obtain more details to determine whether abuse had occurred or not. A telephone interview was conducted with CNA 1 on 6/10/26 at 7:15 A.M. CNA 1 stated she had not been assigned to work with Resident 1 in a long time. CNA 1 stated she had never ordered food delivery for Resident 1 using her phone and had never assisted Resident 1 in ordering food from his phone or tablet. CNA 1 stated she had not been disciplined for the reported incident, and she had not been suspended from her job. CNA 1 stated nobody at the facility had requested to see her phone or asked her any questions regarding using Resident 1's debit card. A follow up telephone interview was conducted with the Admin on 6/10/26 at 8:30 A.M. The Admin stated CNA 1 had provided access to her phone, including the food delivery app and payments. Per the Admin, there were no purchases made using Resident 1's debit card number. The Admin stated Resident 1 had admitted he was trying to get the SSD's attention by reporting the incident. The Admin stated as the facility's Abuse Coordinator, he should have suspended CNA 1 and conducted an investigation, but he had not done so. A follow up interview and document review was conducted with the SSD on 6/15/26 at 2:30 P.M. The SSD stated she should have asked Resident 1 for proof of the missing funds and spoken to CNA 1 to assist with the investigation. The SSD stated the Admin was the Abuse Coordinator for the facility. The SSD reviewed the facility's Abuse Prevention and Management policy and stated CNA 1 should have been suspended while she and the Admin conducted an investigation, but they had had not done so. According to a facility policy, revised 5/30/24 and titled Abuse Prevention and Management, .Reports of resident abuse.are promptly reported and thoroughly investigated.when the Administrator.receives a report of an allegation of abuse.will initiate an investigation immediately.if the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation.

Based on observation, interview and record review, the facility failed to provide a safe, comfortable, homelike environment for three of four sampled residents (Residents 1, 2, and 3) when a broken HVAC (Heating, Ventilation, and Air Conditioning) unit was not repaired in a timely manner, resulting in the inability for staff to control the temperature within a unit of the facility.As a result, Residents 1, 2, and 3 were uncomfortable and reported feeling too cold during the night.Findings:1. During a record review on 12/10/25 the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included fibromyalgia (a condition that causes widespread body pain, fatigue, and sleep issues), need for assistance with personal care.During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 1 on 12/10/25 at 7:22 A.M., Resident 1 was observed in bed, with multiple white and brown blankets covering her. There was an air vent observed on the ceiling, directly above the foot of Resident 1's bed. Resident 1 stated, The last few nights its been very cold. I've got a lot of blankets on me right now. At night, its so cold, even with the covers my body is like ice. Resident 1 stated the vent blew air towards her, which made her feel colder. Resident 1 stated she slept with her head under the covers because it was so cold.2. During a record review on 12/10/25 the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses which included need for assistance with personal care, chronic obstructive pulmonary disease (a lung disease which makes breathing difficult) and bradycardia (a slow heart rate).During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 2 on 12/10/25 at 7:49 A.M., Resident 2 was observed laying in bed with a brown blanket on her. Resident 2 stated, Its too cold here, not just at night, but all day.It seems like its really cold between 4 and 6 in the morning. Resident 2 stated the thermostat could not be adjusted to a warmer temperature, but she was unsure why. Resident 2 stated staff brought her a space heater to use, but the resident next door was using it.3. During a record review on 12/10/25 the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses which included difficulty in walking, need for assistance with personal care, and unspecified fall.During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 3 on 12/10/25 at 7:53 A.M., Resident 3 was observed laying in bed. There was a space heater observed across the room, on the floor. The space heater was turned on. Resident 3 stated staff provided the space heater to her I have them turn it on from 6 to 9:30 in the morning. Otherwise its too cold at night. Resident 3 stated she would not be able to sleep without the space heater, because she would feel too cold at night.During a concurrent observation and interview with the Maintenance Supervisor (MS) on 12/10/25 at 8:37 A.M., the MS stated, the thermostat stopped working a few weeks ago. The MS stated the broken HVAC unit controlled the temperature for rooms 1 through 5. The MS stated the facility was waiting for approval from the facility's corporate department to fix the broken HVAC unit.During an interview with the Director of Nursing (DON) on 12/10/25 at 9:02 A.M., the DON stated it was important for residents to experience a comfortable environment, which included temperature.During a record review on 12/10/25 the facility policy titled Resident Rooms and Environment, revised January 2012, indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following.F. Comfortable temperatures.

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was provided with a safe and comfortable environment when Resident 3 was observed with a space heater in her bedroom.This deficient practice placed Resident 3 at risk for injury including burns and fire.Findings:1. During a record review on 12/10/25 the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses which included difficulty in walking, need for assistance with personal care, and unspecified fall.During a record review, the MDS (Minimum Data Set-a federally mandated assessment tool) indicated Resident 1 had a BIMS (Brief Interview for Mental Status) of 12, which indicated moderate cognitive impairment.During a concurrent observation and interview with Resident 3 on 12/10/25 at 7:53 A.M., Resident 3 was observed laying in bed. There was a space heater observed across the room, on the floor. The space heater was turned on. Resident 3 stated staff provided the space heater to her I have them turn it on from 6 to 9:30 in the morning. Otherwise its too cold at night. Resident 3 stated she would not be able to sleep without the space heater, because she would feel too cold at night.During a concurrent observation and interview with the Maintenance Supervisor (MS) on 12/10/25 at 8:37 A.M., the MS stated, We're not allowed to have those [space heaters] in residents' rooms. They could get burned. the MS statedDuring an interview with the Director of Nursing (DON) ON 12/10/25 AT 9:02 A.M., the DON stated, We can't give space heaters to the residents. They're a fire hazard.During a record review on 12/10/25, the facility's policy titled Electrical Appliances, revised January 2012, indicated, Only authorized electrical appliances are permitted in resident living areas. The policy did not provide guidance on the use of space heaters in resident rooms.

Based on interview and record review, the facility failed to provide residents and their families with a written Notice of Transfer/Discharge for three of three residents (Resident 1, 2, and 3), when reviewed for discharge. These failures had the potential for residents to experience increased anxiety, when last-minute discharges were conducted, with no ability to appeal the discharge. Findings:An unannounced visit was made to the facility on 8/14/25, in response to a complaint involving a discharge.1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease, stage 4, (severe kidney damage with significantly reduced kidney function), per the facility's admission Record.Resident 1 had a Responsible Party (RP-a person designated to make medical and financial decisions on the resident's behalf) listed on the admission RecordOn 8/14/25, Resident 1's clinical record was reviewed.According to the discharge Minimum Data Set, (MDS-a clinical assessment tool), dated 7/25/25, Resident 1 had a cognitive score of 12, indicating cognition was moderately impaired. According to the facility's nursing notes, titled Discharge summary, dated [DATE] at 12:26 P.M., Resident 1 was discharged to an assisted living facility, via medical transport.There was no documented evidence that a written Notice of Transfer/Discharge was provided to the resident or the RP, prior to discharge.2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included cellulitis (an infection of the skin and subcutaneous tissue), per the facility's admission Record.On 8/14/25, Resident 2's clinical record was reviewed.According to Resident 2's discharge MDS, dated [DATE], a cognitive score of 13 was listed, indicating cognition was intact.The facility's Discharge Planning Review Form, dated 7/11/25, indicated Resident 2 was being discharged to an Independent Living Facility, for a lower level of care.There was no documented evidence that a written Notice of Transfer/Discharge was provided to the resident, prior to discharge.3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included pneumonia (Infection in the lungs), per the facility's admission Record.On 8/14/25, Resident 3's clinical record was reviewed.According to Resident 3's discharge MDS, dated [DATE], a cognitive score of 14 was listed, indicating cognition was intact.The facility's Discharge Planning Review Form, dated 7/18/25, indicated Resident 3 was being discharged to an Assisted Living Facility, for a lower level of care.There was no documented evidence that a written Notice of Transfer/Discharge was provided to the resident, prior to discharge.An interview and record review was conducted with the Director of Nursing (DON) on 8/14/25 at 10:28 A.M. The DON stated Notices of Transfer/Discharge should be provided in writing to residents within 30 days of discharge. The DON stated that a copy of the signed Notice was placed in the medical record. The DON reviewed Resident 1,2, and 3's medical record and could not locate any documentation that a Notice of Transfer/Discharge was provided. The DON stated providing a Notice of Transfer/Discharge was important, so residents and their families knew what was occurring and that preparations were being made in advance. The DON stated the Notice also helped prepare the residents and decreases anxiety, incorporating them into the discharge planning process. The DON stated if a Transfer/Discharge Notice was not provided, it could contribute to a rushed, unsafe discharge. An interview was conducted with Licensed Nurse 1 (LN 1) on 8/14/25 at 1:58 P.M. LN 1 stated Notice of Transfer/Discharge's were usually provided by the Social Service Director (SSD), unless the resident was going to the hospital, then the LNs completed the Notices. LN 1 stated Notice for Transfer/Discharges were important, so residents were aware of what was coming next, and that staff were preparing for the transfer or discharge.An interview was conducted with the SSD on 8/19/25 at 1:58 P.M. The SSD stated she was aware a written Notice for Transfer/Discharge were required to be provided to residents and their RP, 30 days prior to discharge. The SSD stated she was not always able to provide a Notice prior to Discharge, because she, had been spread really thin during July and was not able to provide all residents being their discharged notices.According to the facility's policy, titled Discharge and Transfer of Residents, dated February 2025, .5. Prior to discharge, the Facility will provide the resident/resident representative with the Notice of Proposed Transfer and Discharge document. 6. A copy of the Notice of Proposed Transfer and Discharge will be placed in the Resident's medical record and a copy faxed to the Ombudsman.According to the facility's policy, titled Resident Rights, dated January 2012, .1, State and Federal laws guarantee basic rights to all residents of the Facility.A, Be informed about what rights and responsibility's he or she has; .

Based on interview and record review, the facility failed to develop and implement person-centered care plans related to resident discharges for two of three residents, (Resident 1 and Resident 3), when reviewed for dischargesThis failure had the potential for staff to be uninformed of the residents' wishes for discharge, resulting in an uncoordinated effort for a planned and organized discharge. Findings:An unannounced visit was made to the facility on 8/14/25, in response to a complaint involving a discharge.1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic kidney disease stage 4, (severe kidney damage and significantly reduced kidney function), per the facility's admission Record.Resident 1 had a Responsible Party (RP-a person designated to make medical and financial decisions on the resident's behalf) listed on the admission RecordOn 8/14/25, Resident 1's clinical record was reviewed.According to the discharge Minimum Data Set, (MDS-a clinical assessment tool), dated 7/25/25, Resident 1 had a cognitive score of 12, indicating cognition was moderately impaired. According to the facility's nursing notes, titled Discharge summary, dated [DATE] at 12:26 P.M., Resident 1 was discharged to an assisted living facility, via medical transport.The discharge care plan was created by the Social Service Director (SSD) on the day of discharge, dated 7/25/25, listed interventions such as, Establish a pre-discharge plan and coordinate discharge.2. Resident 3 was admitted to the facility on [DATE], with diagnoses which included pneumonia (Infection in the lungs), per the facility's admission Record.On 8/24/25, Resident 3's clinical record was reviewed.According to Resident 3's discharge MDS, dated [DATE], A cognitive score of 14 was listed, indicating cognition was intact.The Facility's Discharge Planning Review Form, dated 7/18/25, indicated Resident 3 was being discharged to an Assisted Living Facility, for a lower level of care.There was no documented evidence that a discharge care plan had been developed or implemented.An interview and record review was conducted with the Director of Nursing on 8/14/25 at 10:28 A.M. The DON stated discharge care plans should be developed when the resident was admitted , so staff could collaborate with the residents. The DON reviewed Resident 1's care plan and stated it should never have been developed on the day of discharge, because it would be ineffective. The DON reviewed Resident 3's records and could not locate a discharge care plan. The DON stated since there was no discharge care plan, there was a possibility the discharge was not safe or organized.An interview was conducted with Licensed Nurse 1 (LN 1) on 8/14/25 at 11:20 A.M. LN 2 stated discharge care plans were important, so staff were aware of the discharge plans. LN 1 stated discharge care plans helped staff work towards the residents' goal of leaving the facility and to help prepare for leaving. LN 1 stated if discharge care plans were not developed, the discharge could be disorganized and rushed, without thorough preparations being made.An interview was conducted with the Social Service Director (SSD) on 8/19/25 at 1:58 P.M. The SSD stated she did recall Resident 1, his RP, and the discharge. The SSD stated she did develop the discharge care plan on the day of Resident 1's discharge, because she noticed he did not have one. The SSD stated the care plan was inadequate and not appropriate because it should have been developed shortly after admission. According to the facility's policy, titled Transfer and Discharge, dated October 2017, .I. Discharge Planning: A. Discharge planning will begin on the resident's admission to the Facility.H. Social, Services will document the discharge planning, preparation, and the president's post discharge needs.

Based on observation, interview, and record review, the facility failed to list and monitor specific behaviors for the use of a psychotropic medication (a drug that affects mental processes, mood, behavior, or perception), to determine the necessity of the medication for two of five residents (Resident 9 and Resident 48), reviewed for unnecessary medication. These failures had the potential for Resident 9 and Resident 48 to receive unnecessary medications. Findings: 1. Resident 9 was admitted to the facility on [DATE], with diagnoses which included unspecified dementia (progressive memory loss) and suicidal ideations (when one thinks or plans to hurt themselves), per the facility's Admission Record. An observation was conducted with Resident 9 on 5/5/25 at 9:09 A.M., as he wheeled himself back from the smoking patio. Resident 9 had several burn holes in the middle of his sweatshirt. Resident 9's clinical record was reviewed on 5/6/25: According to the admission Minimal Data Set (MDS-a clinical assessment tool), dated 4/2/25, Resident 9 had a cognitive score of 12, indicating moderately impaired cognition. The Mood Assessment score was 16, indicating mood symptoms were present nearly every day. According to the physician's order, dated 3/26/25, Sertraline HCL (used to treat depression) 50 milligrams (mg) one time a day for depression. No specific behavior was listed for monitoring such as: excessive crying, verbalization of wanting to hurt themselves, or self isolation. No behavior monitoring was listed for staff to document when specific behaviors occurred. No side effect monitoring was listed such as headache, nausea, dry mouth, feeling sleepy. The following physician's order were added on 4/4/25, .Trazadone HCL (used to treat depression and anxiety) 50 mg one tablet by mouth at bedtime for depression .Depakote ER (used to treat bipolar disorder), 250 mg one tablet by mouth one time a day for Mood Stabilizer . No specific behaviors were listed in the physician's order for monitoring such as: severe mood changes, excessive crying, verbalization of wanting to hurt themselves, or self isolation. No behavior monitoring was listed for staff to document when specific behaviors occur. No side effects monitoring was listed such as: headache, nausea, dry mouth, feeling sleepy. Resident 9's Medication Administration Record (MAR) was reviewed from 4/1/25 through 5/6/25. There was no documented evidence specific behaviors or side effects were being monitored by staff for Sertraline, Trazadone and Depakote. According to the care plan, titled Risk for adverse reaction related to polypharmacy and side effects, revised 3/28/25, .Antidepressant drugs; interventions included: Closely monitor for clinical worsening and for emergence of suicidal thoughts and behaviors. Request physician to review and evaluate medication. Review Pharmacy Consultant recommendations . According to the care plan, titled 4/3/25, interventions included: administer psychotropic medications as ordered and monitor. According to the facility's Informed Consent for Sertraline HCL 50 mg, dated 3/26/25, the physician listed no specific behaviors to monitor. According to the facility's Informed Consent for Trazadone 50 mg , dated 4/3/25, the physician listed, Diagnosis depression as exhibited by sleeplessness, statements of feeling sad, hopelessness and Depakote ER 250 mg, dated 4/3/25, with no specific behaviors listed for Depakote. An interview was conducted with Licensed Nurse 4 (LN 4) on 5/7/25 at 8:31 A.M. LN 4 stated monitoring behaviors and side effects should always be part of the physician's order when administering psychotropic medications. LN 4 stated each shift should monitor for the specific behaviors listed by the physician and document those behaviors or side effects on the MAR. LN 4 stated it was important to document the number of specific behaviors, so the physician could evaluate the frequency each month to determine if the medication was really needed. An interview and record review was conducted with LN 5 on 5/7/25 at 8:58 A.M. of Resident 9's MAR. LN 5 stated Resident 9 should have specific behaviors listed for each psychotropic medication ordered. LN 5 stated monitoring and documenting the specific behaviors in the MAR was important to determine if the medication was really needed. LN 5 stated there was no monitoring of behaviors or side effects listed in Resident 9's MAR, and there should be. An interview and record review was conducted with the Pharmacy Consultant (PC) on 5/7/25 at 2:25 P.M. of the April 2025 Medication Regimen Review (MRR- when a pharmacist conducts a thorough examination of a resident's medications to identify and address potential problems). The PC stated when he conducted his monthly MRR, he did look at physician's order and the MAR. The PC stated whenever a psychotropic medication was ordered, the physician should list a specific behavior for staff to monitor for. The PC stated staff monitoring of behaviors was important to determine if the medication was working, if it was really needed, or if the dose needed to be adjusted. The PC reviewed the April MRR for Resident 9 and stated, I missed it completely. The PC stated it was his responsibility to bring the omission of specific behavior monitoring to the facility's attention. The PC stated he missed it and the facility and physician relied on him to capture these mistakes, so they could be corrected. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 8:57 A.M. The DON stated specific behaviors needed to be listed for all residents on psychotropic medication for monitoring, along with possible side effects. The DON stated if staff were not monitoring behaviors, there was the potential for harm because the medication might be not even be needed. The DON stated this could then be considered an unnecessary medication, which could have damaging, long term side effects. According to the facility's policy titled Behavior/Psychoactive Drug Management, November 2018, .F. Any order for psychoactive medications must include; .v. Specific Behavior manifested .H. Parameters for using Anti-Psychotics: .ii. The residents behavior symptoms should meet at least one of the following criteria in order to justify the use of an anti-psychotropic medication: .b. the behavioral symptoms present a danger (documented) to the resident or others; .Monitoring for side effects: 1. Depending on the specific classification of psychoactive medication the resident should be observed and/or monitored for side effects and adverse consequences . 49330 2. According to the facility's Admission Record, Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy (a condition which causes a disturbance in the brain's functioning, affecting thinking skills and memory) and major depressive disorder (a mental illness causing feelings of sadness). During a record review on 5/6/25, Resident 48's physician's order, dated 1/17/25, indicated quetiapine (an antipsychotic medication) for schizophrenia. No specific behaviors were listed for staff monitoring. On 5/6/25 at 8:35 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated he was familiar with Resident 48 and had provided care for him in the past. CNA 6 stated Resident 48 had behaviors of yelling out and calling out someone's name, .but that's it. I've never seen him aggressive or violent. He will just yell out names . CNA 6 stated he was not aware of Resident 48 having any episodes of delusions or hallucinations. On 5/7/25 at 8:14 A.M., a telephone interview was conducted with Family Member (FM) 1. FM 1 stated Resident 48 seemed confused, but she had not observed any violent behavior, delusions, or hallucinations. On 5/7/25 at 9:27 A.M., an interview was conducted with the Minimum Data Set (MDS-an assessment tool) Nurse (MDSN). The MDSN stated the criteria for psychotropic medication required documentation and monitoring of a specific behavior. On 5/8/25 at 8:08 A.M., a telephone interview was conducted with the Psychiatric Nurse Practitioner (PNP). The PNP stated staff told him that Resident 48 had delusions, hallucinations and violent behavior but he did not see the behaviors documented in Resident 48's chart. The PNP stated he did not observe the behaviors when he visited the resident and his assessment was based on verbal reports from staff. On 5/8/25 at 10:33 A.M., and interview was conducted with LN 5. LN 5 stated Resident 48 had episodes of restlessness, anxiety, and agitation but he had not observed behaviors such as delusions or hallucinations. LN 5 stated, I don't recall him ever hitting anybody or having violent behavior . On 5/8/25 at 11:25 A.M., a joint interview and record review was conducted with the DON. The DON stated there was no consistent documentation of resident having behaviors that would indicate schizophrenia. The DON stated, We should documented specific behaviors .make sure the physician has accurate data. We should have looked at [Resident 48's] behaviors and questioned whether this diagnosis is appropriate . The DON stated it was important to document specific behaviors, .so we don't give unnecessary drugs . On 5/8/25 at 1:27 P.M., a telephone interview was conducted with the Medical Director (MD). The MD stated his expectation was for Resident 48's behaviors to be documented, particularly because Resident 48 was taking antipsychotic medications. The MD stated it was important to document specific behaviors to ensure the medications were appropriate for the residents. A review of the facility's policy titled Psychotropic Medication Use, dated June 2021 indicated, .3. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .

Based on observation, interview, and record review, the facility failed to maintain resident room walls in a clean, homelike, and visually appealing manner for two of 24 residents (Resident 47 and Resident 54), reviewed for homelike environment. This failure had the potential for residents to feel not valued or appreciated. Findings: 1. An observation was conducted during initial tour of Resident 54's room on 5/5/25 at 8:46 A.M. The lower left side of the wall, near the head of the bed, had a large area of discoloration and peeling paint. This area of the wall was closest to the room entrance and visible when standing near the foot of the bed. An observation and interview was conducted with Licensed Nurse 1 (LN 1) as she sat on the right side of Resident 54's bed, assisting the resident with breakfast on 5/6/25 at 8:09 A.M. LN 1 was asked to look at Resident 54's wall, near the head of the bed. LN 1 observed the left side of the wall, near the head of the bed and stated, Oh, that doesn't look good and should be fixed. An interview was conducted with Certified Nursing Assistant 1 (CNA 1) of Resident 54's room on 5/7/25 at 3:46 P.M. CNA 1 stated Resident 54's daughter visited the resident about once a week. CNA 1 stated the daughter usually sat next to the resident's bed when visiting, facing the head of the bed. CNA 1 stated if something needed to be fixed in the resident's room, staff were expected to document it in the maintenance log, kept at the nurse's station. CNA 1 stated maintenance staff checked the maintenance book several times a day and would sign off the book, when the repair was fixed. An observation and interview of Resident 54's bedroom wall was conducted with CNA 1, at 5/7/25 at 3:52 P.M. Resident 54's bed was empty and made. CNA 1 looked at the left side of the wall near the head of the bed and stated, Oh, that does not look good. The wall does not look presentable or homelike. 2. An observation was conducted during initial tour of Resident 47's room on 5/5/25 at 9:40 A.M. The lower right side of the wall, near the head of the bed had a large area of discoloration and peeling paint. The area of the wall was furthest from the front door entrance and had a cushioned chair next to it for visitation. An interview was conducted with CNA 1 on 5/7/25 at 3:46 P.M. CNA 1 stated Resident 47's son visited every afternoon with the resident inside the room. An observation and interview was conducted with CNA 1 of Resident 47's room on 5/7/25 at 3:50 P.M. CNA 1 stated the residents' wall did not look good and it should be painted and fixed. CNA 1 stated the wall did not appear homelike or welcoming. A review of the maintenance book, stored at the East nurse's station was reviewed on 5/7/25 at 3:54 P.M. The maintenance book was reviewed from 12/1/24 through 5/4/25, and no documentation was listed for Residents 54's or 47's walls to be repair. An interview was conducted with the Director of Maintenance (DM) on 5/7/25 at 4:08 P.M. The DM stated he routinely inspected resident rooms. The DM stated they made repairs to resident rooms on the west unit and were getting ready to do repairs on the east unit. The DM stated he had not documented the repairs needed on the east unit. An observation and interview of Resident 54's room was conducted with the DM on 5/7/25 at 4:12 P.M. The DM stated the resident's room wall looked bad and needed to be repaired. An observation and interview of Resident 47's room was conducted with the DM on 5/7/25 at 4:15 P.M. The DM stated, This room also did not look good and the walls were not homelike. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 8:57 A.M. The DON stated all resident rooms should be presentable and homelike. The DON stated she expected staff to document issues in the unit's maintenance book when repairs were identified. According to the facility's policy, titled Resident Room and Environment, dated January 2012, .The facility provides residents with a safe, clean, comfortable, and homelike environment 1. The Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order . According to the facility's policy, titled Maintenance-Work Orders, dated January 2012, .Maintenance work orders shall be completed in an effort to sustain maintenance services as a priority .III. Work order request are to be placed in a designated location at the nurses' station. A. Work orders are to be picked up daily by Maintenance Staff .

Based on observation, interview, and record review, the facility failed to develop a care plan related to hospice (end of life), care for one of one resident (Resident 47), reviewed for hospice care. This failure had the potential for Resident 47 to receive inconsistent care by staff. Findings: Resident 47 was admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss), per the facility's Admission Record. Resident 47's clinical record was reviewed on 5/5/25: According to the physician's order, dated 4/29/25, .Admit to (name) hospice . There was no documented evidence a care plan for hospice care had been developed. An observation of Resident 47 was conducted on 5/5/25 at 3:26 P.M., as she laid in bed, covered with a personal blanket. Resident 47 was asleep with her hair combed and placed in a bun on top of her head. Many personal items were in the room, such as decorations and family photos. An interview and record review was conducted with Licensed Nurse 2 (LN 2) on 5/6/25 at 3:52 P.M. LN 2 stated care plans were important for staff communication and to guide consistent resident care. LN 2 reviewed Resident 47's clinical record and could find no documented evidence a hospice care plan had been developed or implemented when Resident 47 was admitted to hospice. LN 2 stated by not developing a care plan related to hospice, staff interventions were not being implemented consistently. An interview was conducted with LN 3 on 5/6/25 at 4:02 P.M. LN 3 stated care plans were important so resident needs could be identified. LN 3 stated when residents were admitted to hospice, the LN taking the order should immediately develop a hospice care plan. LN 3 stated if a care plan was not developed, then the residents' needs were not being met. An interview and record review was conducted with the Director of Nursing (DON) on 5/6/25 at 4:08 P.M. The DON stated when residents were admitted to hospice, the hospice agency developed a care plan, and the facility developed its own care plan, in order to have consistent, coordinated care among staff. The DON reviewed Resident 47's clinical record and stated a care plan for hospice had not been developed, and it should have been. The DON stated by not having a hospice care plan, staff would not be on the same page when providing care. According to the facility's policy, titled Comprehensive Person-Centered Care Planning, dated August 2023, .4. Comprehensive Care Plan .b. Additional changes or updates to the residents' comprehensive care plan will be made based on the assessed needs of the resident . According to the facility's policy, titled Hospice Care of Residents, dated January 2012, .III. If the resident and/or surrogate decision maker decides to utilize hospice care .B. The Hospice and Facility will collaborate on a Care Plan for the resident .

Based on observation, interview, and record review, the facility failed to change a peripheral intravenous catheter (PIV-a tube inserted into a vein used to draw blood and administer medications) per physician's order. This failure had the potential to place Resident 36 at further risk for infection. According to the Admission Record, Resident 36 was admitted on [DATE] with diagnoses which included severe sepsis (an illness in which the body had an extreme response to an infection), urinary tract infection, and bacteremia (an infection in the bloodstream). On 5/5/25 at 10:29 A.M., an observation was conducted inside Resident 36's room. Resident 36 had a PIV catheter inserted into his left arm. The PIV was covered with a transparent dressing and was dated 4/29/25. On 5/6/25 at 10:10 A.M., a concurrent observation and record review was conducted with Licensed Nurse (LN) 3. LN 3 stated 4/29/25 was the date the PIV was inserted. A review of Resident 36's physician's order dated 4/29/25 indicated, Change peripheral IV line and dressing on Left arm every 48 hours. The order indicated the IV line and dressing was scheduled to be rotated on 5/1/25, 5/3/25, and 5/5/25. LN 3 stated, It hasn't been changed since the 29th. It should have been changed last on 5/5/25. [The PIV site] is rotated to make sure the line isn't clogged and to prevent infection . On 5/7/25 at 2:50 P.M., a concurrent observation and interview was conducted with LN 9 in Resident 36's room. Resident 36 had the PIV on the left arm, which was still dated 4/29/25. LN 9 stated Resident 36's IV should have been changed on the scheduled days. LN 9 stated, .It should have been changed to prevent infection, and to double check that the IV line was still functional. It's important to have been changed because it was a doctor's order, and we need to meet the goal for [Resident 36]'s care . On 5/8/25 at 11:34 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the date of 4/29/25 on Resident 36's IV dressing indicated the IV was not changed per physician's orders. The DON stated, It should have been changed because the protocol here is to change it per the doctor's orders . The DON stated the resident was at risk for further infection because the IV line and dressing were not changed. During a review of the facility ' s undated policies and procedure (P&P) titled, Intravenous Therapy, indicated, all dressing changes will be labeled (time, date, and initials) and documented in medical record on IV medication record .the licensed nurse will check physician's order for the completeness .Complete orders include: 7. Site rotation .

Based on observation, interview and record review, the facility failed to document a rationale for the use of oxygen for one of three residents (Resident 39) reviewed for oxygen therapy. This failure had the potential to place Resident 39 at risk for unnecessary treatments and services. Resident 39 was readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the lungs), per the facility's Admission Record. An observation and interview with Resident 39 was conducted on 5/5/25 at 11:24 A.M. Resident 39 was in bed, with a clear plastic oxygen tube under his nose. Resident 39 stated he used the oxygen most of the time because he had COPD. Resident 39 stated he went out of the building three times a week for a medical appointment, and he did not use the oxygen tube for those trips. Resident 39 stated it would not be safe to go to the appointments with oxygen, and it was a short trip so he was fine not using the oxygen. A record review was conducted of Resident 39's electronic health record (EHR) on 5/6/25. Resident 39's Brief Interview for Mental Status (BIMS) score was 14, indicating intact cognition. Per a physician's order, dated 12/31/24, Resident 39 was to receive oxygen to keep oxygen saturation levels (the amount of oxygen in the blood, with a normal range of 95-100%) at or above 92%. The physician's order requested staff to specify a diagnosis or reason for oxygen use. Resident 39's oxygen saturation levels were reviewed on the Medication Administration Record (MAR). For April 2025, Resident 39's oxygen saturation levels were always above 92% when measured on oxygen, and when measured on room air (without oxygen). The MAR had no documentation as to the reason for oxygen use. On 5/6/25 at 10:20 A.M., and on 5/8/25 at 10 A.M., an observation of Resident 39 was conducted. Resident 39 was returning from a medical appointment and was being wheeled into the facility in a wheelchair. Resident 39 did not have the oxygen tube under his nose. On 5/8/25 at 10:23 A.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 11. LN 11 stated Resident 39 was on oxygen to treat his COPD. LN 11 stated every order for a medication or treatment required an indication for use, or a diagnosis. LN 11 reviewed the physician's order, and stated there was no indication or diagnosis for the use of oxygen. Per LN 11, without the indication for use, staff would not know what the oxygen was for. LN 11 stated since the physician had ordered the oxygen, it had to be on all the time, even during transportation to appointments. LN 11 stated, We made a mistake. It needs to be fixed. On 5/8/25 at 10:53 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated all oxygen orders required a rationale for use. The DON stated if the physician wanted the resident to use oxygen at all times, the facility should send him to appointments with a portable oxygen tank. Per a facility policy, revised November 2017 and titled Oxygen Therapy, Purpose: To ensure the safe storage and administration of oxygen .Licensed Nursing staff will administer oxygen as prescribed .Administer oxygen per physician order .

Based on observation, interview and record review, the facility failed to implement Registered Dietitian (RD 1) recommendations for one of three residents reviewed for nutrition (Resident 43). This failure had the potential for Resident 43 to not receive foods and supplements he preferred with his meals and snacks. Findings: Resident 43 was admitted to the facility on [DATE] with diagnoses to include brain cancer, per the facility's Admission Record. An observation and interview was conducted with Resident 43 on 5/5/25 at 3:15 P.M. Resident 43 was in bed, wearing jeans and a shirt. An end table was next to the bed, with a large bag of Cheetos and other chips on top. Resident 43 stated he had told people from the kitchen he did not like the foods he was getting. Resident 43 stated he received shakes with his meals, but the shakes were too sweet and he did not want them. Resident 43 stated he liked the frozen shakes he had tried, but he never got them. A record review was conducted on 5/8/25. Resident 43's Brief Interview for Mental Status (BIMS) score was 12 when assessed on 3/21/25, indicating moderately impaired cognition. Per a Dietary Profile note, authored by the Dietary Services Supervisor (DSS 1) and dated 3/17/25, Resident 43 had a fair appetite, and liked pudding, jello, milk and peanut butter and jelly sandwiches. Labs were drawn on 3/19/25. Albumin (a protein in the blood) level was 3 grams per deciliter (g/dL), indicated as low. Per a Nutrition Assessment, written by RD 1 and dated 3/23/25, Resident 43 had a so-so appetite, and RD 1 recommended allowing more foods on Resident 43's trays to encourage intake. RD 1 documented Resident 43 requested fried chicken and potato chips, as he loved crunchy foods. RD 1 documented those food items would not be allowed on Resident 43's current diet. RD 1 documented she had reviewed recent labs, and would add a protein powder to help increase Resident 43's low albumin level. Per an Interdisciplinary Team (IDT, a group of healthcare professionals) Progress Note, dated 3/25/25, Resident 43 had experienced weight loss. RD 1 and DSS 1 were present at the IDT. RD 1 documented the rationale for the weight loss was possibly due to inadequate intake at mealtimes. RD 1's documented plan to slow the weight loss was to add four ounce protein shakes with meals. Per an IDT Progress Note, dated 5/2/25, Resident 43 had continued weight loss. RD 1 and DSS 1 were present at the IDT. RD 1 documented the weight loss was likely due to poor appetite. RD 1 documented Resident 43 was sick of the protein shakes, but was willing to try a frozen supplement, Magic Cup. RD 1 documented her plan to discontinue the protein shakes, add Magic Cups twice daily, add peanut butter to all meals, and update Resident 43's snack at night to his preferred tuna sandwich. Per a Nursing & Dietary Supervisor Report, authored by RD 1 and dated 5/2/25, the dietary recommendations were to be implemented within three days. An observation and interview with Resident 43 was conducted on 5/7/25 at 8:45 A.M. Resident 43 was sitting at the bedside, with his breakfast tray in front of him. The tray contained partially consumed hot cereal, a scrambled egg, milk, juice, peaches, and a vanilla protein shake. The protein shake was unopened. Resident 43 stated he still had not received the frozen Magic Cup. A concurrent interview and record review was conducted with DSS 1 on 5/7/25 at 3:30 P.M. DSS 1 stated he attended the IDT meetings, and when RD 1 made changes to residents' supplements or food preferences, she emailed the recommendations to him, then he entered the changes into the dietary software. DSS 1 opened his email, and identified RD 1's Nursing & Dietary Supervisor report, discontinuing the protein shakes, adding the Magic Cups, and adding peanut butter with all meals. DSS 1 stated the report was written 5/2/25, and he had received it on 5/5/25, but was busy and had not entered the changes into the computer. DSS 1 stated, Best case scenario, I should have entered them (into the computer) Monday 5/5, and we could have provided the Magic Cups and peanut butter by lunch time. This delay could cause continued weight loss and poor intake, we don't want that. A concurrent observation and interview with Resident 43 was conducted on 5/8/25 at 9 A.M. Resident 43 was seated on the edge of his bed, finishing his breakfast. Resident 43 had eaten about half of the foods on his breakfast tray. The tray had a four ounce vanilla protein shake on it, but the protein shake had not been opened. Resident 43 stated, See? It's not the frozen one. These are too sweet. I already told them I don't want these. A container of peanut butter was on the tray, and Resident 43 had consumed about half. An interview was conducted with RD 1 on 5/8/25 at 9:30 A.M. RD 1 stated she had emailed her recommendations for Resident 43 on Friday 5/2/25 at the end of the day. RD 1 stated the changes should have been entered into the computer on Monday 5/5/25 so Resident 43 would get his preferred Magic Cup, as well as the peanut butter for added calories and protein. RD 1 stated the facility policy allowed 72 hours to place dietary preferences into the computer, but they had exceeded the 72 hours. RD 1 stated she did not know why the food preferences were not provided to Resident 43 in a timely manner. An interview was conducted with the Administrator (ADM) on 5/8/25 at 11:14 A.M. Per the ADM, the expectation was for dietary staff to implement RD 1's recommendations as soon as possible. A facility policy, dated 2023 and titled Nutritional Screening/Assessments/Resident Care Planning, indicated, .All recommendations will be noted on a Facility Registered Dietitian Report .The FNS Director will complete the dietary recommendations within three days of receiving the Facility Registered Dietitian Report . A facility policy, dated 2023 and titled Food Preferences, indicated, .Updating of food preferences will be done as the resident's needs change .

Based on interview and record review, the facility failed to offer one of five residents (Resident 5) influenza (flu-annual season October through March) and pneumococcal (protects against serious lung infection referred to as pneumonia) vaccines as recommended by the Centers for Disease Control (CDC-a Federal agency responsible for preventing and controlling diseases), when reviewed for Immunization. This failure put Resident 5, and all other residents at risk of contracting and/or transmitting influenza and pneumococcal. Findings: Resident 5 was admitted to the facility on [DATE], with diagnoses which include dementia (progressive memory loss) and schizoaffective disorder, (a mental health condition where a person experiences symptoms of both schizophrenia and mood disorder), per the facility's Admission Record. Resident 5's had a Responsible Party (RP-a person legally assigned to make medical and financial decisions on the resident's behalf). The RP was a listed as the Public Conservator's office, (an entity appointed by the court system to act as a conservator for a person, who is unable to care for themselves due to mental illness). According to the copy of court documents in Resident 5's clinical record, conservatorship was established 3/18/24. On 5/7/25, Resident 5's clinical record was reviewed for verification of immunizations. There was no documented evidence Resident 5 or the RP had been offered the vaccine for influenza or pneumococcal, or that the risks and benefits had been explained verbally or in writing. An interview and record review was conducted with the Infection Control Nurse (ICN) on 5/7/25 at 3:01 P.M. The ICN stated all residents should be offered the influenza and pneumococcal vaccines upon admission. The ICP stated vaccinations were important because their residents were vulnerable and at risk of contracting the flu or pneumonia. The ICN stated all residents should be educated on the risk and benefits before accepting or declining the vaccines. The ICP stated they maintain consent forms in each residents' clinical record, indicating the vaccine was accepted or declined, and they had been informed of the risks and benefits. The ICN reviewed Resident 5's clinical record for immunizations. The ICN stated there was no evidence indicating Resident 5 was offered vaccinations. The ICN stated she recalled when Resident 5 was admitted , she was conserved by the County's Public Conservator's office. The ICN stated she asked the Social Services Director (SSD) to assist her with contacting the conservator's office to get permission for Resident 5's vaccinations. The ICN stated she never followed up with the SSD or Public Conservator's office, and the ball was dropped. The ICN stated since the conservatorship's office was never contacted for consent of vaccinations, Resident 5 was at risk for contracting influenza and pneumococcal. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 8:57 A.M. The DON stated she expected all residents to be offered the influenza and pneumococcal vaccines, with documentation of whether they had accepted or refused, along with the risk and benefits being explained to them. The DON stated by not offering the vaccines, all other residents' and staff were at risk of contracting infections from Resident 47, if infected. According to the facility's policy, titled Influenza Prevention and Control, dated September 2020, .The facility will follow infection control prevention and control policies and procedures to minimize the risk of Residents acquiring, transmitting or experiencing complications from influenza .B. Resident are offered an influenza immunization every year during flu season .C. The resident or resident's representative must give consent prior to receiving the vaccine. They can refuse the immunization-with such a refusal being noted in the Resident's medical record .D .i. The Resident or Resident representative was provided education regarding the risk and benefits and potential side effects . According to the facility's policy, titled Pneumococcal Disease Preventions, dated February 2021, .The facility will offer pneumococcal immunization to each Resident .A. Adults [AGE] years old or older .d. Before offering vaccine, each Resident (or Resident representative) must be given education regarding the benefits and potential side effects of the immunization .VI .v .Informed consent or refusal placed in the residents' medical record .

Based on interview and record review, the facility failed to offer one of five residents (Resident 5) a COVID-19 (a highly contagious virus caused by the SARS-CoV-2) vaccine recommended by the Centers for Disease Control (CDC-a Federal agency responsible for preventing and controlling diseases), when reviewed for Immunizations. This failure put Resident 5, and all other residents at risk of contracting and/or transmitting the COVID-19 virus. Findings: Resident 5 was admitted to the facility on [DATE], with diagnoses which include dementia (progressive memory loss) and schizoaffective disorder, (a mental health condition where a person experiences symptoms of both schizophrenia and mood disorder), per the facility's Admission Record. Resident 5 had a Responsible Party (RP-a person legally assigned to make medical and financially decisions on the resident's behalf). The RP was the Public Conservator's office, (an entity appointed by the court system to act as conservator/RP for a person, who is unable to care for themselves due to mental illness). According to a copy of the Resident 5's court document, conservatorship was established on 3/18/24. On 5/7/25, Resident 5's clinical record was reviewed for verification of immunization. There was no documentation Resident 5 or the RP had been offered the vaccine for COVID-19, or that the risks and benefits had been explained verbally or in writing. An interview and record review was conducted with the Infection Control Nurse (ICN) on 5/7/25 at 3:01 P.M. The ICN stated all residents should be offered the COVID-19 vaccine upon admission. The ICN stated vaccines were important because their residents were vulnerable and at risk of contracting COVID, if not vaccinated. The ICN stated all residents should be educated on the risk and benefits before accepting or declining the vaccines. The ICP stated they maintained consent forms in each resident's clinical record, indicating the vaccine was offered, that they accepted or declined, and were informed of the risks and benefits. The ICN reviewed Resident 5's clinical record for immunizations. The ICN stated there was no indication Resident 5 was offered a COVID-19 vaccination. The ICN stated she recalled when Resident 5 was admitted , she was under conservatorship by the County's Public Conservator's office. The ICN recalled asking the Social Services Director (SSD) to assist her by contacting the conservator's office, to get permission for Resident 5's vaccinations. The ICN stated she never followed up with the SSD or Public Conservator's office, and the ball was dropped. The ICN stated since there was no documented evidence the conservatorship's office was ever contacted for consent of Resident 5's COVID-19 vaccination this put Resident 5 was at risk of possibly contracting COVID-19. An interview was conducted with the Director of Nursing (DON) on 5/8/25 at 8:57 A.M. The DON stated she expected all residents' to be offered the COVID-19 vaccine, with documentation whether they had accepted or refused, along with the risk and benefits being explained to them. The DON stated by not offering the vaccine, all other residents and staff were at risk of contracting COVID-19 from Resident 5, if infected. According to the facility's policy, titled COVID-19 Vaccination Program, dated March 2022, .The facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all Residents. They will be encouraged but not required to be vaccinated or boosted . II. Preparation for a Vaccine Administration Clinic: .D. Send educational material provided by the vaccine provider to residents, their families, responsible parties, legal representative .E. Obtain general consent .

Based on interview and record review, the facility failed to ensure the inhaler (handheld devices that deliver medicine through the mouth into the lungs) medication ordered by the physician was available for administration for one of three sampled residents (Resident 1). This failure had the potential for adverse health outcomes. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD- a lung disease that makes it hard to breathe) per the Admission Record. A review of Resident 1's medical record was conducted. Per the Order Summary dated 6/28/24, Resident 1 was to receive the inhaler medication, one puff orally once a day for COPD. Per the Medication Administration Record from 6/28/24 through 7/8/24, Resident 1's medication was unavailable for eight days. On 10/2/24 at 1:10 P.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 1 had an order to receive the inhaler medication daily, but the medication was unavailable. LN 1 further stated that she had called the pharmacy and was told that authorization (approval) was needed to deliver the medicine. On 10/2/24 at 1:22 P.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated she could not explain what happened to the authorization and needed to investigate. The DON stated Resident 1 did not receive the inhaler medication as the physician had ordered for eight days and should have. The facility could not provide a policy and procedure related to medication dispensing.

Based on observation, interview and record review, the facility failed to apply a splint to Resident 1 ' s right hand as ordered by a physician. This failure had the potential to worsen Resident 1 ' s wrist drop (a medical condition that prevents the wrist and fingers from extending fully). Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included right wrist drop. On 8/14/24 at 2:40 P.M. an observation and interview were conducted with Resident 1 in her room. Resident 1 ' s right wrist was in a downward position and she was not wearing a splint (a device that positions a part of the body). Resident 1 stated, I don ' t have full use of my right hand. No one put my splint on me today, they often don ' t. On 8/14/24 at 3:30 P.M. an interview was conducted with the Director of Nursing (DON) who stated Resident 1 had a provider order for daily application of a splint to her right wrist except while exercising or showering. On 8/14/24 at 4:20 P.M. a concurrent observation was conducted with the DON of Resident 1 in her bed. Resident 1 was not wearing a splint on her right wrist, was not exercising or showering. The DON stated she would have to check the documentation of the Restorative Nursing Assistant (RNA, a staff member who helps restore and maintain a patient ' s highest level of function). On 8/19/24 at 3:33 P.M. a concurrent review with the DON via telephone of the RNA documentation was conducted. The document indicated range of motion exercises were provided 10 days of 26 possible days. The DON stated Resident 1 did not receive daily RNA interventions as ordered. On 8/20/24 at 3:25 P.M. an interview was conducted with the DON regarding documentation received dated 8/14/24, the date of the joint observation of Resident 1 without her splint on. The RNA document indicated, Wrist splint applied for RUE (right upper extremity) QD (every day) 7x/week (seven times per week), on at all times except during shower and exercise. The DON stated during the joint observation Resident 1 was not wearing a splint, and was not exercising or showering. A review of the facility policy entitled Restorative Nursing Program Guidelines revised September 19, 2019 indicated, Restorative nursing . includes nursing interventions that promote a patient ' s ability to attain, and maintain his/ her optimal functional potential.

Based on interview and record review, the Facility failed to report allegations of abuse by staff members against one resident, Resident 1. Resident 1 reported feeling violated while in the Facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis left ankle and foot (inflammation of bone), anxiety (a condition which creates excessive worry or nervousness about real or perceived threats), alcohol abuse and withdrawal (unhealthy consumption of alcohol accompanied by physical and psychological symptoms when alcohol consumption stops), and unspecified psychosis not due to a substance or known physiological condition (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality) . On 5/2/24 at 12:36 P.M. a telephone interview was conducted with Resident 1 who was no longer residing in the Facility. Resident 1 stated, In the past week one of the nurses drug [sic] her finger up my inner thigh to wake me up during the night shift . I reported to the old and new social worker and to the Director of Nursing and administrator. I talked to the ombudsman with the administrator and social worker. The Director of Nursing herself sexually made advances on me. I am so hurt and violated. I thought the administrator was going to handle all of this. A review of an email dated 10/26/23 at 3:58 P.M. provided by Resident 1 was reviewed. The email was sent to the Facility Social Worker (SW), Administrator (ADM) and Director of Nursing (DON). The email indicated, To all: I (Resident 1) have put up with assaults, harassment, women entering my secured and safe 10 by 10 (WITH curtain DRAWN) and have asked to have an INCIDENT REPORT DONE. I ASKED (name of administrator) AND SOCIAL SERVICES FOR THE INCIDENT REPORTS. A review of an email dated 4/23/24 at 6:52 A.M. provided by Resident 1 was reviewed. The email was sent to the Facility Administrator (ADM), Director of Nursing (DON) and Social Worker (SW). The email indicated, This morning at 5:50 a.m. [sic] (name) doesn ' t knock comes in runs her fingers up from my ankle to my knees.I ' ve texted DON, (name of social worker) told (name) another med nurse and now I want to file a report as soon as anyone of authority comes to work. Once again ive [sic] got to deal with 100% PERVERT and illegal. Why is she touching me. No knock, nothing! Just touching and fondling. A review of an email dated 4/23/24 at 9:13 A.M. provided by Resident 1 was reviewed. The email was sent to the Facility ADM, SW and DON. The email indicated, Just straight to rubbing FINGERS from my ANKLE past my KNEE by your employee (name) MED NURSE at 5:50 a.m. [sic] I asked her 3 times to leave AFTER being CAUGHT TOUCHING ME. She THEN threatened me telling me she ' d hold my medications in the future. An interview and concurrent record review were conducted with the Administrator on 5/2/24 at 3:35 P.M. The ADM stated, I did an investigation regarding (name) about one week ago, I knew the allegation was false so I didn ' t report it. The facility policy entitled Abuse - Reporting and Investigations revised 12/21/23 indicated, The Administrator or designated representative will notify law enforcement by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of initial report. The Administrator or designated representative will send a written SOC341 (a report of suspected or known abuse) report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within twenty-four (24) hours. The facility policy entitled Abuse - Prevention, Screening, & Training Program revised July 2018 indicated, The Facility provides and staff sign an acknowledgement of their responsibility to report alleged or suspected abuse, neglect, exploitation, misappropriation of resident property and/ or mistreatment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the water management program included a risk assessment to identify legionella and other waterborne pathogens that could grow in the facility water system. This deficient practice had the potential to affect all residents who currently resided in the facility. The facility also failed to ensure staff wore sterile gloves when they set up equipment to perform an indwelling catheter insertion for 1 (Resident #60) of 2 sampled residents reviewed for urinary catheters. Findings included: 1. A facility policy titled, Water Management, with a revision date of 05/25/2023, revealed, The facility will develop and utilize water management strategies, using the Core Elements of a Water Management Plan, to reduce the risk of growth and spread of Legionella and other opportunistic water-borne pathogens in facility water systems. During an interview on 05/22/2024 at 1:34 PM, the Maintenance Supervisor stated there has not been a completed risk assessment to identify risk areas that could have the potential for legionella. Per the Maintenance Supervisor, he did not know how the water flowed through the facility. The Maintenance Supervisor acknowledged he had not completed a risk assessment. During an interview on 05/22/2024 at 1:43 PM, the Infection Preventionist (IP) she had nothing to do a risk assessment regarding legionella. According to the IP, the Maintenance Supervisor was responsible for the completion of the risk assessment. During an interview on 05/22/2024 at 2:18 PM, the Administrator stated the facility had not identified the risk area regarding the potential for legionella. The Administrator stated the facility's water management plan had not been customized for the facility and a risk assessment had not been completed. During an interview on 05/23/2024 at 8:50 AM, stated the Maintenance Supervisor was responsible for completing the risk assessment to determine the potential for legionella. 41493 2. A facility policy titled Catheter-Care of, with a revised date of 06/10/2021, revealed IV. Catheter Insertion A. Catheters are to be inserted using aseptic techniques and sterile equipment, including gloves, drape, sponges, appropriate antiseptic solution for periurethral cleaning, and single-use packet of lubricant jelly for insertions. An Admission Record, revealed the facility admitted Resident #60e resident on 04/10/2024 with diagnoses that included obstructive and reflux uropathy, benign prostatic hyperplasia without lower urinary tract symptoms. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #60 had a Brief Interview for Mental Status (BIMS) of 11, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had an indwelling catheter. Resident #60's care plan, initiated on 04/11/2024, revealed the resident had an indwelling catheter. Resident #60's Order Summary Report, with active orders as of 05/23/2024, revealed an order dated 04/10/2024 that directed staff to change the urinary catheter as needed. During an observation on 05/21/2024 at 3:47 PM, Licensed Vocational Nurse (LVN) #7 removed sterile gloves from the indwelling catheter package and laid them to the side, while she set up the indwelling catheter supplies with the non-sterile gloves she had on. After LVN #7 set up the supplies, she placed a drape over Resident #60's perineal area, then removed the non-sterile gloves, washed her hands, and put on a pair of sterile gloves. During an interview on 05/22/2024 at 11:01 AM, LVN #7 stated she thought this was first indwelling urinary catheter that she had inserted in a long time. LVN #7 stated she realized she messed up and acknowledged she needed more training. During an interview on 05/23/2024 at 10:14 AM, the Director of Nursing (DON) stated if sterile technique was broken, staff should stop and start over with all new supplies. The DON stated she expected if staff did not know how to complete a procedure, that they would review the policy first before they began or ask for assistance from another staff person. During an interview on 05/23/2024 at 11:37 AM, the Administrator stated there was a process in place the staff should follow, but he did not know the actual process.

Based on interview, record review, facility policy review, and the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) manual, the facility failed to ensure the annual Minimum Data Set (MDS) assessment was accurate for the preadmission screening and resident review (PASARR) Level II for 1 (Resident #15) of 4 residents reviewed for PASARR. Findings included: A facility policy titled, RAI Process, revised 10/04/2016, indicated the purpose was, To provide resident assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements. The facility will utilize the Resident Assessment Instrument (RAI) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS [Centers for Medicare and Medicaid Services] RAI MDS 3.0 Manual. A document titled, Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, revised 10/2023, indicated The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. The RAI manual indicated, A1500: Preadmission Screening and Resident Review (PASRR) (cont.) -Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. An Admission Record revealed the facility admitted Resident #15 on 05/06/2022. According to the Admission Record, the resident had a medical history that included schizophrenia and schizoaffective disorder. An annual MDS, with an Assessment Reference Date (ARD) of 07/29/2023, revealed a Staff Assessment for Mental Status (SAMS) was conducted, which indicated the resident had severe impairment in cognitive skills for daily decision making. Section A1500 Preadmission Screening and Resident Review (PASRR) indicated Resident #15 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or related condition. A Department of Health Care Services letter dated 05/06/2022 revealed the Level I Screening for Resident #15 was positive for suspected mental illness and a Level II Mental Health Evaluation Referral was required. A Department of Health Care Services letter dated 08/09/2022 revealed a Level II evaluation had been completed on 06/08/2022 and the determination report was attached. The Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 08/09/2022, revealed specialized services were recommended for Resident #15. During an interview on 05/23/2024 at 11:04 AM, the MDS Coordinator stated that she had only been working at the facility for three months, so was not present for the MDS for Resident #15. She said if a resident had a Level II PASRR, then she would trigger it on the MDS. During an interview on 05/23/2024 at 12:06 PM, the Director of Nursing (DON) stated her expectation was that the MDS for residents be accurate. The DON indicated the MDS should have been marked for Level II because nothing had changed with Resident #15. During an interview on 05/23/2024 at 11:48 AM, the Administrator stated his expectation was the MDS for residents be accurate, timely, and true.