Every finding on record at California Post-Acute Care

Based on observation, interview, and record review, the facility failed to maintain a comfortable and safe environment for two out of three sampled residents (Residents 1 and 2) when the ambient (surrounding air) temperature was measured at 86 degrees Fahrenheit ( F- unit of measure). This failure had the potential to result in discomfort and increased risk of heat-related illnesses for Resident 1 and Resident 2.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including diabetes mellitus ( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough health red blood cells) and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool) dated 6/11/2026, the MDS indicated, Resident 1's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated, Resident 1 needs set up or clean up assistance with activities of daily living ([ADLs] activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 1's History and Physical (H&P) dated 3/26/2026, The H&P indicated, Resident 1 had the capacity to understand and make decisions.During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis including left sided hemiplegia (paralysis of one side of the body), hyperlipidemia (too much fat in your blood) and muscle weakness.During a review of Resident 2's H&P dated 6/09/2026, The H&P indicated, Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's had moderate cognitive impairment. The MDS indicated, Resident 2's was dependent (helper does all the work) with ADLs.During an observation on 8/29/26 at 3:47 p.m. in the facility lobby the thermostat (regulates temperature) was observed to be 86 F.During an interview on 8/29/26 at 4:44 p.m. with Resident 1, Resident 1 stated it had been hot in this place and very uncomfortable. Resident 1 stated he just got a fan in his room after three years. Resident 1 stated his roommates did not have a fan. Resident 1 stated he could not imagine how his roommate's felt in this heat.During an interview on 8/30/26 at 1:15 p.m. with Resident 2, Resident 2 stated it had been real hot in the facility and it made him feel very uncomfortable because of the temperature being so hot.During an interview on 8/30/26 at 1:30 p.m. with the Maintenance Supervisor (MS), the MS stated it was 86 F in the facility and the temperature of the building needs to stay between 71 and 81 F. The MS stated the residents were at risk of getting dehydrated (abnormally low fluid levels in the body) when the building temperature reaches above 81 F.During an interview on 8/30/26 at 2:30 p.m. with the Director of Nursing (DON), the DON stated he was made aware the facility was 86 F on 8/29/2026 and the facility's temperature should not exceed 80 F. The DON stated the residents were at risk for heat exhaustion and overall discomfort when the facility's temperature go above 80 F.During an interview on 8/30/26 at 2:50 p.m. with the Administrator (ADM), the ADM stated she was aware the facility was 86 F and that the facility's temperature needs to stay between 71-81 F. The ADM stated the residents were at risk of becoming dehydrated and could possibly have a heat stroke (over heating) when the facility's temperature goes above 81 degrees F.During a review of the facilities Policy and Procedure (P&P) titled Preventing Heat Related Condition dated 3/2016, the P&P indicated, the purpose was to ensure the safety and wellbeing of all the residents, staff and visitors during periods of extreme heat by implementing preventive measures and providing guidelines for managing heat-related condition. The P&P indicated, ambient temperature (71-81 degrees (F) will be maintained at comfortable and safe temperature level's.

Based on observation, interview and record review, the facility failed to ensure infection prevention and control measures were implemented to 2 of 3 residents' (Residents 2 and 3), who were on contact precautions (refer to infection prevention and control interventions to be used in addition to routine practices and are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact) for:Resident 3 who had Clostridioides difficile (C-Diff, bacteria that infects the large intestine and causes severe diarrhea and inflammation) toxins (bacteria) in stools and for Resident 2 who was Methicillin Resistant Staphylococcus Aureus (MRSA - strong bacteria that is spread through contact and cannot be killed with common antibiotics) in the left lower extremity wound. The facility failed to: 1). Post contact precautions signage on Resident 3's entrance door who was on C-Diff contact precautions. 2). Ensure staff performed hand washing hygiene in a C. Diff resident room before and after each procedure. 3). Use a disposable cloth to place all items to be used during procedure on the clean field as indicated in the facility's policy and procedure (P&P) titled, Wound Care. 4). Ensure wounds were completely covered with the appropriate size of dressing after wound care to prevent exposure to organisms. 5). Ensure isolation gown (a piece of personal protective equipment (PPE) worn by healthcare personnel to protect both themselves and patients from the transfer of microorganisms, body fluids, and particulate material during medical and isolation) was worn correctly according to standards of practice, during wound care.6) Ensure Resident 2 was placed on contact precautions for the presence of Methicillin Resistant Staphylococcus Aureus (MRSA - strong bacteria that is spread through contact and cannot be killed with common antibiotics) in the left lower extremity wound. These failures had the potential to spread C. Diff and MRSA infections to all the residents, staffs and visitors in the facility and placed Resident 3's wounds at risk for infection. Findings: a). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included dysphagia (difficulty or discomfort when swallowing food, liquids, or saliva), and muscle weakness. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/29/2026, the MDS indicated Resident 3 rarely or was never able to understand and be understood by others. Resident 3 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for ADL such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting/taking off footwear and personal hygiene. Resident 3 was dependent on staff on rolling from left to right, chair/bed to chair transfer and tub/shower transfer. Resident 3 was incontinent of bowel. The MDS indicated Resident 3 had three pressure ulcers and one unhealed. During a review of Resident 3's History & Physical (H&P) dated 7/21/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's physician's orders, the orders indicated the following:1). On 8/9/2026, the order indicated to cleanse the occiput (head) pressure ulcer (wound) with Normal Saline (NS- a cleansing solution), pat dry, apply medihoney (sterilized medical-grade honey used to treat and heal wounds and burns) to wound bed, then calcium alginate (gel-like, absorbent material made from brown seaweed that stops bleeding and helps heal wounds), and secure with silicone foam dressing (soft, multi-layered bandage used to cover and heal wounds while protecting fragile skin), kerlix (sterilized medical-grade honey used to treat and heal wounds and burns) and tape. Change dressing every (Q) two (2) days or as needed (PRN) when soiled.2). On 8/11/2026, the order indicated to cleanse sacrum pressure ulcer with NS or wound cleanser, pat dry, apply medihoney to wound bed, then calcium alginate, and secure with silicone foam dressing, change dressing Q 2 days or PRN when soiled and every dayshift for 21 days, strict offloading using pillows and wedges as needed.3). On 8/11/2026, the order indicated to cleanse the hip (unspecified site) with NS, pat dry, apply medihoney to wound bed, then collagen, and secure with silicone foam dressing, change dressing Q 2 days or PRN when soiled and every dayshift for 21days, strict offloading using pillows and wedges as needed. During a review of Resident 3's laboratory (lab) test results dated 8/7/2026, the lab test result indicated a positive C-Diff toxins in stool. During a review of Resident 3's physician order dated 8/11/2026, the order indicated contact isolation (measures that are intended to prevent transmission of infectious agent which are spread by direct or indirect contact with the resident or the resident's environment) due to C-Diff infection (in stools). During a concurrent observation and interview on 8/19/2026 at 1:41 p.m., with the Treatment Nurse (TN), the TN stated Resident 3's entrance door had no contact precautions signage posted on the door for C-diff positive. The TN stated Resident 3 should be on contact precautions until 8/21/2026. The TN was observed entered Resident 3's room with untied isolation gown. The back was open. The TN placed the trash bag in the middle of Resident 3's pre-set up clean dressings on a bedside table. The TN removed the dirty dressing from Resident 3's right hip and placed the dirty dressing inside the trash bag. The TN removed gloves, sanitized hands and put on clean gloves, then pat dry with gauze. The TN's isolation gown was observed slipping off the shoulders with the back of gown completely open. The TN stated it was easier to keep gown untied to remove later. The TN tied the isolation gown's neck ties, and the back was left open. The TN removed the gloves, sanitized hands and put on clean gloves then continued to cleanse wound. The TN removed gloves, sanitized hands and put on clean gloves, then pat the wound dry with gauze. The TN stated she should not have placed the trash bag on the table with clean supplies. The TN stated she was going to re-start the treatment. The TN left Resident 3's room to wash hands outside, came back to Resident 3's room, put on gloves, sanitized the table and allowed to air dry, then placed three silicone foam dressings, one packet of calcium alginate, medihoney tube, two rolls of kerlix and taped the trash bag to the edge of the bedside table. The TN removed gloves, sanitized hands and put on clean gloves. The TN cleansed Resident 3's right hip wound and placed two silicone foam dressings to cover the entire wound, however, the dressing was not fully secured to Resident 3's skin and the resident's right hip wound was exposed. The TN removed gloves, sanitized hands and put on clean gloves. The TN continued to turn Resident 3 to her side and removed the dirty dressing from the sacrum. The TN removed gloves, sanitized hands and put on clean gloves and cleansed the sacrum. The TN the removed the dirty gloves, sanitized hands and put on clean gloves. The TN struggled in keeping Resident 3 on her left side. The TN let go of the resident's hip, the resident laid on the linen with a wound uncovered with a dressing. The TN removed gloves, sanitized hands and put on clean gloves, walked towards the wound treatment cart (cart with wound treatment supplies for all residents) and opened the cart. The TN removed gloves, sanitized hands and put on clean gloves and turned Resident 3, struggling in keeping Resident 3 positioned on the side for wound care. The TN cleansed Resident 3's sacrum area with NS solution, removed gloves, sanitized hands and put on clean gloves then dried the sacrum. The TN removed gloves, sanitized hands and put on clean gloves then placed a dressing on the sacrum that did not fully cover the wound. Resident's 3 sacral wound was exposed. The TN removed gloves, sanitized hands and put on clean gloves, then placed a clean diaper on Resident 3 and turned Resident 3 on her back. The TN removed gloves, sanitized hands, put on clean gloves and cleansed the head wound. The TN left Resident 3's head wound open (no dressing) and fell onto the pillow while the TN gathered additional supplies. The TN stated she will change Resident 3's sacrum dressing after she cleanses Resident's hands. During an interview on 8/20/2026 at 12:30 p.m., with TN, TN stated it was important to wear the PPE (isolation gown) properly by tying the strings of the gown prior to entering Resident 3's room that was on contact precaution. Not wearing the isolation gown properly could lead to the spread of infection to other residents and staff. The TN stated leaving wounds open (uncovered) and touching the dirty/ used linen and pillows, could grow germs and cause infections. The TN stated everyone should wash hands when there is C-Diff infection. TN stated she only sanitized her hands and did not wash prior to using the cart because there was no sink nearby. The TN stated she did not use a disposable tablecloth to protect the clean area. The TN stated using wound dressings that were too small for the wound, exposed the wounds to germs and can cause infection. The TN stated she should not have left Resident 3's head, right hip and sacral wounds open and touched the surface with used linen and pillowcase because of risk of germs infecting the wounds. The TN stated it was important to tie the isolation gown prior to entering Resident 3's room to prevent the contamination of germs. During an interview on 8/20/2026 at 3:22 p.m. with Registered Nurse (RN), the RN stated all staff should wash hands with soap and water prior to exiting or touching anything from a room with C-Diff (Resident 3's room). C-Diff toxins are highly contagious. Using hand sanitizer could not kill C-Diff spores (tiny germs). RN stated posting contact precautions on a C-Diff positive room was important to alert staff and visitors to wear the proper PPE and to protect them from possible transmission. b). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included peripheral venous insufficiency (a circulation disorder that narrows, blocks, or spasms the blood vessels, most commonly reducing blood flow to the legs and feet), and muscle weakness. During a review of Resident 2's lab results dated 7/30/2026 at 1:28 p.m., the lab results indicated Resident 2 had positive MRSA of the left lower extremity (LLE) wound. During a review of Resident 2's physician order, there was no order for MRSA contact isolation on 7/30/2026. During a review of Resident 2's dated 8/12/2026, the MDS indicated Resident 2 was able to understand and be understood by others. Resident 2 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating. Resident 2 required set-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.) for oral hygiene. Resident 2 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene. Resident 2 required moderate assistance for shower/bathing self, upper body dressing and was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for lower body dressing, putting on/taking off footwear and personal hygiene. Resident 2 required maximal assist on rolling from left to right, sit to lying, lying to sitting on side of the bed was dependent on staff for sitting to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 2 frequently incontinent of urine and was always bowel incontinent. The MDS indicated Resident 2 had open lesions (area of damaged, injured, or abnormal tissue in or on the body) other than ulcers. During a review of Resident 2's physician order dated 8/15/2026, the physician's order indicated Bactrim DS (Sulfamethoxazole-Trimethoprim - antibiotic) oral tablet 800-160 mg give one tablet by mouth two times a day for infection (unspecified) for five days. During a concurrent interview and record review on 8/19/2026 at 1:41 p.m., with the TN, Resident 2's physician's order dated 8/15/2026, was reviewed. The TN stated Resident 2's Physician Assistant (PA) ordered Bactrim last 8/15/2026 for a leg infection (unspecified). The TN stated Resident 2's left shin venous ulcer (slow-healing open sore on the lower leg, usually near the ankle, caused by damaged vein valves that trap blood and fluid) culture (test) was not in the resident's electronic record and was unable to find out the type of infection or bacteria Resident 2 had. During a phone interview with on 9/2/2026 at 11:40 a.m. with the Director of Nursing (DON), the DON stated on 7/30/2026 (time not specified), the facility was not informed of Resident 2's positive MRSA. The DON stated Resident 2 did not have an order for contact precautions and was not placed on contact precautions. The DON stated it was important to place residents on contact precautions to prevent the spread of infections. The staff and the other the residents in the room were exposed to MRSA and were at risk of contracting MRSA. The DON stated the PA informed him (DON) that the MRSA result was called to him (PA) late on (unknown date) and did not let the facility know. During a review of the facility's Policy and Procedure (P&P) titled, Isolation - Notices of Transmission-Based Precautions, dated 1/2018, the P&P indicated notices should be used to alert personnel and visitors of transmission-based precautions. The P&P indicated a sign indicating contact precautions on the door to the resident's room. During a review of the facility's P&P titled, Wound Care, dated 1/2018, the P&P indicated to use disposable cloth to place all items to be used during procedure on the clean field. The P&P indicated to place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. During a review of the ACDC website https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html#:~:text=Isolate%20patients%20with%20possible%20C.,if%20you%20only%20suspect%20CDI.&text=Order%20a%20C.%20diff%20test&text=Wear%20gloves%20and%20a%20gown,potential%20infectious%20diarrhea%2C%20including%20C., the facts for clinicians indicated C. diff spores can transfer to patients by the hands of healthcare personnel who have touched a contaminated surface or item. CDC indicated to isolate patients with possible C. diff immediately, even if the facility had only suspected C. Diff infection (CDI), to wear gloves and a gown when treating patients with potential infectious diarrhea, including C. diff infection, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff. In addition, handwashing alone may not be sufficient to eliminate all C. diff spores. If CDI is confirmed continue isolation and contact precautions.

Based on interview and record review, facility did not meet professional standards of quality by failing to ensure wound care orders were followed and documented after being provided to one of three residents, (Resident 3).This deficient practice had the potential that wound care and services were not provided, causing delay in wound healing, worsening of wound condition and infection that could lead to hospitalization. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included dysphagia (difficulty or discomfort when swallowing food, liquids, or saliva), and muscle weakness. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/29/2026, the MDS indicated Resident 3 was rarely/never able to understand and be understood by others. Resident 3 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for ADL such as eating, oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting/taking off footwear and personal hygiene. Resident 3 was dependent on staff on rolling from left to right, chair/bed to chair transfer and tub/shower transfer. The MDS indicated Resident 3 was bowel incontinent. The MDS indicated Resident 3 had one unhealed pressure ulcer/injury. The MDS indicated Resident 3 had three pressure ulcers. During a review of Resident 3's History & Physical (H&P) dated 7/21/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's physician's orders, the orders indicated the following:1). On 8/9/2026, the order indicated to cleanse the occiput (head) pressure ulcer (wound) with Normal Saline (NS- a cleansing solution), pat dry, apply medihoney (sterilized medical-grade honey used to treat and heal wounds and burns) to wound bed, then calcium alginate (gel-like, absorbent material made from brown seaweed that stops bleeding and helps heal wounds), and secure with silicone foam dressing (soft, multi-layered bandage used to cover and heal wounds while protecting fragile skin), kerlix (sterilized medical-grade honey used to treat and heal wounds and burns) and tape. Change dressing every (Q) two (2) days or as needed (PRN) when soiled.2). On 8/11/2026, the order indicated to cleanse sacrum pressure ulcer with NS or wound cleanser, pat dry, apply medihoney to wound bed, then calcium alginate, and secure with silicone foam dressing, change dressing Q 2 days or PRN when soiled and every dayshift for 21 days, strict offloading using pillows and wedges as needed.3). On 8/11/2026, the order indicated to cleanse the hip (unspecified site) with NS, pat dry, apply medihoney to wound bed, then collagen, and secure with silicone foam dressing, change dressing Q 2 days or PRN when soiled and every dayshift for 21days, strict offloading using pillows and wedges as needed. a). During a review of Resident 3's Treatment Administration Record (TAR) for the month of August 2026, the TAR indicated the following:1). Resident 3's (unspecified side) hip pressure ulcer TAR dated 8/15/2026, 8/16/2026, 8/17/2026, 8/18/2026, 8/19/2026 and 8/20/2026 were blank.2). Resident 3's head wound TAR for 8/16/2026, 8/18/2026 and 8/20/2026 were blank.3). Resident 3's sacrum pressure ulcer TAR for 8/15/2026, 8/16/2026, 8/17/2026, 8/18/2026, 8/19/2026 and 8/20/2026 were blank. b). During a concurrent observation on 8/19/2026 at 1:41 p.m., the Treatment Nurse (TN), the TN was observed with an untied isolation gown (a piece of personal protective equipment (PPE) worn by healthcare personnel to protect both themselves and patients from the transfer of microorganisms, body fluids, and particulate material during medical and isolation) by the neck and back prior to entering Resident 3's room. The TN started wound care on Resident 3's (unspecified side) hip and sacral wounds. The TN applied medihoney on the calcium alginate, applied the silicone foam dressing on the (unspecified side) hip and sacral wound, then removed the silicone foam dressing and applied the regular dressings. During a concurrent interview and record review on 8/20/2026 at 12:30 p.m., with the Treatment Nurse (TN), Resident 3's treatment orders for the head, sacrum and hip pressure ulcer dated 8/9 to 8/11/2026 and Resident 3's TARs for the month of August 2026 were reviewed. The TN stated the hip TAR dated 8/15/2026, 8/16/2026, 8/17/2026, 8/18/2026, 8/19/2026 and 8/20/2026, the TAR for sacrum pressure ulcer dated 8/15/2026, 8/16/2026, 8/17/2026, 8/18/2026, 8/19/2026 and 8/20/2026, the TAR for head dated 8/16/2026, 8/18/2026 and 8/20/2026 were blank. The TN stated she was very busy and that she did not document the wound care performed for the head, hip and sacral wounds. The TN stated the order for both the hip (unspecified side) and the sacral wound were to apply the medihoney directly to wound bed. The TN stated putting it directly on the wound and on calcium alginate would have the same effect. The TN stated the order indicated to use silicone foam dressing for the hip and sacrum but because the dressing were not very good they kept falling off, it was that is why she used the regular dressings. TN stated the dressings were the same thing as long as the wound was covered. During a phone interview on 9/1/2026 at 3:36 p.m., with the Director of Nursing (DON), the DON stated it was important to follow Resident 3's wound care physician doctors. The DON stated not putting medihoney directly on the wound bed could result in delayed wound healing. DON stated the purpose of using silicone foam dressing versus a regular dressing was to provide cushion to the wound and improve wound healing. During a review of the facility's P&P titled, Administering Medications, dated 1/2018, the P&P indicated medications should be administered in a timely manner, and as prescribed. The P&P indicated the person licensed or permitted by this state should administer and document the administration of medications.

Based on interview and record review, the facility failed to provide a safe environment and adequate supervision to prevent a fall to one of three residents (Resident 1).This deficient practice had the potential to result in severe injuries, complications, hospitalizations and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included muscle weakness, difficulty walking and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/8/2026, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for eating and oral hygiene. Resident 1 required maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene, shower/bathing self, and putting on/taking off footwear. Resident 1 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for upper/lower body dressing and personal hygiene. Resident 1 was dependent on staff for rolling from left to right and maximal assistance from sitting to lying position, sit to stand, chair/bed, toilet transfer and tub/shower transfer. Resident 1 required moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for lying to sitting on side of bed. The MDS indicated Resident 1 was incontinent of urine and bowel. During a review of Resident 1's care plan, titled The resident (Resident 1) was at Risk for Falls related to confusion, gait/balance problems, poor communication., dated 7/10/2024, the goal of the care plan was to minimize fall with injuries daily. One of the interventions indicated to follow facility fall protocol (procedure) During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured way to communicate to the care team about a resident's change in condition), dated 8/3/2026 at 5:45 a.m., the SBAR indicated 8/3/2026 at 5:45 a.m., Resident 1 fell from bed during incontinent care. The SBAR indicated bedrails were not in use. The SBAR indicated while the Certified Nurse Assistant (CNA, unidentified) changed (unspecified) Resident 1, the CNA realized additional supplies were needed. The CNA left Resident 1 to obtain clean linens from the linen room. When he returned, Resident 1 was found on the floor beside the resident's bed. The SBAR indicated Resident 1 sustained skin tears on the left forehead and left ear. During a review of Resident 1's Fall Risk Assessment dated 8/3/2026 at 8:00 a.m., fall assessment indicated Resident 1 was at risk for falls. During a review of Resident 1's General Acute Care Hospital (GACH) records titled Emergency Department (ED) Provider Note dated 8/3/2026, the ED record indicated Resident 1 had left ear laceration (a torn or jagged wound in the skin and soft tissues caused by an impact or a cut) repair with 3 sutures. During a review of Resident 1's History & Physical (H&P) dated 8/15/2026, the H&P indicated that Resident 1 had the capacity to understand and make decisions. During an interview on 8/24/2026 at 2:25 p.m., with Certified Nurse Assistant (CNA 4), CNA 4 stated Resident 1 fell off the bed while he (CNA 4) went to get a towel from a chair at the other side of the room. CNA 4 stated he heard a thump when he got the towels and when he saw Resident 1, Resident 1 was on the floor. CNA 4 stated he should not have left Resident 1 alone unattended on the bed. CNA 4 stated he did not know how bad Resident 4 got hurt but Resident 4 had blood on his forehead and ear. During a review of the facility's Policy and Procedure (P&P) titled, Falls and Fall Risk, Managing, dated 1/2018, the P&P indicated the staff should 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.

Based on observation, interview and record review, the facility failed to provide a homelike environment by ensuring the room temperature of the three of six residents (Residents 2, 3, and 4), was maintained between 71 and 81 degrees Fahrenheit ( F), as indicated in the facility's policy and procedure (P&P) titled, Ambient Temperature.This deficient practice had the potential to cause increased residents' discomfort and had the potential to negatively impact their quality of life. Findings:During a concurrent observation and interview on 8/13/2026 at 2:30 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 2's room, Resident 2 was observed lying in bed wearing a brief, with curtains open. The room's temperature felt hot. CNA 1 stated Resident 2 preferred to wear briefs, wants the curtains open, probably because the room is hot. During a concurrent observation and interview on 8/13/2026 at 2:35 p.m. with the Maintenance Supervisor (MS), the room temperatures were measured. Resident 2's room temperature was 86 F, Resident 3's room temperature was 84 F, and Resident 4's room temperature was 83 F. The MS stated that the air conditioning (AC) company had come earlier that day (8/13/2026) to fix the AC system but did not complete the repairs because they were unsure how to proceed. The MS stated that he had contacted another AC company, which was scheduled to arrive the following morning, 8/14/2026, to repair the AC. During a concurrent observation and interview on 8/13/2026 at 3:30 p.m. in the resident's room, Resident 2 was observed lying in bed with an electric fan on the right side of the bed. Resident 2 refused to be covered with blankets or to have the curtains closed. Resident 2 stated, It is hot in this room; that is the reason I do not like to be covered. 1). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2 diagnoses chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and pulmonary hypertension (is a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). During a review of Resident 2's History and Physical examination (H&P) dated 12/30/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Residents 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/26/2026, the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was dependent on assistance with staff for Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. 2). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses Diabetes Mellitus, hypertension (HTN-high blood pressure) and bipolar disorder (mental health condition with episodes of high energy (mania or hypomania) and low mood (depression). During a review of Resident 3's H&P dated 9/1/2025 indicated Resident 3 has the capacity to understand and make decisions. During a review of Residents 3's MDS dated [DATE], the MDS indicated Resident 3 had intact cognitive. The MDS indicated Resident 3 was set-up cleaning assistance on staff with ADLs such as dressing, toilet use, transfer and mobility. Resident 3 was not interviewable and was unable to verbalize how hot the room was. 3). During a concurrent observation and interview on 8/13/2026 at 3:40 p.m. with Resident 4, in Resident 4's room, Resident 4 was observed lying in bed wearing a gown, uncovered with bedsheets. An electric fan was observed at the right side of the bed but was turned off. Resident 4 stated, I do not want to turn the electric fan on. It feels hot here. Resident 4 stated, I prefer the room to be little bit cooler. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure) and hyperlipidemia (high cholesterol, characterized by elevated levels of cholesterol in the blood) During a review of Resident 4's H&P dated 10/1/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Residents 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognition. The MDS indicated Resident 4 required substantial/ maximal assistance on staff with ADLs such as dressing, toilet use, transfer and mobility. During an interview on 8/13/2026 at 4:10 p.m. with the MS, the MS stated that maintenance on the AC system was performed monthly. The MS stated 3 random resident rooms had been checked daily for temperatures. The MS stated that an AC company came (dates not identified) but did not which rooms to fix. The MS stated it was important to maintain appropriate room temperatures for residents because high temperatures placed residents at risk for dehydration and hospitalization. During a concurrent interview and record review on 8/17/2026 at 11:10 a.m., with the MS, the MS stated the facility policy indicated, room temperatures must be kept between 71 and 81 F. The MS stated the temperature in room [ROOM NUMBER], 35 and 39 were higher than the recommended temperature. During an interview on 8/17/2025 at 4:31 p.m. with the Director of Nursing (DON), the DON stated that room temperatures should be checked daily by the MS. The DON stated due to hot weather, all residents' room temperatures should be checked. The DON stated nurses conduct rounds to identify if any resident rooms feel hot and then inform maintenance. The DON stated residents' room temperature should be maintained at 81 F. The DON stated it was important to ensure proper room temperatures, so residents remain comfortable and help prevent dehydration. During a review of the facility's policy and procedures (P&P) titled, Ambient Temperature dated 1/2018, the P&P indicated Ambien temperature (71 F - 81 F) should be maintained at comfortable and safe temperature levels. Staff should report any issues in rooms with ambient temperature to the Maintenance Supervisor.

Based on observation, interview, and record review, the facility failed to develop a comprehensive, person-centered care plan for one of six sampled residents' (Resident 1), who refused to wear right shoulder sling (a medical support device made of cloth or straps designed to immobilize the shoulder joint, limit movement, and take weight off the arm while an injury). This deficient practice resulted in the resident not receiving alternative interventions and had the potential to worsen the resident's current condition, cause pain and discomforts.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the right non-dominant side, Schizophrenia (serious, chronic mental health condition that affects how a person thinks, feels, and behaves, often causing a loss of contact with reality through symptoms such as delusions, hallucinations, disorganized thinking, and unusual behavior), major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). During a review of Resident 1's History and Physical examination (H&P) dated 2/26/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, the MDS indicated Resident 1 had intact cognition. Resident 1 required substantial to maximal assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 4 was independent of toileting hygiene, shower/ bathing self. During a review of Resident 1's Physicians Orders dated 4/6/2026, the physician's orders indicated Resident 1 may benefit from right shoulder sling. During a concurrent observation and interview on 8/16/2026 at 3:40 p.m. with Resident 1 in his room, Resident 1's blue arm sling was observed on top of a drawer next to Resident 1's bed. Resident 1 stated, he should use the right hand sling so his arm would not hang because of right sided paralysis. Resident 1 stated he did not want to use the sling because it makes him hot. Resident 1 stated the therapist gave him the sling, but he does not want to wear it. During an interview on 8/17/2026 at 1:40 p.m. with the Rehabilitation Director (RD), the RD stated that she gave Resident 1 the sling for his right arm. The RD explained that Resident 1's right side is flaccid and could benefit from the use of the sling to prevent right shoulder subluxation. The RD stated that Resident 1 refused to use the sling. She stated, I put it on him and told him he needed to use it, but he takes the sling off. The RD stated that Resident 1 said the sling makes him hot. The RD also stated that the facility's protocol was to create a care plan whenever a resident refused any treatment. The RD stated that the care plan would include documentation that Resident 1 was educated on the importance of using the sling and alternatives for providing appropriate care. During a concurrent interview and record review on 8/17/2026 at 4:31 p.m. with the Director of Nursing (DON), Resident 1's care plan was reviewed. The DON stated there was no care plan addressing Resident 1's refusal to use the arm sling. The DON stated that the care plan should have been developed when a resident refuses any treatment. The DON stated it was important to develop a care plan so that nurses can provide proper care and implement alternative interventions for Resident 1. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated the comprehensive, person -centered care plan should describe services that would otherwise be provided for the above but were not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on observation, interview and record review, the facility failed to ensure one of six sampled residents' (Resident 1), wooden and plastic dresser was properly arranged to ensure accessibility when needed by the resident. This deficient practice placed the resident at risk of injury when trying to access the belongingsFindings: During a concurrent observation and interview on 8/13/2026 at 3:40 p.m. in Resident 1's room (room [ROOM NUMBER]), Resident 1's wooden and a plastic dresser where he kept his belongings, were difficult to access. Resident 1 stated, I cannot move freely around with my chair because the space is small. Resident 1 stated that when he needs something from the dresser, he asks the nurses to move the bed so he can access the drawers. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the right non-dominant side, Schizophrenia (serious, chronic mental health condition that affects how a person thinks, feels, and behaves, often causing a loss of contact with reality through symptoms such as delusions, hallucinations, disorganized thinking, and unusual behavior), major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). During a review of Resident 1's History and Physical examination (H&P) dated 2/26/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, the MDS indicated Resident 1 had intact cognition. Resident 1 required substantial to maximal assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 4 was independent of toileting hygiene, shower/ bathing self. During an interview on 8/17/2026 at 11:05 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated that Resident 1's dressers are very close to his bed. CNA 1 stated that when Resident 1 requests something from the dresser, she needs to move the bed to allow access. CNA 1 stated the bed is too close to the dresser and should be arranged so that the furniture fits properly. During an interview on 8/17/2026 at 11:10 p.m. with the Maintenance Supervisor (MS), the MS stated that it is possibility that Resident 1 may feel his room is crowded because multiple residents share the space. The MS stated that Resident 1 could be at risk for anxiety due to the limited room size. The MS stated that if Resident 1 requested it, his furniture could be rearranged, or his room could be changed. During an interview on 8/17/2026 at 4:31 p.m. with the Director of Nursing (DON), the DON stated that the facility is responsible for providing residents with proper accommodation. The DON stated that residents' belongings must always be accessible. The DON stated that it is Resident 1's right to have adequate space to move freely. During a review of the facility's policy and procedures (P&P) titled, Bedrooms, dated 1/2018, the P&P indicated all residents should be provided with clean and comfortable bedrooms. Each resident should be provided with his or her own personal closet space with clothes racks and shelves accessible to the resident. During a review of the facility P&P titled, Accommodation of Needs, dated 1/2026, the P&P indicated the facility should accommodate individual needs and preferences. Adaptations may be made to the physical environment, including the residents' bedrooms by arranging furniture's as the resident request, providing the arrangements were safe, his or her roommate agrees, and space allows.

Based on interviews and record review, the facility failed to obtain a physician's order with indication as to why one of the six sampled residents (Resident 1), was transferred to a General Acute Hospital Center (GACH) on 7/29/2026. This deficient practice had the potential for inappropriate transfer and affecting in maintaining the resident's highest practicable mental, psychosocial, medical and physical well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the right non-dominant side, Schizophrenia (serious, chronic mental health condition that affects how a person thinks, feels, and behaves, often causing a loss of contact with reality through symptoms such as delusions, hallucinations, disorganized thinking, and unusual behavior), major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). During a review of Resident 1's History and Physical examination (H&P) dated 2/26/2026, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/1/2026, the MDS indicated Resident 1 had intact cognition. Resident 1 required substantial to maximal assistance on staff with Activities of Daily Living (ADLs) such as dressing, toilet use, transfer and mobility. Resident 4 was independent of toileting hygiene, shower/ bathing self. During a review of Resident 1's Progress Notes, the progress notes indicated the following:1). On 7/29/2026 at 1:36 p.m., the Services Department (SSD) called and informed Resident 1's Family Member (FM) 1 that Resident 1 had arrived at the facility from GACH.2). On 7/29/2026 at 4:50 p.m., the emergency medical services arrived at the facility to transport Resident 1 to GACH for unknown reasons. The Registered Nurse (RN) verified the transfer with the Director of Nursing (DON) prior to the resident's departures.3). On 7/29/2026 at 5:50 p.m., the SSD documented that Resident 1 was transferred to GACH with all personal belongings. During a review of Resident 1's care plan titled, Episodes of hallucinations related to schizophrenia, dated 7/13/2026, the interventions indicated to consult with the physician. During review of Residents 1's Physician orders, the physician's order did not indicate an order for Resident 1 to be transferred to GACH on 7/29/2026. During a review of Resident 1's Change of Condition (COC), there was no COC documented for Resident 1's transfer to GACH on 7/29/2026 at 4:50 p.m. During a concurrent interview and record review on 8/17/2026 at 4:31 p.m. with the Director of Nursing (DON), Resident 1's clinical records were reviewed. The DON stated Resident 1's clinical records did not indicate COC documentations or a physician's order to transfer Resident 1to GACH. The DON stated that Resident 1 had returned from the hospital to the facility on 7/29/2026 after being sent out on 7/21/2026 due to a 51/50 (process allows designated professionals, such as peace officers or mental health professionals, to detain individuals who are experiencing mental health crisis and meet certain criteria, including being a danger to themselves or others, or being gravely disabled) transfer. The DON stated that, after Resident returned to the facility from GACH on 7/29/2026, the nurses (unidentified) noticed documentation indicating Resident 1 was a danger to himself and others, while reviewing Resident 1's GACH records. The DON stated Resident 1, being a danger to himself and others, led the nursing staff to decide to send Resident 1 back to the GACH. The DON stated that there was no COC documented for Resident 1 and the physician was not called to obtain an order to transfer to GACH. The DON stated that it was very important to follow proper discharge process, indicating reasons why Resident 1 needed to be transferred back to GACH. The DON stated that failing to follow this process placed Resident 1 at risk for inappropriate discharge placement and receiving the proper treatment. During an interview on 8/21/2026 at 4:00 p.m. with the Registered Nurse (RN), RN stated that on 7/29/2026, at 4:50 p.m., Resident 1 returned to the facility from the GACH and the assessment was completed. RN stated that later that afternoon, transportation services arrived at the facility to pick up Resident 1. RN1 stated she was unsure why Resident 1 was being sent back to GACH. RN stated, I asked the DON, and he told me it was okay and that Resident 1 would be transferred. RN stated that during her assessment she did not observe any changes in Resident 1's condition. RN 1 stated Resident 1 did not express any concern and denied any hallucinations. RN stated she assumed the DON called Resident 1's physician and documented a change of condition (COC). RN stated nurses were responsible to make sure where and why residents are being transferred to GACH, to avoid jeopardizing Resident 1's physical and mental wellbeing. During a review of the facility's Policy and Procedure (P&P) titled, Transfer or Discharge, Emergency, dated 1/2026, the P&P indicated if it was necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility should notify the residents' attending physician and note that transfer was appropriate or necessary. During a review of the facility's P&P titled, Changed in a Residents Condition or Status, dated 1/2026, the P&P indicated the nurses should notify the residents' attending physician on call when there was a need to transfer the resident to a hospital/ treatment center.

Based on observation, interview, and record review, the facility failed to notify the physician and a resident's Responsible Party (RP) after one of three sampled residents (Resident 1) sustained a skin tear (a traumatic wound) to the right lower leg. This deficient practice had the potential to delay physician evaluation and treatment, delay timely implementation of appropriate interventions, prevent the RP from participating in care decisions, and increased the risk of wound deterioration, infection, pain, and delayed healing, and other adverse clinical outcomes. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN- high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 7/21/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to process information) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's care plan titled Skin Tear, dated 7/13/2026, the care plan indicated to assess and treat Resident 1's skin tear, and notify the physician and family. During a telephone interview on 7/22/2026 at 11:30 a.m., with Resident 1's Responsible Party (RP) 1, RP 1 stated she routinely visited Resident 1 at the facility. RP 1 stated during a visit on 7/18/2026, she observed wounds on Resident 1's right lower leg. The staff had not notified her of the wounds. RP 1 stated she expected the facility to promptly notify her and the physician of any changes in Resident 1's condition, including injuries. During a concurrent observation and interview on 7/23/2026 at 9:30 a.m., at Resident 1's bedside with Resident 1, Resident 1 was observed with skin tears to the right lower leg. Resident 1 stated she sustained the wounds during a resident-to-resident physical altercation that occurred a few days earlier. Resident 1 was unable to recall the exact day or time of the incident. During a concurrent interview and record review on 7/23/2026 at 10:45 a.m., with Registered Nurse (RN) 1, Resident 1's progress note dated 7/13/2026 timed at 3:50 p.m., was reviewed. The progress note indicated Resident 1 was noted to have four (4) wounds to the right lower leg. RN 1 stated on 7/13/2026 at approximately 3:30 p.m., she assessed Resident 1 following an allegation of a resident-to-resident physical altercation. RN 1 stated upon assessment, she observed Resident 1 with 4 wounds to Resident 1's right lower leg. RN 1 stated she did not immediately notify the physician or RP 1 after identifying the wounds. RN 1 stated Resident 1's wounds were a change in condition and should have been immediately reported to the physician and RP 1. RN 1 stated timely notification to the physician and RP 1 was essential to ensure appropriate medical interventions, ongoing evaluation of the resident's condition, and RP 1's participation in care and treatment decisions. During an interview on 7/23/2026 at 11:40 a.m., with the Director of Nursing (DON), the DON stated Resident 1's skin tears represented a change in condition that required immediate notification to the physician and RP. The DON stated licensed nursing staff were expected to assess the resident, document the findings, and promptly notify the physician and RP. The DON stated the physician and RP were not notified after Resident 1's wounds were identified on 7/13/2026. The DON stated this was not consistent with the facility's policy or expected standard of nursing practice. The DON stated timely notification was necessary to ensure physician evaluation, timely implementation of physician-directed interventions, and monitoring the resident's condition, and appropriate follow-up care. The DON stated that was important to keep RP 1 informed so she could participate in treatment decisions, care planning, and provide informed consent for change in Resident 1's care when needed. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition of Status, dated 1/2026, the P&P indicated the facility will promptly notify the physician and resident responsible party of change in the resident's physical, mental, or psychosocial status, including injuries.

Based on interview and record review, the facility failed to submit a report of the findings of its investigation of an allegation of abuse within five (5) working days to the State Survey Agency for one of three sampled residents (Resident 1). This deficient practice had the potential to delay regulatory oversight and verification that the allegation had been thoroughly investigated, appropriate actions have been implemented, and residents were protected from further potential abuse. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN- high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 7/21/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to process information) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 7/13/2026, the SBAR indicated on 7/13/2026, Resident 1 alleged an altercation with another resident. During a review of the facility's document titled Verification of Investigation Report, dated 7/20/2026, the document did not indicate a written report of the investigation findings was submitted to the State Survey Agency within five days following the allegation of Resident 1's abuse. During an interview on 7/23/2026 at 2:45 p.m., with the Administrator (ADM), the ADM stated the facility was required to submit the written report of the investigation findings to the State Survey Agency within five working days following an allegation of abuse. The ADM stated he completed the investigation report, but I forgot to submit it within 5 working days. The ADM stated the written report of the investigation findings was not submitted to CDPH within the required timeframe. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 1/2026, the P&P indicated all abuse allegations were thoroughly investigated and reported to local, state and federal agencies. The P&P indicated the administrator must submit a written report of the findings to those agencies within five (5) working days of the incident.

Based on interview and record review, the facility failed to ensure residents' medical records were accurate, complete, and current for one of three sampled residents (Resident 1), by failing to:1. Ensure Treatment Nurse (TXN) 1 accurately documented Resident 1's skin tears identified on 7/13/2026 in the resident's medical records. 2. Ensure TXN 1 accurately completed, signed, and dated Resident 1's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents) on 7/13/2026, to reflect the resident's change of condition. These deficient practices had the potential to result in inaccurate or incomplete medical records, miscommunication among healthcare staff, delayed assessment and treatment, and compromised continuity of care for Resident 1. Cross Reference to F580. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and hypertension (HTN- high blood pressure). During a review of Resident 1's History and Physical (H&P) dated 7/21/2026, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 1's cognitive skills for daily decision making (ability to process information) was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 7/23/2026 at 9:30 a.m., with Resident 1, at Resident 1's bedside, Resident 1 was observed with skin tears to the right lower leg. Resident 1 stated she sustained the wounds during a resident-to-resident physical altercation that occurred a few days earlier. During a concurrent interview and record review on 7/23/2026 at 2:12 p.m., with Treatment Nurse (TXN) 1, Resident 1's SBAR, dated 7/12/2026, was reviewed. The SBAR indicated Resident 1 sustained a self-inflicted skin tear to the right thigh. The SBAR was not signed or dated by TXN 1. TXN 1 stated she completed the SBAR on 7/13/2026 and acknowledged the date of 7/12/2026 was incorrect. TXN 1 stated Resident 1 sustained skin tears to the right lower leg on 7/13/2026. TXN 1 stated that documenting a self-inflicted skin tear to the right thigh was inaccurate. TXN 1 stated the SBAR was not signed or dated and did not accurately, completely, or currently reflect Resident 1's skin condition. TXN 1 stated medical records should be accurate, complete, current, signed, and dated to ensure continuity of care and effective communication among healthcare staff and physicians. During an interview on 7/23/2026 at 2:30 p.m., with the Director of Nursing (DON), the DON stated medical records should be accurate, complete, and documented timely to reflect the resident's condition and all changes in condition including injuries. The DON stated clinical documentation, including SBARs, must be signed and dated by the author to authenticate the record and ensure accountability. The DON stated Resident 1's SBAR did not include the accurate date, injury location, and cause of the injury. The SBAR also lacked the required signature and date. The DON stated the SBAR did not accurately reflect Resident 1's skin condition and had the potential to result in staff relying on inaccurate clinical information, delays in appropriate assessment and follow-up care, and compromised continuity of care. During a review of the facility's policy and procedure (P&P) titled Charting and Documentation Accuracy, dated 1/2026, the P&P indicated medical record documentation must be objective, complete, and accurate, and include the date, time, signature, and title of the person documenting.

Based on interview and record review, the facility failed to ensure a resident, who experienced a change in condition, received timely assessment, monitoring, and emergency intervention for one out of three sampled residents (Resident 1) when the following occurred: 1. Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 failed to promptly initiate emergency services for Resident 1 after he began experiencing a change of condition, which included a decreased oxygen saturation level of 78 percent (%, the percentage of oxygen in a person's blood, normal range 93-100 %), right hand and leg swelling, cold and pale skin, difficulty breathing, and progressive lethargy (a state of severe fatigue, sluggishness, and lack of energy or motivation that affects both physical and mental functioning).2. LVN 1 and RN 1 failed to initiate emergency services after Resident 1's change of condition per the facility's Policy and Procedure (P&P), titled Emergency Transfer or Discharge, which delayed emergency transport for over four hours.3. LVN 1 and RN 1 did not perform or document ongoing vital signs (measurement of the basic functions of your body, they include your body temperature, blood pressure, pulse and respiratory [breathing] rate) monitoring during Resident 1's change of condition from the last documented vital-signs at 12:00 p.m., until Resident 1's transfer to the general acute care hospital (GACH) at 2:55 p.m. (approximately 3 hours). These deficient practices resulted in Resident 1 experiencing a change of condition of decreased oxygen saturation level, right hand and leg swelling, cold and pale, difficulty breathing, and progressive lethargy. Resident 1 was transferred to the General Acute Care Hospital (GACH) after 4 hours, and was diagnosed with acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot adequately transfer oxygen into the bloodstream, resulting in dangerously low blood oxygen levels), hypotension (low blood pressure) , unspecified shock (a life-threatening medical emergency where reduced blood flow prevents vital organs from receiving enough oxygen), occlusion (slow blood blockage) of the celiac artery (which feeds the liver, spleen, and stomach) and the superior mesenteric artery (SMA, which feeds the small intestine), and acute systolic heart failure (occurs when the heart muscle suddenly weakens and cannot contract effectively, causing blood to back up into the lungs and body). Resident 1 expired on 8/24/ 2025, four days later.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1 's diagnoses included asthma (a chronic inflammatory lung disease), the presence of an automatic (implantable) cardiac defibrillator (AICD, a battery-powered device surgically placed under the skin that continuously monitors heart rhythms and corrects life-threatening irregular heartbeats by delivering pacing signals or a shock), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (partial weakness or the inability to move one entire side of the body) following cerebral infarction (loss of blood flow to a part of the brain) affecting the right side, transient ischemic attack (a temporary blockage of blood flow to the brain), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), acute myocardial infarction (MI- heart attack), and acute kidney failure (condition where your kidneys lose their ability to filter waste and excess fluid from your blood). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive skills (ability to think and reason) for daily decision making were moderately impaired (significant decline in thinking and memory skills that noticeably affects daily activities). The MDS indicated Resident 1 was dependent on staff for toileting, showering, and dressing. The MDS indicated Resident 1 required set-up assistance for eating and oral hygiene. During a review of Resident 1's Care Plan, titled Congestive Heart Failure, initiated [DATE], the care plan indicated to monitor for labored breathing, vital signs, cool skin, weakness, lethargy, and disorientation (a temporary state of mental confusion where a person loses their bearing). During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated [DATE] and timed at 1:15 p.m., the SBAR indicated the following:1. On [DATE] at 10:44 a.m., Registered Nurse (RN) 1 noted Resident 1 had difficulty breathing, right hand and leg swelling, and a fluctuating oxygen saturation level which ranged from 78 to 95% on room air. Resident 1's vital signs (measurements of the body's most basic functions) were as follows: blood pressure of 134/67 millimeters of mercury (mm hg, unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120-129 [top number] and 80-84 [bottom number]), respiratory rate of 18 breaths per minute (normal is 12 to 20 breaths per minute), temperature of 98.4 Fahrenheit (normal range 97 to 99 degrees Fahrenheit [ F, a unit of measurement]), and heart rate of 76 beats per minute (bpm, normal range 60 -100). Resident 1 was administered oxygen at two liters (a unit of measurement) via nasal cannula (a small plastic tube, which fits into the person's nostrils for supplemental oxygen). 2. At 10:46 a.m., Physician 1 was made aware and ordered to transfer Resident 1 to general acute care hospital (GACH) 2 for evaluation and treatment. 3. At 10:47 a.m., GACH 2 was made aware to arrange for transportation.4. At 11:30 a.m., Resident 1 was reassessed and was noted to be sleeping with no signs of acute distress. 5. At 11:30 a.m., Resident 1's blood pressure was 134/76 mm hg, heart rate of 76 bpm, respiratory rate of 17, oxygen saturation level of 98% on 2 liters of oxygen via nasal canula. 6. At 12:00 p.m., Resident 1 was reassessed and was noted to be sleeping with no signs of acute distress. Vital signs were as follows: blood pressure of 134/76 mmHg, heart rate at 76, respiratory rate of 17, oxygen saturation of 98% on two liters of oxygen via nasal canula. RN 1 called GACH 2 and was informed that GACH 2 was working on arranging transportation. Physician 1 was made aware. 7. At 2:45 p.m., 911 was called to evaluate Resident 1's condition. 8. At 2:50 p.m., paramedics arrived at Resident 1's bedside to evaluate and transfer the resident to GACH 1. 9. At 2:55 p.m., Resident 1 was transferred to GACH 1 in stable condition. During a record review of Resident 1's Fire Department Incident Report, dated [DATE] and timed at 2:10 p.m., the report indicated on [DATE], the Fire Department was dispatched and arrived to the facility at 2:14 p.m. Resident 1 was found lying in bed, alert to name. Resident 1's skin was pale and cold to touch. The report indicated Resident 1 was tachypneic (rapid breathing), hypotensive (low blood pressure), and the resident's blood pressure and radial pulse (heart rate felt at the radial artery in the wrist) were unattainable. Resident 1 was placed on a non-rebreather (a medical device used to deliver high concentrations of oxygen to spontaneously breathing patients) at 15 liters per minute. Resident 1 was transported to GACH 1 and began to deteriorate during transport. During a review of Resident 1's, Emergency Department (ED) Provider Notes, dated [DATE], timed at 2:38 p.m., the ED Provider Notes indicated Resident 1 presented to the ED altered and obtunded (an altered level of consciousness where a patient has mild to moderate reduced alertness) and in acute distress, with large pitting edema (swelling caused by fluid trapped under the skin where pressing a finger into the swollen area for a few seconds leaves a temporary dent or pit) to the right upper extremity (arm) and bilateral (pertaining to both side) lower extremities (legs). Resident 1 was cool, pale, clammy, and tachypneic (rapid breathing), on 15 liters of oxygen via non-rebreather, and a systolic blood pressure of 60. The ED provider note indicated Resident 1's vital signs were as follows: 96.7 F, 133/76 mm hg, heart rate 84, respiratory rate 29, oxygen saturation 89%. Resident 1 had a lactic acid value (a substance produced by cells during metabolism when oxygen levels are low) of 6.98 millimoles per liter ([mmol/L, a unit if measurement] normal levels at rest are less than 2.0 mmol/L. Values over 4.0 mmol/L indicate severe, medical emergency known as lactic acidosis) and a B-type natriuretic peptide (BNP, a blood test that checks for heart failure) of 3,584.49 picograms per milliliter([pg/Ml, a unit of measurement] a normal BNP level is usually less than 100 pg/mL; if level is above this, the heart is working too hard). Resident 1 was intubated (a medical procedure where a flexible tube is inserted into the body to establish and maintain an open airway, allowing for the delivery of oxygen) at 2:56 p.m. Resident 1's final diagnoses were acute respiratory failure with hypoxia (a life-threatening condition where the lungs cannot adequately transfer oxygen into the bloodstream, resulting in dangerously low blood oxygen levels), hypotension (low blood pressure) , unspecified shock (a life-threatening medical emergency where reduced blood flow prevents vital organs from receiving enough oxygen), occlusion (blood slow blockage) of the celiac artery (which feeds the liver, spleen, and stomach) and the superior mesenteric artery (SMA, which feeds the small intestine), and acute systolic heart failure (occurs when the heart muscle suddenly weakens and cannot contract effectively, causing blood to back up into the lungs and body). During a review of the GACH Discharge Summary Note, dated [DATE], the note indicated on [DATE], Resident 1's Family Member (FM 1) agreed to comfort care (medical treatment focused on relieving pain and easing symptoms, rather than curing an illness). Resident 1 was extubated (the removal of a breathing tube from a patient's windpipe after they no longer require mechanical ventilation) and expired on [DATE] at 3:18 a.m. During a review of Resident 1's Certificate of Death, dated [DATE], the record indicated Resident 1 expired on [DATE] at 3:18 a.m. due to cardiorespiratory arrest (the sudden cessation of breathing and blood circulation). Resident 1's other underlying causes of death were acute respiratory failure (a life-threatening emergency where the respiratory system can no longer get enough oxygen into the blood), pneumonia (lung infection), and cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). During a phone interview on [DATE] at 4:15 p.m. with, FM 1, FM 1 stated on [DATE], Resident 1 was in stable condition and able to engage in conversation during lunch. FM 1 stated a few days after Resident 1's hospitalization on [DATE], she visited the facility to inquire about his condition prior to transfer to the GACH. FM 1 stated she spoke with RN 1, the RN Supervisor working the day of Resident 1's transfer, who stated she did not know anything. FM 1 stated that she was later informed by another staff (whose name she could not recall) that RN 1 was aware of Resident 1's declining condition throughout that day, and RN 1 communicated to the nurses that Resident 1's condition did not warrant a 911 call and chose not to act. During the interview, FM 1 became tearful and stated that she was the only family member responsible for Resident 1's care. FM 1 tearfully stated that she had to make the difficult decision to discontinue life-sustaining measures for Resident 1, who passed away on [DATE], four days after being transferred to the hospital. During a phone interview on [DATE] at 1:14 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on [DATE] around 7:00 a.m., Resident 1 was able to take his medications and exhibited stable vital signs. LVN 1 stated, before lunch (exact timing not recalled), Certified Nurse Assistant (CNA 1) asked her to assess Resident 1. LVN 1 stated, upon assessment, Resident 1 attempted to sit up, appeared uncomfortable, was reluctant to lie down, and had trouble breathing. LVN 1 stated that she should have contacted Physician 1 and activated emergency medical services for Resident 1 at that time. LVN 1 stated, instead, she informed RN 1 who performed an assessment. RN 1 took Resident 1's blood pressure and completed her own evaluation. LVN 1 stated she expected RN 1 to initiate emergency services and call 911; however, RN 1 determined that Resident 1 was fine. LVN 1 stated, later in the shift (exact timing not recalled), CNA 1 again requested LVN 1 to assess Resident 1, who continued to exhibit discomfort and restlessness, resulting in a call to 911. LVN 1 stated that she should have called 911 earlier but refrained from doing so to avoid upsetting RN 1, who was her supervisor. LVN 1 further stated that she should have ensured Resident 1 was transferred out sooner, as any delay placed him at risk for poor clinical outcomes and reduced his chances of recovery. During an interview on [DATE] 3:52 p.m. with CNA 2, CNA 2 stated she worked closely with CNA 1 (the CNA assigned to Resident 1) on [DATE]. CNA 2 stated she recalled that at approximately 7:50 a.m., Resident 1 stated he felt cold and unwell, and CNA 2 noted that his temperature was measured at 96.8 F. CNA 2 stated CNA 1 communicated this concern to LVN 1, who performed an assessment around 9:00 a.m. CNA 2 stated she, LVN 1, and CNA 1 informed RN 1 of Resident 1's condition. At about 10:00 a.m., LVN 1 and RN 1 conducted another assessment. CNA 2 remembered standing beside Resident 1, taking his vital signs, and observed that he was cold to the touch. CNA 2 stated, at that time, she recalled that Resident 1's oxygen saturation was 82% on room air. The licensed nurses then placed Resident 1 on oxygen at the highest setting, which increased his oxygen saturation to 92-93%. CNA 2 stated she expressed her concerns to RN 1, stating that Resident 1 was cold, did not look well, and should be sent to the hospital. RN 1 responded that it was not an emergency, despite Resident 1 being placed on the highest setting of oxygen. RN 1 also stated she contacted transportation for transfer, which upset CNA 2. CNA 2 stated she checked on Resident 1 (could not recall what time) and Resident 1 appeared to be sleeping with his eyes closed. CNA 2 stated she asked Resident 1 if he wanted to go to the hospital, to which he replied yes. CNA 2 communicated this response to RN 1. CNA 2 stated, later, at 12:30 p.m., she checked on Resident 1 again, touched his leg, which was cold. CNA 2 stated Resident 1 attempted to get out of bed, pulled out his oxygen, and said he was thirsty. CNA 2 returned to Resident 1's room at another point and observed that he felt even colder. CNA 2 stated that by 1:30 to 2:00 p.m., Resident 1 appeared pale and cold, with weak responses and little movement. CNA 2 requested the Director of Staffing (DSD), who was the designated Quality Assurance Nurse (QAN) at the time, to conduct an assessment. CNA 2 stated DSD questioned why Resident 1 had not been sent out, and RN 1 replied that it was not an emergency. CNA 2 stated that she insisted that it was an emergency due to Resident 1's low oxygen levels since that morning. CNA 2 stated eventually, 911 was called. CNA 2 stated when paramedics arrived, Resident 1 remained pale and cold, struggled to speak coherently, and had low blood pressure. CNA 2 concluded that licensed nurses, and even herself, should have called 911 earlier in the morning to address Resident 1's critical condition. During an interview on [DATE] at 4:19 p.m. with the DSD, the DSD stated she recalled being asked by CNA 2 to come and assess Resident 1 because he was having difficulty breathing and the oxygen tank was almost empty. The DSD stated Resident 1 exhibited signs of respiratory distress including use of accessory muscles (additional muscles used when a resident exhibits difficulty breathing), lethargy, decreased responsiveness, and presence of a venti mask (a medical device that delivers a precise, controlled concentration of oxygen to patients); although she could not recall the precise liters of oxygen administered, she confirmed it exceeded five liters. The DSD stated Resident 1 was usually very alert. The DSD stated she summoned another LVN to bring the crash cart, proceeded to measure Resident 1's vital signs, and called RN 1 into the room. Upon RN 1's arrival, the DSD communicated her assessment findings, after which RN 1 increased the oxygen flow. The DSD stated, at that time, Resident 1 was unable to speak and was only able to open his eyes. RN 1 then initiated emergency services (911). The DSD stated, based on her assessment, the licensed nurses should have initiated emergency services sooner to ensure timely treatment and further evaluation for Resident 1, reducing the risk of long-term complications. The DSD stated LVN 1 had a responsibility to call 911, as licensed nurses were expected to prioritize the best interests of residents, regardless of whether RN 1 took such action. During a concurrent interview and record review on [DATE] at 1:21 p.m. with the Director of Nursing (DON), Resident 1's SBAR Note, dated [DATE], was reviewed. The SBAR note indicated on [DATE] at 10:44 a.m., Resident 1 experienced a change in condition and 911 was called at 2:40 p.m. The DON stated a critical change in Resident 1's condition of difficulty breathing and an oxygen saturation of 78% was identified at 10:44 a.m. The DON stated these changes warranted not only physician notification but an immediate transfer to the GACH via 911. The DON questioned the delay in calling emergency services, stating, Why did it take [RN 1] until 2:40 p.m. to call 911? 911 should have been called at 10:44 a.m. The DON stated that licensed nurses, particularly the RN Supervisor (RN 1), were responsible for ensuring that appropriate interventions were provided promptly, especially in life-or-death situations. The DON stated Resident 1 should have been ordered to be transferred to the nearest GACH to maximize the chances of a positive clinical outcome, not to GACH 2. The DON stated that the delay in treatment and care placed Resident 1 in distress and danger. The DON stated that symptoms such as pallor, cold skin, nausea, vomiting, and altered mental status were late signs of hypoxemia (low oxygen in the blood), indicating that the brain and body were not receiving sufficient oxygen. The DON stated RN 1 and the licensed nursing staff should have maintained continuous monitoring of Resident 1 every 15 minutes due to the resident's compromised respiratory system. The DON stated that if LVN 1 disagreed with RN 1's clinical judgment and believed an immediate transfer via 911 was necessary, LVN 1 should have acted accordingly. The DON stated that this delay in treatment led to Resident 1 experiencing respiratory distress placing the resident's life at risk. During a phone interview on [DATE] at 3:19 p.m. with Physician 1, Physician 1 stated without prompt intervention, Resident 1's comorbidities (two or more distinct medical or psychological conditions present in the same person at the same time), including the presence of an AICD, history of multiple strokes, and hypertension, placed him at high risk for adverse clinical events. Physician 1 stated that if Resident 1 exhibited symptoms such as respiratory compromise and swelling of the right hand and leg, immediate transport to the nearest hospital via 911 would have been warranted. Physician 1 stated his orders relied heavily on reliable and accurate nursing assessments. Physician 1 stated to mitigate the risk of poor clinical outcomes, the care for Resident 1 should not have been delayed. Physician 1 stated Resident 1 should have been transferred promptly. During a review of the facility's Policy and Procedure (P&P), titled, Transfer or Discharge Emergency, dated 1/2026, the P&P indicated emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). The P&P indicated a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. The P&P indicated residents would not be transferred unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. During a review of the facility's RN Job Description, dated [DATE], the job description indicated the RN was to ensure the following:1.Complete, maintain and submit accurate and relevant clinical notes regarding the patient's condition and care given. Records pain/symptom management changes/outcomes as appropriate.2. Assess and evaluate patient's status by initiating the plan of care and regularly re-evaluating patient needs.

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Trauma Informed Care, dated 1/2026, by ensuring staff received training and/or in-services to ensure they were equipped to provide all facility residents with trauma-informed care (an organizational and clinical framework requiring skilled nursing and long-term care facilities to recognize, understand, and respond to the effects of trauma). This failure placed the facility residents at risk of not receiving care to meet their behavioral health needs, including person-centered care approaches designed to meet their individual goals.Findings: During a review of the facility document titled In Service Schedule 2026, dated 2026, the document did not indicate in-services related to trauma (effects from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being), trauma-informed care, post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event), or trauma assessments were provided to or scheduled for facility staff. During a review of the employee files for five sampled staff (Certified Nursing Assistant [CNA] 1, CNA 2, Licensed Vocational Nurse [LVN] 1, Registered Nurse [RN] 1, and RN 2), the employee files did not contain any records that training related to trauma, trauma-informed care, PTSD, or trauma assessments was received. During an interview on 6/17/2026 at 12:46 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she did not receive training or in-services related to trauma, PTSD, or trauma-informed care training. During an interview on 6/18/2026 at 1:02 p.m., with the Social Services Director (SSD), the SSD stated she or the Social Services Assistant (SSA) were primarily responsible for completing the Brief Trauma Questionnaire (a short assessment designed to assess traumatic exposure). The SSD stated that to her knowledge, there were no other staff who were trained to complete the brief trauma questionnaire or assess residents for trauma and/or identify triggers. During an interview on 6/18/2026 at 1:34 p.m., with the Director of Staff Development (DSD), the DSD stated she had been the DSD since 11/2025. The DSD stated in-services/training related to trauma-informed care or PTSD were not conducted for staff. The DSD stated that to her knowledge these training topics had never been on the training calendar. The DSD stated that in-services and training related to trauma-related training/in-services were important for CNAs to ensure they knew how to address the residents and could identify behavior patterns or triggers while providing care. The DSD stated that a history of trauma or PTSD could impact the resident's plan of care and willingness to participate or accept care. During an interview on 6/18/2026 at 1:49 p.m., with the Director of Nursing (DON), the DON stated he had not provided any in-services related to trauma, trauma-informed care, or PTSD. The DON stated that to his knowledge, this was also not a topic that was included as part of routine onboarding for new hires, or as part of ongoing training in the facility. The DON stated that a history of trauma can result in staff unknowingly triggering a resident if the trigger was not previously identified. The DON stated that this can impact the resident both emotionally and/or physically depending on their history. During a review of the facility's policy and procedure (P&P) titled Trauma Informed Care, dated 1/2026, the P&P indicated trauma-informed care was culturally sensitive and person-centered. The P&P indicated that all staff were to be provided in-service training about trauma, its impact on health, and post-traumatic stress disorder in the context of the healthcare setting. The P&P indicated nursing staff were to be trained on screening tools, trauma assessments, and how to identify triggers associated with re-traumatization.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was not held down by Certified Nursing Assistants (CNA 1 and CNA 2) during care. This failure resulted in Resident 1 experiencing psychosocial distress and physical pain after being held down despite Resident 3's refusal of care.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included malignant neoplasm (cancer) of the ovary, liver, and bile duct, and morbid obesity (a serious, chronic disease diagnosed in individuals who are severely overweight). During a review of Resident 1's record titled Physician's Certification for Hospice Benefit, dated 5/20/2026, the record indicated Resident 1 had a PleurX catheter (a small, flexible silicone tube surgically placed under the skin into the chest or abdomen) to the right side of her abdomen. The record indicated Resident 1 complained of moderate pain at the catheter site. The record indicated Resident 1 was bedbound and had widespread metastatic disease (when cancer cells break away from the original tumor and form new tumors in other parts of the body) and generalized weakness. The record indicated Resident 1 had severe debility (a state of physical weakness, feebleness, or loss of strength) and required extensive assistance (when a resident is totally dependent or requires hands on assistance more than half the time while performing part of an activity) with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/25/2026, the MDS indicated Resident 1 had clear speech and was able to make herself understood. The MDS indicated Resident 1 had no cognitive impairment (problems with memory, thinking, learning, or decision-making) or disorganized thinking. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half of the work to complete the activity) from staff to roll side to side while in bed and was dependent on staff (helper does all of the work) for toileting hygiene. During a review of Resident 1's Change of Condition (COC) assessment, dated 6/13/2026 at 5:00 a.m., the assessment indicated on 6/13/2026, Resident 1 became aggressive while being turned by two certified nursing assistants (CNAs).During a review of Resident 1's COC assessment, dated 6/13/2026 at 8:43 a.m., the assessment indicated on 6/13/2026, Resident 1 alleged she was abused by the CNAs who were providing her care during the 11:00 p.m. to 7:00 a.m. shift on 6/13/2026. During a review of the facility record titled Written Statement Regarding Resident Care Incident, dated 6/13/2026, authored by CNA 1, the record indicated that on 6/13/2026, between 4:30 a.m. and 5:00 a.m., CNA 1 and CNA 2 entered Resident 1's room to provide perineal care (the cleansing of the genital and anal areas) and change her incontinent brief (adult diaper). The record indicated that while cleaning Resident 1, the resident became increasingly agitated and began yelling they (CNA 1 and CNA 2) were killing her. The record indicated that CNA 1 continued to hold Resident 1 in a side-lying position as Resident 1 struck CNA 1. The record indicated Resident 1's behavior continued to escalate and CNA 2 attempted to prevent further strikes by controlling one of the resident's hands. The record indicated that Resident 1 displayed continued physical aggression and made repeated requests that [they] leave her alone. The record indicated that after care was stopped, Resident 1 continued to request that CNA 1 and CNA 2 not touch her and that they leave the room. The record indicated that after the incident, Resident 1 reported that CNA 1 and CNA 2 physically assaulted her and requested for law enforcement to be notified. During a review of Resident 1's progress note, dated 6/15/2026, the progress note indicated on 6/13/2026, Resident 1 reported that two CNAs attempted to hold her down while providing care. During an interview on 6/17/2026 at 3:02 p.m., with Resident 1, Resident 1 stated she had multiple areas on her body that required staff to be sensitive, work at a slower pace, and handle gently due to the significant amount of pain the areas cause her. Resident 1 stated she also had a surgical wound on the right side of her abdomen that caused her a lot of pain. Resident 1 stated on 6/13/2026 around 4:30 a.m., two unidentified staff were assisting her into a side lying position. Resident 1 stated she told the staff she could not turn further because the repositioning was causing pain. Resident 1 stated the two staff continued what they were doing, and the pain became so extreme that she demanded that they stop touching her. Resident 1 stated they did not listen to her request and continued to provide care. Resident 1 stated that she began to strike at them and scream because they were not listening to her requests to discontinue care. Resident 1 stated she did not feel safe in the facility, and stated the facility told her she was the perpetrator (a person who carries out a harmful, illegal, or malicious act) for defending herself. Resident 1 stated that after the staff discontinued their care, her pain, on a scale of one to 10 (with 10 being the worst pain), was a billion. During a telephone interview, on 6/18/2026 at 8:39 a.m., with CNA 1, CNA 1 stated that on 6/13/2026, they turned Resident 1 onto her left side. CNA 1 stated that once Resident 1 was turned onto her left side, she was combative within seconds. CNA 1 stated Resident 1 was moving around a lot and attempting to return to lying on her back. CNA 1 stated she placed one of her hands behind Resident 1's right shoulder to keep her on her left side. CNA 1 stated Resident 1 then struck her with her left arm, while screaming, You're killing me, you're gonna kill me! CNA 1 stated CNA 2 used her hand to restrain Resident 1's left arm. CNA 1 stated that while Resident 1's left arm was restrained by CNA 2, Resident 1 then struck her again with her right arm. CNA 1 stated Resident 1 was still screaming and using profanity. CNA 1 stated Resident 1 kept saying, I'm gonna die. CNA 1 stated Resident was saying, Stop touching me!, using profanity, and telling CNA 1 and CNA 2 to get out of her room. CNA 1 stated that after she was hit, CNA 2 made the decision to stop care. During a telephone interview on 6/18/2026 at 2:01 p.m., with CNA 2, CNA 2 stated that the morning of 6/13/2026, CNA 1 was assisting her to provide perineal care and a brief change to Resident 1. CNA 2 stated they informed Resident 1 they needed to turn her onto her side to perform perineal care on her backside. CNA 2 stated that while turning Resident 1 onto her left side, Resident 1 repeatedly said no, but they continued to turn her onto her side. CNA 2 stated CNA 1 began cleaning Resident 1's backside, and Resident 1 leaned back and hit CNA 1 with one of her hands. CNA 2 stated she grabbed Resident 1 by the wrist to restrain her. CNA 2 stated that while restraining one of Resident 1's arms, Resident 1 began to move her other, unrestrained arm. CNA 2 stated she assumed Resident 1 was going to hit her or CNA 1, so she grabbed Resident 1's other arm to restrain it. CNA 2 stated that while restraining both of Resident 1's arms, she tried to use her body to push Resident 1 back onto her back. CNA 2 stated Resident 1 kept saying they [CNA 1 and CNA 2] were trying to kill her and that she [Resident 1] was going to die. CNA 2 stated that while Resident 1 was saying, You're gonna kill me, she assumed it was due to Resident 1 being in pain. CNA 2 stated Resident 1 had a right to refuse care. CNA 2 stated she and CNA 1 did not stop what they were doing when Resident 1 was repeatedly saying no while being turned. When asked why they did not honor Resident 1's request for care to be stopped, CNA 2 stated they were focused on cleaning her and did not want to fall behind on their patient care tasks. CNA 2 stated she felt that they were short-staffed during that shift. During an interview on 6/18/2026 at 3:29 p.m., with the Administrator (ADM), the ADM stated that if a resident was refusing care, or saying No, no, no! while care was being attempted, staff should respect the resident's refusal. The ADM stated if the resident appeared to not want the care being provided, the staff should stop. The ADM stated that pausing care would allow staff to identify why the resident was refusing. The ADM stated that continuing to provide care, and ignoring the resident's requests, was a violation of their right to refuse care, and was going against the resident's wishes. The ADM stated if the CNA felt staffing was an issue, they should have asked their charge nurse, or gotten additional help. During a review of the facility's policy and procedure (P&P) titled Use of Restraints, dated 1/2026, the P&P defined restraints as including any manual method that restricts freedom of movement or restricts normal access to one's body. The P&P indicated restraints were only to be used for the safety and well-being of the resident, and only after other alternatives have been tried unsuccessfully. The P&P indicated restraints should not be used for staff convenience. During a review of the facility's P&P titled Abuse and Neglect Clinical Protocol, dated 1/2018, the P&P defined abuse as the willful infliction of.unreasonable confinement.resulting in physical harm, pain or mental anguish. The P&P defined willful as the individual acting deliberately, not that the individual must have intended to inflict injury or harm. During a review of the facility's P&P titled Resident Rights, dated 1/2018, the P&P indicated that federal and state laws guaranteed basic rights to all facility residents, including:A dignified existenceBeing treated with respect, kindness, and dignityBeing free from physical restraintsSelf-determinationBeing supported by the facility in exercising their rights During a review of the facility's P&P titled Dignity, dated 1/2026, the P&P indicated each resident was to be cared for in a manner that promotes and enhances his or her sense of well-being. The P&P indicated staff were to treat residents with dignity and respect at all times. The P&P indicated that when assisting a resident with care, the resident was to be supported in exercising their rights.

Based on interview and record review, the facility failed to provide one of one sample resident (Resident 3) with a daily bath or shower, as indicated in her care plan. This failure did not honor Resident 3's care preferences, and placed her at risk of not having her care needs met.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included generalized muscle weakness, morbid obesity (a serious, chronic disease diagnosed in individuals who are severely overweight), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both knees. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 3 had no cognitive impairment (ability to think and reason). The MDS indicated Resident 3 required substantial to maximal assistance from staff for showering and bathing and mobility while in bed. During a review of Resident 3's care plan titled The resident has an activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) self-care performance deficit related to limited mobility, musculoskeletal impairment, ., created 9/22/2025 and revised 1/8/2026, the care plan indicated Resident 3 was totally dependent on one staff to provide a bath/shower daily and as necessary. During a review of the facility record titled Documentation Survey Report, dated 5/1/2026 to 5/31/2026, and 6/1/2026 to 6/30/2026, the records indicated the Certified Nursing Assistants' (CNAs) were to provide baths/showers to Resident 3. The records did not indicate Resident 3 was provided with a daily bath/shower from 5/1/2026 to 5/31/2026, or 6/1/2026 to 6/23/2026. During an interview on 6/22/2026 at 2:46 p.m., with the Director of Nursing (DON), the DON stated Resident 3's care plan indicated Resident 3 was to receive a daily bath. The DON stated provision of a daily bath was important to meet Resident 3's needs. The DON stated frequent baths/showers aided in prevention of skin breakdown, and was important for maintaining the resident's dignity and overall well-being. During an interview on 6/22/2026 at 2:56 p.m., with the DON, the DON stated the documentation in Resident 3's medical record did not indicate staff provided Resident 3 with a daily bath as indicated in her care plan. During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADLs), Supporting, dated 1/2018, the P&P indicated staff were to provide care and services for residents who are unable to carry out ADLs independently, in accordance with the resident's plan of care. During a review of the facility's P&P titled Bath/Shower, dated 1/2018, the P&P indicated that the purpose of the P&P was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. The P&P indicated staff were to document the date and time the shower/bath was performed.

Based on interview and record review, the facility failed to ensure care plans were updated for one of two sampled residents (Resident 5) to reflect the physician's orders for 1:1 supervision (one-to-one, a high level of patient monitoring where a single healthcare staff member is assigned exclusively to one patient to observe, protect, and assist them continuously), following Resident 5's involvement as the aggressor in a resident-to-resident altercation. This failure resulted in Resident 5's care plan not reflecting the interventions needed to prevent further altercations, and placed the safety of Resident 5, and other facility residents, at risk.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included left-sided hemiplegia (inability to move one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain), schizophrenia (mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 5 had no cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required supervision/touch assistance from staff to wheel her wheelchair. During a review of Resident 5's Change of Condition (COC) assessment, dated 6/16/2026 at 10:59 a.m., the assessment indicated on 6/16/2026, Resident 5 was aggressive towards others and was involved in an altercation with another resident resulting in her pulling the other resident to the floor. During a review of Resident 5's physician order, dated 6/16/2026, the physician order indicated Resident 5 was to have 1:1 supervision due to a physical altercation that occurred on 6/16/2026. During an interview on 6/23/2026 at 10:43 a.m., with the Director of Nursing (DON), the DON stated care plans were revised after resident-to-resident altercations. The DON stated these revisions would include adding interventions necessary in response to the altercation. The DON stated including the interventions on the care plan would ensure staff were aware of the intervention and ensure it was implemented. The DON stated Resident 5's intervention for 1:1 supervision was not included in her care plan. During a concurrent interview and record review, on 6/23/2026 at 10:41 a.m., with the DON, Resident 5's physician order dated 6/16/2026 was reviewed. The order indicated 1:1 supervision from 6/16/2026 to 6/22/2026. The DON stated the 1:1 supervision was indicated due to Resident 5's physical altercation with another resident. The DON stated it was important for the 1:1 supervision to be implemented, as ordered, to ensure the safety of the facility's residents was maintained. During a review of the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered, dared 1/2018, the P&P indicated the resident's comprehensive, person-centered care plan was to describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The P&P indicated the resident's comprehensive care plan was also to incorporate risk factors associated with identified problems.

Based on interview and record review, the facility failed to provide one of one sample resident (Resident 3) with her required level of assistance during provision of activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). This failure placed Resident 3's safety at risk from not having the required assistance and supervision during care.Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included generalized muscle weakness, morbid obesity (a serious, chronic disease diagnosed in individuals who are severely overweight), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both knees. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 3 did not have cognitive impairment (ability to think and reason). The MDS indicated Resident 3 required substantial to maximal assistance from staff (staff does more than half of the effort) for showering and bathing herself. The MDS indicated Resident 3 required substantial to maximal assistance for toileting hygiene. During a review of the facility record titled Documentation Survey Report, dated 5/1/2026 to 5/31/2026, and 6/1/2026 to 6/30/2026, the records indicated the Certified Nursing Assistants' (CNA) were to document baths/showers and toileting hygiene provided to Resident 3. The records did not indicate staff provided substantial to maximal assistance for bathing or toileting hygiene. During an interview on 6/22/2026 at 2:40 p.m., with the Director of Nursing (DON), the DON stated Resident 3's MDS indicated she required substantial to maximal assistance from staff for bathing/showering and toileting hygiene. The DON stated the MDS guided the plan of care and staff should provide the level of care indicated in the MDS. The DON stated it was important to provide the required level of assistance to ensure that the resident's care needs were being met and to ensure the resident's safety. The DON stated failure to provide the required level of assistance could result in the resident not being adequately cleaned, which could result in a urinary tract infection (UTI, a bacterial infection in any part of your urinary system), skin breakdown, or negatively impact her dignity. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument Process (RAI), dated 1/2018, the P&P indicated the Resident Assessment Instrument (MDS) was used to provide the caregiving staff with ongoing assessment information necessary to provide the appropriate care and services for each resident. During a review of the facility's P&P titled Activities of Daily Living (ADLs), Supporting, dated 1/2018, the P&P indicated staff were to provide care and services for residents who are unable to carry out ADLs independently, in accordance with the resident's plan of care.

Based on interview and record review, the facility failed to ensure the need for specialized rehabilitation services was determined for one of one sample resident (Resident 3) following a decline in Resident 3's ability to perform activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility. This failure delayed the opportunity for Resident 3's care team to determine if Resident 3 could benefit from physical and/or occupational therapy (healthcare specialties that help individuals reduce pain, restore mobility, and regain functional independence). Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 3's diagnoses included generalized muscle weakness, morbid obesity (a serious, chronic disease diagnosed in individuals who are severely overweight), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both knees. During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 6/10/2026, the MDS indicated Resident 3 was independent in daily decision making. The MDS indicated Resident 3 required substantial to maximal assistance from staff (staff does more than half of the effort) for showering and bathing herself. The MDS indicated Resident 3 required substantial to maximal assistance to roll from side to side in bed, and to transition from a lying position to a sitting position. During a review of Resident 3's record titled Occupational Therapy Discharge Summary, dated 10/7/2025 to 12/11/2025, the record indicated Resident 3 received physical therapy from 10/7/2025 to 12/11/2025. The record indicated that upon discharge from occupational therapy services, Resident 3 was able to complete hygiene and grooming tasks with standby assistance from staff (a caregiver or therapist remains within arm's reach of an individual to ensure safety during a task). The record indicated Resident 3 had achieved her maximum potential. During a review of Resident 3's record titled Physical Therapy Discharge Summary, dated 10/7/2025 to 12/11/2025, the record indicated Resident 3 received physical therapy from 10/7/2025 to 12/11/2025. The record indicated that upon discharge from physical therapy services, Resident 3 was able to roll from side to side in bed with standby assistance from staff. The record indicated Resident 3 was able to transition from a lying position to a sitting position with minimal assistance from staff (the resident performs at least 75% of a physical or daily living task). The record indicated Resident 3 had achieved her maximum potential. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 required substantial to maximal assistance from staff (staff does more than half of the effort) for toileting hygiene. The MDS indicated Resident 3 required substantial to maximal assistance from staff to roll side to side in bed, and to transition from a lying to sitting position in bed. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 continued to require substantial to maximal assistance from staff for toileting hygiene. The MDS indicated Resident 3 continued to require substantial to maximal assistance from staff to roll side to side in bed, and to transition from a lying position to a sitting position in bed. During an interview on 6/22/2026 at 11:40 a.m., with the Rehabilitation Coordinator (RC), the RC stated she was not notified of Resident 3's decline in ability to perform hygiene tasks, or mobility while in bed, identified in her MDS dated [DATE] and 3/27/2026. The RC stated prompt notification was important to ensure that interventions could be implemented. The RC stated that failure to identify a decline increased the risk for further decline and placed Resident 3 at risk for complications related to ADL and mobility decline, such as pressure injuries, poor circulation, and blood clots. During an interview on 6/22/2206 at 12:35 p.m., with the RC, the RC stated that upon discharge from physical and occupational therapy services on 12/11/2025, Resident 3 was at her highest level of functioning. The RC stated that if there were a decline following her discharge from therapy services, Resident 3 would have benefited from renewed services. The RC stated that if there were an observed decline, Resident 3's physician could be notified to determine if orders for new physical and occupational therapy evaluations were appropriate. During an interview on 6/22/2026 at 3:05 p.m., with the Director of Nursing (DON), the DON stated there was no documentation in Resident 3's medical record indicating her physician was notified of her decline in ability to perform ADLs and mobility, identified in her MDS on 12/26/2025 and 3/27/2026. The DON stated staff should have notified Resident 3's physician of the change to ensure that her care plan could be revised and to address the change of condition. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument Process (RAI), dated 1/2018, the P&P indicated the Resident Assessment Instrument (MDS) was used to provide the caregiving staff with ongoing assessment information necessary to provide the appropriate care and services for each resident. During a review of the facility's P&P titled Changes in Resident Condition, dated 4/2005, the P&P indicated that the attending physician was to be notified when a change in condition occurred, including a significant change in the resident's physical status or when there was a need to alter the treatment plan. The P&P indicated this information was to be documented in the medical record.

Based on interview and record review, the facility failed to ensure the physician completed the Physician Discharge Summary assessment for two of two sampled residents (Resident 3 and Resident 4). This failure placed Residents 3 and 4 at risk of being discharged without a physician assessment or a physician-guided plan of care upon discharge.Findings: 1. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), generalized muscle weakness, morbid obesity (a serious, chronic disease diagnosed in individuals who are severely overweight), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of both knees. During a review of Resident 3's Discharge Minimum Data Set (MDS, a resident assessment tool), dated 6/10/2026, the MDS indicated Resident 3 was independent in making daily decisions. The MDS indicated Resident 3 required substantial to maximal assistance from staff for showering and bathing herself and mobility while in bed. During a review of Resident 3's progress note, dated 6/10/2026, the progress note indicated Resident 3 was transferred to the hospital via emergency medical services on 6/10/2026 due to low blood pressure, low blood oxygen levels, and a flushed appearance (sudden increase of blood flow to your cheeks, neck or upper chest). During a review of Resident 3's Electronic Medical Record (EMR), the EMR indicated a Physician's Discharge Summary assessment was completed for Resident 3 on 6/10/2026. 2. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE]. Resident 4's diagnoses included generalized muscle weakness, abnormal gait (manner of walking) and mobility, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), delusional disorders (a psychiatric condition where a person experiences fixed, false beliefs (delusions) that persist for at least one month), anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry out of proportion to actual situations), major depressive disorder (a serious mood disorder characterized by persistent sadness, hopelessness, and a profound loss of interest in activities), and inability to move the right side of her body following a cerebral infarction (loss of blood flow to a part of the brain). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had no cognitive impairment (ability to think and reason). The MDS indicated Resident 4 required set-up/clean-up assistance from staff for most activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 4's EMR, the EMR indicated a Physician's Discharge Summary assessment was completed for Resident 3 on 6/10/2026. During a review of Resident 4's progress note, dated 6/16/2026, the progress note indicated on 6/16/2026, Resident 4 was transferred to the hospital due to an altercation with another facility resident. During an interview on 6/22/2026 at 8:57 a.m., with Registered Nurse (RN) 3, RN 3 stated the Physician's Discharge Summary was an assessment completed when a resident was transferred out of the facility. RN 3 stated he was not sure of the assessment's purpose and stated he figured it's information that someone would need to know. RN 3 stated the assessment was not completed by a physician and was completed by an RN. RN 3 stated that in the section indicated for the physician's electronic signature, the RN would type in in the physician's name. RN 3 stated it was rare that the physician came in to see the resident before they were transferred out of the facility, and it was rare that they completed documentation related to the transfer. During an interview on 6/22/2026 at 1:07 p.m., with the Director of Nursing (DON), the DON stated the Physician's Discharge Summary was an assessment completed by the registered nurse performing the resident's transfer. During a concurrent interview and record review, on 6/22/2026 at 1:16 p.m., with the DON, the facility's policy and procedure (P&P) titled Preparing a Resident for Transfer or Discharge, dated 12/2016, was reviewed. The P&P indicated the nurse was responsible for obtaining the Physician's Discharge Summary. The DON stated the nurse was responsible not completing the physician discharge summary. The DON stated it was not appropriate for the nurse to complete an assessment intended to be completed by a physician. The DON further stated that the physician's signature should not be filled in by a nurse. The DON stated the physician should be completing and signing off on the assessment.

Based on observation, interview, and record review, the facility failed to ensure adequate abuse prevention for one of two sampled residents (Resident 5) by failing to provide Resident 5 with 1:1 supervision (one-to-one, a high level of patient monitoring where a single healthcare staff member is assigned exclusively to one patient to observe, protect, and assist them continuously), as ordered by the physician, following Resident 5's involvement as the aggressor in a resident-to-resident altercation on 6/16/2026. This failure resulted in Resident 5 wandering the facility unsupervised, placing her at risk of involvement in another altercation with and abuse of another facility resident.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE]. Resident 5's diagnoses included left-sided hemiplegia (inability to move one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain), schizophrenia (mental illness that is characterized by disturbances in thought), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) not due to a substance or known physiological condition. During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 5 had no cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required supervision/touch assistance from staff to wheel her wheelchair. During a review of Resident 5's Change of Condition (COC) assessment, dated 6/16/2026 at 10:59 a.m., the assessment indicated on 6/16/2026, Resident 5 was aggressive towards others and involved in an altercation with another resident resulting in her pulling the other resident to the floor. During a review of Resident 5's physician order, dated 6/16/2026, the physician order indicated Resident 5 was to have 1:1 supervision due to a physical altercation that occurred on 6/16/2026. During a review of the facility staffing record, dated 6/16/2026, for the 3:00 p.m. to 11:00 p.m. (evening shift) and 11:00 p.m. to 7:00 a.m. on 6/17/2026 (NOC shift), the staffing record did not indicate Resident 5 was assigned 1:1 supervision. During a review of the facility staffing record, dated 6/17/2026 to 6/22/2026, the staffing did not indicate Resident 5 was assigned 1:1 supervision. During an interview on 6/18/2026 at 10:17 a.m., with the Director of Staff Development (DSD), the DSD stated she was responsible for creating the staffing assignment for the certified nursing assistants (CNAs) and stated that a CNA would typically be the staff assigned to provide 1:1 supervision. The DSD stated the facility had enough staff to ensure that if 1:1 supervision was ordered it could be provided. During an interview on 6/23/2026 at 10:39 a.m., with the Director of Nursing (DON), the DON stated 1:1 supervision required a pre-designated staff to be with the resident at all times. The DON stated he was responsible for notifying the DSD of any 1:1 supervision orders, as soon as they were entered, to ensure the DSD designated a staff to provide 1:1 supervision. During a concurrent interview and record review, on 6/23/2026 at 10:41 a.m., with the DON, Resident 5's physician order dated 6/16/2026 was reviewed. The order indicated 1:1 supervision from 6/16/2026 to 6/22/2026. The DON stated the 1:1 supervision was indicated due to Resident 5's physical altercation with another resident. The DON stated it was important for the 1:1 supervision to be implemented, as ordered, to ensure the safety of the facility's residents was maintained. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Program, dated 1/2018, the P&P indicated the facility was to develop and implement policies and procedures to aid the facility in preventing abuse, neglect, or mistreatment of our residents. The P&P indicated staff were to protect residents during abuse investigations. During a review of the facility's P&P titled Safety and Supervision of Residents, dated 1/2018, the P&P indicated resident safety and supervision to prevent accidents were facility-wide priorities. The P&P indicated the interdisciplinary team (group of different disciplines working together towards a common goal of a resident) was to analyze information obtained from assessments and observations to identify specific resident risks and develop interventions. The P&P indicated that implementation of these interventions was to be accomplished by communicating the specific interventions to all relevant staff, and ensuring they were implemented.

Based on interview and record review, the facility failed to ensure one of three (3) sampled residents (Resident 4), did not develop a stage 3 pressure ulcer (a severe skin injury with full-thickness skin loss where the underlying fat is exposed) at the facility. The facility failed to:1). Ensure Resident 4's pressure points (sacrum [triangular-shaped bone at the base of the spine], coccyx [tailbone], ischium [the lower and back part of the hip bone], trochanter [hip]) were inspected daily, as indicated in its policy and procedure (P&P) titled, Prevention of Pressure Injuries (injuries to the skin over bony areas), which indicated, the facility will inspect residents' pressure points daily, for the presence of erythema (redness), skin temperature and soft tissue edema (swelling), during residents care. 2). Implement Resident 4's care plan titled Impaired Skin Integrity related to immobility, incontinence (no control of bowel and bladder function), poor perfusion (reduced or not enough blood flow to body parts), malnutrition as evidenced by stage two ([2] a partial-thickness skin loss involving damage to the outer layers of the skin [the epidermis and dermis]) on the left thigh, which indicated the facility will reposition the resident every 2 hours and as needed, and assess the resident's skin every shift for skin breakdown (open areas or changes in skin). 3). Ensure the Certified Nurse Assistants (CNAs) observed and documented Resident 4's skin condition during showers and bed baths, on the Skin Monitoring: Comprehensive Certified Nurse Assistant Shower Review form for timely identification of new skin breakdown and providing intervention. 4). Turn Resident 4 every 2 hours, change the resident when soiled and keep the resident clean and dry, per Resident 4's Situation, Background, Assessment, Recommendation Communication Form (SBAR- a communication tool used by healthcare workers when there is a change in a resident's condition). 5). Ensure Resident 4's name was included in the Activities of Daily Living (ADL) Repositioning Rounds Monitoring log on 5/3/2026 (afternoon shift) and 5/3/2026 to 5/4/2026 (night shift). These failures resulted in Resident 4 acquiring a stage 3 pressure ulcer on the sacrum area on 5/4/2026.Findings: During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or partial paralysis affecting one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, muscle weakness, muscle wasting (muscle thinning) and atrophy (muscle tissue loses mass and shrinks), severe protein-calorie malnutrition (a severe form of undernutrition caused by insufficient intake of both protein and calories, leading to muscle wasting, fat loss, and impaired bodily functions), absence of left leg below knee, peripheral vascular disease (a common condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping) and dysphagia (difficulty swallowing). During a review of Resident 4's admission Skin assessment dated [DATE], the admission skin assessment indicated Resident 4 had an ulcer on the left hip (no measurement or other descriptions indicated). During a review of Resident 4's Braden Scale (a standardized tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers, or bedsores) dated 4/7/2026 and 4/14/2026, the Braden scale indicated Resident 4 was at risk for developing pressure ulcers. During a review of Resident 4's Care Plan titled Impaired Skin Integrity related to immobility, incontinence poor perfusion malnutrition as evidenced by stage 2 on the left thigh, dated 4/7/2026, the interventions indicated to reposition every 2 hours and as needed, assess skin every shift for skin breakdown (open areas or changes in skin), keep skin clean and dry after each incontinence episode, offload pressure to bony areas. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 4/11/2026, the MDS indicated Resident 4 was usually able to understand and be understood by others. The MDS indicated Resident 4 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for ADL such as eating, oral hygiene, toileting, shower/bathe, and upper/lower body dressing. Resident 4 was dependent on staff on rolling from left to right, from sitting to lying position, lying to sitting on side of the bed, chair/bed, and tub/shower transfer. Resident 4 had an indwelling catheter (thin, flexible tube inserted into the bladder to continuously drain urine) and was always incontinent of bowel. Resident 4 was at risk of pressure/injuries and had one or more unhealed pressure ulcers /injuries. During a review of Resident 4's Nursing Weekly Summary (a document containing records of vital signs, skin assessment, bowel and bladder function, pain management, cognitive patterns, ADL function, nutrition and hydration status), dated 4/8/2026, 4/15/2026, 4/22/2026 and 4/29/2026, the Nursing Weekly Summary did not indicate Resident 4 was included on the turning and repositioning program or that the resident's skin was assessed. During a review of Resident 4's Skin Monitoring: Comprehensive CNA Shower Review form, dated 4/7/2026 to 5/5/2026, the form indicated to perform a visual assessment of the resident's skin during showers, report any abnormal looking skin to the charge nurse immediately, by describing and graphing all abnormalities by number, using the body chart (in the form). The section subtitled visual assessment dated 4/7/2026 to 5/5/2026 were blank. During a review of the ADL Repositioning Rounds Monitoring log dated 5/3/2026, for the evening shift (3pm-11pm) and 5/3/2026 to 5/4/2026, for the night shift (11pm to 7pm), the log did not indicate Resident 4 was included in the repositioning schedule and was not turned or repositioned every 2 hours. During a review of Resident 4's every shift Documentation Survey Report for the month of 5/2026, the sections subtitled, Monitor- Resident turned and repositioned every 2 hours, unless otherwise indicated, and Monitor- skin observation, were blank on 5/3/2026 and 5/5/2026 day shifts (7a.m. to 3p.m.). During a review of Resident 4's SBAR dated 5/4/2026 at 3:29 p.m., the SBAR indicated Resident 4 had a stage 3 pressure injury at the sacrum/coccyx area. The SBAR indicated resident not being repositioned every 2 hours or changed when soiled, made the condition worse, and repositioning the resident every 2 hours and keeping the resident clean and dry, could have made the condition or symptoms better. During a review of Resident 4's Physician Assistant's Wound Progress Note dated 5/4/2026, the progress notes indicated Resident 4 had a newly developed sacral pressure ulcer acquired on 5/4/2026. The progress notes indicated the pressure ulcer was a stage 3, measured 4 centimeters (cm- unit of measurement [unspecified]) by 4 cm (unspecified), with a 0.10 cm depth, 51 to 75 percent (%) granulation (new tissues) and 1 to 25 % slough (dead tissue, yellowish, or white stuff that forms inside a cut or wound while it heals). During a concurrent interview and record review on 6/11/2026 at 2:53 p.m., with the Licensed Vocational Nurse (LVN) 3, Resident 4's SBAR dated 5/4/2026, was reviewed. The SBAR dated 5/4/2026 3:30 p.m., indicated a stage 3 pressure injury at the sacrum coccyx area likely related to prolonged pressure and inadequate repositioning. The LVN 3 stated the SBAR indicated on 5/4/2026, Resident 4 developed a stage 3 pressure ulcer on the sacrum. The LVN 3 stated Resident 4's sacral wound developed due to lack of turning and prolonged pressure. Resident 4 was bedridden, could not turn on his own, did not have diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), and had an intact skin at the sacral area. LVN 3 stated Resident 4 had a healed surgical left stump (below the knee amputation [removal of part of the limb]) wound, a pressure ulcer on the left hip, skin tear on the inner left thigh, and a skin tear to the right buttock but no wound on the sacrum area. LVN 3 stated before a wound progresses to a stage 3, the wound would have started as a stage 1 (the earliest form of skin damage caused when a certain spot on the body is squeezed by sitting or lying down for too long, causing the skin to turn red or change color and get a little sore), then stage 2 , then stage 3 where the wound would become deep into fat or muscle. LVN 3 stated Resident 4's stage 3 pressure ulcer did not develop overnight. LVN 3 stated that when CNAs provided residents with ADL care, the CNAs did not check Resident 4's skin and report skin changes to charge nurses so the resident could be treated right away to prevent the skin from becoming worse. During a concurrent interview and record review on 6/15/2026 at 2:08 p.m., with the Director of Nursing (DON), Resident 4's Skin Monitoring: Comprehensive CNA Shower Review dated 4/11/2026, 4/14/2026, 4/18/2026, 4/21/2026, 4/25/2026, 4/28/2026, and 5/1/2026, Resident 4's ADL Repositioning Rounds Monitoring report dated 5/3 to 5/4/2026 p.m. (evening) and the 5/3/2026 to 5/4/2026 noc (night shift) and Resident 4's care plan titled Impaired Skin Integrity related to immobility, incontinence, poor perfusion, malnutrition as evidenced by stage 2 on the left thigh, dated 4/7/2026, were reviewed. The Skin Monitoring: Comprehensive CNA Shower Review indicated to perform a visual assessment of Resident 4's skin during showers, document and report any abnormal looking skin to the charge nurse immediately. The DON stated the licensed nurses were not documenting resident's daily skin assessments. The DON stated Resident 4 had multiple skin issues (unspecified), however the CNAs did not indicate the resident's skin condition in the skin monitoring reports dated 5/1/2026 and 5/5/2026. Resident 4's ADL Repositioning Rounds Monitoring reports did not indicate Resident 4 was included in the repositioning schedule to be turned or repositioned every 2 hours. Resident 4's care plan interventions indicated to reposition the resident every 2 hours and as needed, assess the skin every shift for skin breakdown, and keep Resident 4's skin clean and dry. The DON stated there was no indication Resident 4's skin was assessed or the resident was turned or repositioned every 2 hours. The DON stated any care not document meant it was not done and led to unidentified skin problems. During a phone interview on 6/25/2026 at 9:39 a.m. with CNA 4, CNA 4 stated Resident 4 was supposed to be turned every two hours. CNA 4 stated the facility had a folder for titled Repositioning Rounds Monitoring and the CNAs would log in when they turned residents and the LVN would co sign. CNA 4 stated she did not know if Resident 4's name was missing on 5/3 to 5/4/2026 from the list. CNA 4 stated CNAs document turning every 2 hours on the Kiosk (small electronic device to document tasks) and she did not know why it was not documented for Resident 4 on 5/3/2026. CNA 4 stated they are supposed to document any new skin changes on the skin monitoring shower sheet. CNA 4 stated she was assigned to Resident 4 a couple of times, but she did not remember Resident 4 having any new skin issues. CNA 4 stated she never documented anything for Resident 4. During a concurrent phone interview and record review on 6/26/2026 at 9:58 a.m. with the DON, Resident 4's Skin Monitoring: Comprehensive CNA Shower Review document indicating to perform a visual assessment of the resident's skin during showers, was reviewed. The DON stated CNAs were not allowed to perform skin assessment because it's not within their scope of practice. The DON stated CNAs were to report new skin issues for license nurse to assess. During a review of the facility's P&P titled, Bath/ Shower, dated 01/2018, the P&P indicated all assessment data (such as reddened areas, or sores on the resident's skin) obtained during the shower/ tub bath should be documented. During a review of the facility's P&P titled, Prevention of Pressure Injuries, dated 1/2018, the P&P indicated to conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors. The P&P indicated inspect presence of erythema, temperature of skin and soft tissue and edema during the skin assessment. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs, identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter). The P&P indicated to reposition resident as indicated on the care plan. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines.

Based on observation, interview, and record review, the facility failed to protect resident's right to be free from sexual abuse for one of three residents (Resident 1), who was subjected to Resident 2's sexual advancements. The facility failed to: 1. Follow its policy and procedure (P&P) titled Abuse and Neglect Prohibition Policy, which indicated the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur. 2. Follow its P&P titled Wandering Behavior Management, which indicated each resident who was a wandering risk was provided the appropriate intervention and adequate supervision. 3. Address Resident 2's refusals of quetiapine furnarate (medication used to manage schizophrenic [mental illness that was characterized by disturbances in thought] symptoms) and donezepril (medication used to treat dementia [a progressive state of decline in mental abilities]). These deficient practices resulted in Resident 2 wandering into Resident 1's room and touching Resident 1's left breast. These deficient practices also violated Resident 1's right to be free from sexual abuse. Cross Reference F580. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included cataracts (a common age-related eye condition that could affect vision in older adults) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 1 had severely impaired cognitive skills for daily decision making (ability to think and reason). The MDS indicated Resident 1 had impaired vision. The MDS indicated Resident 1 required setup assistance with eating. The MDS indicated Resident 1 required supervision with oral hygiene. The MDS indicated Resident 1 required moderate assistance with (helper did less than half the effort) personal hygiene. The MDS indicated Resident 1 was dependent (helper did all the effort) with toileting hygiene, showering/bathing self, and tub/shower transferring. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there was a change of condition among the residents) form, dated 5/28/2025 at 3:04 p.m., the SBAR indicated on 5/28/2025, Resident 1 exposed her breast to Resident 2. The SBAR indicated Resident 2 was seen moving his hand away from Resident 1's breast. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included severe dementia (a progressive state of decline in mental abilities) with behavioral disturbance (any pattern of behavior that was persistently disruptive, inappropriate, or causes problems for the individual or those around them), schizophrenia (a mental illness that was characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that ranged from the lows of depression to elevated periods of emotional highs). During a review of Resident 2's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 2 had a behavior of rejecting care that was necessary to achieve his goals for health and well-being daily. The MDS indicated Resident 2 required setup assistance with eating. The MDS indicated Resident 2 required supervision with chair/bed-to-chair transferring and walking. The MDS indicated Resident 2 required maximal assistance (helper did more than half the effort) with oral hygiene. The MDS indicated Resident 2 was dependent with toileting hygiene and showering/ bathing self. The MDS indicated Resident 2 had impairment to the lower extremities (legs) and used a wheelchair for mobility. During a review of Resident 2's care plan titled Has a behavior problem and desires r/t (related to) schizophrenia, constant walking in the hallway for no apparent reason, initiated 8/4/2021, the care plan indicated staff were to administer medication as ordered, monitor/ document for side effects and effectiveness, and intervene as necessary to protect the rights and safety of others. During a review of Resident 2's SBAR, dated 5/28/2025 at 2:40 p.m., the SBAR indicated on 5/28/2025, Payroll Director (PD 1) observed Resident 2 in Resident 1's room. The SBAR indicated PD 1 observed Resident 2 touching Resident 1's breast. The SBAR indicated Resident 2 thought Resident 1 was his wife. During a review of Resident 2's Physician's Order dated 6/12/2023, the order indicated to administer Donezepril HCL (medication used to treat dementia) 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime for dementia. During a review of Resident 2's Physician's Order dated 2/3/2025, the order indicated to administer Quetiapine Furnarate (medication used to manage schizophrenic symptoms) 400 mg by mouth two times a day for schizophrenia manifested by constantly roaming around the facility in circles. During a review of Resident 2's Medication Administration Record (MAR) for 5/2025, the MAR indicated Resident 2 refused 16 out of the 28 doses of donezepril. The MAR indicated Resident 2 refused 17 of 57 doses of quetiapine furnarate. The MAR indicated Resident 2 had increased behavior episodes from 5 episodes to 15 episodes of constantly roaming around the facility from 5/24/2025 to 5/28/2025. During observations on 5/29/2025 at 9:58 a.m., 10:18 a.m., and 1:12 p.m., Resident 2 was observed in the hallways wandering around the facility in his wheelchair unsupervised. During an interview on 5/29/2025 at 10:20 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 5/28/2025 around 2:15 p.m., Resident 2 was observed by PD 1 in Resident 1's room touching Resident 1's breast. CNA 1 stated on 5/28/2025 around 2:16 p.m., she observed Resident 2 coming out of Resident 1's room pushing his wheelchair with one hand and pulling up his pants with the other hand. CNA 1 stated it was not Resident 2's first time entering Resident 1's room. CNA 1 stated Resident 2 wandered around the facility and liked to go to Resident 1's room. CNA 1 stated she was instructed by an unidentified charge nurse to remove Resident 2 from Resident 1's room, and to provide frequent redirection to Resident 2 because the resident kept passing by Resident 1's room. CNA 1 stated Resident 2 was very non-compliant with care and needed frequent redirection. During an interview on 5/29/2025 at 10:37 a.m. with PD 1, PD 1 stated on 5/28/2025 around 2:15 p.m., she observed Resident 2's hand on Resident 1's left breast in Resident 1's room. PD 1 stated Resident 2 immediately removed his hand and PD 1 instructed Resident 2 to leave the room. PD 1 stated Resident 2 told her that Resident 1 was his wife. During a concurrent interview and record review on 5/29/2025 at 11:29 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR for 5/2025 was reviewed. The MAR indicated Resident 2 refused donezepril and quetiapine furnarate on multiple shifts in 5/2025. LVN 1 stated the MAR indicated Resident 2 refused donezepril for six consecutive days from 5/19/2025 to 5/24/2025 at 8 p.m. LVN 1 stated Resident 2 had dementia, and it was important for Resident 2 to take his donezepril to prevent any sexual allegation. LVN 1 stated the donezepril was to manage Resident 2's wandering behavior. LVN 1 stated the nurse should have notified the physician when Resident 2 continued to refuse his medications. During a concurrent interview and record review on 5/29/2025 at 11:52 a.m. with Registered Nurse (RN) 1, Resident 2's Nursing Progress Notes for 5/2025 were reviewed. The notes did not indicate documentation regarding Resident 2's refusals of donezepril and quetiapine in 5/2025. RN 1 stated the nurse should have documented and notified Resident 2's physician of Resident 2's medication refusals. RN 1 stated the purpose of notifying the physician was to provide updates of Resident 2's condition and possibly receive an alternative medication order. RN 1 stated the physician might have ordered to transfer Resident 2 to the hospital for further evaluation due to medication refusal. RN 1 stated there was a risk for Resident 2's wandering and dementia behavior to worsen. RN 1 stated it was possible for Resident 2 to wander into the female residents' room and cause unwanted sexual interactions. RN 1 stated it was inappropriate for Resident 2 to touch Resident 1's breast because it violated Resident 1's rights to be free from abuse. RN 1 stated Resident 2 touching Resident 1's breast was considered sexual abuse. RN 1 stated staff should have provided constant monitoring on Resident 2's movement and redirected the resident to prevent any sexual abuse. c. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included DM and generalized muscle weakness. During a review of Resident 3's H&P, dated 10/17/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 3 had adequate vision and was able to understand others. During an interview on 5/29/2025 at 10:03 a.m. with Resident 3 (Resident 1's roommate), Resident 3 stated on 5/28/2025 (unable to recall time), she called staff to assist when Resident 2 entered the room for the second time that day. Resident 3 stated she was unable to see what was happening between Resident 1 and Resident 2 because Resident 1's privacy curtain was closed. Resident 3 stated Resident 2 had been coming inside Resident 1's room since 10/2024. Resident 3 stated staff would come into the room and take Resident 2 away. During an interview on 5/29/2025 at 11:52 a.m. with RN 1, RN 1 stated Resident 3 was alert. RN 1 stated nurses should report to the charge nurse when a male resident was observed going into a female resident's room to avoid sexual abuse. During an interview on 5/29/2025 at 1:16 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 2 propelled around the facility in his wheelchair. The ADON stated staff should have monitored the behaviors and medication compliance for the dementia residents. The ADON stated the dementia residents were forgetful and had wandering behaviors. The ADON stated the residents could be aggressive at the late stage of dementia. The ADON stated the risks of not taking medication for the dementia residents were worsening wandering behavior and aggressive behavior toward self, residents, and staff. The ADON stated when residents refused medications, the nurses needed to inform resident's physician, complete a change of condition, and update the care plan. The ADON stated the purpose of notifying the physician was for an alternative medication regimen and care interventions. The ADON stated it also kept the physicians updated on the residents' conditions so staff could provide the appropriate care. The ADON stated it was a delay of necessary care because it was important for Resident 2 to take his medications. The ADON stated staff should have closely monitored Resident 2 to ensure his whereabouts. The ADON stated there was potential for sexual interaction when Resident 2 wandered into the other residents' rooms. The ADON stated Resident 2 refusing his medications contributed to Resident 2's thinking Resident 1 was his wife. The ADON stated Resident 2 touching Resident 1's breast violated Resident 1's rights and was considered sexual abuse. During a telephone interview on 5/29/2025 at 4:09 p.m. with Resident 2's Nurse Practitioner (NP 1), NP 1 stated he expected the nurse to notify him or the primary physician when Resident 2 refused his medications. NP 1 stated it was important for Resident 2 to take donezepril and quetiapine furnarate as ordered to prevent unwanted behavior. NP 1 stated one of the side effects (an effect of a drug or other type of treatment that was in addition to or beyond its desired effect) of refusing donezepril and quetiapine furnarate was the increased risk of wandering into other residents' rooms and increased hypersexual activities for Resident 2. NP 1 stated Resident 2 was disorganized manifested by wandering and confusion. NP 1 stated if he was aware Resident 2 touched Resident 1's breasts on 5/28/2025, he would have increased Resident 2's medication for safety. NP 1 stated Resident 2's behavior would been more manageable. During a review of the facility's P&P titled Wandering Behavior Management, dated 12/2016, the P&P indicated to ensure that each resident who was a wandering risk was provided the appropriate intervention and adequate supervision. The P&P indicated the facility was to modify the plan of care as needed to address the wandering risk behaviors by monitoring for any type of medical causes that increases wandering. During a review of the facility's P&P titled Abuse and Neglect Prohibition Policy, dated 6/2022, the P&P indicated to ensure that facility staff were doing all that was within their control to prevent occurrences of abuse for all the residents. The P&P indicated that the facility should be identifying, correcting, and intervening in situations in which abuse was more likely to occur, and it included analysis of the supervision of staff to identify inappropriate behaviors. The P&P indicated that the facility should analyze the assessment, care planning, and monitoring of the residents with needs and behaviors which might lead to conflict, such as the residents who have behaviors such as entering other residents' rooms. The P&P further indicated that sexual abuse was non-consensual sexual contact of any type with a resident.

Based on observation, interview, and record review, the facility failed to provide services to maintain range of motion ([ROM] full movement potential of a joint [where two bones meet]) for one of four sampled residents (Resident 86) with mobility (ability to move) concerns, by failing to: 1. Perform a Joint Mobility Assessment ([JMA] brief assessment of a resident's range of motion in both arms and both legs) on both of Resident 86 ' s arms and legs upon admission to the facility on [DATE] and quarterly in accordance with the facility ' s policies titled, Functional Impairment - Clinical Protocol and Resident Mobility and Range of Motion. 2. Provide Resident 86 with passive range of motion ([PROM] movement of joint through the ROM with no effort from the person) exercises to the left arm and the left leg from 10/27/2022 (admission) to 6/12/2023 (approximately 8 months) in accordance with the hospice (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) physician ' s recommendations, dated 10/27/2022. These failures resulted in Resident 86 developing left shoulder moderate joint mobility limitation (50 to 75 percent [%] ROM limitation), left wrist moderate joint mobility limitation, left hand minimal joint mobility limitation (25 to 50% ROM limitation), left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation as indicated in the Resident 86 ' s JMA, dated 6/12/2023. These failures also resulted in the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) on Resident 86 ' s left hip, left knee, and left wrist, causing Resident 86 to have increased pain in the left arm. Cross reference F656. Findings: During a review of Resident 86 ' s Admission Record, the Admission Record indicated the facility admitted Resident 86 on 10/27/2022 with diagnoses including traumatic hemorrhage of the cerebrum (bleeding in the brain caused by a severe injury or trauma to the head) and alcohol abuse (drinking excessive alcohol) with alcohol-induced psychotic disorder (serious condition where drinking alcohol causes someone to experience mental health problems, causing confusion and distress). During a review of Resident 86 ' s History and Physical (H&P), dated 10/27/2022, the H&P indicated to initiate Resident 86 ' s hospice care plan and to monitor for any signs or symptoms of decline (becoming smaller, less, or decreased). The H&P indicated Resident 86 did not have the capacity to understand and make decisions. During a review of Resident 86 ' s physician orders, dated 10/27/2022 timed at 7:00 PM, the physician orders indicated to admit Resident 86 under hospice care with the primary diagnosis of intracranial hemorrhage (severe bleeding inside the brain). During a review of Resident 86 ' s Physician ' s Certification for Hospice Benefit (physician confirmation a resident is terminally ill with a life expectancy of six months or less), dated 10/27/2022, the Physician ' s Certification included a Prognosis (outcome or course of a disease) Summary which indicated Resident 86 was weak to four extremities (both arms and both legs) with left arm paralysis (loss of the ability to move) and left leg contracture (unspecified joints). Resident 86 ' s Prognosis Summary indicated a recommendation for PROM exercises as tolerated to prevent further contractures. During a review of Resident 86 ' s Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 11/7/2022, the MDS indicated Resident 86 had functional limitations (limitations that interfered with daily functions or placed resident at risk of injury) in ROM to one arm and one leg. During a review of Resident 86 ' s MDS quarterly assessments, dated 2/6/2023 and 5/4/2023, the MDS assessments indicated Resident 86 had functional limitations in ROM to one arm and one leg. During a review of Resident 86 ' s JMA, dated 6/12/2023, the JMA indicated Resident 86 had left shoulder moderate joint mobility limitation, left wrist moderate joint mobility limitation, left hand minimal joint mobility limitation, left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation. During a review of Resident 86 ' s quarterly Rehabilitation Screening (brief assessment to determine whether a person would benefit from therapy services), dated 6/12/2023, the quarterly Rehabilitation Screening indicated recommendations for a Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program to maintain Resident 86 ' s joint mobility. The Rehabilitation Screening recommendation indicated splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) were not indicated due to Resident 86 ' s pain and discomfort. During a review of Resident 86 ' s Restorative Nursing Program (RNP) Referral/Care Plan, dated, 6/12/2023, the RNP Referral/Care Plan indicated Resident 86 was at risk for decline in ROM to the left arm and left leg. The RNP goal indicated to maintain Resident 86 ' s current ROM to the left arm and left leg. The RNP approach (intervention) included RNA to perform PROM exercises to Resident 86 ' s left arm and left leg, three times per week as tolerated. During a review of Resident 86 ' s physician orders, dated 6/12/2023 timed at 4:10 PM, the physician orders indicated for the RNA to provide PROM exercises on Resident 86 ' s left arm and left leg, three times per week as tolerated. During a review of Resident 86 ' s Documentation Survey Report (record of nursing assistant tasks) for RNA services, dated 6/2023, the Documentation Survey Report indicated Resident 86 received PROM exercises to the left arm and the left leg, three times per week, starting on 6/14/2023. During a review of Resident 86 ' s physician orders, dated 8/23/2023 at 3:26 PM, the physician orders indicated to discharge Resident 86 from hospice services. During a review of Resident 86 ' s physician orders, dated 8/23/2023 (untimed), the physician orders indicated for RNA to provide PROM exercises on Resident 86 ' s left arm and left leg, three times per week as tolerated. During a review of Resident 86 ' s H&P, dated 8/24/2023, the H&P indicated Resident 86 was admitted under hospice care but doing better. The H&P indicated Resident 86 ' s diagnoses included intracranial bleeding, history of alcohol abuse, and weakness with Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]). The H&P indicated Resident 86 had capacity to understand and make decisions. During a review of Resident 86 ' s MDS, dated [DATE], the MDS assessments indicated Resident 86 had functional limitations in ROM to one arm and one leg. During a review of Resident 86 ' s MDS, dated [DATE], the MDS indicated Resident 86 had clear speech, expressed ideas and wants, clearly understood others, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 86 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying assistance as resident completes the activity) for eating, partial/moderate assistance (helper does less than half the effort) for upper body dressing, and dependent (helper does all the effort) for oral hygiene, toileting hygiene, and lower body dressing. The MDS indicated Resident 86 had functional limitations in ROM to one arm and one leg. During an interview on 2/20/2024 at 9:37 AM in the bedroom, Resident 86 stated being unable to move the left arm and the left leg. During a follow-up observation and interview on 2/20/2024 at 10:03 AM in the bedroom, Resident 86 was lying in bed with the head-of-bed (HOB) elevated. Resident 86 ' s left elbow was slightly bent, the left forearm was turned with the palm facing upward, and the left wrist was bent to 90 degrees. Resident 86 ' s left hip was rotated away from the body and the left knee was bent. Resident 86 stated the facility staff (unspecified) provided Resident 86 with exercises, but Resident 86 stated she felt pain during the exercises. During an interview on 2/20/2024 at 12:06 PM with the Rehabilitation Coordinator (RC), the RC stated the PT and OT perform screens on the residents (in general) for mobility and ROM upon admission and quarterly. During a concurrent observation and interview on 2/21/2024 at 10:21 AM with Restorative Nursing Aide 1 (RNA 1) in the bedroom, Resident 86 was awake and alert while lying in bed fully dressed, wearing a shirt and pants. Resident 86 stated, I can only handle so much (of the exercises). RNA 1 performed PROM exercises to Resident 86 ' s left shoulder, elbow, wrist, and hand. Resident 86 complained of pain during PROM of the left elbow. RNA 1 lifted the left wrist from a bent position but did not bend the left wrist upward (wrist extension). RNA 1 bent the large knuckles of Resident 86 ' s left-hand fingers but did not bend the fingertip joints. Resident 86 ' s left knee was bent, and the left hip was bent upward and rotated away from Resident 86 ' s body at rest. RNA 1 provided PROM exercises to the left hip, left knee, and left ankle. RNA 1 placed one pillow under Resident 86 ' s left arm and another pillow under Resident 86 ' s left knee to turn the left hip toward the body at the end of the RNA session. During an interview on 2/21/2024 at 10:32 AM with RNA 1, RNA 1 stated she provided PROM to the left arm and left leg to Resident 86 ' s pain tolerance. RNA 1 stated she did not bend Resident 86 ' s left-hand fingertip joints into a fist because Resident 86 cannot tolerate PROM at the fingertips due to pain. RNA 1 stated Resident 86 ' s left knee was bent and unable to fully straighten. During a concurrent interview and record review on 2/21/2024 at 3:04 PM with the RC, the RC reviewed the therapy documentation system and stated Resident 86 never received therapy services, including PT and OT. During a review of Resident 86 ' s JMA, dated 2/21/24 completed by Physical Therapist 1 (PT 1), the JMA indicated Resident 86 had left hip minimal joint mobility limitation, left knee moderate joint mobility limitation, and left ankle minimal joint mobility limitation. During an interview on 2/22/2024 at 8:53 AM in the bedroom, Resident 86 stated the facility admitted Resident 86 approximately two years ago after hitting Resident 86 ' s head on a wooden bus stop while drunk. Resident 86 stated both the left arm and left leg were straight upon admission to the facility. Resident 86 stated the facility provided exercises but sometimes refused the exercises because Resident 86 cannot take the pain. During a concurrent interview and record review on 2/22/2024 at 9:38 AM with the RC, the RC reviewed Resident 86 ' s Census List (record of hospitalization s, room changes, and payer source changes) and stated Resident 86 was never hospitalized since admission to the facility on [DATE]. The RC stated Resident 86 should have received a JMA and Rehabilitation Screen upon admission to the facility under hospice services on 10/27/2022. The RC reviewed Resident 86 ' s JMA and Rehabilitation Screen records and was unable to locate any JMA or Rehabilitation Screens for Resident 86 prior to 6/12/2023 (approximately 8 months after admission). The RC stated Resident 86 ' s JMA, dated 6/12/2023, indicated Resident 86 had left shoulder moderate ROM limitations, left wrist moderate ROM limitations, left hand minimal ROM limitations, left hip minimal ROM limitations, left knee moderate ROM limitations, and left ankle minimal ROM limitations. During an interview on 2/22/2024 at 10:55 AM with the Director of Staff Development (DSD), the DSD stated RNA services included providing ROM exercises and assisting with ambulation (the act of walking) or sit to stand transfers to maintain residents ' function and prevent the development of contractures. During an interview on 2/22/2024 at 11:07 AM with the DSD and the Director of Nursing (DON), the DON stated hospice residents received the same services as all the facility ' s residents, including the screening assessments and RNA services. During a concurrent interview and record review on 2/22/2024 at 11:13 AM with the DSD and DON, the DSD and DON stated Resident 86 was admitted to the facility on [DATE] with hospice services. The DON and DSD reviewed Resident 86 ' s MDS upon admission, dated 11/7/2022. The DON stated Resident 86 had functional limitations in ROM to one arm and one leg due to Resident 86 ' s hemiplegia (weakness to one side of the body) on the left side of the body. The DON stated Resident 86 ' s MDS did not include ROM measurements of both arms and both legs. The DON stated the therapists completed ROM measurements of the residents (in general) using the JMA. The DON was unable to locate Resident 86 ' s JMA upon admission on 10/27/2022 and stated the facility did not have any documented evidence of Resident 86 ' s ROM in both arms and both legs upon admission. The DON and DSD stated Resident 86 started to receive RNA services for PROM exercises to the left arm and left leg in accordance with the physician orders, dated 6/12/2024. The DON and DSD stated there was no evidence Resident 86 received any RNA services for PROM exercises to the left arm and the left leg for 8 months from 10/27/2022 (admission) to 6/12/2023. The DON and DSD stated contractures developed over time and could be prevented with ROM exercises. The DON and DSD stated Resident 86 ' s left arm and left leg contractures were preventable. During a concurrent observation and interview on 2/22/2024 at 4:18 PM with Occupational Therapist 1 (OT 1) in the bedroom, Resident 86 was lying in bed with the HOB elevated. Resident 86 moved the right arm without any ROM limitations, and OT 1 stated Resident 86 ' s right arm was strong. OT 1 moved Resident 86 ' s left arm at the shoulder, elbow, wrist, and hand joints. OT 1 lifted Resident 86 ' s left arm to shoulder height and stopped due to Resident 86 ' s complaint of pain. Resident 86 stated the intensity of the left shoulder pain was an 8 out of 10 (zero [0] to 10 pain scale with 0 indicating no pain and 10 indicating severe pain). OT 1 bent Resident 86 ' s left elbow past 90 degrees and stopped due to Resident 86 ' s complaint of 7 out of 10 pain. OT 1 moved Resident 86 ' s left wrist up from a bent position and stopped when Resident 86 complained of 8 out of 10 pain. Resident 86 had a slightly bent position of the left wrist. OT 1 observed having difficulty bending the fingertips of Resident 86 ' s left hand. During an interview over the telephone on 2/22/2024 at 4:45 PM with Physical Therapist 1 (PT 1), PT 1 stated Resident 86 had a flexion (bending) contracture of the left hip and the left knee. During a review of Resident 86 ' s JMA, dated 2/22/2024 completed by OT 1, the JMA indicated Resident 86 had left shoulder minimal joint mobility limitations, left wrist moderate joint mobility limitations, and left hand moderate joint mobility limitations. During an interview on 2/22/2024 at 5:05 PM with OT 1, OT 1 stated Resident 86 had a flexion contracture of the left wrist since Resident 86 had a slight bend in the wrist, and OT 1 was unable to move the left wrist into extension. During a concurrent interview and record review on 2/23/2024 at 9:04 AM with the RC, the RC stated the purpose of the JMA was to monitor a resident ' s ROM. The RC stated the facility missed three opportunities to measure Resident 86 ' s ROM in both arms and both legs, including upon admission (10/27/2022) and two quarterly assessments. The RC did not know why Resident 86 did not receive three JMA assessments for ROM while residing at the facility. During a concurrent interview and record review on 2/23/2024 at 11:03 AM with the Social Worker (SW), the SW stated she was the facility ' s hospice coordinator which included calling the hospice company to schedule interdisciplinary team (IDT) meetings, checking for the hospice resident ' s Physician ' s Certification, and communicating with the hospice team regarding the hospice resident ' s plan of care. The SW reviewed Resident 86 ' s Physician ' s Certification for Hospice Benefit, dated 10/27/2022, recommending PROM exercises to prevent further contractures. The SW stated she did not recall communicating the hospice physician ' s recommendation to the facility staff, including the therapists. The SW reviewed the SW documentation in Resident 86 ' s clinical record. The SW stated there was no documentation SW communicated the hospice physician ' s recommendation to provide Resident 86 with PROM exercises on 10/27/2022. During a review of the facility ' s Policy and Procedure (P&P) titled, Functional Impairment - Clinical Protocol, dated 1/2018, the P&P indicated Upon admission to the facility, whenever a significant change of condition occurs, and periodically during a resident/patient ' s stay, the physician and staff will assess the resident/patient ' s function along with their physical condition. During a review of the facility ' s P&P titled, Resident Mobility and Range of Motion, dated 1/2018, the P&P indicated the nurse will identify the resident ' s current range of motion of his or her joints as part of the resident ' s comprehensive assessment. The P&P also indicated Resident will not experience an avoidable reduction in range of motion (ROM). Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.

Based on observation, interview, and record review, the facility failed to implement its abuse policy to protect four of 24 sampled residents (Residents 1, 4, 5 and 6) from being financially abused. Residents 1 and 2 were asked to borrow money by Certified Nurse Assistant 1 (CNA 1) for school payments, flight tickets, rent and for an orthodontist (dentist who is qualified to treat irregularities in the teeth and jaws) payment. Resident 5 and 6's bank cards were used to make online purchases by an unknown person. These deficient practices resulted in CNA 1 asking Resident 1 to let her use her bank card and withdrawing a total of $10,699.88 from Resident 1's bank account leaving Resident 1 feeling angry and sad for not being able to pay her personal bills; Resident 4 being angry for losing $2,800.00 and Residents 5 and 6 feeling angry for having their account withdrawn without their authorization. Findings: A review of the facility's final investigation related to Resident 1 being financially abused, dated 3/20/19 indicated that Resident 1 reported to Licensed Vocational Nurse 1 (LVN 1) that CNA 1 had borrowed money and did not return the money back. A review of the Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS) a comprehensive assessment and care-screening tool, dated 5/19/18, indicated Resident 1 had a BIMS ((Brief Interview Mental Status) thought process) score of 15 (13-15 cognitively intact), had no impairment in cognitive skills (ability to reason and think) for daily decision-making and no memory problems. The MDS indicated Resident 1 required limited assistance of a one-person physical assist for dressing, eating, personal hygiene and bathroom use. According to the MDS, indicated that Resident had impairment of upper and lower bilateral extremities. A review of the Interdisciplinary Team (IDT-group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) notes, dated 3/8/19 and timed at 11:45 a.m., indicated that Resident 1 did not inform any staff of the money that was borrowed by CNA 1, because she was trying to help the staff. The IDT Team indicated that other staff members had bored money from Resident 1, but they had returned the money back to resident. A review of Resident 1's care plan titled, Requires Assistance with Activities of Daily Living (ADLs) of one-two Person Physical Assist, dated 11/21/17 indicated the goal for Resident 1 was to participate in ADLs performance without physical limitations. The staff's intervention included to assist with ADLs and allow the resident to participate. On 3/13/19 at 2:57 a.m., during an interview, Resident 1 stated that she started loaning money to CNA 1 approximately one year prior (3/2018) for school purposes. Resident 1 stated that CNA 1 first asked for $1,000.00 for school and was told she would pay her back, $400.00 to fix CNA 1's child braces, $600.00 for rent, and $1,000.00 to buy a flight ticket to visit a family member that was sick in another country. Resident 1 stated that she let CNA 1 use her debit bank card to get the money because she would come to her room and cry. Resident 1 stated that she did not report CNA 1 because she thought CNA 1 was going to pay her when she received her tax refund. On 3/13/19 at 4:20 p.m., during an interview and observation, Resident 1 stated, I'm just realizing that she (CNA 1) preyed on the kindness of my heart by using her kids and saying she needed money for school. I feel like sh-t, like an idiot. Before talking to the bank I was going to let it go and not do anything because CNA 1 had confessed to have taken the money without my permission, but now I feel like a victim. I was victimized by her (CNA 1) and she used my kindness, how did I trust her? Resident 1 was observed with watery eyes shaking her head and looking down to the floor. On 3/13/19 at 4:40 p.m., during a concurrent interview and record review, in the presence of Resident 1, the facility's social services director (SSD) and social services assistant (SSA), review of the bank statements, dated 5/2019 through 10/2019 were conducted to highlight the transactions that Resident 1 had not approved. Resident 1 was observed nodding her head and constantly apologizing for the trouble that she had caused. The SSD stated the transactions found were not made by Resident 1. On 3/13/19 at 5:50 p.m., during an interview, the SSD stated that the staff was aware that any transactions needed by the residents had to be directed to social services and not receive any money or bank cards. At 1:45 p.m., on 3/14/19, during an interview, the Administrator (ADM) stated that CNA 1 called him and told him that she did take the money from Resident 1's bank card because she was trying to help Resident 1 and she did not mean any harm to Resident 1. The ADM stated that the staff are not supposed to accept money or gifts from the residents and staff are in-service constantly regarding the abuse policy. CNA 1 should have not taken the money from Resident 1. On 3/18/19 at 2 p.m., during an interview and review of the bank statements, the SSA stated that CNA 1 withdraw a total of $10,699.88 from Resident 1's bank account. The staff know they cannot be taking money from the residents. b. On 3/13/19 at 5:56 a.m., during an interview, Resident 2 stated that she overheard a conversation between Resident 1 and someone else and Resident 1 stating, You took my card. Resident 2 stated not been able to see who the other person was because the curtain was closed. A review of the Resident 2's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE] indicated Resident 2 had a BIMS score of 15 (13-15 cognitively intact), had no impairment in cognitive skills (ability to reason and think) for daily decision-making and no memory problems. On 3/14/19 at 1:30 p.m., during a concurrent interview and review of the facility's census for 3/14/19, in the presence of the SSD and SSA, the Business Office Manager (BOM) stated that they were not aware which residents who had bank cards. The BOM stated that the facility did not have a list or a system in place to identify residents that had a bank card in their possession because it was the residents right to keep their own bank card. The BOM stated that because of those rights, they were not aware if the residents had money missing from their account. The BOM stated after it was brought to their attention they checked and found out that there were 21 residents were identified that kept their bank card with them. On 3/14/19 at 2:10 p.m., during an interview, the SSA stated that on 3/7/19 she was told by Resident 2 that she overheard a conversation between Resident 1 and an unknown person regarding CNA 1 not paying Resident 1 the money that she had borrowed. The SSA stated that immediately an investigation was conducted. The SSA stated that approximately a month prior (2/2019) she requested a psych evaluation (assessment) because she had noticed Resident 1 sad and with a change in behavior but was unaware why. On 3/14/19 at 2:15 p.m., during an interview with the residents, in the presence of the SSD, SSA, and BOM, two of 16 residents (Resident 5 and 6) had money withdrawn from their account. Resident 5 stated that on 12/2018 he had money withdrawn from his account and was told by the facility that hackers (person who uses computers to gain unauthorized access to data) had purchased items online. Resident 5 stated that he does not even know how they gained access to his card number. Resident 6 stated that in 11/2018 two transactions were made online for a total of $448.00. The SSA stated that both Residents 5 and 6 losses were reported to the bank and were reimbursed by the bank. c. A review of the Resident 5's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 5's [DIAGNOSES REDACTED]. A review of Resident 5's MDS, a care screening and assessment tool, dated 1/17/19, indicated Resident 5 had a BIMS score of 15 (13-15= cognitive intact), which indicated Resident 5 had no problems remembering or any impaired cognition (thought process). A review of a Fraud Service Statement dated 1/17/19, indicated that Resident 5 had two transactions being disputed, one on 11/12/18 for $72.66 and a second one for $530. 22. The Fraud Service statement indicated the following transitions: 10/10/18 Victoria Secret.com $119.31 10/10/18 PayPal & Mulligator $ 101.94 10/10/18 Victoria Secret.com $236.31 11/12/18 Fashinnova.com $72.66 On 3/14/19 at 2:35 p.m., during an interview, Resident 5 stated that he notified the facility of money missing from his account. Resident 5 stated that he felt angry and upset that someone was able to make purchases on-line without having his bank card number, but felt comfortable once the facility was able to help him submit a claim form to the bank for reimbursement. d. A review of the Resident 6's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 6's [DIAGNOSES REDACTED]. A review of Resident 6's MDS, a care screening and assessment tool, dated 4/7/19, indicated Resident 6 had a BIMS score of 15 (13-15= cognitive intact), which indicated that Resident 6 had no problems remembering or impaired cognition. On 3/14/19 at 2:43 p.m., during an interview, Resident 6 stated that he became aware on 12/2018 that he was missing money from his account and notify the facility staff. Resident 6 stated that he felt angry because he does not know how people gain access to his card. e. At 5:05 p.m., on 3/20/19, during an interview, Resident 4 stated that she had let CNA 1 borrow money since 1/2019 to pay for her school. Resident 4 stated that CNA 1 borrowed $2,800.00 and was going to pay her back when she finishes with her school. Resident 4 stated feeling hurt because CNA 1 came across as a nice and sweet person. Resident 4 stated that she gave her cash all the time. A review of the Resident 4's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 4's [DIAGNOSES REDACTED]. A review of Resident 4's MDS, a care screening and assessment tool, dated 1/1/19, indicated Resident 4 had a BIMS score of 15 (13-15= cognitive intact), which indicated that Resident 4 had no problems remembering or impaired cognition. A review of the facility's document, dated 3/12/19 and titled, Notice of Employee Separation, indicated CNA 1 was terminated because she (CNA 1) had violated the facility's policy. The document indicated CNA 1 was attempting to communicate with Resident 1 while the investigation was under investigation. A review of a document dated 3/20/19 and titled, Law Firm, indicated CNA 1 was represented by the law firm and any question to be directed to her lawyer (person who practices or studies law; an attorney or a counselor). A review of the facility's policy, dated 1/2018 and titled, Resident Rights, indicated that residents had the right to be free from abuse, neglect, misappropriation of property, exploitation, coercion, and reprisal.

Based on interview and record review, the facility failed to provide a safe environment and prevent injuries for one of three sampled residents (Resident 1). Resident 1, who was at risk for elopement (intentional, an unauthorized departure without staff knowledge), wore a Wanderguard bracelet (A departure prevention system consisting of alarmed exit doors and a bracelet worn by the resident. The bracelet will trigger the alarm to go off when going through the door) and the facility failed to ensure: 1. The alarm of the entrance/exit door (Door 4) was activated when Resident 1, who was wearing a wandering bracelet, goes through the alarmed door. As a result, Resident 1 went through an unalarmed (Door 4), climbed a ladder, tried to go over a wired wall, and fell to the ground. Resident 1 sustained seven fractures (broken bones) and a cut on the right axilla (armpit). Resident 1 required a transfer to General Acute Care Hospital 1 (GACH 1), where he underwent surgical repairs of the fractures and the cut. Findings A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1 on 7/1/19, with [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk assessment dated [DATE] indicated that Resident 1 had a high risk for falls with a score of 13 (10 or higher meant at risk for falls). A review of Resident 1's physician's orders [REDACTED]. -Applying a Wanderguard (bracelet) to alert staff if Resident 1 was getting out of the facility, -Checking the Wanderguard (bracelet) placement and functionality every shift for safety, and -Applying a bed and a wheelchair alarm and monitor the alarm for functionality and placement every shift for safety. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 7/29/19 indicated Resident 1 had some memory recall (recall of information, events and memories from the past) problem, required extensive assistance with transfers and walking with a one-person physical assist, used a wheelchair and walker for mobility, and did not have a steady balance with walking. A review of Resident 1's Elopement (intentional, an unauthorized departure without staff knowledge) Risk assessment dated [DATE], indicated Resident 1 was at risk for eloping. The score was 10 (10 or higher meant elopement risk). The plan was to frequently monitor Resident 1, nursing staff to check the Wanderguard bracelet every shift, and to care plan Resident 1's elopement risk. A review of Resident 1's Nursing Progress Notes dated 8/8/19, timed at 11:35 p.m., indicated that around 9 p.m., Resident 1 was found in the alley (outside the facility) lying on the ground bleeding from his arms and legs and complained of pain. When Certified Nursing Assistant 1 (CNA 1) staff asked him how he got there, Resident 1 pointed to the roof. Licensed Vocational Nurse 1 (LVN 1) called paramedics (911 emergency team), and the paramedics took Resident 1 to GACH 1. A review of Resident 1's Trauma / history and physical examination [REDACTED]. Resident 1 sustained a total of seven breaks of bones: -Left sacral (bone at the bottom of the spine), -Left medial acetabular (head of the femur (long bone on the thigh)), -Left superior-inferior pubic ramus fracture (pubic bone), -Left proximal (upper part) femur fracture, -Lumbar (lower back) five (L5 - last lumbar vertebrae (spine bone)) compression fracture, -Left [MEDICATION NAME] process fracture of L5, and -T12 (last [MEDICATION NAME] (trunk) vertebra) vertebral body fracture Resident 1 required a reduction (a surgical procedure to repair a fracture or dislocation to the correct alignment of the bone) of the left leg and a Hare traction (traction splinting device, realigns a fractured femur to its proper position). Resident 1 also had a and a five-centimeter (cm- unit of measurement) laceration (cut) on the right axilla for which he underwent repair with staples. A review of Resident 1's Operative Report, from GACH 1, dated 8/9/19 indicated Resident 1 underwent an open reduction and internal fixation ((ORIF) type of surgery used to stabilize and heal a broken bone) and nailing (applying a surgical nail) to the left femur fracture. On 8/16/19 at 9 a.m., during a telephone interview, Registered Nurse 1 (RN 1) stated Resident 1's Wanderguard bracelet did not trigger the alarm at the back door (Door 4 - laundry exit door) to alert staff Resident 1 was getting out. On 8/16/19 at 9:19 a.m., during a telephone interview, LVN 1 stated Resident 1 was on elopement and fall precautions. LVN 1 said she gave Resident 1 his medications on 8/8/19 at 8 p.m. LVN 1 said the Wanderguard alarm did not go off when Resident 1 went through the laundry exit door. On 8/27/19, at 9:45 a.m., during an interview, CNA 2 stated on the day of the incident (8/8/19), Resident 1 kept saying he wanted to leave. CNA 2 reported that the Director of Staff Development (DSD) showed them the video of what happened. CNA 2 stated Resident 1 climbed a ladder, got stuck on the fence wire, and slowly dropped down to the ground. Resident 1's shirt was torn completely. On 8/28/19 at 11:19 a.m., during an interview, LVN 2 stated Resident 1 had improved physically and could walk around the facility without the use of a walker or a wheelchair. On 8/28/19 at 11:31 a.m., during an interview, LVN 3 stated Door 4 alarm was disabled for quite some time. On 8/28/19 at 12:15 p.m., during an interview, the DSD stated the Wanderguard alarm did not go off because the alarm on Door 4 was not activated. On 8/28/19 at 12:30 p.m., during an interview, the Maintenance Supervisor confirmed Door 4 alarm was disabled in the evenings because the staff used Door 4 as an entry/exit door. On 8/28/19 at 12:45 p.m., during an interview, the Administrator stated Door 4 alarm for the Wanderguard was disabled at the time Resident 1 eloped from the facility. The administrator explained Door 4 alarm was turned off for six months because the staff did not expect Resident 1 to go through that area of the facility.

Based on interview and record review, the facility failed to ensure the licensed nurses indicated the frequency of monitoring the amount of urinary output, consistently documented and evaluated it, and determined whether the findings related to the urinary output monitoring were reportable to the physician as care planned and failed to obtain consultation with a urologist (a physician who specializes in the study/treatment of [REDACTED]. Resident 109 was incontinent of bladder function (unable to control elimination of urine), and had benign prostate hypertrophy (([MEDICAL CONDITION]) overgrowth of tissue that occurs in some men that tends to obstruct urination). This deficient practice resulted in: 1. Resident 109 to have low urinary output. 2. Resident 109 required transfer to General Acute Care Hospital (GACH 1) where an indwelling urinary catheter (a flexible tube that is passed through the urethra and into the bladder to drain urine in to a bag outside of the body) was inserted and 2,500 milliliters (ml) of urine (the bladder capacity is between 400 ml to 600 ml) was drained from the urinary bladder. 3. Resident 109 was diagnosed with [REDACTED]. 4. Resident 109 was placed at risk for further complications due to delayed urology evaluation. Findings: A review of Resident 109's Admission Record indicated Resident 109 was admitted to the facility on [DATE], and re-admitted on [DATE] and 8/17/19, with [DIAGNOSES REDACTED]. A review of an undated care plan for Resident 109 for [MEDICAL CONDITION] titled, 'Risk for Urinary Tract Infection,' indicated nursing interventions included observation of incontinence episodes, monitoring low urinary output, flank (the side between the ribs and the hip) pain, and reporting abnormal findings to the physician. A review of an undated care plan for Resident 109 regarding bladder incontinence related to [MEDICAL CONDITION], indicated nursing interventions included recording and monitoring amount of urine output, pattern of urinary incontinence, low urine output, and reporting abnormal findings to the physician. A review of the form titled, Documentation Survey Report v2 for the month of 4/2019, indicated Resident 109 urinated one to three times during an eight-hour shift, from 4/1/19 to 4/28/19. There was no documentation Resident 109 urinated from 4/29/19 to 4/30/19 during the 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m. shifts. On 9/21/19 at 1:18 p.m., during an interview, Resident 109's Responsible Party (RP) stated the resident did not void urine for two days on 4/29/19 and 4/30/19, and was having a backache. The RP stated on 4/30/19 the facility transferred Resident 109 to GACH 1 where they inserted an indwelling urinary catheter to help him urinate. During an interview on 9/21/19 at 3:19 p.m., Registered Nurse (RN 2) stated Resident 109's RP informed the nursing staff on 4/29/19 and 4/30/19, that the resident was not passing urine. RN 2 stated RP was at the facility every day and was very involved with Resident 109's care. On 9/22/19 at 9:32 a.m., during an interview, the Director of Nursing (DON) validated there was no documented evidence the licensed nurses monitored Resident 109 for decreased or absence of urinary output as indicated in the plan of care. The DON could not provide documented evidence the licensed and non-licensed nurses were recording and monitoring the amount of urine in order to identify Resident 109's low urinary output. A review of Resident 109's history and physical examination [REDACTED]. A review of GACH 1's Interfacility Transfer form dated 5/7/19, indicated Resident 109 was discharged to the facility with [DIAGNOSES REDACTED]. A review of Resident 109's Office Visit Report form and a physician's orders [REDACTED]. On 9/21/19 at 1:18 p.m., during an interview, Resident 109's RP The RP stated, the resident has been waiting for over nine weeks for the urologist consult and staff told RP they were waiting for insurance approval. The RP stated the urology consult authorization came through on 9/9/19 or 9/10/19 and Social Services Assistant (SSA) did not contact the urologist to make an appointment. On 9/21/19 at 2:39 p.m., during an interview, SSA confirmed the facility recently got the authorization for the urology consult. During an interview on 9/22/19 at 8:16 a.m., Business Office Staff 1 (BO 1) provided a copy of the urology consult authorization dated 9/12/19. A review of the Notice of Action form dated on 9/3/19, indicated Resident 109's insurance authorized the urology consult on 8/30/19. BO 1 stated he provided the authorization to SSA on 9/12/19. A review of the facility's policy titled, Charting and Documentation dated 1/2018, indicated all services provided to the resident, progress toward the care plan goals or as changes in the resident's medical, physical, functional or psychosocial, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy indicated the changes in condition are communicated from shift to shift. A review of the facility's policy titled, 'Urinary Incontinence-Clinical Protocol' dated 1/2018, indicated when persistent or recurrent retention is a problem, the staff and physician would seek treatable causes and try intermittent catheterization if feasible. A review of the facility's policy titled, Pain Assessment Management dated 1/2018, indicated to develop interventions consistent with the resident's goals and needs and address underlying causes of pain.

Based on observation, interview, and record review, the facility failed to provide effective pain management to one of 5 sampled residents (80), who was diagnosed with [REDACTED]. not: 1. Ensuring to monitor for signs and symptoms of pain, using a pain rating scale (zero to 10, zero indicating no pain, and 10 indicating the worst pain experienced). 2. Ensuring to provide non-pharmacological (non-medication) interventions at an attempt to relieve the pain experienced. 3. Ensuring to inform the attending physician about the uncontrolled severe pain, rated 10 out of 10 (10/10) on a pain rating scale. 4. Ensuring to provide routine pain medications to effectively manage the severe pain experienced by the resident. These deficient practices resulted in Resident 80 suffering on 9/21/19, and 9/22/19, as manifested by fidgeting (making movements with the body, usually hands and feet), clenching both fists with fingernails pressing into the palm of the hands, and verbalizing about experiencing 10/10 pain. Findings: A review of Resident 80's Admission Records indicated the facility readmitted the resident on 2/14/19 with last re-admitted d 7/1/19. The Admission Records indicated Resident 80's [DIAGNOSES REDACTED]. A review of Resident 80's Minimum Data Set (MDS), a standardized assessment and care-screening tool) dated 7/8/19 indicated the resident's cognitive skills (ability of an individual to perform the various mental activities most closely associated with learning and problem solving) for daily decision-making was moderately impaired. A review of Resident 80's history and physical examination [REDACTED]. A review of Resident 80's Physician order [REDACTED]. A review of the Physician order [REDACTED]. However, the severity of pain was not specified. On 9/21/19 at 12:36 p.m., during an observation, and concurrent interview, Resident 80 was in the dining room, sitting in a wheelchair, and was crying. Resident 80 stated I hurt all over. It has been one and half year. I don't have a pain doctor. I was taking lots of pain medication. I told them my body hurts all the time. During observation, Resident 80 was fidgeting, and stated she was clenching the fists because she was hurting all over her body. Resident 80 stated her pain was a 10/10 (severe pain). On 9/21/19 at 1:08 p.m., during observation, and interview, Resident 80 was observed sitting in her wheelchair and was crying, as Certified Nursing Assistant (CNA 5) wheeled her back to her room. Resident 80 stated to CNA 5, I am crying because I am in pain. I hurt everywhere, my back, knees, everywhere. Resident 80 was clenching her fists and stated the pain experienced was 10/10 (severe pain). A review of Resident 80's Medication Administration Records (MARs) dated 9/21/19 and timed at 1:10 p.m., indicated the resident was administered two Tylenol 325 mg tablets for 10/10 pain. On 9/21/19 at 2:07 p.m., during an observation and concurrent interview, Resident 80 was seating in her wheelchair in an upright position. During observation, Resident 80 clenched her fists (her fingernails were pressing against the palms of her hands), and her head was turned to the side. Resident 80 stated she was in severe pain. On 9/21/19 at 5:07 p.m., during an observation and concurrent interview, Resident 80 was lying in bed and said she was not having pain. On 9/22/19 at 9:08 a.m., during an observation and concurrent interview, Resident 80 was lying in bed, curled up, crying, her face was red, and stated she had severe pains (10/10). Resident 80 complained the night nurse, Licensed Vocational Nurse (LVN 4), did not give her anything for pain. On 9/22/19 at 10:42 a.m., during an observation, Resident 80 was in the activity room crying. Resident 80 stated, I can't stop, it hurts so much. On 9/22/19 at 1:22 p.m., during an observation and concurrent interview, Resident 80 was at the Nurse's Station, sitting in a wheelchair, stating she could not take it anymore because she was in severe pain (10/10) all over her body. Resident 80 was observed with bulging vein on her forehead, while clenching her fists. The Quality Assurance Nurse (QAN) and LVN 2, who were at the Nurse's Station, were interviewed. LVN 2 stated she had not given pain any medication to Resident 80. The QAN acknowledged and stated Resident 80 looked miserable. On 9/22/19 at 3:40 p.m., during an interview, the QAN stated she contacted Resident 80's physician, who ordered [MEDICATION NAME] (treats pain) 600 mg every six hours as needed for pain. The QAN, after reviewing Resident 80's clinical records stated there was no documentation of pain assessment on 9/21/19 and 9/22/19. The QAN confirmed there was no documentation Resident 80's pain was monitored or re-assessed. There was no evidence the licensed nurses provided non-pharmacological interventions to Resident 80. There was no documentation the interdisciplinary team (a group of different healthcare disciplines such as nursing staff, physician, resident, rehabilitation staff) addressed the lack of routine pain medication, based on the severity of the pain exhibited by the resident and did not suffer unnecessary pains. A review of Resident 80's care plan titled, At risk for chronic pain related to diabetes, [MEDICAL CONDITION] and diabetic [MEDICAL CONDITION] dated 9/22/19, indicated the interventions included not limited to administering pain medication as ordered, anticipating needs for pain relief, responding immediately to any complaint of pain, evaluating effectiveness, monitoring and recording pain characteristics every shift and as necessary for quality, severity (pain scale from zero to 10, zero indicating no pain and 10, indicating the worst possible pain ), location, onset, duration, aggravating and relieving factors. The care plan indicated to monitor, record, and report any signs and symptoms of non-verbal pain not limited to grunting, moans, yelling out, silence, increased irritable, restless, tearing, crying, and or curled up, and remove and limit causes where possible. A review of the facility's policy and procedure titled, Pain Assessment Management dated 1/2018 indicated staff would assess pain by gathering history of pain, its treatment including pharmacological and non-pharmacological interventions, characteristics, impact on quality of life, factors that precipitate or exacerbate pain, and factors and strategies that reduce pain.

Based on interview and record review, the facility failed to protect one of six (6) sampled residents (Resident 1) from being hit on the face with a wash towel by Certified Nurse Assistant 1 (CNA 1). Cross Reference F 226. This deficient practice resulted in Resident 1 feeling angry and sad. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident's 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 9/9/17, indicated a Brief Interview for Mental Status (BIMS) score of 12 (8-12 moderately impaired in cognitive skills (thought process)) and had no memory problems. The MDS indicated Resident 1 required an extensive one-person physical assist with bathing. A review Resident 1's care plan, dated 8/14/17, indicated the resident had Decline in hygiene/grooming, requiring one-two person assist with activities of daily living (ADLs). The goal indicated the resident would remain clean, dry, and odor free. The staff approaches included to assist the resident with ADLs, approach calmly, and maintain good personal hygiene and a neat appearance. A review of Resident 1's Licensed Progress Note, dated 9/24/17, and timed at 3:59 p.m., indicated that Resident 1 reported to CNA 3 that CNA 1 threw a towel at Resident 1 when the resident asked CNA 1 to clean her. A review of the facility's investigation, dated 9/24/17, indicated that Resident 2 stated she overheard Resident 1 state, Why did you throw the towel at me. The report indicated the facility was not able to substantiate the allegation because they were not able to determine if the alleged abuse occurred. On 9/27/17, 7:10 a.m., during an interview, Resident 1 stated that on 9/23/17, during the 11 p.m. to 8 a.m. shift, a CNA (CNA 1) threw a towel at her hitting her face during a bed bath. Resident 1 stated that she felt angry and bad because CNA 1 rolled her eyes when she asked CNA 1 to wash her with water and CNA 1 didn't want to clean her. On 9/27/17 at 8 a.m., during an interview, Resident 2 stated that she overheard Resident 1 ask CNA 1 to please use water to wash her perineal (region between the anus and genitalia) area when changing her adult brief (diaper) and CNA 1 responded NO. Resident 2 stated that she was not able to see what happened during the exchange of words between Resident 1 and CNA 1 but she remembered hearing Resident 1 saying, Don't do that twice. Resident 2 further stated it was not the first time that CNA 1 was bad to Resident 1. Resident 2 stated she had notified the night shift supervisors but they would not do anything about it. A review of Resident 2's MDS, dated [DATE], indicated the resident had a BIMS score of 14 (13-15 cognitive skills and communication intact), and had no memory problems. On 9/27/17, at 9:05 a.m., during an interview, CNA 3 stated that on 9/24/17, during morning care, Resident 1 told her that CNA 1 threw a towel at her hitting her face when she asked CNA 1 to wash her. CNA 3 stated that it was not the first time that Resident 1 complained about CNA 1, but she did not report the prior incidents to the supervisor because of the residents preferred her to not say anything. On 9/27/17 at 9:10 a.m., during an interview, the Administrator stated that they did not perform any background checks on CNA 1 because it was done by the contracted registry. The Administrator stated he was not aware if CNA 1 had a history of [REDACTED]. On 9/27/17 at 10:53 a.m., during an interview and concurrent record review of CNA 1's employee file, the Director of Nursing (DON) stated that the facility did not have a file available for CNA 1. The DON further stated that the facility was responsible for the safety of all the residents in the facility. A review of the facility's policy and procedure titled, Abuse-Prevention Program, dated 7/2017, indicated abuse is define as the willful infliction of injury, involuntary seclusion, physical or chemical restraint not required to treat the resident's symptoms, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, pinching and/kicking. The policy indicated the facility screens potential employees for history of abuse, neglect, or mistreating residents; including checking with the appropriate licensing boards and registries.

Based on interview and record review, the facility failed to implement its policy of reporting an incident of physical abuse to the facility's Abuse Coordinator for two of three sampled residents (Residents 1 and 2). Residents 1 and 2 reported to Certified Nursing Assistant 2 (CNA 2) that CNA 1 was physically abusive towards them. This deficient practice resulted in Resident 1 and 2 feeling afraid of being attacked and had the potential for other residents to be abused. Findings: A review of Resident 1's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 12/6/17, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 = cognition (ability to think) intact), with no problems with memory. The MDS indicated Resident 1 required an extensive physical assistance of one person for personal hygiene and bed mobility. A review of Resident 2's Admission Record (face sheet) indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated the resident had a BIMS score of 9 (8-12 = moderately impaired cognition), with no problems with memory. The MDS indicated Resident 2 required extensive physical assistance of one person for personal hygiene and bed mobility. On 3/2/18 at 4:20 p.m., during an interview, Resident 1 stated Certified Nurse Assistant 1 (CNA 1) was rough with her and Resident 2 when CNA 1 was transferring the residents to the bed two months prior. Resident 1 stated that they both remained quiet and were afraid of CNA 1's retaliation. Resident 1 stated that she felt humiliated and cried because during the transfer, her feet were thrown on the bed and her knees made a cracking sound. Resident 1 stated that she reported the incident to CNA 2. On 3/2/18 at 4:25 p.m., during an interview, Resident 2 stated that she witnessed CNA 1 being rude and throwing Resident 1 on the bed, hurting Resident 1's back and legs. Resident 2 stated that CNA 1 was always rude and she felt scared that CNA 1 would come back to care for them. On 3/2/18 at 4:29 p.m., during an interview in the presence of Resident 2, CNA 2 stated that Residents 1 and 2 reported to her that CNA 1 would call them by nicknames, curse at them, not take them to the restroom, and rough handle them when putting them to bed. CNA 2 stated that this was reported to her two weeks prior. CNA 2 stated that she did not report the incident to her supervisor but did mention it to another CNA (CNA 3). On 3/2/18 at 4:38 p.m., during an interview, CNA 3 stated that CNA 2 mentioned to her two weeks prior that CNA 1 was mistreating and hitting Resident 1 and 2. CNA 3 stated that she too did not report the incident. On 3/2/18 at 4:50 p.m., during an interview, the Administrator (ADM) stated CNA's 2 and 3 should have reported the incident immediately. On 4/13/18 at 4:48 p.m., during an interview, the Director of Staff Development (DSD) stated that an investigation was conducted upon report of alleged abuse. The DSD stated that CNAs 2 and 3 should have made a report to their supervisor so that an investigation could have been conducted and stopped the abuse from happening again. A review of the facility's policy titled, Abuse Investigation and Reporting, dated 2/2018, indicated that the facility would report all allegations of abuse as required by law to the appropriate agencies. The policy indicated the facility was to promptly and thoroughly investigate all reports of resident abuse, mistreatment, neglect, and misappropriation of resident property or injuries of an unknown source when appropriate.

Based on interview and record review, the facility failed to follow its policy to ensure one of three sampled residents (Resident 1) was free from verbal abuse by Certified Nurse Assistant 1 (CNA 1) twice, as witnessed by Licensed Vocational Nurse 1 (LVN 1). This deficient practice resulted in Resident 1 being fearful and placed the resident at risk for further abuse. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 2/27/18, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 14 (a score of 13 -15 = interviewable). The MDS indicated Resident 1 required an extensive assist of a one-person physical assist in walking, locomotion on unit, dressing, toilet use, and bathing. A review of Resident 1's Nurse's Note, dated 3/10/18, and timed at 9:42 a.m., indicated LVN 1 observed Resident 1 and CNA 1 having a verbal disagreement. The note indicated LVN 1 separated Resident 1 from CNA 1, and assessed the resident for bumps, bruises, and/or skin tears. According to the note, LVN 1 told CNA 1 to clock out. A review of a Nurse's Note, dated 3/10/18, and timed at 10:10 a.m., indicated the local Police Department was notified regarding the incident between Resident 1 and CNA 1. A review of Resident 1's care plan titled, Anxiety, dated 2/21/18, indicated Resident 1 was to be monitored for occurrence of target behavior symptoms, such as inappropriate response to verbal communication, violence/aggression toward staff, and document per the facility's protocol. A review of an undated and untimed Interview/Investigation Record indicated that on 3/10/18, Resident 1 was looking for LVN 1 to ask for his medications when CNA 1 threatened Resident 1 with physical harm. On 3/23/18 at 10:35 a.m., during an interview, Resident 1's roommate (Resident 2) stated Resident 1 informed him that CNA 1 made a verbal threat towards him. Resident 2 stated Resident 1 stated CNA 1 was Gonna kick my a--. A review of Resident 2's MDS, dated [DATE], indicated the resident had no cognitive (ability to think and reason) impairment and had a BIMS score of 15. On 3/23/18 at 11:25 a.m., during an interview, the Director of Staff Development (DSD) stated that, on 3/10/18, LVN 1 observed the verbal altercation between Resident 1 and CNA 1. The DSD stated CNA 1 was not immediately moved away from Resident 1. On 3/23/18 at 12:04 p.m., during a telephone interview, LVN 1 stated that Resident 1 was requesting his medications and she was in the process of administering his medications when CNA 1 interrupted. LVN 1 stated CNA 1 did not approve of the way Resident 1 was talking to the female nursing staff members and a verbal altercation between Resident 1 and CNA 1 followed. LVN 1 stated that she observed CNA 1 lean over towards Resident 1 and verbally threatened Resident 1 by stating, I will f--k you up. LVN 1 stated that she did not immediately separate Resident 1 and CNA 1. LVN 1 stated CNA 1 came back a second time telling the resident, I will f--k you up. LVN 1 stated Resident 1 was the one who called 911 in fear for his safety. At 12:15 p.m. on 3/23/18, during an interview, Social Services Assistant 1 (SSA 1) stated that Resident 1 went to the nurse's station and requested his medications and was told by CNA 1 to go back to his room. SSA 1 stated that CNA 1 verbally threatened Resident 1. SSA 1 stated that CNA 1 told Resident 1 he was going to Kick his a--. On 3/23/18 at 12:30 p.m., during an interview, the Director of Nurses (DON) stated that Resident 1 was to be taken care of and protected and not be verbally threatened by CNA 1. On 3/23/18 1:50 p.m., during an interview, the Administrator stated that based on the interview of Resident 1 and LVN 1, the verbal abuse by CNA 1 occurred. The Administrator stated CNA 1 was terminated for failure to follow the facility policy regarding abuse. On 3/27/18 at 9:21 a.m., during a subsequent telephone interview, LVN 1 stated Resident 1 was the one who called 911 in fear for his life and safety. LVN 1 stated there were two events of verbal threats by CNA 1 directed towards Resident 1. A review of the facility's Corrective Action Memo, dated 3/10/18, indicated CNA 1 was suspended. A review of the Verification of Investigation Report, dated 3/10/18, indicated LVN 1 witnessed CNA 1 involved in a verbal altercation with Resident 1 and noting CNA 1 moved in a threatening manner towards Resident 1 and stated, I will f--k you up. A review of the facility's Verification of Investigation Report indicated CNA 1 was terminated for gross violation of the facility's code of conduct on 3/10/18 towards Resident 1. A review of the facility's policy and procedure titled, Abuse-Prevention Program dated 1/2018, indicated that administration would protect residents from abuse from anyone including the staff. According to the policy, administration were to develop and implement policies and procedures to aid in preventing abuse, neglect, or mistreatment of [REDACTED].

Based on observation, interview, and record review, the facility failed to adhere to its policy and ensure a resident plan of care was initiated and implemented for one of four sampled residents (Resident 1), who was identified as a high risk for elopement (act of leaving without permission). Resident 1, who had a history of [REDACTED]. (Cross Reference F 689) As a result, Resident 1 was found in the streets intoxicated (diminished mental and physical control) of alcohol, placed on a 5150 (a legal hold which authorized involuntary hold of individual suspected to be a danger to self, others, and/or gravely disabled), transported to a general acute care hospital (GACH) by paramedics and admitted into the intensive care unit ((ICU) a specialized unit in a hospital to care for critically ill patients) for seven days. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 10/3/17, indicated the resident had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required staff's supervision for moving between locations. According to the MDS, Resident 1 used a wheelchair for locomotion. A review of Resident 1's Admission Wandering Risk Assessment, dated 1/3/17, indicated the resident was ambulatory (ability to walk) and required no or minimal assistance in the wheelchair, which was used as a walker at times. A review of Resident 1's Interdisciplinary ((IDT) group of disciplines that work together towards a common goal for a resident) Team Care Conference note, dated 1/11/17, indicated an Adult Protective Service ((APS), a state mandated program dedicated to maintain the health and safety of elders and dependent adults who are unable to protect their own interest and subjected to neglect and abuse) worker made a visit to the facility to verify that the resident was at the facility due to a missing person's report from a previous facility. A review of Resident 1's care plan, initiated 1/31/18, indicated the resident was at risk for elopement related to a history of elopement. The staff's interventions included to provide Resident 1 with visual checks. There was no frequency indicated for the visual checks. A review of Resident 1's Nurse' Note, dated 12/21/17, and timed at 2:55 p.m., indicated the resident had not been seen in his room, on 12/21/17, during the lunch meal pass at 12 p.m. The note indicated the staff searched for Resident 1 inside and outside of the facility's premises and parking lot. The note indicated Resident 1 was last seen on the smoking patio at approximately 10 a.m. A review of Resident 1's Nurse's Note, dated 12/21/17, and timed at 4:26 p.m., indicated the resident left the facility without informing staff. The note indicated the resident was discharged Against Medical Leave ((AMA) term used to describe when a resident leaves the facility against the advice of the physician). A review of a physician's orders [REDACTED]. A review of a Post-Event Note, dated 12/22/17 and untimed, indicated a local police officer arrived to the facility and informed the staff that Resident 1 had a history of [REDACTED]. The note indicated the IDT determined that Resident 1 would be discharged AMA as of 12/21/17. A review of the facility's Investigation Report, dated 12/27/17, six days after Resident 1 eloped, indicated Licensed Vocational Nurse 1 (LVN 1) last saw Resident 1 on 12/21/17 at 8 a.m., after taking the resident's vital signs (clinical measurements of the heart rate, temperature, respiration rate, and blood pressure that indicate the state of essential body functions) and administering the resident's medications. The report indicated after lunch, on 12/21/17, LVN 1 was informed by Certified Nursing Assistant 1 (CNA 1) that Resident 1 had not been seen. The report indicated CNA 1 last saw Resident 1 on his bed at 7 a.m. and did not see the resident when the breakfast trays were passed out. The investigation indicated CNA 1 did not immediately look for the resident and that CNA 1 assumed Resident 1 was roaming around the halls. The investigation indicated it was at lunchtime that CNA 1 noticed Resident 1 was not at bedside and that it was hours since CNA 1 last saw the resident. A review of a prior GACH 1 History and Physical (H/P), dated 12/21/16, indicated the resident was brought in by an emergency medical services ((EMS), paramedic services dedicated to providing acute medical care) after being found on the street unresponsive. The H/P indicated Resident 1 was in the ICU with an alcohol level of 274 milligrams per deciliter (mg/dl) (legal limit of intoxication was 80 mg/dl and potentially lethal concentration was > or = 400 mg/dl) and altered mental status . On 12/26/17 at 1:50 p.m., during observation and concurrent interview, the Administrator stated the fire exit door that leads to a street, located across from the nursing station, was unlocked and it did not produce an alarm sound when the fire exit door opened. On 1/23/18 at 8:25 a.m., during a telephone interview, CNA 1 stated at 7 a.m., on 12/21/17, Resident 1 was in his wheelchair in his room. CNA 1 stated at 8 a.m. when she placed Resident 1's breakfast tray in his room, the resident was not in his room. CNA 1 stated at 12 p.m., on 12/21/17 during lunchtime, Resident 1's breakfast tray remained at the bedside uneaten, and the resident was not found in the facility. On 1/23/18 8:49 a.m., during a telephone interview, LVN 1 stated she administered medications to Resident 1 his room the morning of 12/21/17. LVN 1 stated that it was reported to her that Resident 1's breakfast tray was untouched and LVN 1 was not able to find the resident. On 2/28/18 at 11:52 a.m., during an interview, Resident 1 stated he did not want to eat breakfast, but wanted to leave the facility. Resident 1 stated he left the facility at 10 a.m. on 12/21/17 through the back exit doors near the nursing station. Resident 1 stated when he left through the back exit doors, there were no staff present. On 2/28/18 at 2:15 p.m., during an interview and concurrent record review, LVN 2 stated the CNAs were responsible for checking on the residents during mealtime, and when residents were not in their rooms to eat their meals, the CNAs were responsible for finding the residents. During a record review of Resident 1's physician's orders [REDACTED]. On 2/28/18 at 3:15 p.m., during record review of Resident 1's Care Conference note dated 1/11/17 and concurrent interview, the Director of Nursing (DON) stated it indicated on 1/9/17 an Adult Protective Service (APS) worker came to see the resident due to a missing person report and the resident would be assisted with a proper discharge planning. The DON stated Resident 1 had a history of [REDACTED]. The DON stated prior to Resident 1's elopement on 12/21/17, the resident did not have a care plan to address the risk for elopement The DON stated a care plan should have been initiated to address Resident 1's history and risk for elopement. The DON stated a care plan should have been initiated when there was identified resident care issues, and the purpose of a care plan was to tell staff how to take care of the resident related to the identified care issues. On 2/28/18 at 3:15 p.m., during a record review of Resident 1's care plan initiated 1/31/18 and concurrent interview, the Director of Nursing (DON) stated the resident was at risk for elopement related to history of elopement and one facility intervention was to provide visual checks. The DON stated the facility intervention to provide visual checks does not include the frequency of visual checks but it should have indicated frequency of visual checks. A review of Resident 1's GACH 2's Face Sheet (Admission Record) indicated Resident 1 was admitted on [DATE]. A review of Resident 1's GACH 2's H/P, dated 1/27/18, indicated Resident 1 presented to the GACH 2 on a 5150 accompanied by a local police officer. The H/P indicated Resident 1 was found altered, mumbling, and intoxicated at a bank. The H/P indicated Resident 1 was gravely disabled requiring 1-to-1 monitoring by a sitter, monitoring for alcohol withdrawal, and treated with antibiotics (a medication used to treat an infection) for a UTI. A review of Resident 1's GACH Discharge Summary, dated 1/31/18, indicated the resident was discharged with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure titled, Elopement / Wandering Resident, dated (MONTH) (YEAR), indicated the facility would strive to prevent unsafe wandering, while maintaining the least restrictive environment for residents who are at risk for wandering. The policy also indicated staff would identify residents who are at risk for harm because of unsafe wandering, including elopement, and the resident's care plan would indicate the resident was at risk for elopement or other safety issues. A review of the facility's policy and procedure titled, Discharge Against Medical Advice (AMA), dated (MONTH) 2005, indicated the signed AMA form releases the facility from legal responsibility for any medical problems the resident may experience after leaving the facility against the advice of their physician. The policy also indicated when a resident or family member demands discharge against medical advice, notify the physician immediately and if the physician is unavailable or fails to convince the resident to remain in the facility, ask the resident or family member to sign an AMA release. A review of the facility's policy and procedure titled, Comprehensive Plan of Care, dated (MONTH) 2005, indicated each resident would have a comprehensive care plan developed that included goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychosocial needs identified during the comprehensive assessment. The policy indicated the comprehensive care plan must: address the resident's individual needs, strengths, and preferences; include interventions to prevent avoidable decline in function or functional level; and include interventions to attempt to manage risk factors.

Based on observation, interview, and record review, the facility failed to adhere to its policy and ensure supervision and alarm systems were in place for residents, who were at risk for elopement (act of leaving without permission), for one of four sampled residents (Resident 1). Resident 1, who had a history of [REDACTED]. As a result, Resident 1 was found in the streets intoxicated (diminished mental and physical control) of alcohol, placed on a 5150 (a legal hold which authorized involuntary hold of individual suspected to be a danger to self, others, and/or gravely disabled), transported to a general acute care hospital (GACH) by paramedics and admitted into the intensive care unit ((ICU) a specialized unit in a hospital to care for critically ill patients) for seven days. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE], and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 10/3/17, indicated the resident had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 required staff's supervision for moving between locations. According to the MDS, Resident 1 used a wheelchair for locomotion. A review of Resident 1's Admission Wandering Risk Assessment, dated 1/3/17, indicated the resident was ambulatory (ability to walk) and required no or minimal assistance in the wheelchair, which was used as a walker at times. A review of Resident 1's Interdisciplinary ((IDT) group of disciplines that work together towards a common goal for a resident) Team Care Conference note, dated 1/11/17, indicated an Adult Protective Service ((APS), a state mandated program dedicated to maintain the health and safety of elders and dependent adults who are unable to protect their own interest and subjected to neglect and abuse) worker made a visit to the facility to verify that the resident was at the facility due to a missing person's report from a previous facility. A review of Resident 1's care plan, initiated 1/31/18, indicated the resident was at risk for elopement related to a history of elopement. The staff's interventions included to provide Resident 1 with visual checks. There was no frequency indicated for the visual checks. A review of Resident 1's Nurse' Note, dated 12/21/17, and timed at 2:55 p.m., indicated the resident had not been seen in his room, on 12/21/17, during the lunch meal pass at 12 p.m. The note indicated the staff searched for Resident 1 inside and outside of the facility's premises and parking lot. The note indicated Resident 1 was last seen on the smoking patio at approximately 10 a.m. A review of Resident 1's Nurse's Note, dated 12/21/17, and timed at 4:26 p.m., indicated the resident left the facility without informing staff. The note indicated the resident was discharged Against Medical Leave ((AMA) term used to describe when a resident leaves the facility against the advice of the physician). A review of a physician's orders [REDACTED]. A review of a Post-Event Note, dated 12/22/17 and untimed, indicated a local police officer arrived to the facility and informed the staff that Resident 1 had a history of [REDACTED]. The note indicated the IDT determined that Resident 1 would be discharged AMA as of 12/21/17. A review of the facility's Investigation Report, dated 12/27/17, six days after Resident 1 eloped, indicated Licensed Vocational Nurse 1 (LVN 1) last saw Resident 1 on 12/21/17 at 8 a.m., after taking the resident's vital signs (clinical measurements of the heart rate, temperature, respiration rate, and blood pressure that indicate the state of essential body functions) and administering the resident's medications. The report indicated after lunch, on 12/21/17, LVN 1 was informed by Certified Nursing Assistant 1 (CNA 1) that Resident 1 had not been seen. The report indicated CNA 1 last saw Resident 1 on his bed at 7 a.m. and did not see the resident when the breakfast trays were passed out. The investigation indicated CNA 1 did not immediately look for the resident and that CNA 1 assumed Resident 1 was roaming around the halls. The investigation indicated it was at lunchtime that CNA 1 noticed Resident 1 was not at bedside and that it was hours since CNA 1 last saw the resident. A review of a prior GACH 1 History and Physical (H/P), dated 12/21/16, indicated the resident was brought in by an emergency medical services ((EMS), paramedic services dedicated to providing acute medical care) after being found on the street unresponsive. The H/P indicated Resident 1 was in the ICU with an alcohol level of 274 milligrams per deciliter (mg/dl) (legal limit of intoxication was 80 mg/dl and potentially lethal concentration was > or = 400 mg/dl) and altered mental status. On 12/26/17 at 1:50 p.m., during observation and concurrent interview, the Administrator stated the fire exit door that leads to a street, located across from the nursing station, was unlocked and it did not produce an alarm sound when the fire exit door opened. On 1/23/18 at 8:25 a.m., during a telephone interview, CNA 1 stated at 7 a.m., on 12/21/17, Resident 1 was in his wheelchair in his room. CNA 1 stated at 8 a.m. when she placed Resident 1's breakfast tray in his room, the resident was not in his room. CNA 1 stated at 12 p.m., on 12/21/17 during lunchtime, Resident 1's breakfast tray remained at the bedside uneaten, and the resident was not found in the facility. On 1/23/18 8:49 a.m., during a telephone interview, LVN 1 stated she administered medications to Resident 1 his room the morning of 12/21/17. LVN 1 stated that it was reported to her that Resident 1's breakfast tray was untouched and LVN 1 was not able to find the resident. On 2/28/18 at 11:52 a.m., during an interview, Resident 1 stated he did not want to eat breakfast, but wanted to leave the facility. Resident 1 stated he left the facility at 10 a.m. on 12/21/17 through the back exit doors near the nursing station. Resident 1 stated when he left through the back exit doors, there were no staff present. On 2/28/18 at 2:15 p.m., during an interview and concurrent record review, LVN 2 stated the CNAs were responsible for checking on the residents during mealtime, and when residents were not in their rooms to eat their meals, the CNAs were responsible for finding the residents. During a record review of Resident 1's physician's orders [REDACTED]. A review of Resident 1's GACH 2's Face Sheet (Admission Record) indicated Resident 1 was admitted on [DATE]. A review of Resident 1's GACH 2's H/P, dated 1/27/18, indicated Resident 1 presented to the GACH 2 on a 5150 accompanied by a local police officer. The H/P indicated Resident 1 was found altered, mumbling, and intoxicated at a bank. The H/P indicated Resident 1 was gravely disabled requiring 1-to-1 monitoring by a sitter, monitoring for alcohol withdrawal, and treated with antibiotics (a medication used to treat an infection) for a UTI. A review of Resident 1's GACH Discharge Summary, dated 1/31/18, indicated the resident was discharged with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure titled, Elopement / Wandering Resident, dated (MONTH) (YEAR), indicated the facility would strive to prevent unsafe wandering, while maintaining the least restrictive environment for residents who are at risk for wandering. The policy also indicated staff would identify residents who are at risk for harm because of unsafe wandering, including elopement, and the resident's care plan would indicate the resident was at risk for elopement or other safety issues. A review of the facility's policy and procedure titled, Discharge Against Medical Advice (AMA), dated (MONTH) 2005, indicated the signed AMA form releases the facility from legal responsibility for any medical problems the resident may experience after leaving the facility against the advice of their physician. The policy also indicated when a resident or family member demands discharge against medical advice, notify the physician immediately and if the physician is unavailable or fails to convince the resident to remain in the facility, ask the resident or family member to sign an AMA release.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care in prevention and wound healing of a pressure ulcer (damaged skin caused by staying in one position for too long) for one of three sampled residents (Resident 1). Resident 1, who was assessed as a high risk of developing pressure ulcers, was not properly assessed, preventive measures not adhered to per the care plan and the physician was not notified when there was a change in the resident's skin assessment. This deficient practice resulted in Resident 1's blanchable redness (intact skin with a localized area of swelling, which may appear differently in darkly pigmented skin) of skin developing into excoriation (superficial skin loss) and then an unstageable pressure ulcer (when you are unable to determine the depth of the sore). Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Significant Change in Status Minimum Data Set (MDS), a resident assessment and care planning tool, dated 5/26/16, indicated Resident 1 was severely impaired in cognitive skills for daily decision-making and had memory problems. The MDS indicated Resident 1 did not ambulate and was totally dependent in care with a one-person physical assist for activities of daily living including toilet use, personal hygiene and bed mobility. According to the MDS, Resident 1 was at risk of developing pressure ulcers, however assessed as not having any. A review of Resident 1's, Skin Weekly Condition Record, dated 5/13/17 indicated the resident's skin assessment on the coccyx (tailbone) had blanchable redness. A review of the facility's document tiled, Skin Weekly Condition Record 6/20/17 indicated Resident 1 was assessed with [REDACTED]. A review of Resident 1's, Skin Weekly Condition Record, dated 7/3/17, Resident 1 was assessed with [REDACTED]. A review of Resident 1's Resident Care Plan Skin, dated 6/27/17, indicated Resident 1 had a sacralcoccyx with UTD pressure injury. The goal indicted the pressure sore will improve by the next review date. The staff's interventions included using a low air loss mattress ((LAL) tiny laser made air holes in the mattress top surface continually blow out air causing the patient to float), physician notification and applying alginate dressing (highly absorbent, biodegradable alginate dressings derived from seaweed used to cleanse a wide variety of secreting [MEDICAL CONDITION]) and cleaning with wound cleanser. A review of a Resident 1's care plan titled, Diabetes Mellitus (high blood sugar), dated 4/20/17, indicated under interventions that staff would perform body checks for skin break and treat promptly. On 8/11/17 at 12:33 p.m., during an interview, the Licensed Vocational Nurse 1 (LVN 1) stated once the certified nurse assistants (CNAs) identified any new skin problems, including pressure ulcers, LVN 1 would notify the physician. A review of the Nurses Progress Note, dated on 6/20/17, did not indicate that Resident 1's primary physician was notified of the change in skin condition. A review of a Nurse's Note, dated 6/20/17, and timed at 8:20 a.m., indicated Resident 1 was transferred to a General Acute Care Hospital (GACH) for an episode of ([MEDICAL CONDITION]) high blood sugar, temperature of 100.5 Fahrenheit ((F) normal reference range (NRR) is 91.8-100.8 °F) and shortness of breath (SOB). A review of Resident 1's, Skin Weekly Condition Record, dated 6/12/17, indicated redness to coccyx extended to buttocks (tailbone). A review of the GACH's pictures, dated 6/20/17, indicated the left buttocks had two skin tears along the tailbone and redness around the buttocks. On 8/11/17 at 2:10 p.m., during a telephone interview, Resident 1's family member (FM 1) stated that the times she visited the resident, Resident 1 would be sitting on wheelchair with no pressure reliving devices and no special mattress on the bed to prevent the skin from breaking. On 8/11/17 at 3:56 p.m., during an interview, LVN 2 stated when a pressure sore was identified, the primary physician and the wound physician would be notified of the initiation of pressure reliving devices are implemented. The wound assessment and measurements are perform in a weekly basis. On 8/11/17 at 4:15 p.m., during an interview, CNA 1 stated they are supposed to turn the resident every two hours, but since the facility has been short-staffed, sometimes it takes her four hours to turn the resident. CNA 1 stated she mentioned to the Director of Staff Development (DSD), of how being short-staffed affects the care provided to the residents. On 8/11/17 at 4:57 p.m., during an interview and record review, Registered Nurse 1 (MDS RN (RN 1)) stated that Resident 1's assessment completed on 6/26/17 indicated the sacralcoccyx wound measured length of 9cm x width 12cm x UTD. RN 1 stated that there were no pressure reliving devices ordered for Resident 1. An assessment, dated 7/3/17, indicated there was an increase in the size of the sacralcoccyx wound to 14cm x 9.1cm x UTD. RN 1 stated devices, such as an low air loss mattress, should have been ordered for Resident 1. On 10/13/17 at 5:56 p.m., during a telephone interview, Resident 1's FM 1 stated she had not seen staff turning Resident 1 during the times the family would visit. FM 1 stated they were told by the staff not to turn the resident due to her illness. On 10/26/17 at 2:12 p.m., during a review and concurrent interview of the GACH's pictures of Resident 1's coccyx area, with LVN 3, indicated the pictures were taken on 6/20/17. LVN 3 stated, after reviewing the pictures that Resident 1's coccyx images had redness excoriation and it could have been prevented with a LAL mattress. A review of Resident 1's physician orders, from May 2017 through July 2017, did not indicate a LAL mattress was ordered. On 10/26/17 at 6:20 p.m., during an interview and record review of the GACH's images dated 6/20/17, with the Director of Nurses (DON) she stated that the coccyx area had redness with old scabs that opened possibly due to the resident not being repositioned, moisture, and/or perspiration. A review of the facility policy and procedure titled, Skin Care Management, dated 2/2005, indicated that when a pressure ulcer was identified, the licensed nurse will document in the progress notes and the Weekly Pressure Ulcer Record. Documentation to include size, stage, location, drainage, odor, and pain and initiation of care plan and treatment.

Based on observation, interview, and record review, the facility failed to notify the physician of a significant change in a skin condition for one of 24 sampled residents (Resident 13). Resident 13 was not provided with the necessary care and treatments for sacral redness. The facility identified Resident 13 on 6/17/15 with sacral redness and did not receive treatment to the sacral redness until the surveyor observed it 23 days after initially identified. As a result of this deficient practice, Resident 13's sacral redness progressed to a candidiasis (fungal) infection. According to an online article titled,Candidiasis, (fungal infection are characterized by skin redness, itching, burning pain that can lead to a blood infection if not treated), maceration (softening and breaking down of the skin due constant moisture from fecal/urine incontinence {no control} or perspiration), [MEDICAL CONDITION] (skin irritation, redness and itching) and stage II pressure sore (open skin or an injury to the skin or tissue over a bony area caused by unrelieved pressure) <http://www.nlm.nih.gov/medlineplus/rashes.html> Findings: On 7/10/15 at 6 p.m., during an observation conducted with the registered nurse supervisor (RN) 1, assistant director of nursing (ADON) and a licensed vocational nurse (LVN 6), the treatment nurse, the evaluator observed that Resident 13's sacral and gluteal (buttocks area) folds had redness measuring approximately 2x2 cm (centimeters) with five small open skin areas and white tissue in the center of the wound, measuring approximately 0.5 cm x 1 cm. In a concurrent interview, all of the staff mentioned above stated they were not aware that Resident 13 had skin breakdown. According to the Admission Record, Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE]. The residents [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), resident assessment and care screening tool, dated 4/16/15 , Resident 13 had unclear speech, but was usually able to make self understood and understand others. Resident13 was totally dependent and required one person physical-assist with toilet use. Resident 13 was always incontinent of bowel and bladder and was not on a bowel and bladder program, and did not have any skin impairment. A review of a Braden Scale for Predicting Pressure Risk dated 4/16/15, indicated Resident 13 was at risk for pressure sores with a score of 15 (Scoring: at risk=15-18, 13-14=moderately at risk and 10-12=high risk). On 7/10/15 at 6:50 p.m., a Change of Condition (COC) Assessment, dated 6/17/15 and timed at 10:51 p.m., was reviewed with the ADON. The review indicated that a certified nursing attendant (CNA) reported to a registered nurse (RN 3) that Resident 13 had redness of the sacrum. According to the COC Assessment, the redness was reported to a physician and a treatment was ordered and provided. Furthermore, during a clinical record review on 7/10/15 at 6:50 p. m., the evaluator noted that there was no documented evidence that Resident 13's change in skin condition was reported to the physician or that a treatment was provided. There was no documentation that the plan of care was revised and skin reassessment was performed after 6/20/15. A review of a written declaration and an interview with RN 3 on 7/14/15 at 3:43 p.m., indicated that on 6/17/15, a CNA informed her Resident 13's sacrum was red. RN 3 indicated she had documented on the COC Assessment Note that the physician was informed and a new order was received. However, she stated, Honestly, I called the physician, but he did not answer and I could not leave a message, so the physician was not informed and I did not receive an order from the physician. I cannot recall if I informed the RN supervisor. I did not develop a plan of care and the skin was not treated. RN 3 stated she was aware of the facility's policy and procedures regarding COC. She stated she should have called the physician again to inform him about Resident 13's sacral skin redness on 6/17/15. A review of the physician's progress note dated 7/12/15 indicated Resident 13 had stage II pressure ulcer, macerated skin measuring 1.5 cm x 1.5 cm with candidiasis due to being incontinent. The note also indicated the gluteal fold had evidence of moisture associated [MEDICAL CONDITION] (skin redness, rashes and itching). According to a physician order [REDACTED]. During an interview on 7/13/15 at 10:20 a.m., the DON stated it was the responsibility of the ADON and the nursing supervisors to screen monitor and refer the residents to the treatment nurse or charge nurse to follow-up on the care and treatment of [REDACTED]. When asked about Resident 13's change in skin condition, the DON stated I'm sorry but I did not see Resident 13 identified as having pressure sores in the computer and therefore, was missed. According to the facility's undated policy and procedure titled, Change in Resident's Condition or Status, The RN supervisor/Charge nurse will notify the resident's physician or the on-call physician when there was a significant change in physical condition and if there was a need to alter the resident's medical treatment significantly.

Based on observation, interview, and record review, the facility's staff failed to promote care for three of 24 sampled residents (Residents 2, 3 and 4), one of three randomly selected resident (Resident 27), and eight of fifteen residents that attended the group meeting. Resident 4, who was alert and oriented stated she had to wait for over two hours to be cleaned after three facility's staff came in the room and stated Somebody is being reassigned to you. This deficient practice resulted in the Resident being upset and feeling awful The resident verbalized that the day was a nightmare. For Residents 2 , staff was standing over to feed the resident in an undignified manner. For Resident 27, the certified nursing assistant (CNA) left the resident lying in bed in a wet diaper. For Residents 3, and eight of fifteen residents that attended the group meeting. Call lights are not answered promptly. For eight of fifteen residents who attended the group meeting, they stated they wait up to an hour, on the evening shift, before CNAs answer the call lights. Findings: a. On 7/10/15, at 10:15 a.m., during a treatment observation, Resident 4 was observed with opened and reddened areas to the right and left upper buttocks. After the treatment observation, Resident 4 was interviewed. Resident 4 stated, I think they needed more nurses. When Resident 4 was asked to elaborate, she stated on 7/4/15, (a holiday) she was informed by the facility ' s staff that there were a number of nurses that did not show up for work. Resident 4 stated, I was in my soiled diaper for two and a half hours. Resident 4 stated she had to use her cellular phone to call the nursing station because no one came when she turned the call light on. Resident 4 also recalled that while she was waiting, a certified nurse assistant (CNA3) came and turned off her call light. Resident 4 stated she thought CNA3 was going to assist her but instead, CNA3 stated, We are going to assign you to another nurse. Resident 4 stated I felt awful because I was already irritated down there. I felt she could have cleaned me at that time, but she left . nobody came until many hours . Resident 4 further stated when a nurse came to clean and change her, she was already sore and hurting down there, pointing to her buttocks. Resident 4 stated the CNAs do not clean her correctly and she was the one who had to suffer for it. The resident stated the night shift's staff, They don't clean me well. The clinical record for Resident 4 was reviewed. The Admission Record indicated that the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of an annual Minimum Data Set (MDS), an assessment and care screening tool, dated 5/10/15 indicated Resident 4 was able to express ideas and wants and had no impairment with decision-making and memory. The MDS functional content for activities of daily living indicated that the resident was totally dependent and required two-person assist for transferring and toilet use, and an extensive assistance with bed mobility. During an interview, on 7/10/15, at 3:30 p.m., CNA3 stated on 7/4/15, she remembered working for both 3 to 11 p.m. and 11 to 7 p.m. shifts. According to CNA3, it was a busy day because the CNAs had more residents than usual. CNA3 was asked what was the facility's practice with regard to answering call lights. CNA3 stated, Anybody can answer call lights here and if it is just a simple request, then we have to do it for them. CNA3 further stated if it was a request to be cleaned or go to the restroom, they have to get the staff assigned to that resident. The CNA was asked, What if after telling the other staff, but help did not arrive and the resident had to use the call light to request for assistance again, CNA3 stated she will still wait for the assigned CNA to come in. On 7/13/15, at 4:45 p.m., during a telephone interview, Resident 4's family member (FM1) stated, They don't have enough 'help' to assist the residents, especially in the evenings . Resident 4 just had an infection and now a diaper rash. FM1 stated on 7/4/15 she had called the nursing station between 5 and 6 p.m. and the facility's staff informed her that they were short of nurses and that they were going to get to Resident 4 as soon as possible. FM1 stated Resident 4 was really upset that day. During an interview with a registered nurse (RN1), on 7/13/15, at 5:50 p.m., he stated he remembered on 7/4/15 when Resident 4 called and stated she needed to be cleaned. RN1 stated he went to the resident's room and told the resident he would get her help. RN 1 told a CNA and endorsed the resident's request to the evening supervisor, a licensed vocational nurse (LVN 3) because he was about to go home at that time. On 7/13/15, at 6:05 p.m., during an interview, LVN3, the supervising nurse for evening shift, stated Resident 4 had called him again on 7/4/15 trying to find out if he was getting help. LVN3 stated he went to the resident's room and told her that he could not find the CNA assigned to her, because she did not show up to work. LVN3 also told the resident he was trying to find a CNA to assist her. LVN3 stated after speaking to the resident, FM1 called and told him she needed to be changed. According to LVN3, he told FM1, I had to split the assignment and someone was going to be assigned to her. On 7/14/15, at 10:15 a.m., during an interview, Resident 4 stated it was not the first time she had to wait for a long time to be cleaned after an episode of incontinence (inability to control bowel and bladder) but was unable to recall exact dates. The resident was asked why she had not reported these incidents to the facility's administration. Resident 4 stated I ' m afraid to get anybody in trouble. A review of an undated facility's policy and procedure titled Answering Call Light, indicated to do what the resident asks of you, if permitted. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the residents' request, ask the nurse supervisor for assistance. The policy also stipulated if the staff promised the resident they will return with an item or information, do so promptly. b. On 7/9/15, at 7:53 a.m., during a dining observation, Resident 2 was sitting at the table waiting for breakfast. A rehabilitation nursing assistant (RNA 1) was standing over the resident feeding her with a spoon. On 7/10/15 at 8:02 a.m., during another dining observation, RNA 1 was again standing up feeding Resident 2 her breakfast. On both days, RNA 1 did not promote the resident's dignity by sitting down next to her to feed her. c. On 7/10/15 at 1:03 p.m., a family member (FM2) arrived to visit Resident 27. FM2 saw the resident still in bed and became upset. FM2 member spoke in loud tone of voice, and asked a certified nurse assistant (CNA 8) why Resident 27 was still lying in bed in a wet diaper. FM2 again asked CNA 8 why Resident 27 was not up, but the resident's roommate was up, cleaned, and sitting in a chair. FM2 asked, Why don't you get both of them up at the same time? Without answering, CNA 8 proceeded to clean and get Resident 27 out of the bed. A review of Resident 27's clinical record indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 27's Minimum Data Sheet (MDS), a standardized assessment and care screening, dated 5/20/15, indicated the resident rarely or never understood others. According to the MDS, Resident 27 was non-ambulatory, incontinent (no control), and dependent on staff for all care. Resident 27 was at risk for skin breakdown due to being incontinent and needed to be cleaned, dried, and repositioned every two hours. On 7/13/15, at 10:15 a.m., during an interview, the director of staff development (DSD) stated she spoke with FM2 on 7/10/15, about Resident 27 being in the bed at 1 p.m., in a wet diaper. The DSD stated she provided counseling to CNA 8 that same afternoon (7/10/15), regarding patient care and professionalism. d. During an interview, on 7/14/15 at 11:33 a.m., Resident 3 stated, When I use the call light at night, it can take anywhere from 45 minutes to an hour for someone to come. On 7/14/15 at 11:40 a.m., in the presence of the facility's social service director (SSD), Resident 3 stated the nurses turn off the call lights without asking what the resident needs. It takes up to an hour for the CNAs to answer the call lights, especially on the night shift. A review of Resident 3's medical record indicated the resident was readmitted to the facility 2/22/15. The resident's [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated 6/3/15, indicated the resident was able to make her needs known and understand others. According to the MDS, Resident 3 used a wheelchair for mobility, was occasionally incontinent (no control), and required an extensive assistance with activities of daily living (ADLs). e. On 7/9/15 at 10 a.m., during a quality of life group interview, eight of fifteen residents stated they wait up to an hour, on the evening shift, before CNAs answer the call lights. The residents stated staff members would come in the room and turn off the call light in their rooms and walk out, without asking or tending to the resident's. The eight residents stated this was very frustrating to them.

Based on interview and record review, the facility failed to ensure that residents with existing pressure sores and assessed at a high risk for developing more pressure sores received appropriate interventions to promote healing and prevent complications, and development of new pressure sores (any lesion caused by unrelieved pressure resulting in damage of the underlying tissue) for three of 24 sampled residents (Residents 2, 13 and 11). a. Resident 2, who was admitted to the facility with a Stage II pressure sore (is an injury to the skin or tissue over a bony area) to the sacrum (a triangular bone in the lower back between the two hipbones) and a deep tissue injury (DTI A pressure-related injury to subcutaneous tissues under intact skin.) to bilateral great toe. The facility failed to follow its own pressure ulcer policy and procedure, develop an individualized plan of care and ensured that wound measurement and wound assessment were accurate. The facility's lack of the use of pressure relieving devices and an inappropriate use of a [MEDICATION NAME] agent (Santyl ointment) on a 100% granulated wound tissue contributed to the worsening of the wound. b. Resident 13 who was at risk of pressure sore was not provided with the necessary care and treatments for sacral redness. The facility identified Resident 13 on 6/17/15 with sacral redness and did not receive treatment to the sacral redness until the surveyor observed it 23 days after initially identified. c. Resident 11 had a stage I pressure sore and the facility failed to provide the necessary care and treatment to prevent the progression of sacral stage 1 (skin redness) pressure sore to stage II. These deficient practices had resulted and had potential to result in the development of new pressure for resident identified as being at risk of developing pressure sore and the worsening of current pressure sores for those residents currently receiving treatment. Findings: a. On 7/7/15, at 3:50 p.m., during the tour of the facility, Resident 2 was observed lying in bed facing on her left side with both inner knees rubbing together without support of a pillow or cushion in between knees, but had bilateral heel protectors intact and a pillow under both ankles. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS), an assessment and care screening tool, dated 4/6/15, indicated the resident had clear speech, was able to express needs and understand verbal content. The Brief Interview for Mental Status (BIMS), an assessment of the resident's ability to repeat three words, orientation to year, month and day, and the ability to recall, Resident 2 scored 7 out of 15 (meaning, the resident was moderately impaired), required extensive assistance in walking and eating, and was totally dependent on staff for transferring, toilet use, and personal hygiene. A review of the undated facility's policy and procedure titled, Pressure Ulcer Treatment indicated if the wound does not improve in 2-3 weeks, to notify the physician, re-evaluate nutritional support, off loading/redistribution devices and advanced wound product changes. The policy also indicated the protocol for Stage III pressure sore with medium drainage would be to consider substituting alginate (a natural wound dressing derived from carbohydrate sources released by clinical bacterial species) or foam (a highly absorbent dressing, which allows less frequent changing of dressings and decrease maceration of surrounding tissues) with silver (a topical ingredient or a dressing ingredient that has beneficial effects in wound healing) unless resident was sensitive to silver. A review of Resident 2's Weekly Skin Measurement Tool for the sacrum pressure sore indicated the following notes: 1.) On 3/30/15, the Stage II pressure sore to the sacrum area wound bed had 100% granulation, small amount of serosanguinous drainage (consisting of both blood and serous fluid), measurements were 3.0 cm x 3.5 cm x 0.2 cm (length, width, depth), treatment orders was to apply Santyl ointment (an approved prescription medicine that removes dead tissues from wounds) once a day for 21 days. On 4/6/15, the Stage II pressure sore to the sacrum area wound bed had 100% granulation tissue (a new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process), small amount of serosanguinous drainage, measurements were 2.7 cm x 3.3 cm x 0.2 cm (length, width, depth), treatment orders was to apply Santyl ointment once a day. On 4/13/15, the Stage II pressure sore to the sacrum wound bed had100% granulation, small amount of serosanguinous drainage, measurements were 2.5 cm x 3.0 cm x 0.1 cm (length, width, depth), treatment orders continued with application of Santyl ointment once a day. On 4/20/15, the Stage II pressure sore to the sacrum wound bed with 100% granulation; measurements were 2.5 cm x 3.0 cm x 0.1 cm (length, width, depth). However, the drainage had increased to moderate serosanguinous drainage but the treatment orders remained the same and the Santyl ointment was reordered by the attending physician (MD1) once a day for 21 more days. On 4/27/15, the Stage II pressure sore to the sacrum had a 100% granulation, the width measurements had increased to 2.5 cm x 3.2 cm x 0.2 cm (length, width, depth), moderate serosanguinous drainage, and treatment orders to apply Santyl ointment once a day. It was documented that the resident refused to be repositioned. There was no documented evidence on an advanced wound product being ordered after receiving four weeks of treatment, from 3/30/15 to 4/27/15, as indicated in the facility's policy, that if a wound does not improve within two to three weeks, a wound product that is more advanced would be ordered. On 5/4/15, the Stage II pressure sore to the sacrum wound bed had 100% granulation; width measurements had increased to 2.3 cm x 3.5 cm x 0.2 cm (length, width, depth), moderate serosanguinous drainage and the treatment order was changed to duoderm patch (a gel-like dressing that absorb excretions from the wound and protect the wound debris from potentially causing bacteria) every day for 14 days. It was also documented in the Weekly Skin Measurement Tool that Resident 2 May see wound consultant, when available. There was no documented evidence of coordination between the facility and the attending physician to order a wound consultant in the clinical records. On 5/11/15, Stage II pressure sore to the sacrum wound bed with 100% granulation; measurements were 2.3 cm x 3.3 cm x 0.2 cm (length, width, depth), small serosanguinous drainage with treatment order for the duoderm patch. It was also noted, that the resident had episodes of refusing to be reposition while in bed. On 5/18/15, the Stage II pressure sore to the sacrum wound bed with 100% granulation, length measurements had decreased to 2.1 cm x 3.3 cm x 0.2 cm (length, width, depth), small serosanguinous drainage, and the Santyl ointment was reordered to be applied to the wound bed and in addition to a new treatment order to apply zinc oxide cream to the wound edges for 21 days. An alternating Pressure Pad (APP) mattress was also indicated when available. There was no evidence in the clinical record that an individualized care plan was developed and interventions were implemented for Resident 2's episodes of refusing to be repositioned while in bed that was documented on the 4/27/15 and 5/11/15 Weekly Skin Measurement Tools. There was also no evidence in the clinical record that an APP mattress was ordered for Resident 2. There was no documented evidence in the clinical record the resident was seen by a wound consultant from 5/4/15 to 5/21/15. During an interview, on 7/10/15 at 9 a.m., the treatment nurse (LVN6), stated Resident 2 was on a regular concave mattress (a bed that is concave in the middle designed to prevent a resident from sliding to the edges of the bed to prevent falls) since admission (3/30/15). On 5/22/15, the resident's Stage II pressure sore progressed to a Stage III pressure sore (A full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slou8gh may be present but does not obscure the depth or tissue loss) on the sacrum, the wound bed had 90% granulation, the wound measurements increased to 5.0 cm x 2.0 cm x 0.3 cm (length, width, depth), with moderate serosanguinous drainage. The wound consultant ordered an indwelling urinary catheter for wound management and a treatment for [REDACTED]. A review of a physician progress notes [REDACTED]. The progress note indicated zinc oxide cream would be applied to the sacrum twice daily and as needed. However, a concurrent review of the Treatment Administration Record dated 5/2015, indicated the zinc oxide cream was applied to the Stage III sacrum pressure sore only once a day starting 5/23/15. On 6/30/15, the resident's Stage III pressure sore to the sacrum wound bed had 70% granulation, the wound measurements were 4.0 cm x 1.5 cm x 0.3 cm (length, width, depth), with moderate serosanguinous drainage, and 30% slough (a stringy mass that may or may not be firmly attached to surrounding tissue). The wound care treatment and interventions remained the same. On 7/7/15, the Stage III pressure sore to the sacrum wound bed had 70% granulation, wound measurements at 3.8 cm x 1.3 cm x 0.3 cm (length, width, depth), with moderate serosanguinous drainage, and 30% slough. However, the treatment orders were changed back to applying zinc oxide cream to the peri-wound (wound edges) and Santyl ointment to the wound bed. A review of a physician's telephone order, dated 7/7/15, indicated an order for [REDACTED]. 2.) During a treatment observation on 7/10/15, at 11:20 a.m., Resident 2 was observed lying in bed on her left side with heel protectors, on but no pillows or cushion in between the legs. LVN 6 was seen measuring the length and the width of the sacrum pressure sore inaccurately, because LVN 6 did not include the peri-wound (wound edges that was pale in color) in the wound measurements. LVN 6 was asked to measure again to include the peri-wound. The measurement was 4.4 cm length and 3.8 cm width which was an increase from the last wound measurement of 3.8 cm x 1.3 cm, three days prior to 7/7/15. LVN 6 removed the dressing on the right heel deep tissue injury (DTI). The right heel was observed to be an opened wound with red to pink colored wound bed. LVN 6 stated she was still documenting it as a DTI because that was the last documentation of the wound consultant from 5/22/15 and because the right heel opened up after application of the [MEDICATION NAME] spray (a wound medication used for treating skin wounds) which had a [MEDICATION NAME] action. LVN 6 was also observed applying the [MEDICATION NAME] spray directly to a number of 4x4 gauze pads and placed the gauze pads to Resident 2's right heel and then covered it with a dressing. A review of the licensed nurses' narrative notes, dated 5/16/15, and timed at 3:22 p.m., indicated that during morning care, Resident 2 was observed by the treatment nurse to have a DTI to the right heel. The right heel DTI was described to be maroon (purple) in color, boggy (soggy), and warm to touch. A review of Resident 2's Weekly Skin Measurement Tool for the right heel indicated the following: On 5/16/15, the DTI to the right heel was assessed as having 100% eschar (used to describe a leathery, dry hard tissue), no drainage and measurements were 5.0 cm x 6.2 cm but unable to determine the depth (length, width), the treatment order was to apply [MEDICATION NAME] spray once a day for 21 days but depth was undetermined (UTD). On 5/30/15, 6/6/15, 6/16/15, 6/20/15, 6/27/15 and 7/4/15, the facility documented that the right heel wound was a DTI with 100% eschar tissue on the Weekly Skin Measurement Tool by the treatment nurse (LVN6) with the same treatment order of [MEDICATION NAME] spray (a topical medication typically used to treat various skin wounds). There was no documented evidence in the clinical record that the treatment was changed or an advanced wound product was ordered after 52 days that the DTI to the right heel did not improve as indicated in the facility's policy. During Resident 2's treatment observation, on the same date and time, 7/10/15, at 11:20 a.m., an open area to the left inner knee area was observed. LVN 6 stated it was not a pressure sore and documented it as excoriation (damaged or removed part of the surface of the skin). LVN 6 was asked what may have caused the excoriation and LVN 6 stated it was because Resident 2 had a habit of lying on her side and when sitting in the wheelchair the knees rub against each other causing friction causing excoriation. LVN 6 stated that was why she would remind the staff to place a pillow in between the resident's legs/knees when she was lying on her side and sitting in the wheelchair. However, Resident 2 did not have a pillow in between the legs prior to the start of the wound care. LVN 6 was asked if the resident's skin breakdown to the left inner knee could be a pressure sore because of the possible friction she had mentioned. LVN 6 agreed and stated she had not thought about it, but the left inner knee excoriation should be classified as a Stage II pressure sore. During the course of the treatment observation, LVN 6 was asked to identify a maroon, map-like skin discoloration observed at the right inner lower leg. LVN 6 stated that she had seen the skin discoloration previously and stated it was just a skin discoloration. LVN 6 stated she did not report it to the physician. LVN 6 was asked to describe the skin discoloration, she stated it was purple/maroon in color, intact skin located on the right inner lower leg. LVN 6 was asked again if that could be a possible DTI that warrants a physician notification. LVN 6 stated yes it was and she would call the physician right away to inform and get possible treatment orders. A review of the Change of Condition (Skin) Report, dated 7/8/15, indicated Resident 2 was observed by the treatment nurse (LVN 6) to have an excoriation to the left inner knee with 100% scattered fragile [MEDICATION NAME] tissues. Resident 2 was also observed to have uneven excoriations to the right and left gluteal folds (a prominent fold that marks the upper limit of the thigh from the lower limit of the buttock). According to the report, Resident 2 was at risk for further skin breakdown, due to incontinence of bowel and bladder, and that the resident's preference to sit long period of times on manual wheelchair. A review of the care plan initiated on 7/10/15 indicated Resident 2 had excoriation to the left inner knee and was reclassified as a Stage II pressure sore. The staff's interventions included to place a pillow in between the resident's knees to prevent friction. On 7/13/15, at 8 a.m., during an observation, Resident 2 was observed in the dining room sitting in a wheelchair with a restorative nurse assistant (RNA1). Both inner aspects of the knees were observed to be rubbing together with no cushion or pillow to protect from friction or pressure. RNA1 stated she did not know Resident 2 had a pressure sore in the left inner knee and was not aware of the plan of care to put a pillow in between knees while sitting in the wheelchair. According to the undated facility's policy and procedure titled Change in a Resident's Condition or Status, indicated the facility shall promptly notify the attending physician in the resident's medical/mental condition and/or status. According to the undated facility policy and procedure titled Pressure Ulcer Treatment, a deep tissue injury (DTI) is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue pressure and/or shear. On 7/14/15, at 9:45 a.m., during a telephone interview, Resident 2's physician (MD1) stated she usually ordered a wound consult for residents with pressure sores/skin issues, and discuss treatment plans with the facility because it was not her area of expertise. MD1 further stated Resident 2 definitely had a lot of risk factors that would put her at risk for skin breakdown and that was why she ordered a wound consult. MD1 stated she did not know how often the wound consultant comes and sees a resident. MD1 was asked if Santyl ointment was the treatment of [REDACTED]. MD1 stated, it could be and depending on what the Stage II pressure sore looked like. A review of Santyl ointment's Manufacturer's information, Santyl ointment is a Sterile enzymatic [MEDICATION NAME] ointment . and possesses the unique ability to digest collagen in necrotic tissue. It is also indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas . Use of Santyl ointment should be terminated when debridement of necrotic tissue was complete and granulation tissue is well established. The Santyl ointment was continuously used throughout the start of Resident 2's treatment to the sacrum pressure sore which was documented to be at 100% granulation tissue from 3/30/15 to 5/18/15. There was no evidence of necrotic tissues on the wound bed of Resident 2's Stage II sacrum pressure sore as indicated in the manufacturer's information for Santyl ointment use. The wound bed was described as having 100% granulation tissue from 3/30/15 to 5/18/15 but Santyl ointment was still being applied. Prevention of Pressure Ulcers indicated the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. b. On 7/10/15 at 7:50 a.m., Resident 13 was observed in the dining room siting in a wheelchair without a cushion or a pressure relieving device to prevent a skin breakdown as stipulated in the facility's policy and procedure for prevention and management of pressure sore. On 7/10/15 at 6 p.m., during an observation conducted with the registered nurse supervisor (RN) 1, assistant director of nursing (ADON) and a licensed vocational nurse (LVN 6/the treatment nurse), the evaluator observed that Resident 13's sacral and gluteal (buttocks area) folds had redness measuring approximately 2x2 cm (centimeters) with five small open skin areas and white tissue in the center of the wound, measuring approximately 0.5 cm x 1 cm. In a concurrent interview, all of the staff mentioned above stated they were not aware that Resident 13 had skin breakdown. According to the Admission Record, Resident 13 was admitted to the facility on [DATE] and re-admitted on [DATE]. The residents [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), resident assessment and care screening tool, dated 4/16/15 indicated, Resident 13 had unclear speech, but was usually able to make self, understood and understand others. Resident was totally dependent and required one person physical-assist with toilet use, and was always incontinent of bowel and bladder and not on bowel and bladder program, and did not have any skin impairment. A review of a Braden Scale for Predicting Pressure Risk dated 4/16/15, indicated Resident 13 was moderately at risk for pressure sores with a score of 15 (Scoring: at risk=15-18, moderately at risk =13-14, and high risk =10-12). On 7/10/15 at 6:50 p.m., a Change of Condition (COC) Assessment, dated 6/17/15 and timed at 10:51 p.m., was reviewed with the ADON. The review indicated that a certified nursing assistant (CNA) reported to a registered nurse (RN 3) that Resident 13 had redness of the sacrum. According to the COC Assessment, the redness was reported to a physician and a treatment was ordered and provided. Furthermore, during a clinical record review on 7/10/15 at 6:50 p. m., the evaluator noted that there was no documented evidence that Resident 13's change in skin condition was reported to the physician or that a treatment was provided. There was no documentation that the plan of care was developed for the sacral skin redness or skin reassessment was performed after 6/20/15. In an interview with LVN 6 on 7/10/15 at 7 p.m. she stated residents who were at risk of skin breakdown should have had a frequent skin assessment, the skin should be kept clean and dry, and provided with pressure relieving devices such as, cushion and a specialized mattress. On two separate observations, on 7/10/15 at 7:50 a.m. and 6:10 p.m., Resident 13 was not observed to have pressure relieving devices in his wheelchair or on his mattress. A review of a written declaration and an interview with RN 3 on 7/14/15 at 3:43 p.m., indicated that on 6/17/15, a random CNA informed her Resident 13's sacrum was red. RN 3 indicated she had documented on the COC (change of Condition) Assessment Note that the physician was informed and a new order was received. However, she stated, Honestly, I called the physician, but he did not answer and I could not leave a message, so the physician was not informed and I did not receive an order from the physician. I cannot recall if I informed the RN supervisor. I did not develop a plan of care and the skin was not treated. RN 3 stated she was aware of the facility's policy and procedures regarding COC. She stated she should have called the physician again to inform him about Resident 13's sacral skin redness on 6/17/15. A review of the physician's progress note dated 7/12/15, no time, indicated that Resident 13 had stage II pressure sore, macerated skin measuring 1.5 cm x 1.5 cm with candidiasis due to being incontinent. The note also indicated the gluteal fold had evidence of moisture associated [MEDICAL CONDITION] (skin redness, rashes and itching). According a physician order [REDACTED]. During an interview on 7/13/15 at 10:20 a.m., the DON stated it was the responsibility of the ADON and the nursing supervisors to screen monitor and refer the residents to the treatment nurse or charge nurse to follow-up on the care and treatment of [REDACTED]. When asked about Resident 13's change in skin condition, the DON stated I'm sorry but I did not see Resident 13 identified as having pressure in the computer and therefore, was missed. According to the facility's undated policy and procedure titled, Change in Resident's Condition or Status, The RN supervisor/Charge nurse will notify the resident's physician or the on-call physician when there was a significant change in physical condition and if there was a need to alter the resident's medical treatment significantly. c. On 7/8/15 at 3p.m., Resident 11 was observed in the dining room sitting in a wheelchair without a cushion or pressure relieving device in place as stipulated in the facility's policy and procedure for prevention and management of pressure sore. According to the Admission Record, Resident 11 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/28/15, Resident 11 had clear speech, was able to make self-understood and understand others; required extensive assistance with two or more persons physical-assist in bed mobility, toilet use, transferring; and one-person physical assist on personal hygiene. According to the MDS; total dependence with one person physical assist on toilet use; was always incontinent (no control) of bowel/bladder, and was not in the bowel and bladder program; and had no skin breakdown. A review of a Braden Scale for Predicting Pressure Risk dated 4/16/15 indicated, Resident 11was at risk for pressure sore with the score of 17 (Scoring: at risk=15-18, moderate risk=13-14, high risk=10-12). On 7/9/15 at 2 p.m., during a wound care observation, LVN 6 stated, Resident 11 has stage II pressure sore in sacral area. The resident did not have a special mattress to help relieve the pressure areas in the body, as stipulated in the facility's policy and procedure on Pressure Ulcer, Interventions and Preventive Measures for Pressure Ulcer. A review of a Weekly Skin Measurement Tool indicated, on 5/2/15 Resident 11 developed a stage 1 pressure sore that measured 3.0 cm length. X 3.5 in width. On 6/28/15, the pressure sore had advanced to stage 11 measuring 3.0 cm. in length. X 2.0 in width x 0.2 in depth. A review of the Braden Scale for Predicting Pressure Risk dated 4/16/15 indicated, Resident 11 was at risk for pressure sore with the score of 15 (Scoring: at risk=15-18, 13-14=moderately at risk, high risk=10-12). A review of a plan of care titled Sacral re-classified to stage II pressure sore dated 6/28/15 indicated, Resident 11 was at risk for pressure sore due to bowel and bladder incontinence, impaired mobility, and refusal to be turned and repositioned. The interventions indicated to follow facility's policy and procedure on management of pressure sore. According to the facility's undated policy and procedure titled Pressure Ulcer, Interventions and Preventive Measures for Pressure Ulcer included, implement pressure relieving device such as special mattress, use foam, gel or air mattress, document if the resident refused the treatment and the reason why and develop a plan of care and interventions individualized for the resident and their particular risk factor. However, during an observation on the on 7/8/15 at 3 p.m. and on 7/9/15 at 2 p.m. Resident 11 was observed with no pressure relieving device in his wheelchair and his bed. During an interview with RN 1 on 7/9/15 at 3:20 p.m. he stated, Resident 11 usually spends four to five hours in his wheelchair every day or sometimes spends more time in the dining room if he is watching television. In an interview on 7/9/15 at 2:10 p.m., LVN 6 stated, she should have been more assertive in doing Resident 11's plan of care by indicating the specific measures to be done to off-load the site, consulted the dietician, obtained an order for [REDACTED]. On 7/13/15 at 11:20 a.m. during an interview, the DON was asked if the plan of care for the Resident 11 was developed to ensure that the interventions met the residents need since she was part of the interdisciplinary team and in-charge of screening residents with impaired skin breakdown daily, she responded No, I did not review the plan of care. A review of the Resident 11's plan of care dated 1/23/15 titled, Resident at risk for pressure ulcer development indicated, to monitor nutritional status, serve diet as ordered, monitor and record nutritional intake. However, on n 7/13/15 at 2 p.m. during an interview the ADON stated the Dietician had not evaluated Resident 11' s nutritional needs since the resident's pressure sore advanced to stage 11 on 6/28/15. According to the facility's undated policy and procedure titled Care Planning the facility's Care Planning and Interdisciplinary Team is responsible for the development of the individualized comprehensive care plan for each resident. A review of another undated facility policy and procedure titled Prevention of Pressure Ulcers indicated, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed.

Based on observation, interview and record review the facility failed to provide care and services according to the current standard of care, the proposed plan of care and the facility's policy and procedures for 2 of 24 sampled residents (Residents 2 and 4). 1. The facility failed to provide documented evidence that behavioral interventions including non-pharmacological interventions were attempted as stipulated in the facility's policy for one of 24 sampled residents (Resident 2). Resident 2 was receiving an antipsychotic medication ([MEDICATION NAME]) for behavioral management. This deficient practice put Resident 2 at risk for adverse side effects and complications and an increased risk of death, due to a black box warning of the use of [MEDICATION NAME]. 2. Resident 4, who was incontinent (inability to control bowel and bladder) of bowel and bladder, the facility failed to ensure the resident was kept clean and dry to prevent skin breakdown. As a result, Resident 4 developed a moisture-related excoriation (damaged or removed part of the surface of the skin) to both upper buttocks. Findings: 1. On 7/7/15, at 3:50 p.m., during the tour of the facility, Resident 2 was observed lying in bed facing on the left side, staring out the window. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. skin or tissue over a bony area) to the sacrum (a triangular bone in the lower back between the two hipbones). A review of an Admission Minimum Data Set (MDS), an assessment and care screening tool, dated 4/6/15, indicated the resident had clear speech, was able to express needs and understand verbal content. The Brief Interview for Mental Status (BIMS), an assessment of the residents ' ability to repeat three words, orientation to year, month and day, and the ability to recall, Resident 2 scored 7 out of 15 (meaning, the resident was moderately impaired), required extensive assistance in walking and eating, and was totally dependent on staff for transferring, toilet use, and personal hygiene. A review of Resident 2's Medication Administration Record [REDACTED]. A review of a physician's telephone order, dated 6/25/15, and timed at 4 p.m., indicated an order for [REDACTED]. A review of a [MEDICAL CONDITION] assessment dated [DATE], indicated Resident 2 had a behavior of constant yelling and screaming without a valid reason. Resident 2 was seen and examined by a nurse practitioner with a new medication ordered to manage the resident's psychiatric condition. Another [MEDICAL CONDITION] assessment dated [DATE], also indicated the plan of care was to continue to implement managing resident's psychiatric condition. There was no documented evidence of non-pharmacologic interventions implemented prior to initiating the antipsychotic medication to Resident 2, as stipulated in the facility's policy. A review of two care plans, initiated on 6/25/15 titled, The resident uses [MEDICAL CONDITION] medications related to [MEDICAL CONDITION] manifested by constant screaming and crying without valid reason, and Screaming for no apparent reason, did not indicate an individualized approach to address Resident 2's behavior. However, the staff's interventions indicated to discuss with the physician and family of the ongoing need for use of the medication and review behavioral interventions and alternate therapies attempted and their effectiveness as per facility policy. A review of a licensed nurses' progress note, dated 6/27/15, timed at 6:26 p.m., indicated the resident is being monitored for screaming without apparent reason. The resident was alert with confusion, no signs and symptoms of pain or discomfort. The note also indicated the nurse approached the resident when she was yelling loudly and asked resident what was wrong, and if she needed something. The resident stated, she was just singing. On 7/9/15, at 3:55 p.m., during an interview, the director of nurses (DON) stated she could not find the pharmacist's consultant (PharmD) medication regimen review (MRR) for Resident 2 s [MEDICATION NAME]. The DON stated she called the PharmD to ask if he had any reviews or recommendation for Resident 2's [MEDICATION NAME]. According to the DON, PharmD stated he did not have any recommendations yet and the note he wrote on the progress note on 7/1/15 is just to remind him to look at it the next time he reviews Resident 2's clinical record. The PharmD stated it was too early to review Resident 2's MRR because the medication was just ordered on [DATE]. A review of a Psychiatric Follow-up Note, dated 5/27/15 indicated that a psychiatrist diagnosed the resident with dementia. The note also indicated Resident 2 was not on any [MEDICAL CONDITION] medications. On 6/25/15, another Psychiatric Follow-up Note indicated Resident 2 had a [DIAGNOSES REDACTED]. On 7/10/15, 12:30 p.m., during an interview, a certified nurse assistant (CNA 6) indicated that Resident 2's behavior was sudden and it just started sometime 6/2015. The resident had a habit of refusing to be turned or be touched but was never violent. CNA6 stated when Resident 2 screamed she would ask her why and the resident would say she did not know. CNA6 also stated when she would stay with the resident she would stop screaming. On 7/10/15 at 4:10 p.m., during an interview, and after reviewing Resident 2's record, the social services director (SSD) stated she could not find any documented evidence that the facility implemented non-pharmacologic interventions before the psychiatrist started the resident on [MEDICATION NAME]. A review of the Care Plan Conference Summary dated 4/9/15 and 7/2/15 did not indicate documented evidence that the facility's interdisciplinary team had evaluated Resident 2's behavioral problem as to the possible cause and risk factors including implementation on non-pharmacologic interventions. A review of an undated facility policy titled, Medication Management (General) and Gradual Dosage Reduction, indicated that non-pharmacologic interventions are considered before initiating a new medication. The policy stipulated the resident would be evaluated according to the resident's current condition that may include a detailed evaluation of mental, physical, psychosocial, and functional status, including comorbid conditions, resident's goals and preferences and history of prior non-pharmacological interventions. A review of the US Food and Drug Administration (FDA), the FDA Black Box Warning indicated that medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). According to the FDA Black Box Warning, [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. On 7/10/15, at 9:55 a.m., during a telephone interview, the PharmD stated, there are laundry lists of non-pharmacological interventions that should be done before a resident is started on an antipsychotic medication. The PharmD further stated that antipsychotic medications should be the last resort. 2. A review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of an Annual Minimum Data Set (MDS), an assessment and care screening tool, dated 5/10/15 indicated Resident 4 was able to express ideas and wants and had no impairment with decision-making and memory. The MDS functional content for activities of daily living indicated the resident was totally dependent and required two person assist for transferring and toilet use, and an extensive assistance during bed mobility. The MDS also indicated Resident 4 was frequently incontinent of both bowel and bladder function. During a treatment observation with the treatment nurse, a licensed vocational nurse (LVN6) on 7/10/15, at 10:15 a.m., Resident 4 was observed with opened and reddened areas to the right and left upper buttocks. Resident 4 was also observed wearing a diaper and required extensive assistance during bed mobility and personal hygiene. After the treatment observation, Resident 4 was interviewed. Resident 4 stated, I think they needed more nurses. When Resident 4 was asked to elaborate, she stated on 7/4/15, because it was a holiday, she was informed by the facility's staff there were a number of nurses that did not show up for work. Resident 4 stated, I was in my soiled diaper for two and a half hours. Resident 4 stated she had to use her cellular phone to call the nursing station because no one came when she turned the call light on. Resident 4 also recalled, while she was waiting, a certified nurse assistant (CNA3) came and turned off her call light. Resident 4 stated she thought CNA3 would assist her, but instead CNA3 stated, We are going to assign you to another nurse. Resident 4 stated, I felt awful because I was already irritated down there. I felt she could have cleaned me that time, but she left . nobody came until many hours . Resident 4 further stated when a nurse came to clean and change her, she was already sore and hurting down there pointing to her buttocks. Resident 4 also stated the CNAs do not clean her correctly and she was the one who had to suffer for it. The resident stated the night shift's staff, They don't clean me well. On 7/10/15, during an interview with the treatment nurse at 2:30 p.m., LVN 6 stated Resident 4 asked her to check her buttocks a few days prior, because she was feeling sore. LVN6 stated during the body assessment, Resident 4's right and left buttocks were observed to have scattered excoriation (damaged or removed part of the surface of the skin) and redness around the area. On 7/13/15, at 4:45 p.m., during a telephone interview, Resident 4's family member (FM1) stated, They don't have enough help to assist the residents, especially in the evenings . Resident 4 just had an infection and now a diaper rash. FM1 stated on 7/4/15 she had called the nursing station between 5 to 6 p.m. and the facility's staff informed her they were short of nurses and that they would get to Resident 4 as soon as possible. FM1 stated Resident 4 was really upset that day. During an interview on 7/13/15, at 5:15 p.m., CNA4 and translated by CNA5, CNA4 stated she remembered Resident 4 had complained before of waiting for almost two hours to be cleaned after an incontinent episode. CNA4 stated it was on another day, sometime during the prior week before the end of 6/2015 and not the day in question, 7/4/15. CNA4 stated she had to help Resident 4 get cleaned although she was not assigned to her, because the resident had complained that she had been waiting for two hours already. CNA4 stated she recalled when she changed the resident's diaper it was soaked with urine. At 5:50 p.m., on 7/13/15, RN1 stated he remembered on 7/4/15 when Resident 4 called and stated she needed to be cleaned. RN1 stated he went to the resident's room and told the resident he would get help. RN1 told a CNA and endorsed the resident's request to the evening supervisor, a licensed vocational nurse (LVN3) because he was about to go home at that time. On 7/14/15, at 10:15 a.m., during an interview, Resident 4 stated it was not the first time she had to wait for a long time to be cleaned after an episode of incontinence (inability to control bowel and bladder) but was unable to recall exact dates. The resident was asked why she had not reported these incidents to the facility's administration. Resident 4 stated I'm afraid to get anybody in trouble. A review of Resident 4's care plan titled, Risk for skin breakdown due to poor skin integrity in relation to existing pressure sore, incontinence, and impaired mobility dated 8/29/13 and last updated 5/24/15, the staff ' s interventions included following facility policies and protocols for the prevention and treatment of [REDACTED]. A review of an undated facility policy and procedure titled Prevention of Pressure Ulcers indicated pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substance on the resident's skin such as perspiration, feces, urine, wound discharge. One of the general preventive measures included checking residents for incontinence at least every two hours and clean skin when soiled.