Every finding on record at Capital Post Acute

Based on interview and record review, the facility failed to report immediately to the Department an alleged violation involving verbal and physical abuse between two out of four sampled residents (Resident 1 and Resident 4), when Licensed Nurse (LN) 2 did not report an alleged incident of verbal and physical abuse between Resident 1 and Resident 4 after being notified.This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.Findings:A review of an admission record indicated Resident 1 was admitted to the facility with a diagnosis of depression (a serious mood disorder that causes ongoing sadness, hopelessness, and loss of interest in activities once enjoyed).A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 6/29/26, indicated Resident 1's Brief Interview of Mental Status (BIMS) score was 14 out of 15 with good memory.A review of an admission record indicated Resident 4 was admitted to the facility with diagnoses including depression, borderline personality disorder (a serious mental health condition that causes long-term patterns of intense, unstable emotions, poor self-image, and chaotic relationships), and anxiety.A review of Resident 4's MDS, dated [DATE], indicated Resident 4's BIMS score was 15 out of 15 with good memory.A review of Resident 1's Progress Note, dated 8/8/26, indicated Resident 1 reported to staff that her roommate threw ice pitchers at her head and subsequently had a knot form to the right side of her head. The note further indicated Resident 1 stated to staff she was going to call the police and that she was assaulted.During an interview on 8/26/26 at 3:42 p.m. with Resident 1, Resident 1 stated Resident 4 became upset and threw four ice pitchers filled with water and ice towards her. Resident 1 further stated the second pitcher hit her on the head on the right temple area and she reported the incident to LN 2.A review of Resident 4's Progress Note, dated 8/8/26, indicated Resident 4 reported to staff that she became flustered and started banging on her side rail. The note further indicated Resident 4 also reported to staff that this prompted Resident 1 to call her a b***h and a c**t and Resident 4 subsequently threw the pitchers with water and ice in them.During an interview on 8/26/26 at 3:55 p.m. with Resident 4, Resident 4 stated she became frustrated when Resident 1 had a visitor in the room and threw the ice pitchers out of anger. Resident 4 further stated she told LN 2 about the incident and had explained why she threw the pitchers.During an interview on 8/26/26 at 2:37 p.m., with LN 2, LN 2 stated she heard screaming from Resident 1's room and then observed Resident 1 coming out of room. Resident 1 told LN 2 she was hit on the head with an ice pitcher by Resident 4. LN 2 further stated she did not report the abuse allegation to the facility's abuse coordinator and the Department.During an interview on 8/26/26 at 5:10 p.m. with Director of Nursing (DON), DON confirmed the alleged abuse incident between Resident 1 and Resident 4 was not reported to the Department. DON expected staff to follow the abuse reporting policy during any allegation of abuse.During an interview on 8/26/26 at 5:18 p.m. with Administrator (ADM), ADM expected all cases of alleged abuse to be reported to the Department. ADM stated the alleged abuse incident might have been unnoticed if not reported which could possibly delay investigation.A review of the facility's policy titled, Abuse Reporting and Investigation, dated 3/2025, indicated, All reports of resident abuse . are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of investigations are documented and reported . send a written report within two hours to the local law enforcement agency, the California Department of Public Health (CDPH), and the local ombudsman.

Based on observation, interview, and record review, the facility failed to ensure consistent infection prevention and control practices and guidelines for a safe, sanitary and comfortable environment and to prevent the transmission of infections and foodborne illnesses were provided to a census of 199, when:Certified Nurse Assistant 1 (CNA 1) did not wear complete Personal Protective Equipment (PPE, refers to specialized gear and clothing, such as gloves, masks, gowns, goggles, and face shields worn by healthcare workers to create a physical barrier, which protects the wearer from infectious germs, blood, and harmful body fluids, while also stopping the spread of illness between patients) indicated for enhanced barrier precaution (EBP, infection control guidelines used in nursing homes to stop the spread of dangerous, drug-resistant germs) when she touched the contaminated garbage/linen bin and handled/collected soiled linen; Uncovered food left next to a used urinal left on top of the bedside table;Breakfast tray left at Resident 1's bedside table until almost lunch time; and,Resident 1's face, eyebrows, facial beard and nostrils had whitish-to-yellowish-scab-like-crusty-substances. These failures had the potential to result in the spread of infection, foodborne illnesses, skin irritation, bacterial growth and skin infection.Findings:1. During an observation on 8/14/26 at 12:05 p.m. in room [ROOM NUMBER] entrance door, a door signage indicated EBP. Inside room [ROOM NUMBER] was CNA 1. CNA 1 was not wearing any PPE and was observed doing the following: 1) Putting on a lining sheet on top of 108C bed; 2) Touched the dirty/contaminated garbage bin; 3) Put plastic liner to the dirty/contaminated garbage bin; and 4) collected the soiled linens placed on the floor near the garbage bin. During a concurrent observation and interview on 8/14/26 at 12:05 p.m. in room [ROOM NUMBER] with CNA 1, CNA 1 confirmed she was not wearing the required PPE. CNA 1 stated she removed it ahead of time while still inside room [ROOM NUMBER]. CNA 1 confirmed while not wearing PPEs, she touched the contaminated garbage/linen bin, replaced the garbage bin plastic liner and collected the soiled linens she had removed from the residents' beds. 2. During an observation on 8/14/26 at 12:15 p.m., in room [ROOM NUMBER], an uncovered food was placed next to a used urinal. The urinal was on top of the bedside table. There was no urinal holder available at bedside. During a concurrent observation and interview on 8/14/26 at 12:21 p.m. in room [ROOM NUMBER] with CNA 2, CNA 2 confirmed the uncovered food was next to the used urinal placed on top of the bed side table. CNA 2 stated used urinal should be placed to a urinal holder and food should be covered. During a concurrent observation and interview, on 8/14/26 at 12:57 p.m., in room [ROOM NUMBER] with Licensed Nurse 1 (LN 1), LN 1 confirmed the used urinal was on top of the bedside table near the uncovered food. LN 1 stated urinal should be placed on a urinal holder and not on top of the bedside table. LN 1 stated food should be covered and not left next to a urinal for infection control and to prevent cross contamination. LN 1 stated Resident 1 could get sicker when virus or harmful bacteria would spread. 3. During an observation on 8/14/26 at 12:21 p.m., in room [ROOM NUMBER], on top of the overbed table was a meal tray and the meal ticket indicated breakfast for Resident 1. The breakfast meal tray remained on top of the overbed table until almost lunch time. During a concurrent observation and interview on 8/14/26 at 12:21 p.m., inside room [ROOM NUMBER] with CNA 2, CNA 2 confirmed breakfast meal tray was served at around 7 in the morning. CNA 2 confirmed the breakfast meal tray should have been removed and not left next to Resident 1's overbed table, and stated, Someone could offer the food and feed [Resident 1] with cold and stale food from the breakfast meal tray. During a concurrent observation and interview on 8/14/26 at 12:57 p.m., in room [ROOM NUMBER] with LN 1, LN 1 confirmed the breakfast meal tray was still at the overbed table until almost lunch time. LN 1 stated breakfast tray should not be left longer at bedside because at a certain time food could go bad and not edible. LN 1 stated foodborne illness was likely when stale food was ingested or offered by mistake. LN 1 stated when resident refused to eat meals, trays should be taken away within 30-45 minutes. LN 1 also stated food trays left out too long could attract ants and flies, removing the meal trays on time kept the room smelling fresh and clean. LN 1 stated food left for too long could result in possible foodborne illness when consumed.4. During an observation on 8/14/26 at 12:27 p.m. in room [ROOM NUMBER], Resident 1 was in bed, his face, eyebrows, facial beard and nostrils had whitish-to-yellowish-scab-like-crusty-substances. During a concurrent observation and interview on 8/14/26 at 12:57 p.m., in room [ROOM NUMBER] with LN 1, LN 1 confirmed Resident 1's face, eyebrows, facial beard and nostrils had whitish-to-yellowish-scab-like-crusty-substances. LN 1 stated Resident 1 had refused care, but the duty to keep the resident clean was foremost to preserve dignity. LN 1 stated, Keeping resident's 1 skin clean and safe prevents skin breakdown, prevents bacteria from entering the body and prevent skin infections. During an interview on 8/14/26 at 3:25 p.m. with the Director of Nursing (DON), the DON stated her expectations to prevent the spread of infection, cross contamination, foodborne illnesses, and skin irritations/infections while maintaining overall health and safety were: 1) Staff should wear PPEs where indicated and PPEs should be worn while inside the room and handling contaminated garbage bins and soiled linens. 2) Urinals should be placed on a urinal holder and food should be covered. 3) Breakfast meal trays left for long periods of time presented the risk of staff serving stale food to residents and could cause foodborne illness. 4) Resident care refusals should be addressed the same as providing care to the best interest of the Resident by keeping them clean and dignified. A review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, revised 10/2018, the P&P indicated, .PPE appropriate to specific task requirements is available at all times.#3. The type of PPE required for a task is based on: a. The type of transmission-based precaution; b. The fluid or tissue to which there is a potential exposure; c. The likelihood of exposure; d. The potential volume of material; e. The probable route of exposure; and f. The overall working conditions and job requirements.A review of the facility's P&P titled, Bedpan/Urinal, Offering/Removing, revised 02/2018, the P&P indicated, Steps in the procedure #8. Clean the bedpan or urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. Store the bedpan or urinal per facility policy.The United States Food and Drug Administration (FDA), https://www.fda.gov/food/consumers/what-you-need-know-about-foodborne-illnesses - Foodborne disease-causing organisms that frequently cause illness in the United States, indicated, the threats are numerous and varied, with symptoms ranging from relatively mild discomfort to very serious, life-threatening illness. While the very young, the elderly, and people with weakened immune systems are at greatest risk of serious consequences from most foodborne illnesses, some of the foodborne organisms pose grave threats to all people. Foodborne illness (commonly known as food poisoning) is often caused by consuming food contaminated by bacteria and/or their toxins, parasites, viruses, chemicals, or other agents. Foodborne illness occurs when people eat or drink food or beverages contaminated with pathogens, chemicals, or toxins .The Nursing Home Reform Act (a federal law passed in 1987 that sets national quality standards and protects the rights of residents in long-term care facilities): Key Provisions and Standards. Residents' [NAME] of Rights: Grants individuals the right to be free from . abuse, neglect, and mistreatment, alongside rights to privacy, dignity, and self-determination .

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice when:1a. Resident 1's Midodrine (medication to increase blood pressure) order for orthostatic hypotension (a sudden significant drop in the blood pressure after standing up from a sitting or lying position causing symptoms like dizziness or lightheadedness) was not consistently followed; and, 1b. Resident 1's Midodrine PRN (given as needed or requested) order was not clarified and carried out as ordered.These failures increased the potential for Resident 1 to experience dizziness and lightheadedness and potentially increase incidents for falls due to low blood pressure. A review of the admission Record indicated Resident 1 was admitted to the facility March 2026 with diagnoses including metabolic encephalopathy (altered brain function caused by chemical imbalance, epilepsy (sudden, uncontrolled electrical disturbance in the brain which can cause jerking movements, blank stares, and loss of consciousness), lack of expected normal physiological development in childhood (developmental delay), unsteadiness on feet, and dizziness. Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used to screen and identify memory, orientation, and judgement status) dated 3/11/26 was not completed due to Resident 1 was rarely/never understood. The staff assessment for mental status indicated Resident 1 had short-term and long-term memory problems. A review of Resident 1's undated care plan indicated Resident 1 was at risk for falls and/or injuries related to diagnoses including epilepsy and weakness and a care plan for actual fall on 3/13, 4/2, 4/23, 4/47 [sic], 5/3, and 5/14. The interventions included to evaluate postural hypotension, Midodrine medication adjustment and iMRR (interim medication regimen review-consultant pharmacist conducts thorough review of the medication and collaborates with the physician to make necessary medication adjustment).1a. A review of Resident 1's Medication Administration Record (MAR) for the Midodrine order indicated Midodrine HCl (hydrochloride) 5 milligram (mg, unit of measurement) 1 tablet three times a day for orthostatic hypotension. Hold if SBP [systolic blood pressure- the top number in the reading and measures the pressure of the blood pushing against the artery walls when the heart beats] >130 [above 130], the order was dated 3/5/26. The following information below indicated the Midodrine order was not followed: - medication had a check mark (means medication was given) on 3/28 at 8 a.m. for SBP of 138;-medication had check mark for SBP above 130 on 4/1 at 8 a.m. for SBP of 134, on 4/2 at 8 a.m. for SBP of 138, on 4/6 at 12 noon for SBP of 131, and on 4/22 at 8 a.m. for SBP of 132; and,-medication had check mark for SBP above 130 on 5/28 at 12 noon for SBP of 141, and on 5/30 at 8 a.m. for SBP of 155.1b. A review of Resident 1's Change in Condition (COC) Fall note dated 4/27/26 indicated Resident 1 had a witnessed fall in the gym. The COC note further indicated During therapy [Resident 1] wearing gait belt, while therapist working on [Resident 1's] balance.[Resident 1] showed LOB [loss of balance and slid forward.with [both] knees landed on the floor while therapist guarding [Resident 1's] head, and [Resident 1] ended [sic] on [left buttocks side sitting on floor.A review of Resident 1's Interdisciplinary Team (IDT) note dated 4/28/26 indicated Resident 1 had a witnessed fall on 4/28/26 [sic] and the new intervention implemented included iMRR.A review of the 'Consultant Pharmacist's Medication Regimen Review' dated 4/30/26 indicated recommendation to screen Resident 1 for postural hypotension, to review blood pressure (BP) since Resident 1 on Midodrine for hypotension management. The iMRR recommendations were acknowledged by the physician and the physician made written orders which included, Midodrine 5 mg 1 tablet TID every 8 hours PRN?? for BP below 100 and the order was noted on 5/5/26.A review of Resident 1's MAR for May indicated Resident 1 had an order for Midodrine HCl [hydrochloride] 5 mg 1 tablet every 8 hours as needed for hypotension admin [administer] if SBP < 130 [below 130] on 5/15/26. Resident 1's MAR for May did not indicate an order for Midodrine PRN on 5/5/26. A review of Resident 1's BP readings for May indicated Resident 1 had SBP readings below 130 from 5/15 to 5/28 and there was no Midodrine PRN administered.During a telephone interview on 6/18/26 at 2:07 p.m. with the Director of Nursing (DON), the DON stated if there was recommendation from the pharmacy consultant (PC), the facility inform the physician as soon as possible and it would depend on the physician if he/she agrees or disagree with the PC recommendation. During a follow up telephone interview on 6/23/26 starting at 2:13 p.m. with the Director of Nursing (DON), Resident 1's iMRR, MAR from March to May and progress notes were reviewed. The DON confirmed the check mark in the MAR indicated the medication was given and initialed by the licensed nurse. The DON stated Resident 1's iMRR was conducted on 4/30/26, the written orders from the physician were noted by the licensed nurse on 5/5/26 (6 days later) and Midodrine PRN order was clarified on 5/15/26 (10 days later). The DON further stated Resident 1's Midodrine was given when SBP was above 130 on 3/28, 4/1, 4/2, 4/6, 4/22, 5/28, and 5/30. The DON added Resident 1 did not receive Midodrine PRN from 5/15 to 5/28/26. The DON further added her expectation was for the licensed nurse to clarify the Midodrine PRN order if it was not clear. The DON was asked how she interpreted the Midodrine PRN order for Resident 1, the DON stated if the resident's BP remain low after the routine or scheduled Midodrine was given, then the PRN dose can be administered.A review of the facility's policy and procedure dated 4/3/26 and titled, Physician Orders and Telephone Orders indicated, All physician orders shall be documented in the medical record.Orders should be implemented promptly and accurately.If an order is unclear, incomplete, or appears to be a potential error, the nurse shall contact the ordering physician to clarify before implementing the order.The clarification and any modifications shall be documented.

Based on observation, interview and record review the facility failed to maintain an effective pest control program when pests were noted inside the rooms of two of three sample residents (Resident 1 and Resident 2).This failure had the potential to jeopardize the residents' living conditions, their health and safety. A review of Resident 1's clinical record indicated Resident 1 was admitted [DATE] with a diagnosis of encounter for surgical aftercare.A review of Resident 1's MDS (Minimum Data Set- an assessment tool) dated 2/5/26 indicated Resident 1 was cognitively intact.During an observation and interview on 4/29/26 at 11:08 a.m. with Resident 1 in Resident 1's room, a live roach was observed on the floor and a live brown spider 1 inch in length was observed on the sliding door in the resident room. Two (2) roaches were observed on a trap under Resident 1's bed and two 1-inch black spiders and a roach were observed under a wooden cabinet on a trap in Resident 1's room. Resident 1 became angry and stated she felt hurt and uncomfortable by having to sleep with pests in her room. Resident 1 stated the facility is not clean and bugs are found in her room often.During a concurrent observation and interview on 4/29/26 at 11:08 a.m. with Activities Assistant (AA) in Resident 1's room with Resident 1. AA confirmed a live 1-inch brown spider was present in Resident 1's room. AA further confirmed the presence of pests including: One (1) live roach on the floor, 2 roaches on a trap under Resident 1's bed, 1 roach and 2 spiders under a wooden cabinet on a trap by the sliding door in Resident 1's room.A review of Resident 2's clinical record indicated Resident 2 was admitted [DATE] with a diagnosis of essential hypertension. A review of Resident 2's MDS dated [DATE] indicated Resident 2 was cognitively intact. During an observation and interview on 4/29/26 at 11:44 a.m. with Resident 2 in Resident 2's room, Resident 2 was observed sitting in her wheelchair. Resident 2 stated on Saturday (4/25/26) a roach crawled onto her foot while she was in bed and then crawled away in the room. Resident 2 stated she felt uncomfortable in the facility. During an interview on 4/29/26 at 12 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed the presence of pests in Resident 1's room via photographic record review. LN 1 stated the presence of pest is unsanitary and a resident can get an allergic reaction from a bug bite if spiders are present in the Resident's room. LN 1 further stated the presence of pests in Resident 1's room can make the resident feel uncomfortable with care at the facility.During an interview on 4/29/26 at 1:39 p.m. with Director of Nursing (DON), the DON stated the expectation is for residents' rooms to be clean and free of pests.During a review of facility policy and procedure (P&P) titled, .Pest. dated, indicated, .facility maintains an ongoing pest control program to ensure the building is kept free of insects and rodents.

Based on observation, interview and record review the facility failed to maintain proper infection prevention practices for one of three sampled residents (Resident 1) when a licensed nurse did not perform hand hygiene during wound care between changing gloves. This failure increased the potential to contaminate Resident 1's wound. A review of Resident 1's clinical record indicated Resident 1 was admitted in February 2026 with a diagnosis of aftercare following joint replacement surgery. A review of Resident 1's MDS (Minimum data set- an assessment tool) dated 2/16/26, indicated Resident had moderate cognitive impairment.During a concurrent observation and interview on 2/26/26 at 10:37 a.m. in Resident 1's room with Licensed Nurse (LN 1), Resident 1 was observed lying supine in bed with steri-strips to the left thigh. LN 1 was observed placing wound care supplies directly on Resident 1's bed without separation of the clean and dirty area. LN 1 was observed not performing hand hygiene between changing gloves at 10:37 a.m., 10:39 a.m., and 10:41 a.m. LN 1 confirmed that she did not have a separate clean and dirty section which increased the potential for Resident 1 to get infections through cross contamination.During an interview on 2/24/26 at 11:36 a.m. with Infection Preventionist (IP), the IP stated the expectation is to perform Hand hygiene before and after glove changes, sanitize non dedicated equipment after each use. IP stated expectation was to have a separate clean and dirty area during wound care to prevent cross contamination and spread of infections.During an interview on 2/24/26 at 11:49 a.m. with Director of Nursing (DON), the DON stated the expectation is for staff to perform hand hygiene after each glove change and to sanitize equipment after use. DON stated there should be a separate clean and dirty area for items during wound care changes to prevent cross contamination and prevent spread of infections. DON stated the expectation was to maintain infection control practices during direct patient care.During a review of facility Policy and Procedure (P&P) titled, .Hand Hygiene. , Revised October 2023, indicated, .Hand hygiene is indicated . immediately before touching a resident . after touch a resident . immediately after glove removal.During a review of facility Policy and Procedure (P&P) titled, . Wound Care Policy. dated 2/2026, indicated, . Use disposable cloth (paper towel is adequate) to establish clean field .

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 116 when:1. Resident 54's nebulizer mask (a medical accessory that fits over a patient's nose and mouth to deliver medication directly into the lungs) had been sitting outside of the antimicrobial bag exposed for an unknown time; and,2. Staff did not follow enhance barrier precaution and did not perform hand hygiene when providing care for residents in Rooms 403, 404, 405 and 407. Findings:1.During a review of Resident 54's clinical record, indicated Resident 54 was admitted [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and acute and chronic respiratory failure (occurs when not enough oxygen transfers from the lungs to the blood, or when the lungs can't properly remove carbon dioxide from the blood).A review of Resident 54's active physician order, dated 1/14/26, indicated, Use Enhanced barrier precautions [EBP - infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents] required due to (d/t) MDRO [Multidrug-resistant bacteria]- CRE urine cx (culture) 1/6/26 and risk factor (Abdominal Wound: Open surgical incision). Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting.During a concurrent observation and interview on 2/17/26 at 9:20 a.m., 9:24 a.m., and 9:27 a.m., respectively with the Respiratory Therapist (RT), in Resident 54's room, Resident 54's nebulizer mask was observed placed on the nebulizer machine tray, uncovered. RT stated nebulizer masks should be placed in an antimicrobial bag after each use. RT placed the nebulizer mask lying on nebulizer machine tray for unknown time in the antimicrobial bag. RT stated and confirmed that the nebulizer mask should have been changed and placed into an antimicrobial bag after each use to prevent infection.During an interview on 2/19/26 at 10:14 a.m., with the Infection Preventionist (IP), stated the expectation for nebulizer masks was that they should be in an antimicrobial bag when they were not being used to prevent germs or infections from developing. During an interview on 2/19/26 at 11:15 a.m., with the Director of Nursing (DON), sated the expectation for the staff was to follow the infection control policy and procedures. DON stated and confirmed that nebulizer masks were supposed to be in a microbial bag with not being used.During a review of the facility's policies and procedure (P&P) titled, Departmental (Respiratory Therapy)-Prevention of Infection, undated, the P&P indicated, . The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. 7. store the circuit in plastic bag or antimicrobial bag.2. During a concurrent observation and interview on 2/18/26 at 5:53 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 did not sanitize hands before entering room [ROOM NUMBER]. CNA 3 had direct contact with Resident 54. CNA 3 stated, Yes, I am supposed to sanitize my hands before entering a resident's room to prevent infection from spreading.During a concurrent observation and interview on 2/18/26 at 6:45 a.m. with CNA 3, CNA 3 removed gown and gloves in room [ROOM NUMBER] and did not sanitize hands after leaving the room. CNA 3 confirmed hand hygiene was not done and stated, sanitizing is for infection control.During a concurrent observation and interview on 2/19/26 at 9:45 a.m., with Licensed Nurse (LN) 3, LN 3 was changing Resident 54's linens without wearing a gown. LN 3 confirmed Resident 54 was on EBP, and stated linen changes for residents on EBP require wearing a gown and gloves. LN 3 stated, I should have worn a gown when changing linens. LVN stated (if not wearing a gown and gloves) we can transport infections to another resident.During a review of Resident 90's clinical record, the clinical record indicated Resident 90 was admitted [DATE] with diagnosis that included DM (diabetes mellitus-a disorder characterized by difficulty in blood sugar control and poor wound healing,) CKD (progressive damage and loss of kidney function) and cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain).A review of Resident 90's active order, dated 12/17/24, indicated, .[on]EBP.During a concurrent observation and interview on 2/18/26 at 5:56 a.m., with LN 2, LN 2 had direct contact with Resident 90 and did not sanitize hands when leaving the room. LN 2 confirmed hand hygiene was not done and stated not sanitizing hands can spread infection.A review of Resident 1's clinical record indicated Resident 1 was admitted [DATE] with diagnosis that included CVA, pressure ulcer (a small open sore or wound generally found in the stomach or on the skin), dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).A review of Resident 1's active order, dated 7/18/25, indicated, .[on]EBP.During a concurrent observation and interview on 2/18/26 at 6:17 a.m., with CNA 4, CNA 4 did not sanitize hands after direct contact with Resident 1. CNA 4 confirmed Resident 1 was on EBP and stated that not sanitizing hands can spread germs.A review of Resident 40's clinical record indicated Resident 40 was admitted [DATE] with diagnosis that included heart failure (progressive condition where the heart muscle is too weak or stiff to pump blood efficiently to meet the body's needs), failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity).During a concurrent observation and interview on 2/18/26 at 6:39 a.m. with CNA 5, CNA 5 removed gown and gloves in the room after direct contact with Resident 40 and did not sanitize hands after. CNA 5 stated she was supposed to sanitize hands after removing gown and gloves to prevent spread of infection.During an interview on 2/19/26 at 10:14 a.m., with the IP, stated staff were expected to perform hand hygiene (HH) per policy & procedure and to wear a gown and gloves for residents on EBP. IP stated staff were expected to remove the gown and gloves in the room and perform HH before and after performing tasks, and before and after entering rooms. IP stated the purpose of gowning and gloving in accordance with EBP precaution protocol is to prevent the spread of disease and infection.During an interview on 2/19/26 with the DON, stated the expectation for infection control was that staff should follow the policy and procedure to prevent spread of infections from resident to resident and staff. The DON confirmed HH should happen before and after you enter any resident room.During a review of the facility's P&P titled, Handwashing/Hand Hygiene, revised October 2023, and Enhanced Barrier Precautions, revised December 2024, the P&P indicated, .Indications for Hand Hygiene. immediately before touching a resident, after touching a resident, after touching a resident's environment, immediately after glove removal.During a review of the facility's P&P titled, Enhanced Barrier Precautions, revised December 2024, the P&P indicated, EBPs are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents.4. standard precautions apply to the care of all residents regardless of suspected or confirmed infection. 7. EBPs employ targeted gown and glove use. 8. Examples of high-contact resident care. changing linens.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 116 out of 116 residents when: 1.Several metal sheet pans, serving utensils and scoop in clean and ready-to-use storage areas:Were stacked wet while stored awayThere was food debris in scoop and metal strainer [NAME] substance inside of the utensil holder.2.There were bags of food items in the walk-in freezer with issues:1 bag of unopened cream puffs, and two unopened bags of chopped green chilies have freezer burnsWalk in freezer had dark brown substances, white particles and an unknown plastic blue container at the back corner of the freezer floor.These failures had potential to cause food-borne illnesses in a highly susceptible population of 116 out of 116 residents who received food from the kitchen.Findings:1.During a concurrent observation and interview on 2/17/26 at 8:44 a.m., at the kitchen's initial tour with the Certified Dietary Manager (CDM), several metal sheet pans stored at the clean and ready to use areas were observed stacked wet, had food debris, and brown substance. The metal pans included:4 small steam table pans and 1 muffin full sheet pan (wet),1 metal scoop (food debris inside),1 metal strainer with (food debris inside),1 metal utensil holder with brown substance inside.The CDM confirmed the metal sheet pans were wet, the scoop and strainer had food debris, and the metal utensil holder had brown substance inside of it. CDM stated, the metal steam table dishes, pans, pots, and utensils need to be cleaned and air dried before being stacked and stored away.During an interview on 2/19/26 at 9 a.m. with Registered Dietician (RD), the RD stated, dishes, pots and pans, utensils must be fully air dried before stacking to prevent mold, fungus, bacteria to grow that can cause food borne illnesses.During a review of the facility's policy and procedure (P&P) titled, Dishware, Utensils, and Pans drying Policy, undated indicated, .Dishware such as utensils, pots, and pans should be air dried after cleaning and sanitizing. dried items should be stored only in clean designated storage areas.2.During a concurrent observation and interview on 2/17/26 at 9:10 a.m., at the initial kitchen tour, in the walk-in freezer had dark brown substance, scattered white particles on the corner behind the freezer racks, and an unknown plastic blue container on the floor were observed. There was one package of unopened cream puffs, two bags of unopened chopped green chilies that had freezer burns. The CDM confirmed the frozen food had freezer burns and ice crystals inside the bags, and the walk-in- freezer floor had scattered white particles, brown substance, and blue plastic container on the floor.During an interview on 2/19/26 at 9 a.m., with RD, the RD stated, her expectations were, the walk-in freezer must be kept clean. RD further stated any frozen food that has freezer burns must be discarded.During a review of the facility's P&P titled, Refrigerators and Freezers, undated, indicated, .the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, .During a review of the facility's P&P titled, Food Receiving and Storage, undated indicated, .Frozen foods are maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact.

Based on observation, interview, and record review, the facility failed to ensure four residents (Resident 139, Resident 96, Resident 116 and Resident 126) of 32 sampled residents were free of medication administration error rates of five percent or more, when 10 errors out of 28 opportunities for errors occurred during the medication administration to the residents.These failures resulted in medication administration error rates of five percent or more, which was 35.71 %. Findings:1. During a medication administration observation on 2/18/26 at 8:08 a.m., with Licensed Nurse (LN) 5, LN 5 was observed preparing four medications for Resident 139.During a concurrent interview and record review on 2/18/26 at 8:42 a.m., with LN 5, Resident 139's medical record was reviewed. The medical record indicated a physician's order dated 2/15/26 for sucralfate (a medication used to treat and prevent active duodenal [upper small intestine] ulcers) 1 gm (gram, a unit of measurement/strength of medication) .give 1 gm by mouth four times a day, give on an empty stomach, which was scheduled for 7 a.m. LN 5 acknowledged the medication was scheduled to be administered at 7 a.m. and confirmed the medication was administered more than an hour late. LN 5 stated one of the five medication rights is to ensure medications are administered at the right time.2. During a medication administration observation on 2/19/26 at 7:57 a.m., with LN 7, LN 7 was preparing seven medications for Resident 96, which included aspirin (a medication used to reduce the risk of blood clots, heart attacks, and strokes by thinning the blood) 81 mg (milligram, a unit of measure) chewable tablet and 7.5 ml (milliliter, a unit of measure) of ferrous sulfate (an iron supplement used to treat or prevent iron-deficiency anemia by increasing iron levels in the blood) 220 mg/5 ml oral solution, to be administered through Resident 96's percutaneous endoscopic gastrostomy tube (PEG-tube, a soft, flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medication directly, bypassing the mouth and throat).During a concurrent interview and record review on 2/19/26 at 8:17 a.m. with LN 7, Resident 96's medical record was reviewed. The medical record indicated the following physician orders: aspirin 81 mg oral tablet chewable tablet give one tablet via PEG-tube one time a day, dated 2/26/25; ferrous sulfate oral solution 300 (60 Fe) mg/5 ml, give 7 ml via PEG-Tube one time a day, dated 2/27/25; and pantoprazole sodium (used to treat erosive esophagitis and gastroesophageal reflux disease (GERD) by decreasing stomach acid) 40 mg oral packet, give 1 packet via G-Tube [PEG-tube] one time a day. LN 7 acknowledged the aspirin was scheduled to be administered at 9 a.m. and administered early and the administered dose of ferrous sulfate oral solution was incorrect per the physician's order. LN 7 stated, The pantoprazole sodium packet is unavailable, this will be a medication error since we don't have it. LN 7 indicated the physician should be notified when a medication is unavailable or if the medication available is the incorrect dosage solution. LN 7 stated, The physician's order and the medication on hand should match.3. During a medication administration observation on 2/19/26 at 8:50 a.m., with LN 6, LN 6 was observed preparing ten medications for Resident 116 which included aspirin 81 mg chewable tablet.During a concurrent interview and record review on 2/19/26 at 9:07 a.m., with LN 6, Resident 116's medical record was reviewed. LN 6 acknowledged the physician order for aspirin 81 mg chewable tablet, dated 12/15/25. LN 6 stated, I should have instructed [Resident 116] to chew that one [aspirin]. LN 6 acknowledged one of the medication rights was to ensure the medication was taken by the right route and acknowledged the chewable aspirin allowed for faster absorption.4. During a medication administration observation on 2/19/26 at 9:48 a.m. with LN 5, LN 5 was observed preparing eight medications for Resident 126 which included aspirin 81 mg chewable tablet, multivitamin with minerals (a medication that contains a combination of vitamins and minerals), quetiapine (an atypical antipsychotic used to treat mental heath disorders) 50 mg tablet, and fluticasone/salmeterol (dry powder inhaler used twice daily for long-term maintenance treatment of lung disorders) 100-50 mcg (microgram, a unit of measure).During a concurrent interview and record review on 2/19/26 at 10:06 a.m., with LN 5, Resident 126's medical record was reviewed. LN 5 confirmed Resident 126's aspirin, multivitamin with minerals, quetiapine and fluticasone/salmeterol inhaler were administered late. LN 5 acknowledged the importance of administering medications within the scheduled time frame to ensure the efficacy of the medication.During a concurrent interview and record review on 2/20/26 at 1:20 p.m., the Medication Admin Audit Report for medication Cart 2 was reviewed with the Director of Nursing (DON). The DON acknowledged resident medications should be available for administration as scheduled. The DON confirmed medications need to be administered within the scheduled time frame and according to the physician's order to ensure the right dose is administered to ensure the efficacy of the medication. The DON stated, The nurses need to follow the medication rights; which include the right medication, the right time, and the right dose.During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated October 2017, the P&P indicated, Medications are administered as prescribed. Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.During a review of the facility's P&P titled, Medication and Treatment Orders, revised July 2016, the P&P indicated, Orders for medications must include: Name and strength of drug. dosage and frequency of administration. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.

Based on observation, interview, and record review the facility failed to ensure nine residents (Resident 32, Resident 17, Resident 59, Resident 84, Resident 94, Resident 122, Resident 71, Resident 36 and Resident 126) out of 32 sampled residents were free from involuntary seclusion when resident room doors were left closed.This failure had the potential to increase the risk of psychosocial trauma and physical injury when residents were unable to exit their rooms independently or access staff during an emergency. Findings:A review of Resident 32's admission Record (AR) indicated the resident was initially admitted to the facility in January 2024 with diagnoses which included difficulty speaking and dementia (a progressive decline in memory, language and cognitive function severe enough to disrupt daily life).A review of Resident 32's Minimum Data Set (MDS, an assessment tool) dated 11/18/25 indicated Resident 32's had a moderate memory problems.A review of Resident 17's AR indicated the resident was initially admitted to the facility in October 2024 with diagnoses which included difficulty speaking and seizures (sudden, uncontrolled bursts that cause temporary, involuntary changes in movement, behavior and consciousness).A review of Resident 17's MDS, dated [DATE], indicated Resident 17 is rarely to never understood and based on the facility staff's assessment Resident 17's had severe memory problems.A review of Resident 59's AR indicated the resident was admitted to the facility in June 2024 with diagnoses which included dementia and anxiety disorder (an overwhelming feeling of fear, dread, or unease that impacts daily life and mental wellbeing).A review of Resident 59's MDS, dated [DATE], indicated Resident 59 had no memory problems.A review of Resident 84's AR indicated the resident was initially admitted to the facility in August 2016 with diagnoses which included difficulty speaking, anxiety disorder, and psychosis (hallucinations, delusions, or disorganized thinking).A review of Resident 84's MDS, dated [DATE], indicated Resident 84 had moderate memory problems. A review of Resident 94's AR indicated the resident was admitted to the facility in March 2021 with diagnoses which included psychosis, need for assistance with personal care, and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain).A review of Resident 94's MDS, dated [DATE], indicated Resident 94 had severe memory problems. A review of Resident 122's AR indicated the resident was admitted to the facility in July 2019 with diagnoses which included psychosis and mixed receptive-expressive language disorder (a neurodevelopmental condition characterized by significant difficulties in both understanding (receptive) and producing (expressive) spoken language).A review of Resident 122's MDS, dated [DATE], indicated Resident 122 is rarely to never understood and was unable to complete the BIMS interview and based on the facility staff's assessment Resident 122 had severe memory problems.A review of Resident 71's AR indicated the resident was admitted to the facility in February 2025 with diagnoses which included cognitive communication deficit (an impairment in communication, verbal or nonverbal) and the need for assistance with personal care.A review of Resident 71's MDS, dated [DATE], indicated Resident 71had severe memory problems.A review of Resident 36's AR indicated the resident was admitted to the facility in November 2025 with diagnoses which included dementia and the need for assistance with personal care.A review of Resident 36's MDS, dated [DATE], indicated Resident 36 had moderate memory problems.A review of Resident 126's AR indicated the resident was initially admitted to the facility in January 2020 with diagnoses which included psychosis, anxiety disorder, cognitive communication deficit and major depressive disorder with psychotic features (a severe, high-risk subtype of depression where profound sadness is accompanied by hallucinations or delusions).A review of Resident 126's MDS, dated [DATE], indicated Resident 126 had no memory problems. During the initial facility tour observation on 2/17/26 at 8:15 a.m., multiple residents in the 200 - 203 hallway which housed Resident 32, Resident 17, Resident 59, Resident 84, Resident 94, Resident 122, Resident 71, Resident 36 and Resident 126 were heard calling out for various reasons. Resident 126 repeatedly stated, Help me, help me, I need my medicine, I need my medicine, I need my medicine now. Resident 71 repetitively asked, Can I have some toast?During a concurrent observation and interview on 2/17/26 at 8:43 a.m., in the 200 - 203 hallway, with Certified Nursing Assistant (CNA) 8, stated, Yes, the section back here [Resident 32, Resident 17, Resident 59, Resident 84, Resident 94, Resident 122, Resident 71, Resident 36 and Resident 126] is tough, there are a lot of residents who yell and scream.During a follow-up concurrent observation and interview on 2/17/26 at 8:58 a.m. with CNA 8, outside of Resident 71, Resident 36, and Resident 126's shared room, CNA 8 stated, I checked in on [Resident 126] at 6:30 a.m. and as soon as I opened the door the room smelled of urine. CNA 8 stated when she arrived for her morning shift the residents' room doors were closed. CNA 8 stated, The room doors are only closed if the resident is able to ask for it [to be closed], resident room doors are not supposed to have the doors closed due to resident safety. CNA 8 acknowledged the staff at night have a history of closing the resident room doors since there are multiple residents yelling out in this section.During an observation on 2/18/26 at 5:30 a.m., Resident 71's, Resident 36's, and Resident 126's room doors were closed.During an observation on 2/18/26 at 6:03 a.m., Resident 32's, Resident 17's, Resident 59's, Resident 84's, Resident 94's, Resident 122's, Resident 71's, Resident 36's and Resident 126's room doors were closed.During a concurrent observation and interview on 2/19/26 at 9:34 a.m., in the 200 - 203 hallway with CNA 9, CNA 9 acknowledged the various residents calling out for assistance, medication and breakfast. CNA 9 stated, I don't have enough time to care for all of these residents, I do my best, but it's hard. CNA 9 agreed residents should have their room doors open, unless they are able to request the door to be closed and everyone in the room agreed, or if a CNA is providing personal care. CNA 9 stated, Rooms shouldn't be closed just because residents are yelling out.During an interview on 2/19/26 at 1:58 p.m., in the 200 - 203 hallway with Licensed Nurse (LN) 5, LN 5 confirmed resident's room doors should be open for safety, due to the concerns for falls and injuries. LN 5 stated, Some residents can request their doors to be closed, but only if they all [residents] can agree.During an interview on 2/20/26 at 1:20 p.m., with the Director of Nursing (DON), the DON acknowledged the nurse assigned to the 200 - 203 hallway has a tough section and confirmed resident room doors (were closed) should be kept open for safety reasons. The DON agreed if residents are unable to independently exit their room or if staff close the doors to minimize the volume of yelling from residents, this was considered involuntary seclusion. The DON stated, Staff should never be closing resident doors without their permission and only if everyone [residents] in the room agrees.During an interview on 2/20/26 at 3:36 p.m., with CNA 9, LN 5 and Resident 126, CNA 9 and LN 5 agreed the residents' rooms in the 200 - 203 hallway were not to be fully closed due to safety. Resident 126 agreed and stated, No, I do not want my door closed.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/5/25, the P&P indicated, It is the policy of the facility to fully uphold the rights of all residents. Resident Rights: a. Dignity, Respect and Freedom. Be free from abuse, neglect. involuntary seclusion. j. Quality of Life. choose visitors, roommates (consistent with safety and rights of others and as facility availability allows).

Based on observation, interview, and record review the facility failed to ensure one resident's (Resident 105) out of 32 sampled residents, call light was accessible to call for staff assistance, when call light was out of reach. This failure had the potential to result in Resident 105's inability to notify staff if there was an emergency. Findings:A review of Resident 105's admission Record indicated he was admitted to the facility in March 2025 with diagnoses which included subarachnoid hemorrhage (where bleeding occurs between the brain and surrounding tissues) and dysarthria (difficulty speaking).A review of Resident 105's Care Plan (CP, a comprehensive, individualized plan of care) indicated the following concerns and interventions:1. The resident is at risk for alteration in musculoskeletal status: . Be sure call light is within reach and respond promptly to all requests for assistance, dated 4/8/25. 2. At risk for skin breakdown: Keep call light within reach and encourage resident to call for assistance, dated 3/29/25. 3. Resident is at risk for falls and/or injuries: Keep the call light within reach and encourage resident to use it for assistance, as needed, dated 3/29/25. During a concurrent observation and interview on 2/17/26 at 1:32 p.m., with Resident 105 and Family Member (FM), in Resident 105's room, Resident 105's touch pad call light (a circular, flattened pad designed for residents with limited hand movement) was observed hung over a tube feed pump (medical device that delivers liquid formula) attached to a pole out of Resident 105's reach on his right side. Resident 105 was unable to visually locate the call light when prompted. FM stated, They [staff] need to put the call light in [Resident 105's] lap where he can see and reach it.During a concurrent observation and interview on 2/17/26 at 1:53 p.m., with Certified Nursing Assistant (CNA) 2, Resident 105's call light was observed out of Resident 105's visual field and reach. CNA 2 acknowledged Resident 105's call light was out of reach and should be placed within reach in case the resident needed to alert staff during an emergency or if the resident needed assistance.During an interview on 2/20/26 at 1:20 p.m., with the Director of Nursing (DON), the DON stated the call light should always be within reach so residents can call for help or notify staff when they need assistance.A review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, undated, the P&P indicated, All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Staff will ensure the call light is within reach of the resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations with the resident's room.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse from one out of five sampled residents (Resident 89) when Resident 61 slapped Resident 89's right hand.This failure resulted in Resident 89 not being free from abuse by Resident 61, and Resident 89's right to be free from abuse not protected.Findings:During a review of Resident 89's admission Record (AR), indicated, Resident 89 was initially admitted [DATE] with diagnosis including Orthopedics (a medical and surgical specialty focused on the prevention, diagnosis, and treatment of muscles, joints, and bones disorders) Aftercare following Surgical amputation (amputation-a surgical removal of all or part of a limb or extremity to treat severe infection, disease such as diabetes [Diabetes Mellitus -a disorder characterized by difficulty in blood sugar control and poor wound healing]).During a review of Resident 89's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 11/24/25, indicated, Resident 89 had intact memory.During a review of Resident 89's Progress notes dated 2/8/26 at 8:18 p.m., indicated, .CNA [certified nursing assistant] 7, who was present at the time along with CNA 6. Per CNA 6's report, Resident 89 extended his hand outward in front of him as Resident 61 was walking down the hallway toward Resident 89. Resident 61 allegedly made contact with and hit Resident 89's right hand.During a review of Resident 61's AR, indicated, Resident 61 was admitted [DATE] with diagnosis including Cerebral Infarction (a type of stroke where a part of the brain dies due to lack of oxygen caused by a blocked vessel) and Vascular Dementia ( a decline in thinking skills caused by restricted blood flow to the brain often following a stroke) with other Behavioral Disturbance.During a review of Resident 61's MDS dated [DATE] indicated, Resident 61 has severe memory problems.During a review of Resident 35's AR, indicated, Resident 35 was initially admitted [DATE] with diagnosis including Central Cord Syndrome (a type of incomplete spinal cord injury, usually in the neck, characterized by disproportionate weakness in the arms compared to the legs.) at C4 level of Cervical Spinal Cord.During a review of Resident 35's MDS dated [DATE] indicated Resident 35 has intact memory.During a review of a signed note by CNA 6 dated 2/8/26, indicated.Resident 61 was coming in the direction of Resident 89. Resident 89 stretched his hands and told Resident 61 to go back. Resident 61 got angry and started cursing and hit Resident 89.During an interview on 2/19/26 at 3:20 p.m. at Resident 89's room, Resident 89 stated he was at Resident 35's doorway talking with Resident 35 when Resident 61 walked straight at him and slapped his right hand. Resident 89 further stated, Resident 61 was angry and was saying he would kick his butt and hurt him.During an interview on 2/19/26 at 3:35 p.m. at Resident 35's room, Resident 35 stated he witnessed Resident 61's right hand raised up and slapped Resident 89's right hand. Resident 35 further stated, Resident 61 was angry and was yelling at Resident 89 saying, .I'm gonna hurt you.I'll kick your butt.During an interview on 2/19/26 at 4:20 p.m. with the Administrator (ADM), the ADM confirmed that residents in their facility have the right to be free from any form of abuse by any individual.During a review of the facility's policy and procedure (P&P) titled, Resident Right's, dated 12/5/25, indicated, .resident rights. be free from abuse, neglect, misappropriation, exploitation, corporal punishment, involuntary seclusion, and retaliation.'

Based on record review, and staff interview, the facility failed to ensure an alleged violation involving elopement was reported to the State agency within the required time frames. The facility failed to report the elopement of one out of 32 sampled resident (Resident 138) whose whereabouts were unknown on 11/19/25.This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure residents' safety.Findings:During a closed record review on 2/20/26, the admission Record (AR) indicated Resident 138 was admitted on [DATE] with diagnoses of Acute Pyelonephritis (a serious bacterial infection of the kidney, usually caused by a bladder infection that has spread upwards). Resident 138's clinical record indicated, a history of Diabetes Type 1 (DM 1- a chronic autoimmune condition where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas), Bacteremia (the presence of bacteria in the blood stream), Bipolar Disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels), and Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying events, causing long-lasting symptoms like nightmares, flashbacks, severe anxiety, and avoidance of reminders ).Closed review of on 2/20/26 for Resident 138's clinical record also indicated, Resident 138 was on intravenous (giving medicines or fluids through a needle or tube inserted into a vein) antibiotic daily to treat bacterial infection. An outside interfacility medical record review dated 11/19/25 indicated Resident 138 has history of marijuana use and intravenous methamphetamine (controlled drug that needs prescription, highly addictive) abuse.Record review of Resident 138's Progress Notes dated 11/19/25 at 10:58 p.m., indicated .Roughly around 7 p.m., CNA notified charge nurse that the resident was not in her room. per CNA patient was seen 30 minutes before elopement.There was no documented evidence the incident was reported to the State Agency within required timeframes.During a review of facility's incident reporting documentation revealed no submission of a report related to the 11/19/25 elopement.During an interview on 2/20/26 at 11:30 a.m., with Administrator (ADM), and Director of Nursing (DON), confirmed that facility did not report the resident's elopement to the State Agency.During a review of the facility's policy and procedure titled, Resident Rights, dated 12/25 indicated, .any allegation of violating, including privacy breaches, property loss, abuse/neglect.must be reported immediately, investigated per policy and regulatory timelines, and reported to California Department of Public Health (CDPH), law enforcement, and or the ombudsman as required.

Based on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 38 and Resident 41) received assistance with their Activities of Daily Living (ADLs-normal daily functions required to meet basic needs) when Resident 41 and Resident 38 had long facial hair and long fingernails with blackish substance underneath.This failure had the potential to negatively affect their self-esteem, comfort, and personal hygiene.Findings:During a review of Resident 41's admission Record (AR), the AR indicated Resident 41 was re-admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (damage to the heart caused by long term unmanaged high blood pressure), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness and depression (persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities).During a review of Resident 41's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/3/25, the MDS indicated, Resident 41 did not have any memory or cognitive impairment. The MDS also indicated, Resident 41 required substantial/maximal assistance with shower/bathing and partial/moderate assistance with personal hygiene.During a review of Resident 38's AR, the AR indicated Resident 38 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition (severe deficit in energy and protein intake leading to significant weight loss), rhabdomyolysis (rare muscle injury where the muscles break down), dementia (a progressive state of decline in mental abilities) and anxiety disorder (persistent, excessive, and uncontrollable worry or fear that interferes with daily life.)During a review of Resident 38's MDS, dated [DATE], the MDS indicated, Resident 38 had moderate impairment in memory and cognition. The MDS also indicated, Resident 38 was dependent on staff assistance for shower/bathing and personal hygiene.During a concurrent observation and interview on 2/17/26 at 9:44 a.m., with Resident 41, in Resident 41's room, Resident 41 had long, thick facial hair. Resident 41 stated staff did not offer to shave or trim his beard and that he needed his beard trimmed and his fingernails cut. Resident 41 showed his fingernails, which were observed to be long with black substance underneath.During an interview on 2/17/26 at 9:47 a.m., with Director of Staff Development (DSD), in Resident 41's room, the DSD stated that on shower days the certified nursing assistant (CNA) checked residents' nails and facial hair. The DSD stated the CNA could trim facial hair and perform nail care, which included cutting and cleaning the nails. The DSD further stated that if a resident was diabetic, the nurse would perform the nail care. At 9:51 a.m., the DSD observed and confirmed that Resident 41 had long facial hair and long fingernails and required trimming. Resident 41 stated he got food stuck in his facial hair and that was why he needed it trimmed. The DSD stated it was important to trim facial hair and nails for infection control and hygiene purposes and that residents could injure themselves if their fingernails were long.During a concurrent observation and interview on 2/17/26 at 10:16 a.m., with Resident 38, Resident 38 was observed with long facial hair and long fingernails with black substance underneath. Resident 38 stated he would appreciate having his facial hair and nails cut and did not recall being offered assistance with trimming.During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised 4/25, the P&P indicated, .appropriate care and services are provided for residents who are unable to carry out ADLs independently with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care).

Based on observation, staff interview, and record review the facility failed to provide for two residents (Resident 138 and Resident 139) out of 32 sampled residents:Adequate supervision when Resident 138 eloped the facility without staff being aware of Resident 138's whereabouts; and,No smoking assessment completed for Resident 139.These failures placed residents at risk for serious injury, harm, or death related to elopement and fire hazards.Findings: 1.During a closed record review on 2/20/26, the admission Record (AR) indicated Resident 138 was admitted on [DATE] with diagnoses of Acute Pyelonephritis (a serious bacterial infection of the kidney, usually caused by a bladder infection that has spread upwards). Resident 138's medical record indicated, a history of Diabetes Type 1 (DM 1- a chronic autoimmune condition where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas), Bacteremia (the presence of bacteria in the blood stream), Bipolar Disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels), and Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing terrifying events, causing long-lasting symptoms like nightmares, flashbacks, severe anxiety, and avoidance of reminders ). Resident 138's medical record also indicated, Resident 138 was on intravenous (giving medicines or fluids through a needle or tube inserted into a vein) antibiotic daily to treat bacterial infection. An outside interfacility medical record review dated 11/19/25 indicated Resident 138 has history of marijuana use and intravenous methamphetamine (controlled drug that needs prescription, highly addictive) abuse. A review of Resident 138's order summary report indicated she was receiving intravenous (IV) antibiotic, Ertapenem Sodium Injection Solution 1 Gram (IV antibiotic) use 50 ml intravenous one time a day.until 11/24/25. During a review of Resident 138's Progress Note (PN), dated 11/19/25, the PN indicated, .roughly around 7 p.m., Certified Nurse Assistant (CNA) notified the charge nurse that the resident was not in her room.CNA reported last seeing Resident 138 approximately 30 minutes prior to the elopement. The facility medical record did not contain the following: An individualized nursing assessment for Resident 138 addressing risk for unauthorized departure. Documentation that Resident 138's behavioral and medical history were evaluated in relation to supervision needs. Documentation of physician notification at the time of departure. Documentation verifying Resident 138 safety during the period of absence. Documentation of Interdisciplinary Team Notes related to Resident 138's elopement. Documentation of Resident 138's stated intent to leave against medical advice (AMA) nor a refusal to sign an AMA form. Resident 138 remained absent overnight without documented verification of her location or her safety. During an interview on 2/20/26 at 11:30 a.m., the Administrator and Director of Nursing (DON) confirmed that the facility was unaware of Resident 138's whereabouts when she eloped on the night of 11/19/2025. No documented evidence that Resident 138 came back the following day. No documented evidence that Resident 138 was found at all. During a review of the facility's policy and procedure titled, Elopement Prevention and Response Policy, undated, indicated, .facility identifies residents at risk for elopement and follows a structured response when a resident leaves the facility without authorization, or required supervision. Actions are based on assessed risk, resident capacity, and regulatory requirements . 2. Review of Resident 139's admission Record, indicated that Resident 139 was admitted [DATE] with diagnoses including arthritis due to other bacteremia (joint inflammation caused by infection), emphysema (chronic lung disease in which air sacs become damaged), asthma (chronic lung disease that causes airway lining to become inflamed) and tobacco use. Review of Resident 139's records on 2/17/26, indicated no smoking assessment was completed and no care plan in place related to smoking. During an observation on 2/17/26 at 1:30 p.m., Resident 139 was in the designated smoking area with other residents and was in possession of cigarettes in her purse. During an interview on 2/19/26 at 8:45 a.m., with Licensed Nurse (LN) 1, LN 1 stated that upon admission, each resident undergoes a smoking assessment, and a staff member provides education on the associated risks and safety precautions. During an interview on 2/19/26 at 9:10 a.m., with Activities Director (AD), AD stated she is responsible for the smoking assessments and was not sure if Resident 139 was a smoker. AD confirmed that a smoking assessment was not done for Resident 139. During an interview on 2/19/26 at 1:40 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that he provided care for Resident 139 for two shifts and stated that Resident 139 smoked outside about two times per shift. During an interview on 2/19/26 at 2:19 p.m., with the Director of Nursing (DON), DON stated her expectation would be that every resident who smokes have a smoking assessment done on admission. The DON further stated if the smoking assessment was not done it could place the residents at risk for safety concerns. Review of the facility policy and procedure (P&P), titled, Resident Smoking Policy, undated, the P&P indicated, The interdisciplinary team.will help to support the resident's right to make an informed decision regarding smoking by: a) including the resident. in discussions regarding the risks associated with smoking, d) developing a safe smoking plan .and 15 b)assessment of relevant functioning and cognitive factors affecting ability to smoke safely.

Based on observation, interview and record review, the facility failed to ensure safe storage of medication for one (Resident 139) out of 32 sampled residents.This failure resulted in the facility's inability to monitor Resident 139's medication administration, placing Resident 139 at risk for improper dosing and non-therapeutic medication levels.Findings:Review of Resident 139's admission Records, indicated that Resident 139 was admitted on [DATE] with diagnoses including anxiety disorder (a condition characterized by persistent worry and interferes with daily life), panic disorder (a condition that is characterized by unexpected panic attacks) and depression (a condition that causes persistent sadness that affects how a person feels, thinks and functions in daily life).Review of Resident 139's clinical record indicated no Interdisciplinary Team (IDT-a group of healthcare professionals who collaborate assess and plan a resident's care) notes, no order and no care plan indicating Resident 139 was able to self-administer medications safely.During a concurrent observation and interview on 2/17/26 at 2:36 a.m., in Resident 139's room with Licensed Nurse (LN) 2, Resident 139 was found to have a container of Trazadone (a medication used to treat depression) 100 mg (milligram, unit of measure) tablets with directions give 1-2 tablets at bedtime for depression. LN 2 confirmed this finding and stated that storing medications with a resident's personal belongings was not consistent with the facility policy.During an interview on 2/19/26 at 8:38 a.m., with LN 1, LN 1 stated if a resident were to have medications in their possession, it would require a physician's order, care plan and awareness by the IDT. LN 1 further stated that the resident's cognitive status would be assessed to determine if this was appropriate.During an interview on 2/19/26 at 2:16 p.m., with the Director of Nursing (DON), the DON stated that the facility does not allow residents to keep medication in their possession unless there was a physician's order and the IDT did assessement and approved. The DON stated the potential negative outcomes could be a resident not receiving the correct dose, overdose and inability of nursing staff to monitor medication administration.Review of the facility policy and procedure (P&P), titled, Medication Ordering and Receiving from Pharmacy, dated August 2014, indicated, Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after contents are verified.and if the packaging meets facility's guidelines.

Based on interview and record review, the facility failed to ensure resident's food preference was honored for one of 32 sampled residents (Resident 5) when Resident 5's request for a diet upgrade was not followed.This failure had the potential to negatively impact the residents' food intake and well-being.Findings:During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was re-admitted on [DATE] with diagnoses that included injury of cervical spinal cord (uppermost part of the spinal cord), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and adjustment disorder with depressed mood (persistent, intense, and long-lasting feeling of sadness or a loss of interest in activities).During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/5/25, the MDS indicated, Resident 5 did not have any memory or cognitive impairment. The MDS also indicated Resident 5 did not have any swallowing disorder.During an interview on 2/17/26 at 9:15 a.m., with Resident 5, Resident 5 stated he had been cleared a couple of weeks prior for an upgrade to the next texture level above puree. Resident 5 stated he received one meal tray with the upgraded texture but had continued to receive pureed meals. Resident 5 stated he wanted his diet upgraded.During a review of Resident 5's Progress Note (PN), dated 11/2/25, indicated, Resident 5 had a swallow evaluation completed by the speech language pathologist (ST-speech therapist; treats speech and swallowing disorders) and was cleared for a regular diet with thin liquids but requested to remain on pureed diet at that time. The PN indicated Resident 5 could request a diet upgrade without a speech therapy order.During an interview on 2/19/26 at 10:51 a.m., with Registered Dietician (RD), the RD stated Resident 5 had been on a pureed diet until she changed the diet texture on 2/17/26. RD stated that resident preferences should be honored.During a concurrent interview and record review on 2/19/26 at 11:00 a.m., with Certified Dietary Manager (CDM), Resident 5's Diet Order Change History (DOCH), dated 2/19/26 was reviewed. The DOCH indicated Resident 5's diet was changed from pureed to regular texture in the dietary department's nutritional system on 2/18/26. The CDM confirmed diet order was changed on 2/18/26 and stated the one upgraded meal tray Resident 5 received was a trial tray.During an interview on 2/19/26 at 4:12 p.m., with Director of Nursing (DON), the DON stated there was documentation in the progress note indicating a diet change for Resident 5; however, the diet order was not carried out. The DON confirmed the diet change should have been carried out when the resident requested the upgrade.During a concurrent interview and record review on 2/20/26 at 10:16 a.m., with Speech Therapist (ST), Resident 5's PN, dated 1/28/26 was reviewed. The PN indicated speech therapy received an order to evaluate Resident 5 for a diet upgrade to soft texture, an evaluation was completed on 11/1/25 with a recommendation for a regular diet, documented that Resident 5 affirmed request to trial of soft and bite-sized diet with thin liquids, noted the electronic health record (EHR) order would be updated and dietary notified, PN also indicated the provider was free to adjust (upgrade or downgrade) the diet based on Resident 5's preference. The ST stated the diet upgrade should have been ordered once Resident 5 requested it, as he had been cleared to upgrade or downgrade based on his preference.During a review of the facility's policy and procedure (P&P) titled, Resident Food Preference, revised 07/17, the P&P indicated, .modifications to diet will only be ordered with the resident's or representative's consent.During a review of the facility's P&P titled, Resident Rights, dated 12/5/25, the P&P indicated, .it is the responsibility of all staff to honor resident rights.Resident rights. j. Resident Choice: make decisions about personal routines, participation in activities and aspects of daily living.

Based on interview and record review the facility failed to ensure necessary treatment and care services was provided for one (Resident 118) of 32 sampled residents in accordance with professional standards of practice when rehabilitation referral for restorative nursing (RNA) was not started right away for Resident 118.This failure had the potential to place Resident 118 at risk for decline in functional ability, including decreased mobility and muscle strength.Findings:During a review of Resident 118's admission Record (AR), the AR indicated Reisdent 118 was re-admitted on [DATE] with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), paraplegia (loss of movement and/or sensation, to some degree, of the legs) and muscle wasting/atrophy (weakening, shrinking, and loss of muscle).During a review of Resident 118's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/22/25, the MDS indicated, Resident 118 did not have any memory or cognitive impairment. The MDS also indicated Resident 118 did not receive any restorative programs the last 7 days.During an interview on 2/17/26 at 10:01 a.m. with Resident 118, Resident 118 stated he had a concern with his therapy services and felt therapy was initiated late, just last month. Resident 118 further stated he has MS and expressed concern regarding potential decline in strength and mobility in his upper extremities.During an interview on 2/19/26 at 11:23 a.m. with Director of Rehabilitation (DOR), DOR stated Resident 118 was discharged from physical therapy (PT) on 12/18/25 and discharged from occupational therapy (OT) on 12/17/25.During a review of Resident 118's RNA Program Referral, dated 12/17/25, the RNA referral indicated a referral for a therapeutic exercise/range of motion (ROM) program, including upper and lower extremity passive range of motion (PROM) exercises three times a week per week as tolerated. The RNA referral also indicated the exercises were reviewed with the rna and licensed nurse overseeing the program, with an effective date of 12/19/25.During an interview on 2/19/26 at 3:14 p.m. with Director of Staff Development (DSD), DSD stated Resident 118 was started on RNA in January 2026.During an interview on 2/19/26 at 3:37 p.m. with DOR, DOR stated once RNA training was completed and the referral was entered, it was provided to the staff member overseeing the restorative program. The DOR stated the RNA typically began the program right away, which might not be the same day as the referral, but that an almost two-week delay was too long.During an interview on 2/19/26 at 3:39 p.m. with DSD, DSD stated expectation was for the RNA program to begin right away. The DSD stated a delay in starting the program could result in a delay of care, which could lead to a decline in the resident's functional ability.During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, revised 07/17, the P&P indicated, .residents may be started on a restorative nursing program upon admission, during the course of the stay or when discharged from rehabilitative services.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1), when the facility failed to identify, implement and monitor new interventions to prevent falls after Resident 1 fell at the facility on 1/4/26 and fell twice more on 1/10/26.These failures could have contributed to a fall on 1/13/26 that resulted in a broken clavicle (a break in the outer end of the collarbone, often caused by a direct fall onto the shoulder causing intense pain), pain, and a four-day hospitalization for Resident 1. Findings:Resident 1 was admitted to the facility on [DATE] with multiple medical diagnoses which included dementia (a progressive state of decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 1/6/26, the MDS indicated, .brief interview for mental status [BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident] be conducted .No [Resident 1] is rarely/never understood .cognitive skills for daily decision making severely impaired .never/rarely made decisions. The MDS indicated Resident 1's functional status required two-person assistance with dressing, bathing, toileting hygiene (cleaning after voiding or bowel movement), and transferring on and off the toilet. Resident 1 required one-person assistance with oral and personal hygiene (brushing teeth, combing hair, etc.), transferring to and from a bed to a chair, and with standing from a seated position.During a review of Resident 1's physician progress note (PPN), dated 1/6/26, the PPN indicated, [Resident 1] Baseline functional status: nonverbal, poor participation, history of falls, requires assistance for ADLs, feeding, and mobility. Baseline cognitive status: minimally interactive, unable to engage in meaningful interviews, lacks capacity for informed consent.Resident 2 was admitted to the facility in March 2019. Resident 2 had a BIMS score of 13 out of 15 which indicated Resident 2's cognitive function was intact.During an observation on 1/26/26 at 2:30 p.m. in Resident 1's room, an attempted interview was made. Resident 1 made eye contact, but Resident 1's words were impossible to understand. Resident 1 could not participate in the interview. No fall mats were observed on either side of Resident 1's bed on the floor.During an interview on 1/26/26 at 3:57 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 had fallen in the facility and required transfer to the emergency department on 1/13/26. LN 1 stated she joined Certified Nursing Assistant (CNA) 1 in Resident 1's shared bathroom when she heard Resident 2 screaming for help. LN 1 stated she saw Resident 1 lying on the bathroom floor; Resident 1 was confused and had difficulty communicating. LN 1 stated Resident 2 reported Resident 1 had hit his head. LN 1 stated 911 was called and Resident 1 was transported to the hospital on 1/13/26.During an interview on 1/26/26 at 4:09 p.m. with CNA 1, CNA 1 stated Resident 1 had fallen in the facility on 1/13/26. CNA 1 stated Resident 1 was impulsive, confused, and a known fall risk. CNA 1 stated when he entered Resident 2's room, he saw Resident 1 lying on the bathroom floor. CNA 1 stated he alerted LN 1 and remained with Resident 1 until paramedics arrived at the facility.During an interview on 1/26/26 at 4:18 p.m. with Resident 2, Resident 2 stated he witnessed Resident 1 fall on 1/13/26. Resident 2 stated he was in his room when he saw Resident 1 standing in the shared bathroom. Resident 2 saw Resident 1 trip and fell forward hitting his head hard against the door then fell backwards and hit the back of his head when he landed on the ground. Resident 2 stated Resident 1 began shaking and shaking on the floor of the bathroom. Resident 2 stated he turned on his call light and yelled for nursing staff as loud as I could.During an interview on 1/26/26 at 4:44 p.m. with LN 2, LN 2 stated he was familiar with Resident 1. LN 2 stated he had witnessed Resident 1 fall in the facility on 1/10/26, prior to 1/13/26 fall, and referred to Resident 1's progress notes (PN), dated 1/10/26.During a concurrent interview and record review on 1/28/26 at 12:06 p.m. with Administrator (Admin) and Director of Nursing (DON), Resident 1's care plan (CP), dated 1/4/26 and 1/10/26, Resident 1's IDT Fall [IDTF], dated 1/6/26, 1/12/26, and 1/12/26, and Resident 1's PN, dated 1/4/26 and 1/10/26 were reviewed.During a review of Resident 1's CP, dated 1/4/26, and revised on 1/10/26 and 1/13/26, indicated, [Resident 1] has had an actual fall with no injury [on] 1/4/2026.[on] 1/10/2026.[on] 1/13/2026.During a review of Resident 1's progress note (PN), dated 1/4/26, the PN indicated, This nurse and another nurse heard [roommate] scream, 'Man down!' Upon arrival [Resident 1] was on the floor next to the bed . [Resident 1] has discoloration to the R [right] forehead, which contradicted Resident 1's CP, dated 1/4/26, which indicated Resident 1 sustained no injuries from the fall on 1/4/26. DON acknowledged the discrepancy and stated the PN could be expanded.DON stated Resident 1's fall on 1/4/26 (a weekend) was reviewed by the interdisciplinary team (IDT). DON stated she had not interviewed any nursing staff or residents to investigate Resident 1's fall on 1/4/26, nor had she instructed any other staff to do so. DON stated Resident 1's CP had been updated on 1/4/26. During a review of Resident 1's CP, dated 1/4/26 indicated, Monitor/document /report PRN [as needed] x 72h [72 hours] to MD [medical doctor] for s/sx [signs and symptoms]: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. DON stated no other steps were taken to identify, monitor or prevent Resident 1 from future falls. During a review of Resident 1's CP, dated 1/4/26, no new interventions were indicated to prevent falls.During a review of Resident 1's IDT Fall [IDTF], dated 1/6/26, the IDTF indicated, New Fall Prevention Intervention Implemented: Sent to hospital for eval [evaluation], Report to EMT [Emergency Medical Technician], which contradicted Resident 1's MR, that did not indicate Resident 1 was sent to the hospital on 1/4/26.During a review of Resident 1's PN, dated 1/10/26, the PN indicated, [Resident 1] had. unwitnessed fall .no visible injuries noted.During a review of Resident 1's IDTF, dated 1/12/26, the IDTF indicated, New Fall Prevention Intervention Implemented: fall mats and lower bed, which contradicted Resident 1's CP which did not indicate fall mats.During a review of Resident 1's IDTF, dated 1/12/26, the IDTF indicated, Nurse witness [Resident 1] roll to R [right] side of bed, falling out of bed, colliding head with roommates bed, onto floor. [Resident 1] LOC [loss of consciousness] for 20 sec [seconds] .active bleeding noted from R [right] forehead .[Resident 1] nonverbal, when asked if in pain [Resident 1] nods head up.down .[Resident 1] transferred to [emergency department] .New Fall Prevention Intervention Implemented: transfer to acute.During a review of Resident 1's Prehospital Care Report [PCR], dated 1/10/26, the PCR indicated, [Resident 1] .presented with a [one] inch laceration above his right eye. During a review of Resident 1's ED [Emergency Department] Provider Notes [EDN], dated 1/10/26, the EDN indicated, FALL .after closed head injury .small right frontal abrasion [an injury located on the forehead, forehead region, or face, caused by the friction or shearing of the skin against a rough surface, characterized by the scraping away of the outermost layer of skin]. During a review of Resident 1's ED RN [Registered Nurse] Flowsheet [EDRNF], dated 1/10/26, the EDRNF indicated, Wound Skin Tear 1/10/26 Right: Upper Face .IRRIGATION [a continuous flow of liquid] .DRY DRESSING.During a review of Resident 1's CP, dated 1/10/26, the CP indicated, [Resident 1] is at risk for falls .Interventions .Anticipate and meet [Resident 1's] needs .Educate [Resident 1] about safety reminders and what to do if a fall occurs .Pt [Physical Therapy] evaluate and treat as ordered or PRN [as needed], however Resident 1's CP, dated 12/31/25 already indicated, [Resident 1] is at risk for falls .Interventions .Anticipate and meet [Resident 1's] needs .Educate [Resident 1] on fall prevention .Refer resident to physical therapy .if indicated, which indicated the interventions added by the facility on 1/10/26, were not new interventions to prevent future falls for Resident 1.DON stated Resident 1's falls on 1/10/26 had occurred over the weekend and both falls were reviewed by IDT on the following Monday. DON stated Resident 1's CP had been updated by the activities department over the weekend to include activities, but during a record review of Resident 1's CP, dated 12/31/25, CP indicated,[Resident 1] is at risk for falls .Encourage resident to participate in activities that promote exercise and physical activity for strengthening and improved mobility, which indicated the activities intervention was not new and had been added upon Resident 1's admission. In addition, during a review of Resident 1's CP, an updated activities care plan was not found for the falls on 1/10/26. DON stated Resident 1's interventions were evaluated when Resident 1 was transferred to the hospital and assessed upon return. DON did not state any other steps were taken to identify, monitor or prevent Resident 1 from future falls. DON further stated Resident 1 had not sustained any injuries from the falls on 1/10/26 based on nursing assessments and hospital records, which contradicted Resident 1's EDN, dated 1/10/26, and Resident 1's IDTF, dated 1/12/26.Admin and DON stated they were aware of Resident 1's fall on 1/13/26. DON stated Resident 1 had been hospitalized on [DATE] and returned to the facility on 1/17/26 and was diagnosed with a right clavicle fracture, which contradicted Resident 1's CP, dated 1/4/26 and revised on 1/13/26, which indicated Resident 1 sustained no injuries from the fall on 1/13/26. DON stated there were no witnesses to the fall and she did not investigate further nor speak with any staff or residents about the fall.During a review of Resident 1's PCR, dated 1/13/26, the PCR indicated, Responded C-3 [Code three-an emergency, high-priority response by police, fire, or EMS units, requiring the immediate use of both emergency lights and sirens] to [facility] for [Resident 1] who fell hit his head on thinners [medications that prevent or reduce the risk of blood clots forming in blood vessels, the heart, or veins by interrupting the body's clotting process)]. Staff stated: [Resident 1] roommate reported a loud bang in bathroom .[Resident 1] laying on floor .does take [thinners] and did get his dose today, small bump to back of his head, old bump above rt [right] eye, from fall several days ago .staff reports bump to back of head .ED [Emergency Department] notification of trauma alert [a formal, pre-hospital notification to a hospital that they are transporting a critically injured patient who meets specific physiological or anatomical criteria].During a review of Resident 1's Orthopedic [specialty physician focused on the bones, joints, ligaments, tendons, muscles, and nerves] ER [Emergency Room] Consult [OEC], dated, 1/14/26, the OEC indicated, Reason for consult: R distal clavicle fx [right distal clavicle fracture] .[Resident 1] minimally verbal .mumbling answers .says yes to pain in his right clavicle .tender to palpation [the medical technique of using hands and fingers to feel the body's surface and underlying structures to assess] over the fracture site.During a review of Resident 1's Trauma admission History and Physical Note [TAHP], dated 1/13/26, the TAHP indicated, Imaging .[chest x-ray - a form of high-energy electromagnetic radiation used to produce images of the body's internal structures to diagnose conditions such as fractures] result date: 1/13/26 IMPRESSION: 1. Acute appearing [acute appearing fracture refers to a bone break that looks recent on imaging (X-ray) .these injuries, caused by sudden trauma or falls, result in immediate, severe pain, swelling, and bruising, and are distinct from chronic overuse injuries] distal right clavicular fracture [a break in the outer end of the collarbone, often caused by a direct fall onto the shoulder causing intense pain] with overlying soft tissue swelling.During a review of Resident 1's Trauma Discharge Summary [TDS], dated 1/17/26, the TDS indicated, Date of admission [hospital] 1/13/26 .date of discharge 1/17/26 .reason for admission .fall at SNF [skilled nursing facility] and sustained RIGHT clavicle fx [fracture] .NWB RUE [non-weight bearing right upper extremity] .medically stable for discharge to SNF.During a review of the facility's policy and procedure titled, Falls - Clinical Protocol, dated March 2018, indicated, The staff .will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .Frail elderly individuals are often at greater risk for serious adverse consequences of falls .If the individual continues to fall, the staff .will reevaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions.During a review of the facility's policy and procedure titled, Assessing Falls and Their Causes, dated March 2018, indicated, Continue to collect and evaluate information until the cause of falling is identified .If the cause is unknown but no additional evaluation is done .nursing staff should note why .When a resident falls, the following information should be recorded in the resident's medical record: Appropriate interventions taken to prevent future falls.During a review of the facility's policy and procedure titled, Comprehensive Assessments, dated October 2023, indicated, Comprehensive .assessments are conducted to assist in developing person-centered care plans.

Based on interview, and record review, the facility failed to protect one of five sampled residents from abuse (Resident 1) when a Certified Nursing Assistant (CNA) hit Resident 1 on the head and the CNA, along with Witness 1 and Witness 2, physically restrained Resident 1 during care.This failure resulted in violation of Resident 1's right to be free from abuse of any type and had the potential to result in physical and psychosocial harm.Findings:During a review of Resident 1's admission record, Resident 1 was admitted in February of 2025 with diagnoses of Traumatic Hemorrhage of Cerebrum (bleeding within the brain tissue), Dementia (disorder affecting memory, thinking, language, and problem-solving) and muscle weakness. Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment (a score of 11 out of 15 suggests the individual has noticeable issues with memory and orientation, requiring more support for daily living tasks). During an interview on 12/12/25 at 11:11 a.m. with Director of Staff Development (DSD), the DSD reported that there were two students that witnessed a CNA hit Resident 1 on the head. The DSD stated, .They [Witness 1 and Witness 2] witnessed the abuse .they [Witness 1 and Witness 2] were petrified .the teacher came to my office with the two students, and they told me the story of what happened. The DSD further stated, the witnesses reported, .she [CNA] used her hand to open slap him [Resident 1] on the face . During an interview on 12/12/25 at 12 p.m. with the Director of Nursing (DON), the DON stated it is never ok to hit or restrain a resident. The DON explained that her expectation is, .every resident should be treated with kindness and respect . The DON reported that after the incident, . [CNA] was suspended and terminated. During an observation and interview on 12/12/25 at 12:40 p.m. with Resident 1, Resident 1 was laying down in bed. Resident 1 declined to be interviewed about the incident. During an interview on 12/12/25 at 1:09 p.m. with the DON, when a policy for restraints and/or policy on restraining residents was requested, the DON stated that she is unsure if they have a restraint policy. Per the DON, it is not the policy of the facility to restrain residents. During an interview on 12/16/25 at 8:36 a.m. with the Clinical Instructor (CI), the CI reported that Witness 1 and Witness 2 reported to her that the [CNA] that they were assigned to shadow, hit Resident 1 on the head during the resident's care. During an interview on 12/16/25 at 8:45 a.m. with Witness 1, Witness 1 stated, We [Witness 1 and Witness 2] were assisting her [CNA] with his [Resident 1] care .we were changing his [Resident 1] brief [incontinent brief] .when we were changing his [Resident 1] shirt .that is when she [CNA] hit him [Resident 1] on the forehead .one time with an open hand .I knew I had to report this .it is not ok to hit someone . During an interview on 12/16/25 at 8:54 a.m. with Witness 2, Witness 2 stated, .we CNA, [Witness 1 and Witness 2] had to give him [Resident 1] a brief [incontinent brief] change. she [CNA] lost control in a way and hit him [Resident 1] with her hand, on his [Resident 1] temple area of his head.we [Witness 1 and Witness 2] felt really uncomfortable .no one should ever place hands on a patient.he [Resident 1] doesn't deserve that . Witness 2 reported [CNA] instructed her and Witness 1 to hold Resident 1's arms and legs during this incident. Witness 2 stated, . [CNA] held his [Resident 1] left arm, and I [Witness 2] was able to hold down his [Resident 1] legs .During an interview on 12/17/25 at 8:44 a.m. with the CNA, the CNA reported that she was asked to have Witness 1 and Witness 2 observe her providing care to Resident 1. CNA reported that during providing care to Resident 1, she observed Witness 1 and Witness 2 holding Resident 1's hand and legs. CNA further reported that she was terminated from her employment at the facility after the investigation stemming from the incident with Resident 1. During a follow up interview on 12/17/25 at 9:41 a.m. with the CI, the CI reported that Witness 1 and Witness 2 have both received training on abuse. During a follow up interview on 12/17/25 at 9:49 a.m. with Witness 1, Witness 1 stated, . [CNA] said that [Resident 1] was violent, so she [CNA] told me that I needed to hold his [Resident 1] arms and [Witness 2] to hold his [Resident 1] legs . Witness 1 reported that she observed Witness 2 holding Resident 1's legs. Witness 1 reported that she received abuse training at her school. During a follow up interview on 12/17/25 at 9:52 a.m. with Witness 2, Witness 2 stated, [Witness 1] had his [Resident 1] right arm and I had his [Resident 1] legs.[CNA] told us to hold him [Resident 1] because he [Resident 1] is aggressive so to hold his [Resident 1] legs and arms down.so that he would not kick at me . Witness 2 reported that she observed Witness 1 holding Resident 1's right arm. Witness 2 reported that she observed [CNA] holding Resident 1's left arm. Witness 2 reported that she received abuse training at her school.During a review of CNAs personnel file, in a review of record titled Training/Correction/Disciplinary Action Form dated 11/18/25, under category labeled, Employee Comments: it indicated that, . [CNA] admitted to restraining patient during resident care . This record was signed by the DSD. During a review of the facility's Policy and Procedure (P&P) titled Abuse Prevention Policy dated 3/17/2025, the P&P indicated, Residents have the right to be free from all forms of abuse .This includes but is not limited to freedom from physical abuse, verbal abuse, mental abuse, neglect, sexual abuse .The facility prohibits and prevents the forms of abuse .

Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) was free from abuse when facility staff witnessed Resident 4 hit Resident 3 with an object.This failure resulted in Resident 3 to feel unsafe in the facility and had the potential for Resident 3 to be harmed.Findings:During a review of Resident 3's clinical record, Resident 3 was admitted [DATE] with diagnosis that included bilateral below the knee amputation (surgical removal of the leg below the knee), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/26/24, Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 3 had intact cognitive.During a review of Resident 4's clinical record, Resident 4 was admitted [DATE] with diagnosis that included depression, anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), psychoactive substance abuse (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior).During a review of Resident 4's MDS, dated [DATE], Resident 4 had a BIMS score of 14 out of 15 which indicated Resident 4 had intact cognitive.During a review of Resident 3's change of condition (COC), dated 11/14/25, the COC indicated Resident 3 had been involved in an altercation (a noisy argument or disagreement) with another resident.During an interview on 11/18/25 at 10:10 a.m. with the Administrator (ADM), the ADM stated staff reported that Resident 3 and 4 were having a hostile (unfriendly and aggressive) argument and while staff were separating them, Resident 4 threw a dessert cup at Resident 3 hitting Resident 3 on the right eye.During an interview on 11/18/25 at 10:49 a.m. with Resident 3, Resident 3 stated Resident 4 threatens him all the time. Resident 3 stated Resident 4 was yelling threats while walking toward him in the hallway on 11/14/25 and when staff tried to intervene (come between to prevent or alter a result or course of event), Resident 4 threw something at him, hitting his right eye. Resident stated, I don't feel safe around here.During an interview on 11/18/25 at 11:12 a.m. with Resident 5, Resident 5 stated he has heard Resident 4 threaten to physically harm and kill Resident 3. Resident 5 confirmed that he saw Resident 4 throw something that hit Resident 3 on the eye on 11/14/25. During an interview on 11/18/25 at 11:16 a.m. with Resident 6, Resident 6 stated he has heard Resident 4 threaten Resident 3 saying, I will beat his ass. Resident 6 stated he witnessed Resident 4 throw something at Resident 3 and it hit Resident 3's eye.During an interview on 11/18/25 with Licensed Nurse (LN) 1 and LN 2 at 2:55 and 4:02 p.m., both stated that Resident 3 and 4 were verbally fighting in the hallway and Resident 4 threw a pudding cup at Resident 3 and hit Resident 3 in the face.During an interview on 11/18/25 with Certified Nurse Assistant (CNA) 1 and CNA 2 at 3:05 p.m. and 3:25 p.m., they both stated Resident 3 and 4 were arguing and Resident 4 threw something at Resident 3, hitting Resident 3.A review of Resident 3's care plan initiated 10/4/24 and 10/8/24, indicated, The resident is/has potential to be physically aggressive r/t Anger, Depression, Poor impulse control related to 10/4/2022 argument incident with another resident; 10/8/24- slapped other resident's face. Interventions included Staff to closely monitor resident to remain distant with the other resident involved in the argument. Monitor episodes of aggressive behavior/s and intervene accordingly. When the resident becomes agitated: Intervene before agitation escalates. A review of Resident 4's care plan initiated on 10/17/25, indicated, The resident has potential to verbally aggressive r/t poor impulse control. Interventions included, Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document.During an interview on 11/18/25 at 4:06 p.m. with the DON, the DON stated she and the ADM were unaware of the ongoing tension between Residents 3 and 4. The DON stated the expectation is that staff report abuse. During a review of the facility's Policy and Procedure (P&P) titled, Abuse Prevention Policy dated 3/14/2025, the P&P indicated, Residents have the right to be free from all forms of abuse. This includes but is not limited to freedom from physical abuse, verbal abuse. Staff will be instructed to report any risks of abuse.

Based on interview and record review, the facility failed to adhere to established facility policy and procedures and nationally recognized standards of practice for 1 of 3 sampled residents (Resident 1) when: 1. The secondary (hallway) ventilator (a machine designed to provide mechanical breathing by moving air into and out of the lungs when a person is unable to perform the function for themselves) alarm (an auditory and visual notification system designed to alert staff of ventilated resident problems) was disabled; 2. The primary ventilator (on the machine itself) alarm was reduced to the minimum auditory level; and 3. The parameter for the abnormal respiration (breathing) rate alarm for Resident 1 was set at 60 breaths per minute, too high to be effective (normal adult respiratory rate at rest is ,d+[DATE] breaths per minute). These failures led to the injury and subsequent death of Resident 1 when his ventilator tubing (the tubing that carries air from the ventilator to the patient's lungs) became disconnected and deprived Resident 1 of oxygen necessary for life. Findings: According to the Admission Record, Resident 1 was a [AGE] year old, admitted to the facility in the fall of 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE], Respiratory Assessment, indicated Resident 1 was alert and cooperative, his color was pink, and his respiration rate was 26. His breath sounds were clear (no [MEDICATION(S)] or wheezing). His sputum (saliva and [MEDICATION(S)] that comes out of the lungs and throat) was described as clear and thin. 1. During an interview with Licensed Vocational Nurse (LVN) 1 on [DATE] at 7:55 a.m., she stated on [DATE] at the beginning of her shift around 6:30 a.m., as she was organizing her cart in front of room [ROOM NUMBER], she heard a pulse oximeter (device used to measure the oxygenation of the blood) alarm and ventilator alarm. LVN 1 stated she had never before heard these 2 alarms go off at the same time (indicating Resident 1 was not receiving enough oxygen); she looked up at the monitor mounted at the end of the hallway and noticed there was no reading. She then looked in Resident 1's room and noticed Resident 1, his eyes were closed and his skin was pale. She called out [Resident 1]! and noticed .the [ventilator] tubing was disconnected from the ventilator . The pulse oximeter and ventilator displays were both flashing and a whooshing sound was coming from the ventilator tubing. LVN 1 stated she reconnected the tubing, got the attention of the Respiratory Therapist (RT) 1, and they initiated CPR (cardio pulmonary resuscitation or chest compressions with assisted breathing for someone who's heart has stopped) while a student RT was sent to the nurse station to initiate a code blue (an emergency situation when emergency medical services (EMS) is contacted and emergency services are requested). During an interview with RT 2 on [DATE] at 10:55 a.m., she stated she had begun her shift at 6:00 a.m. on [DATE], and had just finished speaking with the outgoing RT. Her cart was set up near the cart of LVN 1. She stated that is when LVN 1 got her attention regarding Resident 1, she could not remember seeing or hearing an alarm in the hallway. RT 2 stated the lights on top of the ventilator of Resident 1 were flashing (indicating an audible alarm should be heard). On [DATE], review of the Room Detail, [DATE] through [DATE] was provided by [Vendor 1]. The report indicated the hallway alarm, also known as the secondary alarm, for Resident 1 was disconnected on [DATE] at 10:02 a.m. and not reconnected until [DATE] at 7:00 a.m., 25 minutes after the initiation of the code blue for Resident 1. During a phone interview with the [Vendor 1] on [DATE] at 1:25 p.m., he confirmed that Resident 1's alarm for the hall display was disconnected from [DATE] at 10:02 a.m. until [DATE] at 7:00 a.m., as indicated on the undated Room Detail report. During an interview with RT 1 on [DATE] at 8:20 a.m., he stated the hallway alarm system should sound if the ventilator tubes become disconnected. The facility policy and procedure titled Clinical Alarms - Maintenance and Use Of dated [DATE], indicated, All clinical alarms and medical equipment alarm systems utilized for patient care shall be properly operational and alarms are activated when the appropriate settings are in use. The facility policy and procedure titled Ventilator Maintenance/Monitoring - Recommended Parameters dated [DATE], stipulated, A patient-ventilator maintenance/monitoring shall be performed by an RT every four (4) hours for those patients requiring mechanical ventilation for life support. Patient-ventilator checks for all other patients shall be performed every 4 hours. In addition, a check shall be performed: .After any changes in ventilator settings . Furthermore, the policy noted, Patient-ventilator maintenance/monitoring shall be a documented evaluation of a mechanical ventilator and of the patient's response to mechanical ventilatory support. This procedure is often referred to as a ventilator check .Objectives: .Verify and document that alarms are operational prior to use and at least once per shift when the ventilator is in use .That alarms for airway disconnection and other system disturbances are functional and are set correctly and turned on. During an interview with RT 3 on [DATE] at 12:55 p.m., she stated there were 7 ventilator checks that they were performing (each shift to ensure all aspects of the ventilator are functional) prior to [DATE] but .At that time we weren't doing [every] 1 [hour] checks to make sure the secondary alarm is plugged in . 2. During a phone interview with [Vendor 2] on [DATE] at 10:40 a.m., he stated, upon inspection of Resident 1's ventilator machine on [DATE], the manually-adjusted volume on the ventilator, which may be set from ,d+[DATE], was set at its lowest setting of 1. He could not state when the volume setting was adjusted. During an interview with RT 4 on [DATE] at 1:00 p.m., she stated, The machine alarms should be [set] at 10, or full volume, because that is the first [ventilator] alarm. During a phone interview interview with LVN 2 on [DATE] at 1:40 p.m., she stated she participated in the code after she found out Resident 1 was unresponsive and During the code, I didn't hear any alarms. During a phone interview with Registered Nurse (RN) 1 on [DATE] at 1:55 p.m., she stated, I did not hear an alarm during the code. RN 1 stated she was on the unit in another resident's room. During an interview with RT 3 on [DATE] at 12:55 p.m., she stated there were 7 ventilator checks that they were performing (each shift to ensure all aspects of the ventilator are functional) prior to [DATE] but .At that time we weren't doing [every] 1 [hour] checks to make sure the .primary alarm volume is set at 10. The facility policy and procedure titled Ventilator Maintenance/Monitoring - Recommended Parameters dated [DATE], directed, .Documentation shall include .Documentation that alarms can be heard in the surrounding patient care environment by staff. 3. During an interview with RT 3 on [DATE] at 12:55 p.m., when referring to the upper limit setting for respiration rate alarm, stated, Everybody was at 45, that's where they should have been. During an interview with RT 4 on [DATE] at 1:00 p.m., when asked why the respiration rate alarm on the ventilator would be set at 60, she stated, So it would not alarm. The facility policy and procedure title Ventilators - Guidelines dated [DATE], indicated, Ventilator changes are to be made only with a physicians order and by the Respiratory Therapist. All changes must be documented on the ventilator flow sheet .Routine ventilator rounds/checks are to be made and documented every six (6) hours on the ventilator flow sheet. A request was made to the Director of Nursing to provide documentation of primary and secondary alarm checks and respiration rate alarm changes; no documentation was provided. According to the Prehospital Care Report Summary (ambulance report), dated [DATE], the ambulance was at the facility at 6:47 am. The report indicated Resident 1, .was last seen normal at [6:45am] CPR started at [7:02am] and patient found in PEA (Pulseless Electrical Activity- a heart rhythm where the heart is not beating). Patient bagged (provided rescue breathing) . The report went on to indicate Resident 1 regained his pulse and was loaded into the ambulance. En route to the hospital Resident 1 went back into [CONDITION(S)] (no heart beat) again. Resuscitation efforts continued upon arrival to the Emergency Department (ED). The hospital Discharge Summary, dated [DATE], indicated, .On the morning of [DATE], [Resident 1] was found to be unconscious and pulseless. He was resuscitated x 2 and brought to the ED. He was found to be hypotensive (low blood pressure), hypothermic (low body temperature), and unresponsive , .[Resident 1] has been unable to regain consciousness, except for spontaneous eye opening, no tracking or following commands , and, per family discussions, he was transitioned to comfort care (comfort focus care with no further resuscitative efforts) on [DATE] and passed away. The Certificate of Death, issued on [DATE], listed Resident 1's immediate cause of death as, [CONDITION(S)]. The underlying causes leading to the immediate cause was listed as, Acute on Chronic Respiratory Failure.

Based on interview and record review, the facility failed to ensure Resident 1 was free from physical abuse when Resident 1 was held down and had a towel placed over her face when Certified Nurse Assistants (CNAs) provided care. This failure resulted in Resident 1 to have expressed fear and anxiety and experienced pain in the arm and discoloration on bilateral forearms. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Quarterly MDS (Minimum Data Set-an assessment tool), dated 9/3/21, described Resident 1 as able to make herself understood and as having the ability to understand others. The MDS described Resident 1 as having a BIMS (a brief screening that aids in detecting cognitive impairment) score of 13 which indicated she was cognitively intact and as having no [CONDITION(S)] or behavioral symptoms. Review of Resident 1's SBAR-Alleged Abuse Report of Incident, dated 10/12/21, indicated Resident 1 called 911 and stated, she was abused by staff member, residents states that (sic) she was held down by certain CNA . The form documented Resident 1 was interviewed by a nurse and the Social Service Director (SSD). Resident 1 stated, she was held down by CNA and it hurt her arm. Review of Resident 1's SBAR-Alleged Abuse Report of Incident, dated 10/12/21, indicated under a Social Services Note that, Resident expressed fear and anxiety regarding CNA providing continued care. Review of Resident 1's, Skin Inspection Assessment-V3, dated 12/12/21, indicated Full head to toe done, only issues noted were discoloration on bilateral forearms. Review of a facility form, Interview/Investigative Record, dated 10/11/21, indicated CNA 1 went back into Resident 1's room to help change her due to Resident 1 is supposed to be 2 person assist. CNA [CNA 1] asked for permission to help change resident, resident stated no, CNA [CNA 1] proceeded to help B/C (because) she felt the other CNA needed help. Patient [Resident 1] scratched CNA, held residents hands down, pt (patient) kicked her & called her a [OBSCENITY] , she proceeded to spit. CNA 1 then threw a towel on her face to protect self until care was complete. Review of a facility form Interview/Investigative Record, dated 10/12/21, indicated CNA 2 was interviewed. CNA 2 stated Resident 1, Didn't want to be change; linen soiled transfer bed to w/c (wheelchair) to clean bed; pt (patient) kept pulling off brief. Spit on [CNA 1]; kick [CNA 1]; cussed at [LN 1]. Held arm/hand shut to keep resident safe. CNA 2 did not see towel on mouth or hands held down. Asked [CNA 1] how she protected herself from spit, [CNA 1] said she put towel. Review of facility form, Interview/Investigative Record dated 10/26/21, indicated CNA 2 was interview again by the facility via telephone on 10/26/21. According to the form CNA 2 stated, [CNA 1] held hands shut and at side of body, with grip around wrists. CNA 2 stated Resident started to spit, I saw CNA 1 hold towel on face to cover mouth, not nose or eyes. CNA 1 held towel on face because she [Resident 1] was sitting up, when resident laid down, towel rested on face. Review of the facility document Interview follow up for [CNA 1] undated indicated [CNA 1] holding the pt (patient) hand down, she held her arm down on the side of her body, around her wrist to her side, while pt was held down [CNA 2] was changing her [Resident 1] brief. Review of CNA 1's Disciplinary Action Notice, dated 10/18/21, indicated CNA 1 failed to provide resident care consistent with respect for patient's right to refuse. The notice also indicated CNA 1 failed to provide care consistent with facility policy and procedure with respect to residents right to refuse as evidenced by restraining patient to provide care, patient refusing care. Under the section Summary of disciplinary action to be taken . revealed the allegation of abuse has been substantiated. Under the section Consequence of failure to abide by policy: revealed CNA 1 was terminated. Review of CNA 2's, Disciplinary Action Notice, dated 10/18/21, indicated CNA 2 failed to provide resident care consistent with respect for patients right to refuse. The notice indicated, Allegation of abuse has been substantiated .Consequence of failure to abide by policy: termination. Review of the facility's policy, Abuse Prevention, Intervention, Investigation & Crime Reporting Policy revised November 2016 indicated, The resident has the right to be free from abuse .This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; and ensuring that residents are free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. In an interview with the Assistant Director of Nursing (ADON) on 10/19/21 at 11:25 a.m., she confirmed the allegation was substantiated and both CNAs were terminated.