Every finding on record at Chino Valley Health Care Cente

Based on interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices when complete and accurate temperature logs were not maintained for three of three washing machines (WM 1, WM 2 & WM 3).This failure had the potential to result in the development and transmission of disease (an illness or sickness) and infections to the residents (in general).Findings:During an interview on 8/28/2026 at 12:32 PM with the Maintenance Supervisor (MS), the MS stated WM 1 had not been working since 8/14/2026.During a concurrent interview and record review on 8/28/2026 at 3:42 PM with the Laundry Service Worker (LSW), the Laundry Washer Dryer Temperature Monitoring Log, (LWDT) dated August 2026, was reviewed. The LWDT indicated temperatures for WM 1 were recorded for the evening shifts of 8/20/2026 - 8/23/2026. The LWDT indicated no temperatures were recorded for WM 2 and WM 3 the evenings of 8/24/2026 - 8/27/2026. The LSW stated WM 1 was broken and was not used 8/20/2026-8/23/2026 and the temperatures were written in error. Additionally, the LSW stated the LSW used WM 2 and WM 3 on 8/26/2026 and 8/27/2026 but did not record the temperatures on the LWDT.During an interview on 8/28/2026 at 3:55 PM with the Director of Nursing (DON), the DON stated it was important to maintain complete and accurate LWDT to ensure proper infection control was maintained for the facility's linens.During a review of the facility's Policy and Procedure titled, Infection Control, revised April 2023, the P&P's policy statement indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection. The P&P's policy interpretation and implementation indicated, The objectives of our infection control policies and practices are to: prevent, .and control infections in the facility; maintain a safe, sanitary, and comfortable environment for.residents.provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment.During a review of the facility's undated P&P titled Laundry Water Temperature, the P&P's policy indicated, Water temperature for laundry using non-ozone (a gas used in cleaning) cleaning equipment will be maintained at 140 degrees Fahrenheit or above to ensure proper disinfection is provided. The P&P's procedure indicated, The laundry personnel will maintain a log of daily laundry water temperatures to ensure that water is maintained at the appropriate temperature to provide proper disinfection of soiled linen. Any reduction in temperatures will be reported to maintenance and appropriate corrective interventions will be taken.

Based on interview and record review the facility failed to ensure an adequate number of Licensed Nurses worked in the facility on the NOC shift (overnight shift from 11:00 pm to 7:00 am) on 6/12/2026, in accordance with the facility's Facility Assessment Tool (FAT, facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies).This failure had the potential to result in residents receiving inadequate care and supervision which could have led to falls, elopement, and delayed recognition of residents (in general) significant changes in condition.During a review of the facility's census dated 6/12/2026, the census indicated the facility had a North and South station, with a total of 97 residents in-house (in the facility).During a review of the facility's Nursing Staffing Assignment and Sign-In Sheet (NSASIS), dated 6/12/26, with a shift start time of 11 pm, the NSASIS indicated Registered Nurse (RN) 2 was assigned to the facility's North Station. The NSASIS indicated a strike through (single horizontal line drawn through an error so the original text remains legible, used to correct mistakes without hiding date) RN 2's name with the letter's C/O next to RN 2's name. The NSASIS did not indicate an employee's signature for the 6/12/2026, 11:00 pm shift.During a review of the facility's NSASIS, dated 6/12/26, with a shift start time of 11 pm, the NSASIS indicated RN 1 was assigned to the facility's South Station. The NSASIS did indicate RN 1's signature for the 6/12/2026, 11:00 pm shift.During a review of the facility's untitled assignment sheet, dated 6/12/2026 to 6/13/2026 for the 11:00 pm to 7:00 am shift, North Assignment, the untitled assignment sheet indicated RN 1 was assigned to the facility's North station.During a review of the facility's untitled assignment sheet, dated 6/12/2026 to 6/13/2026 for the 11:00 pm to 7:00 am shift, South Assignment, the untitled assignment sheet indicated RN 1 was assigned to the facility's South station.During a concurrent interview and record review on 7/20/2026 at 3:45 pm with the Director of Nurses (DON), the FAT, the NSASIS from 6/12/2026, and Licensed Nurses Timecards were reviewed. The facility's planned staffing for the 11:00 p.m. to 7:00 a.m. shift consisted of two licensed nurses. The DON stated that on 6/12/2026, one of the scheduled licensed nurses called off (C/O), resulting in only one licensed RN providing licensed nursing coverage for the overnight shift. The DON stated that the facility did not staff the overnight shift in accordance with its staffing plan due to the unexpected call-off.During a review of facility's Policy and Procedure (P&P) titled, Staffing, dated 10/2017, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.During a review of the facility assessment tool titled, Facility Assessment Tool, dated 6/9/2026 of assessment or update, the assessment tool indicated, [.] Example 2. Describe the facility's general staffing plan to ensure that it has sufficient staff members with the appropriate competencies and skill sets necessary to meet the needs of the residents at any given time, as identified through resident assessments and care plans. [.] Staff: licensed nurses (LN): RN, LPN, LVN providing direct carePlan: 11(pm)-7(am) (shift): 1 RN, 1 LVN charge nurse [.].

Based on observation, interview, and record review, the facility failed to ensure the facility was free of five percent or greater medication error rate. The facility had three total medication errors in 33 opportunities for errors yielding a total of 9.09 percent error rate during medication pass (process through which medication is administered [the act of giving a treatment, such as a drug, to a patient]) for one of five sampled residents (Resident 43) when: 1. Licensed Vocational Nurse (LVN) 3 did not administer a delayed release (a drug that does not dissolve or release its active ingredient right away when swallowed) aspirin (ASA, a medication used to treat mild to moderate pain) to Resident 43.2. LVN 3 did not administer Resident 43's lamotrigine (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] disorders) per physician orders when Resident 43 swallowed the medication whole instead of chewing it. 3. LVN 3 did not measure Resident 43's diclofenac (a powerful pain killer used to treat mild to moderate pain, swelling, and joint stiffness) topical gel prior to administration. These failures resulted in Resident 43 receiving an inaccurate dosage of diclofenac and had the potential to result in compromised absorption and therapeutic effect (the desired, beneficial effect of a medical treatment or intervention) of ASA and Lamictal for Resident 43. Findings: During a review of Resident 43's Face Sheet (FS, admission record), the FS indicted Resident 43 was re-admitted to the facility on [DATE] with diagnoses including seizures and fibromyalgia (a long-term condition that causes widespread pain). During a review of Resident 43's History and Physical (H&P), dated 5/13/2026, the H&P indicated Resident 43 did not have the capacity to understand and make decisions. During a review of Resident 43's Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2026, the MDS indicated Resident 43's cognitive (the ability to think and process information) skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 43 required partial/moderate assistance (helper does less than half the work) with toileting, showering, upper and lower body transfers, and sit to stand position. During a review of Resident 43's Order Summary Report (OSR), dated active as of 6/12/2026, the OSR indicated the following medications were ordered on 5/11/2026: 1. ASA 81 [mg-a unit of measurement] oral tablet delayed released, give 1 tablet by mouth one time a day for cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain) prophylaxis (a medication used to prevent the onset or spread of a disease). 2. Lamotrigine oral tablet 25 mg, give 3 tablets by mouth one time a day for absence seizure disorder (a seizure characterized by brief episodes of blanking out or staring into space). The order indicated to chew 3 tablets daily. 3. Diclofenac Sodium External Gel 1%, apply to bilateral (both sides) shoulders topically (applying a medication directly onto the skin) two times a day (BID) for pain management, apply 2 grams (gm - unit of measurement) bilaterally. During a medication pass observation on 6/12/2026 at 9:02 AM with LVN 3, LVN 3 was observed preparing Resident 43's medications. LVN 3 placed one tablet from Resident 43's ASA bottle labeled, chewable aspirin into a medicine cup (MC). LVN 3 took three tablets from Resident 43's Lamotrigine 25 mg bubble pack (a customized monthly pill organizer where medications are sorted into individual, sealed compartments) which indicated, Chew three tablets daily and placed them into the same MC. LVN 3 proceeded to squeeze an unmeasured amount of diclofenac ointment into another MC. LVN 3 walked to Resident 43's bedside and handed Resident 43's ASA and lamotrigine tablets to the resident. Resident 43 swallowed all tablets in the MC without chewing the tablets. LVN 3 proceeded to scoop the diclofenac ointment from the MC and applied the ointment to Resident 43's shoulders. During an interview on 6/12/2026 at 9:32 AM with LVN 3, LVN 3 stated Resident 43 did not chew the aspirin and lamotrigine tablets per pharmacy instructions on the medication labels. LVN 3 stated the facility should follow pharmacy instructions so the medications could be correctly absorbed. LVN 3 stated LVN 3 was supposed to administer 2 grams of diclofenac. LVN 3 stated LVN 3 did not know how much diclofenac LVN 3 administered to Resident 43. LVN 3 stated it was important to give the correct amount of diclofenac [2 grams] to avoid overdosing Resident 43. During an interview on 6/12/2026 at 4:02 PM with the Director of Nursing (DON), the DON stated it was important to follow physician orders and pharmacy instructions to ensure proper absorption of medications and to ensure the medications' therapeutic effects were met. During a review of the facility's policy and procedure (P&P) titled Administering Medications, revised April 2019, the P&P's policy statement indicated, Medications are administered in a safe and timely manner, and as prescribed. The P&P's policy interpretation and implementation indicated, Medications are administered in accordance with prescriber orders . The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in one of one kitchen (Kitchen 1) when the following was observed: On 6/9/2026, an open container, filled with a white flaky powder substance, was unlabeled and undated in Kitchen 1's cooking area. On 6/9/2026, [NAME] (CK) 1 was not wearing a beard cover while preparing food in Kitchen 1. On 6/11/2026, one of two sampled sanitizing solution buckets (Solution Bucket, SB 1) did not have the correct concentration required to effectively kill bacteria (microscopic single-celled organisms some can make people sick) and organisms from kitchen surfaces in accordance with the facility's policy and procedure (P&P) titled, Sanitizing Equipment and Surfaces. These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) or foodborne illness (a sickness caused by eating or drinking food and beverages contaminated with harmful germs, parasites, or toxic chemicals) to the residents consuming the facility's food. Findings: 1. During an observation on 6/9/2026 at 8:38 AM in Kitchen 1, there was an open, half full, container in Kitchen 1's cooking area. The container had a white flaky powdery substance and was unlabeled and undated. During an interview on 6/11/2026 at 1:22 PM with the Dietary Supervisor (DS), the DS stated all food items must be properly labeled and dated to ensure accurate identification of the product being served and to prevent the distribution of expired food to the residents (in general). During an interview on 6/12/2026 at 11:37 AM with the Facility Dietician (FD), the FD stated food should be labeled and dated to prevent expired food from being served to the residents. During a review of the facility's undated P&P titled, Storage of Canned and Dry Goods, the P&P's policy indicated, Food and supplies will be stored properly and in a safe manner. The P&P's procedure indicated, Remove food from packaging boxes upon delivery to minimize pests. The P&P indicated loose items like cookies, crackers, sugar packets, etc. should be placed in containers or bins. The P&P indicated bins will be dated, labeled, and covered. 2. During an observation on 6/9/2026 at 8:45 AM in Kitchen 1's food preparation area, CK 1 had a beard and mustache and was not wearing a beard cover. During an interview on 6/9/2026 at 8:46 AM with CK 1, CK 1 stated a beard net cover should be worn to prevent hair follicles from falling into the residents' food. During an interview on 6/11/2026 at 1:22 PM with the DS, the DS stated beard nets were required to prevent hair from contaminating residents' food. The DS stated contaminated foods could result in residents getting sick. During an interview on 6/12/2026 at 11:37 AM with the FD, the FD stated beard nets were used [by kitchen staff] for food safety purposes and to prevent cross-contamination. Additionally, the FD stated bacteria grew in hair and if ingested could get the residents sick. During a review of the facility's undated P&P titled, Sanitation and Infection Control, the P&P's policy indicated, Food service employees will follow infection control policies to ensure the department operates under sanitary conditions at all times. The P&P's procedures indicated, [NAME] and/or mustaches should be closely trimmed or must be covered at all times. 3. During a concurrent observation and interview on 6/11/2026 at 12:28 PM with Dietary Aid (DA) 1, in Kitchen 1, SB 1 was tested in the dishwashing area by DA 1, the concentration in SB 1 read 100 parts per million (ppm, unit of measurement). DA 1 stated the sanitizing solution should be within the correct range (200 - 400 ppm) to avoid cross-contamination. During an interview on 6/11/2026 at 1:22 PM with the DS, the DS stated the sanitizing solution should between 200 - 400 ppm. The DS stated the sanitizing solution should be within the correct range to ensure food preparation surfaces were clean. During an interview on 6/12/2026 at 11:37 AM with the FD, the FD stated the sanitizing solution should be within the correct range. The FD stated the sanitizing solution was used to remove bacteria [from Kitchen 1 surfaces] that could be harmful to the residents. During a review of the facility's Quat Sanitizer Log, (QSL), dated June 2026, the QSL indicated the quat level (the concentration of quaternary ammonium compounds [chemicals used to eliminate bacteria] in a sanitizing solution) should be at least 200 - 400 ppm. During a review of the facility's undated P&P titled, Sanitizing Equipment and Surfaces, The P&P's policy indicated, Sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as needed. The P&P's procedure indicated, Dietary staff will check for appropriate sanitizer levels using the test strip into the bucket of solution, the test strip should read 200 - 400 ppm.

Based on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to ensure:a.Personal care items found inside the shared restrooms for five of five sampled residents (Residents 37, 2, 107, 48, and 75) were labeled and stored properly.b. The lint screen/trap and base (bottom) for three of three sampled commercial laundry dryers (CLD 1, CLD 2, CLD 3) were free of dense accumulation of lint (a thick, cottony pad [about the thickness of a felt sheet or small quilt] that completely hides the screen).c. One of two sampled [NAME] & [NAME] restrooms (JJR 1 [a shared restroom situated between two bedrooms with direct access from both rooms], specifically the restroom between rooms [ROOM NUMBERS] shared by Residents 33, 53, 59, 61, 65, and 73 ) was in a clean and sanitary condition when fecal matter was observed on the floor and sink area. These deficient practices had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections to the residents including Residents 2, 33, 37, 48, 53, 59, 61, 65, 73, 75, and 107. Additionally, the deficient practice had the potential to result in a damp environment leading to mold and bacterial growth in the dryer and the spread of microorganisms throughout the facility and the potential for increased fire risk. Findings: a. During a review of Resident 37's Face Sheet (FS-admission record), the FS indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including acute (sudden) kidney failure, unspecified, and unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with agitation (a feeling of extreme restlessness, tension, or anxious energy). During a review of Resident 37's History and Physical Examination (H&P), dated 12/14/2025, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set (MDS - a resident assessment tool), dated 3/23/2026, the MDS indicated Resident 37's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 37 required from partial/moderate assistance (helper does less than half the effort) to setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) During a review of Resident 2's FS, the FS indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including personal history of other infections and parasitic diseases (an illness caused by tiny organisms that live on or inside the body) and type 2 diabetes mellitus (DM II – a disorder characterized by difficulty in blood sugar control and poor wound healing) without complications. During a review of Resident 2's History and Physical (H&P), dated 4/10/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were intact (decisions consistent/reasonable). The MDS indicated Resident 2 was dependent (helper does all of the effort) with ADLs. During a review of Resident 2' Order Summary Report (OSR), active orders as of 6/9/2026, the OSR indicated an order on 4/13/2026 for Enhanced Barrier Precautions (EBP - an infection-control practice to prevent the spread of bacteria in nursing homes).every shift. During a review of Resident 2's Care Plan (CP - provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan), titled Resident is at risk for COVID-19 (Coronavirus Disease of 2019 - a highly contagious respiratory illness caused by the SARS-CoV-2 virus) infection., date initiated 4/13/2026, the CP indicated an intervention of continuing infection control practices to prevent the spread of infection. During a review of Resident 107's FS, the FS indicated Resident 107 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection), unspecified organism, and DM II with hyperglycemia (high blood sugar). During a review of Resident 107's H&P, dated 6/3/2026, the H&P indicated Resident 107 had the capacity to understand and make decisions. During a review of Resident 107' OSR, active orders as of 6/9/2026, the OSR indicated an order on 6/03/2026 for EBP. During a review of Resident 48's FS, the FS indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including urinary tract infection (UTI – an infection in the bladder/urinary tract), site not specified, and essential (primary) hypertension (HTN – high blood pressure). During a review of Resident 48's H&P, dated 3/17/2026, the H&P indicated Resident 48 had the capacity to understand and make decisions. During a review of Resident 48's CP titled Resident is at risk for COVID-19 infection., date initiated 3/17/2026, the CP indicated one of the interventions was to continue infection control practices to prevent the spread of infection. During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 48 required substantial/maximal assistance (helper does more than half the effort) to supervision or touching assistance with ADLs. During a review of Resident 75's FS, the FS indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including essential (primary) HTN, and UTI, site not specified. During a review of Resident 75's H&P, dated 2/15/2026, the H&P indicated Resident 75 could make needs known but could not make medical decisions. During a review of Resident 75's MDS, dated [DATE], the MDS indicated Resident 75's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 75 required partial moderate assistance to setup or clean-up assistance with ADLs. During an observation on 6/9/2026 at 9:18 AM, Resident 37 and Resident 2's shared room had an EBP signage posted and a white trimmed colored 3-drawer PPE (personal protective equipment – clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart outside of Resident 37 and Resident 2's shared room. During a concurrent observation and interview on 6/9/2026 at 9:25 AM with Licensed Vocational Nurse (LVN) 2, in Resident 37 and Resident 2's shared restroom, an unlabeled gray colored wash basin was observed with two (2) unlabeled urinals inside, stored on top of the toilet tank. LVN 2 stated the unlabeled gray colored wash basin with 2 unlabeled urinals inside, stored on top of the toilet tank, should not be there. LVN 2 stated it was important to label the gray colored wash basin and the two urinals with Resident 37 and Resident 2's name and to store them at Resident 37 or Resident 2's bedside to know who the gray colored wash basin and urinals belonged to and to prevent cross contamination. During a concurrent observation and interview on 6/9/2026 at 10:50 AM with Certified Nursing Assistant (CNA) 1, in Resident 3, Resident 48 and Resident 75's shared restroom, an opened, unlabeled eight (8) fl oz (fluid ounce – a measurement of volume) bottle of Remedy Essentials (brand name) Cleanse Spray Cleanser (for cleansing and conditioning hair and skin) was observed stored on the sink. CNA 1 stated the cleanse spray cleanser should be labeled with the resident's (in general) name and should be stored in the resident's drawer. CNA 1 stated labeling and storing properly was important because anybody could use or even drink the cleanse spray cleanser. Additionally, CNA 1 stated since Resident 75 was independent and could grab (any personal care items left inside the shared restroom) it was important to ensure the resident's personal care items were stored properly. During an interview on 6/12/2026 at 8:27 AM with the Infection Preventionist (IP), the IP stated labeling personal care items with the resident's name and room number and storing properly, in their nightstand, were important for infection control, to prevent cross contamination and other residents from using the personal care items. During a review of the facility's Policy and Procedure (P&P) titled, Personal Property, revised March 2023, the P&P's policy statement indicated, Residents are permitted to retain and use personal possessions. The P&P's policy interpretation and implementation indicated, The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. b. During a concurrent observation and interview on 6/12/2026 at 11:53 AM with the Laundry (LD) and the EVS Supervisor (EVSS), inside the Laundry Room, CLD 1, CLD 2 and CLD 3 were in use and had a dense accumulation of lint on the lint screen/trap and moderate amount of lint on the base below the lint screen/traps. The LD stated the lint screen/traps were checked and cleaned every 2 hours. The EVSS stated the facility did not keep a log of how often the facility's CLDs were checked and cleaned for lint. The EVSS stated the dense accumulation of lint was a fire hazard. The EVSS stated cleaning the lint screen/traps was important for the safety of the residents and staff. During a review of the facility's undated P&P titled, Maintenance of the Laundry Room and Laundry Equipment, the P&P's procedure indicated, Clean lint filters after each use of washer or dryer every three (3) hours. The Maintenance Supervisor vacuums areas under and around machines at least monthly, or as need[ed], to remove all collected lint. c.During a review of Resident 65's FS, the FS indicated the facility admitted Resident 65 on 2/5/2025, with diagnoses including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a mental illness characterized by excessive, persistent, and irrational worry or fear that can interfere with daily life). During a review of Resident 65's Minimum Data Set (MDS, a resident assessment tool), dated 4/20/2026, the MDS indicated Resident 65's cognition (the ability to think and process information) was moderately impaired. The MDS indicated Resident 65 required partial/moderate assistance (helper does less than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and required partial/moderate assistance (helper does less than half the effort) with mobility. During a review of Resident 65's CP titled Behaviors, revised 1/10/2026, the CP indicated Resident 65 engaged in stool and urine handling, including rectal digging and occasional throwing of stool/urinal. The CP's interventions indicated, Assess what may cause behavior and what may trigger behavior; attempt to reduce/eliminate those triggers if possible. During an observation on 6/9/2026 at 09:30 AM in JJR 1, fecal matter was observed smeared on the floor adjacent to the toilet and inside the sink. During an observation on 6/9/2026 at 1:39 PM in JJR 1, dried fecal matter was observed on the floor adjacent to the toilet and inside the sink. During an interview on 6/11/2026 at 11:30 AM with Registered Nurse (RN) 1, RN 1 stated Resident 59 had behaviors of digging for feces and, at times, throwing stool. RN 1 stated staff should have been conducting purposeful rounding (staff intentionally check on residents at regular intervals to anticipate and address needs such as pain, position, personal needs, and safety), particularly for residents with these behaviors, to promptly identify and address such incidents. The RN stated allowing fecal matter to remain (on the floor and inside the sink) in a shared restroom was unsanitary and created an infection control risk for residents, staff, and visitors. During an interview on 6/11/2026 at 03:18 PM with the Infection Preventionist (IP), the IP stated fecal matter on environmental surfaces (the surfaces of resident-care equipment and housekeeping areas such as floors, walls, bed rails, doorknobs, light switches, and bathroom fixtures) was a significant infection control concern because it could result in cross contamination. The IP Nurse stated residents with known fecal smearing behaviors required interventions and close oversight to minimize environmental contamination and reduce the risk of exposure to other residents, staff, and visitors. During a review of the facility's P&P titled, Policies and Practices – Infection Control, revised April 2023, the P&P's purpose indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P's policy interpretation and implementation indicated, The objectives of our infection control policies and practices are to: maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 77), was free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) when Resident 86, who had a history of sexual inappropriate behavior, touched Resident 77 on the left breast on 5/30/2026.This deficient practice resulted in Resident 77 getting startled, upset, and screaming for help and had the potential to result in psychosocial (relates to how a person's mental health and social environment [relationships, community] affect each other) harm to Resident 77.Findings:During a review of Resident 77's Face Sheet (FS, admission record), the FS indicated Resident 77 was originally admitted to the facility on [DATE] with multiple diagnoses including unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with other behavioral disturbance, and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), unspecified.During a review of Resident 77's Care Plan (CP), initiated 8/11/2025, the CP indicated, I, [Resident 77] have been made aware that the facility has stable systems to prevent not only abuse.I shall not be subject to abuse by anyone., the CP's goal indicated Resident 77 would be free from abuse (verbal abuse, sexual abuse, mental abuse, neglect, misappropriation of resident property).During a review of Resident 77's History and Physical (H&P), dated 3/16/2026, the H&P indicated Resident 77 did not have the capacity to understand and make decisions.During a review of Resident 77's Minimum Data Set (MDS - a resident assessment tool), dated 5/5/2026, the MDS indicated Resident 77's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 77 did not have psychosis (a severe mental condition in which thought and emotions are so affected that contact with reality is lost) behavior such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 77 required substantial/maximal assistance (helper does more than half the effort) to supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with activities of daily living.During a review of Resident 77's COC/Interact Assessment (Change of Condition), dated 5/30/2026, timed at 1:50 PM, the COC indicated on 5/30/2026 at approximately 1:15 PM, Certified Nursing Assistant (CNA) 6 witnessed Resident 86 make an inappropriate physical contact with Resident 77 by grabbing Resident 77's left breast while Resident 77 and Resident 86 were in the hallway.During a review of Resident 86's FS, the FS indicated Resident 86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 86's CP, initiated 5/21/2026, the CP indicated, I [Resident 86] exhibit the following behavior: exhibit sexual advances towards others, the CP's interventions indicated to assess what may cause behavior and what may trigger behavior; and attempt to reduce/eliminate the triggers if possible.During a review of Resident 86's MDS, dated [DATE], the MDS indicated Resident 86's cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 86 did not have psychosis behavior such as hallucinations or delusions. During a review of Resident 86's COC, dated 5/30/2026, timed at 2:59 PM, the COC indicated on 5/30/2026 at approximately 1:15 PM, while CNA 6 was feeding a resident (unidentified), CNA 6 heard Resident 77 scream. The COC indicated CNA 6 witnessed Resident 86 made inappropriate physical contact with Resident 77 while Resident 77 and Resident 86 were in the hallway. The COC indicated CNA 6 witnessed Resident 86 grab Resident 77's left breast. The COC indicated when Resident 86 was interviewed by Licensed Vocation Nurse (LVN) 1, Resident 86 stated, if she's [Resident 77] here, he will initiate sexual advances to her.During a review of Resident 86's Order Summary Report (OSR), active orders as of 6/9/2026, a physician's order, dated 6/8/2026, the order indicated to admit Resident 86 to a secure unit (a specialized, enclosed environment designed for residents with Alzheimer's disease or dementia, its purpose is resident safety).During an interview on 6/11/2026 at 8:59 AM with CNA 5, CNA 5 stated Resident 77 was friendly and so sweet, and got loud when Resident 77 expressed a need. CNA 5 stated Resident 86 had tried to intentionally grab staff (in general) inappropriately multiple times.During an interview on 6/11/2026 at 9:46 AM with CNA 2, CNA 2 stated Resident 86 should not have been left alone with other female residents unmonitored to prevent the incident since staff knew of Resident 86's behavior. CNA 2 stated, CNA 7 who only worked part time might not have been aware of Resident 86's behavior when CNA 7 transported Resident 86 via wheelchair and left Resident 86 next to Resident 77 in the hallway. During an interview on 6/11/2026 at 10:48 AM with Resident 77, in the presence of the Restorative Nursing Assistant (RNA - nurse assistants with extra training to help residents regain or maintain mobility, strength, and independence with activities of daily living), Resident 77 was confused and unable to answer questions asked.During an interview on 6/11/2026 at 10:58 AM with Resident 86 in the presence of the RNA, Resident 86 stated, Resident 86 touched ladies (in general) because the ladies wanted to be touched. Resident 86 stated, Resident 86 might have touched a female resident at the facility because Resident 86 and the female resident were boyfriend-girlfriend. Resident 86 stated Resident 86 used to touch Resident 86's mother. Resident 86 stated, Resident 86 liked to touch women as long as the women allowed Resident 86. During an interview on 6/11/2026 at 11:06 AM with the RNA, the RNA stated prior to the incident, Resident 86 liked touching the girls [female staff]. The RNA stated Resident 77 should not have been left alone with Resident 86 in the hallway and Resident 86 should have been kept away from other female residents to prevent Resident 86 from [inappropriately] touching female residents.During an interview on 6/11/2026 at 11:18 AM with the Director of Nursing (DON), the DON stated, prior to the incident, the staff (in general) were aware of Resident 86's grabbing behavior and [the facility did] not assign female CNAs to Resident 86.During an interview on 6/11/2026 at 12:05 PM with LVN 1, LVN 1 stated LVN 1 remembered reassigning CNA 2 to Resident 86 because Resident 86 made inappropriate comments and touched females inappropriately. LVN 1 stated Resident 86 should not have been left alone with other [female] residents because Resident 86 could touch them (other residents) inappropriately, unwanted touching, and for resident safety.During a concurrent interview and record review on 6/11/2026 at 12:11 PM with the Administrator, a clip of the facility's Surveillance Video (SV), timestamp (the embedded date and time displayed on the SV footage) 5/30/2026 starting at 12:55 PM was reviewed. The SV indicated Resident 77 was sitting alone in a wheelchair in the North [NAME] hallway. The ADM stated CNA 7 wheeled, Resident 86 in a wheelchair [to the Northwest area hallway] and placed Resident 86 next to Resident 77. The SV indicated CNA 7 left after transporting and placing Resident 86 next to Resident 77. The ADM stated, the SV indicated Resident 86 attempted to touch Resident 77's left side three times with Resident 86's right hand. The SV indicated Resident 77 got startled, appeared upset, and tried to stop Resident 86 each time Resident 86 attempted to touch Resident 77. The ADM stated knowing Resident 86's behavior, Resident 86 should not have been placed next to Resident 77 to avoid Resident 86 from touching Resident 77. The ADM stated CNA 7 was a new staff and the ADM did not think Resident 86's behavior was discussed with CNA 7.During an interview on 6/11/2026 at 1:25 PM with CNA 6, CNA 6 stated Resident 86 was admitted to the facility's locked unit. CNA 6 stated, Resident 77 was friendly and screamed Resident 77 did not like something. CNA 6 stated the incident between Resident 77 and Resident 86 happened on 5/30/2026 a little bit after 1:00 PM. CNA 6 stated CNA 6 was feeding a resident (unidentified) next to the DON's office when CNA 6 heard Resident 77 scream and motioned CNA 6 to go over to Resident 77. CNA 6 stated as CNA 6 was approaching towards Resident 77, CNA 6 saw Resident 86 scooted closer to Resident 77 and Resident 86 grabbed Resident 77's left breast. CNA 6 stated Resident 86 should not have been placed next to Resident 77 because of Resident 86's behavior [history]. During a concurrent observation and interview on 6/12/2026 at 12:21 PM with the Facility Dietician (FD), inside the North Nursing Station, Resident 86 was sitting in a wheelchair by LVN 1 for close monitoring. Resident 86 attempted to touch the FD's butt. The FD stated, Resident 86 had tried that before, twice.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. The P&P indicated, to protect residents from abuse by anyone including other residents, to implement measures to address factors that may lead to abusive situations such as adequately preparing staff for caregiving responsibilities.During a review of the facility's P&P titled, Identifying Types of Abuse, revised September 2022, the P&P indicated abuse of any kind against residents was strictly prohibited. During a review of the facility's undated P&P titled, Resident Rights, the P&P indicated federal and state laws guaranteed certain basic rights to all residents of the facility including the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a resident assessment tool) discharge assessment in a timely manner for one of two sampled residents (Resident 14) as indicated in the Centers for Medicare and Medicaid Service's (CMS, a federal agency that manages health care programs in the United States) Resident Assessment Instrument (RAI, a tool used by nursing homes to assess the needs, strengths, and preferences of residents, mandated by CMS) Manual.This deficient practice resulted in a late completion and transmission of Resident 14's discharge MDS to CMS' Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System (an MDS record that passes CMS' standard edits and is accepted into the system) which had the potential to affect the accuracy of Resident 14's clinical information used for care planning and quality reporting.Findings:During a review of Resident 14's Face Sheet (FS-admission record), the FS indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN-high blood pressure).During a review of Resident 14's History and Physical (H&P) dated 1/23/2026, the H&P indicated Resident 14 did not have the capacity to understand and make decisions.During a review of Resident 14's Physicians Orders (PO), the PO indicated Resident 14 was discharged from the facility on 2/23/2026. During a review of Resident 14's Minimum Data Set (MDS, a resident assessment tool), dated 2/23/2026, the MDS's type of assessment indicated, Discharge assessment - return not anticipated.During an interview and concurrent record review on 6/10/2026 at 4:04 PM with the Minimum Data Sheet Nurse (MDSN) Resident 14's medical record was reviewed. The MDSN stated Resident 14 was discharged from the facility on 2/23/2026. The MDSN stated Resident 14's discharge MDS was not completed or submitted. The MDSN stated Resident 14's MDS must be submitted on time to ensure CMS is informed of Resident 14's location, condition, and the care the resident was receiving.During a review of the facility's CMS Submission Report (CMSSR) dated 6/11/2026, the CMSSR indicated Resident 14's discharge MDS, with a target date of 2/23/2026, was not transmitted until 6/11/2026, more than 14 days past the required submission timeframe.During an interview on 6/12/2026 at 2:49 PM with the MDSN, the MDSN stated the facility should follow the RAI rules and regulations regarding the MDS.During a review of the facility's policy and procedure (P&P) titled MDS Completion and Submission Timeframes, revised July 2017, the P&P's policy statement indicated, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The P&P's policy interpretation and implementation indicated, Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual [RAI Manual].During a review of CMS's RAI Version 3.0 Manual, Chapter 2: Assessments for the RAI, (RAI Manual) dated October 2025, the RAI Manual indicated the discharge assessment with a return not anticipated should have a completion date no later than 14 calendar days after the discharge date .

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) accurately reflected the resident's condition for two (2) of 2 sampled residents (Resident 12 and Resident 79) by:Coding Resident 12 as receiving limb restraints when the resident was not using limb restraints.Coding Resident 79 as not having a serious mental illness when the resident had diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). This failure had the potential to result in an inaccurate representation of Resident 12's and Resident 79's clinical status, inappropriate care planning and interventions, and inaccurate quality measure reporting that may have impacted resident care.A. During a review of Resident 12's FS, the FS indicated the facility admitted Resident 12 on 1/22/2020, and readmitted the resident on 4/4/2026, with diagnoses which included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), schizophrenia (a mental illness that is characterized by disturbances in thought), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognition (the ability to think and process information) was severely impaired. The MDS indicated Resident 2 required partial/moderate assistance with ADL and with mobility. Additionally, Section P of the MDS indicated Resident 2 was coded as using limb restraints less than daily. During a review of the facility's Resident Matrix (RM), dated 6/9/2026, the RM indicated Resident 12 had physical restraints. During an observation on 6/9/2026 at 9:39 AM, Resident 12 was observed seated in a wheelchair with no signs or symptoms of anxiety, agitation, or distress. No physical restraints were in use at the time of observation. During a concurrent interview and record review on 6/11/2026 at 11:30 AM, Resident 12's MDS Section P was reviewed with Registered Nurse 1 (RN1)/MDS Assistant (MDSA). RN1/MDSA confirmed that Resident 12 had not required or utilized physical restraints. RN1/MDSA stated that the facility's practice was to implement and exhaust least restrictive measures before considering the use of physical restraints and that Resident 12 had not exhibited behaviors or clinical indications warranting such interventions. RN1/MDSA stated the MDS was coded inaccurately. RN1/MDSA stated accurate MDS documentation was important, as inaccurate coding misrepresented the resident's condition and care needs, impacted care planning and quality measures, and created an inaccurate representation of the resident's overall clinical status. B. During a review of Resident 79's Face Sheet (FS), the FS indicated Resident 79 was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, bipolar type, and major depressive disorder. During a review of Resident 79's History and Physical (H&P), dated 3/15/2026, the H&P indicated Resident 79 had fluctuating capacity to understand and make decisions, but could make immediate need known. During a review of Resident 79's MDS, dated [DATE], the MDS indicated Resident 79's cognitive skills (ability to think and process information) for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 79 required partial/moderate assistance (helper does less than half the effort to complete the activity) to setup or clean-up assistance (helper sets up or cleans up) with activities of daily living (ADL – routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 79 had active diagnoses of anxiety disorder, depression (other than bipolar) and schizophrenia (e.g., schizoaffective and schizophreniform disorders) and was taking antidepressant medications. Section A1500 Preadmission Screening and Resident Review (PASRR - used to ensure individuals who have a mental disorder or intellectual disabilities are placed in the most appropriate setting and receive the services they need in those settings) of the MDS indicated Resident 79 is currently not considered by the state level II PASRR process to have serious mental illness. During a concurrent interview and record review on 6/10/2026 at 2:43 PM with the MDS Nurse (MDSN), Resident 79's Individualized Determination Report (IDR) from DHCS (California Department of Health Care Services), dated 4/25/2025, and the MDS Section A1500 in PCC (Point Click Care – electronic health record) were reviewed. The IDR indicated a PASRR II was conducted on 4/24/2025 and indicated Resident 79 had a significant medical condition with mental stressors. The IDR indicated Resident 79 required nursing facility services due to a medical and/or mental health condition and specialized add-on services were needed. The MDS Section A1500 indicated a No answer to the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The MDSN stated, the answer should have been a Yes and the No answer was a coding error, just human error. The MDSN stated, an MDS was the total assessment of a resident (in general) and was submitted upon resident's admission to the facility, every quarter, annually, when there was a change of condition, upon discharge or transfer. The MDSN stated, Resident 79's MDS was last submitted on 4/3/2026. The MDSN stated, coding correctly and submitting an accurate MDS was important so facility would know how to provide the individualized care and needs of the resident. During an interview on 6/11/2026 at 11:18 AM with the Director of Nursing (DON), the DON stated, the MDS was the assessment of a resident and identified the specific care needed and to be provided for the resident and it was important to submit an accurate MDS since the plan of care was based on the resident assessment. During a review of the facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, revised 11/2019, the P&P indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. During a review of the facility's P&P titled, Resident Assessments, revised 3/2022, the P&P indicated, All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. The P&P indicated the resident assessment coordinator was responsible for ensuring that the interdisciplinary team conducted timely and appropriate resident assessments and reviews.

Based on interview and record review, the facility failed to develop a baseline care plan for one of seven sampled residents (Resident 106) within 48 hours of the resident's admission.This deficient practice had the potential for Resident 106 not receiving necessary care and services.During a review of Resident 106's Face Sheet (FS), the FS indicated Resident 106 was admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet and tobacco use. The FS indicated Resident 106 did not have any other diagnosis.During a review of Resident 106's History and Physical (H&P), dated 6/7/2026, the H&P indicated, Resident 106 lacked capacity to independently make and understand complex medical decisions due to schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and cognitive impairment (problems with mental functions like memory, thinking, learning, and decision-making).During an interview on 6/10/2026 at 1:58 PM with the Minimum Data Set (MDS - a resident assessment tool) Coordinator, the MDS Coordinator stated the baseline care plan for Resident 106 was initiated by the admitting nurse (unidentified) on 6/5/2026 but the baseline care plan had not been completed.During an interview on 6/10/2026 at 3:38 PM with the MDS Coordinator, the MDS Coordinator stated the baseline care plan was not completed and the MDS Coordinator had been working on completing it now.During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, undated, the P&P indicated, Baseline care plan is required to be completed within 48 hours from the time of admission.

Based on observation, interview, and record review, the facility failed to provide appropriate interventions to prevent the development or worsening of existing pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony area that results in damage of underlying tissue) for one of two sampled residents (Resident 2) when Resident 2's, who had a PI, low air loss mattress (LALM, special type of mattress used for both the prevention and treatment of PI, prioritizes moisture control and temperature regulation to prevent skin breakdown) was not set to the correct setting.This failure had the potential to result in delayed wound healing, worsening of Resident 2's PI, and the development of new PI's or skin breakdown to Resident 2.Findings:During a review of Resident 2's Face Sheet (FS-admission record), the FS indicated the facility admitted Resident 2 on 4/9/2026 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), mild protein-calorie malnutrition (not getting enough nutrients and calories, leading to weight and muscle loss), pressure ulcer (PU-localized damage to the skin and/or underlying tissue usually over a bony prominence), and muscle weakness.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 4/15/2026, the MDS indicated Resident 2's cognition (the ability to think and process information) was intact. The MDS indicated Resident 2 was dependent (helper does all of the effort) with activities of daily living (AOL, term used in healthcare that refers to self-care activities) and was dependent on mobility.During a review of Resident 2's Order Summary Report (OSR), dated active as of 6/12/2026, the OSR indicated Resident 2 had a physician's order for a LALM for wound care management to be set at 160 pounds (lbs.-a unit of weight).During a review of Resident 2's Care Plan (CP) titled Pressure Sore, initiated 4/17/2026, the CP indicated Resident 2 was at risk to develop pressure sores. The CP's interventions indicated, Staff will provide pressure relieving device/interventions as ordered [LALM] mattress.During a review of Resident 2's Weight Summary Report (WSR), dated 6/10/2026, the WSR indicated Resident 2 weighed 143 lbs. on 6/10/2026.During an observation on 6/10/2026 at 4:37 PM in Resident 2's room, Resident 2 was observed lying on Resident 2's right side on a LALM. The LALM control unit indicated the pressure dial was set to 200 lbs.During a concurrent interview and observation on 6/11/2026 at 9:45 AM with Licensed Vocational Nurse (LVN) 1, in Resident 2's room, Resident 2's LALM pressure dial was observed to be set at 200 lbs. LVN 1 stated the importance of setting the LALM correctly was to ensure the resident received appropriate pressure redistribution to prevent worsening of existing wounds and reduce the risk of additional skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, revised March 2023, the P&P's purpose indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The P&P's preparation indicated, Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The P&P's prevention indicated, Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice.During a review of the facility's undated Operation Manual (LALM manual), the LALM manual's weight/pressure set up indicated, users can adjust air mattress to a desired firmness according to patient's weight or the suggestion from a health care professional.

Based on observation, interview, and record review, the facility failed to ensure one of four residents' (Resident 4) environment remained as free of accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards as possible when Resident 4 was observed biting and chewing on a towel.This deficient practice had the potential to cause teeth or gum damage, jaw strain and/or choking to Resident 4 risking Resident 4's overall physical health.Findings:During a review of Resident 4's Face Sheet (FS-admission record), the FS indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain is temporarily confused or impaired), unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, with other behavioral disturbance, and dysphagia, oropharyngeal phase (difficulty initiating a swallow due to problems in the mouth or throat).During a review of Resident 4's History and Physical (H&P), dated 2/4/2026, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions, but could make immediate needs known.During a review of Resident 4's Care Plan (CP), titled Altered behavior patterns related to impulse control disorder.Noted biting his blanket and biting his elbow/hand splints, revised date 3/3/2026, the CP indicated interventions including to provide reality awareness and redirection as needed.During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 4/27/2026, the MDS indicated Resident 4's cognitive skills (ability to think and process information) for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 4 was dependent (helper does all of the effort) with activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a concurrent observation and interview on 6/9/2026 at 12:54 PM with Certified Nursing Assistant (CNA) 2, in Resident 4's room, Resident 4 was observed in bed with the head of bed flat. Resident 4 was observed groaning while biting down and chewing on a towel. CNA 2 stated Resident 4 usually bites. CNA 2 stated the towel should not have been left with Resident 4 to prevent Resident 4 from choking. CNA 2 stated a staff (unnamed) might have forgotten to remove the towel after cleaning Resident 4.During an interview on 6/9/2026 at 1:01 PM with Licensed Vocation Nurse (LVN) 3, LVN 3 stated Resident 4 did not eat and had a gastrostomy tube (GT- a surgical opening fitted with a device to allow feedings and/or medications to be administered directly to the stomach common for people with swallowing problems). LVN 3 stated Resident 4 was always biting down and chewing on a towel.During an interview on 6/12/2026 at 11:42 AM with the Director of Nursing (DON), the DON stated Resident 4 was confused and had a habit of obsessive- compulsive behavior (a mental disorder in which you have thoughts [obsessions] and rituals [compulsions] over and over) and was purposely provided a blanket (to bite down/chew on), not a towel, and should have been monitored to prevent Resident 4 from choking. The DON stated the facility should have addressed the use and approval of a towel with Resident 4's family (unnamed) during the Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate, assess, coordinate, and manage each resident's comprehensive health care, including his or her medical, psychological, social, and functional needs) meeting.During a review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated the facility strived to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The P&P indicated the facility's individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of seven sampled residents (Resident 106) when Resident 106's Face Sheet (FS-admission record) did not indicate a complete cumulative diagnosis list (a complete list of a resident's active medical diagnoses).This deficient practice resulted in incomplete documentation for Resident 106 and had the potential to result in Resident 106's medical needs not being addressed.Findings:During a review of Resident 106's FS, dated 6/10/2026, timed at 9:43 AM, the FS indicated Resident 106 was admitted to the facility on [DATE]. The FS's diagnosis information indicated unsteadiness on feet and tobacco use.During a review of Resident 106's History and Physical (H&P), dated 6/7/2026, the H&P indicated Resident 106 lacked capacity to independently make and understand complex medical decisions due to chronic (persistent or long-lasting) schizophrenia (a mental illness characterized by disturbances in thought), dementia (the loss of the ability to think, remember, and reason that affect daily life and activities), and cognitive (the ability to think and process information) impairment. The H&P indicated major healthcare decisions should involve Resident 106's responsible party and designated surrogate decision-maker.During a concurrent interview and record review on 6/10/2026 at 1:58 PM with the Minimum Data Set Nurse (MDSN), Resident 106's FS was reviewed. The MDSN stated Resident 106's FS did not indicate a complete cumulative diagnosis list for Resident 106. The MDSN stated the cumulative diagnosis list should be completed as soon as possible.During a review of the facility's policy and procedure (P&P) titled, Cumulative Diagnosis List Policy and Procedures, revised 9/20/2022, the P&P's purpose indicated, [The] Cumulative Diagnosis list is intended to incorporate all active diagnoses including primary diagnosis and conditions that are part of the resident's current plan. It is to be completed within 72 hours of admission by the licensed nurse and authenticated by the attending physician with the signature. The list serves as a communication tool for healthcare professionals.to identify.diagnoses.in addition to generating an.accurate picture of the resident's current health status.During a review of the facility's P&P titled, Charting and Documentation, revised July 2017, the P&P's policy statement indicated. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P's policy interpretation and implementation indicated, Documentation in the medical record will be . complete and accurate.

Based on interview and record review, the facility failed to report for one of five sampled residents (Resident 3) to the California Department of Public Health (the Department), to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the local law enforcement a resident-to-resident altercation within two hours in accordance with the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, dated September 2022.This failure resulted in the delay of notification to the Department and had the potential for Resident 3 to be subjected to abuse while at the facility.A. During a review of Resident 3's Face Sheet (FS-document that contains a patient's personal and contact information, diagnoses and brief medical history, allergies, and name and contact information of patient's physicians), the FS indicated the facility readmitted Resident 3 on 3/19/2026 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), unspecified dementia (a progressive state of decline in mental abilities), and cognitive communication deficit (difficulty in communication due to impaired thinking and understanding).During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/20/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 3 required partial/moderate assistance (helper does less than half the effort to complete the activity) with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), with transfers and with walking.During a review of Resident 3's COC (Change of Condition) Interact Assessment Form, dated 5/6/2026 and timed at 12:30 PM, the COC indicated on 5/6/2026 at 11:30 AM Registered Nurse (RN) 1 received a report from a licensed vocational nurse (LVN) (unidentified) that Resident 4 pushed Resident 3 to the wall and Resident 3 slid down to the floor.B. During a review of Resident 4's FS, the FS indicated the facility admitted Resident 4 on 10/3/2025 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs), and dementia.During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 rarely/never understood with severely impaired decision making. The MDS indicated Resident 4 required partial/moderate assistance with showering, personal hygiene, lower body dressing, with walking and with transfers.During a review of Resident 4's H&P, dated 5/15/2026, the H&P indicated Resident 4 did not have the capacity to understand and make decisions.During an interview on 5/19/2026 at 2:27 PM with the Director of Nursing (DON), the DON stated the DON was aware that Resident 4 pushed Resident 3 when they were sitting next to each other on 5/6/2026 in the dining room. The DON stated a certified nursing assistant (CNA) (unidentified) reported the incident to the charge nurse (unidentified) who no longer worked at the facility and the CNA and the charge nurse informed the DON regarding the incident. The DON stated the incident was not reported to CDPH because nothing happened. The DON stated the CNA stated Resident 4 had an impulse and Resident 3 stated Resident 3 was fine and Resident 3 did not sustain any injury.During an interview on 5/27/2026 at 3:26 PM with the DON, the DON stated the local law enforcement was not notified when Resident 4 pushed Resident 3 on 5/6/2026. The DON stated the incident was not a reportable incident because Resident 4 had an involuntary reflex that pushed Resident 3.During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, dated September 2022, the P&P indicated, If resident abuse. is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The P&P indicated immediately is defined as within two hours of an allegation involving abuse.

Based on observation, interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 11) who was re-admitted to the facility after a surgical procedure had a skin assessment.This failure had the potential for Resident 11 receiving delayed care and treatment for Resident 11's surgical wounds which could lead to infection.During a review of Resident 11's Face Sheet (FS, document that contains a patient's personal and contact information, diagnoses, and medical history), the FS indicated Resident 11 was re-admitted to the facility on [DATE] with diagnoses that included lack of coordination and displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (patient had surgery on the left thigh bone and is now in the healing phase).During a review of Resident 11's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 10/5/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions.During a review of Resident 11's Discharge/Transfer Documentation, dated 5/26/2026, indicated the resident had an operative procedure of an open treatment of left intertrochanteric (left thighbone) femur (longest bone in a human body) fracture (a break of the bone) with intramedullary nail (a metal rod inserted into the long bone). During an observation on 5/28/2026 at 10:30 am inside Resident 11's room with Certified Nurse Assistant 6 (CNA 6), three separate wounds were observed on Resident 11's lateral (on the outer side) left leg; one wound on the left hip had four staples, one wound on the mid-thigh with six staples, and one wound on the lower thigh with seven staples.During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 5/27/2026 at 3:10 pm, Resident 11's medical record and Resident 11's Skin Reassessment (SR), dated 5/26/2026, were reviewed. RN 1 stated Resident 11's SR, dated 5/26/2026, was blank and RN 1 was unable to find an admission skin assessment for Resident 11. RN 1 stated it was important to do an initial skin assessment upon Resident 11's admission to assess Resident 11's surgical site and the status of the wound. RN 1 stated failure to closely monitor and assess surgical wounds could lead to infection.During a concurrent interview and record review with RN 2, on 5/27/2026 at 4:23 pm, RN 2 stated RN 2 worked as the RN Supervisor when Resident 1 was re-admitted on [DATE]. RN 2 stated RN 2 did not assess Resident 2's surgical wound upon admission. RN 2 stated it was important to assess a wound upon admission to assess for any signs of infection.During a concurrent interview and record review of Resident 11's medical record with the Director of Nursing (DON), on 5/28/2026 at 11:35 am, the DON stated skin assessments were necessary for newly admitted residents, especially for post-surgical residents to ensure a proper baseline was completed and to promptly assess for early signs of infection.During a review of the facility's policy and procedure (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, revised on 9/2012, the P&P indicated , The purpose of the procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission.Conduct a physical assessment, including the following systems: skin. Conduct supplemental assessments (following facility forms and protocol) including skin assessment. The following information should be recorded in the resident's medical record: all relevant assessment data obtained during the procedure.

Based on observation, interview and record review, the facility failed to implement its abuse prevention policy by failing to report one allegation of injury of unknown origin to the state agency (Department of Public Health) and law enforcement within the required reporting time frames for one of five sampled residents (Resident 2).This deficient practice delayed the investigation of abuse and placed Resident 2, and other residents at risk for abuse and feelings of intimidation.Findings: During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a change (confusion, memory loss or loss of consciousness) in how your brain works due to an underlying condition), unspecified dementia with anxiety (significant cognitive decline and excessive worry or restlessness), and long-term use of anticoagulants (medications that prevent or reduce blood clotting). During a review of Resident 2's History and Physical (H&P), dated 11/6/25, the H&P indicated, Resident 2 did not have the capacity to understand and make medical decisions. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 2/5/26, the MDS indicated Resident 2 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 2 required the following: 1) setup or clean-up assistance (helper sets up or cleans up) in eating and upper body dressing; 2) required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) with oral hygiene, toileting hygiene, lower body dressing, and putting on/taking off footwear; and 3) partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less that half the effort) with shower/bathe self and personal hygiene. During a review of Resident 2's Physician Orders (POs) active as of 4/1/26, the POs indicated the following orders:Monitor Anticoagulation Medication: Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, bleeding in any orifice, abnormal lab. Document: 'N' if monitored and none of the above observed. Document 'Y' if monitored and any of the above observed, Notify MD and document in nurses' progress notes, every shift.Aspirin 81 Oral Tablet Chewable 81 mg (milligram; a unit of weight); Give 1 tablet by mouth one time a day for CVA (Cerebrovascular Accident) prophylaxis [prevention of strokes].Apixaban Oral Tablet 2.5 mg; Give 1 tablet by mouth two times a day for DVT (Deep Vein Thrombosis) Prophylaxis [preventive measures to stop dangerous blood clots from forming in deep veins] (Start date: 11/3/25).Galantamine Hydrobromide ER Oral Capsule Extended Release 24 Hour 8 mg; Give a capsule by mouth one time a day for dementia.Memantine HCl (hydrochloride) Oral Tablet 10 mg; Give 1 tablet by mouth two times a day for dementia.Metoprolol Tartrate Tablet 25 mg; Give 1 tablet by mouth two times a day for hypertension hold if systolic blood pressure less than 110 mmHg (millimeters of mercury; a unit of measurement for pressure) or heart rate less than 60 beats per minute. Administer with food to reduce the rate of absorption. This minimizes the risk of hypotension (Order date: 11/14/25). During a review of Resident 2's Medication Administration Record (MAR) for April 2026, the MAR indicated Resident 2 was monitored for side effects of anticoagulation medication every shift, which included bruising, lethargy and bleeding in any orifice (opening: natural passages in the human body). The MAR indicated no side effects were observed from 4/1/26 to 4/23/26, and 4/25/26 to 4/30/26. The only side effects observed during the month of April 2026 were on 4/24/26 on the evening shift. During a review of Resident 2's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) for the month of April 2026 included the following:COC, dated 4/1/26 - Generalized body rash. Nursing comments indicated treatment nurse performed body check on resident, noted generalized body rash; RN notified, full assessment rendered.COC, dated 4/19/26 - Resident noted with increased agitation and aggression behavior toward residents and nursing staff. Nursing comments indicated resident is encouraged to vent feelings. Able to focus and shift attention, complete assessment and evaluation of all body system done.COC, dated 4/23/26 - Resident noted with discoloration to left eye. Nursing comments indicated CNA [CNA 4] found resident's discoloration when CNA [CNA 4] delivered breakfast trays to resident. Charge nurse [LVN 3] assessed patient with left eye and noted no signs/symptoms of pain or discomfort at this time. No swelling, no open wounds, no signs/symptoms of distress noted. MD and RP (Responsible Person) notified. During a review of Resident 2's Interdisciplinary Team Conference (IDTC) notes, dated 5/2/26, the notes indicated on 4/23/26 at approximately 7:50 a.m. Resident 2 was noted with discoloration to left periorbital area, no skin breakage, laceration, bleeding, swelling, open wound, signs/symptoms of pain or discomfort noted at that time. The notes indicated under Additional Comments, the police department arrived at the facility on 5/2/26 to investigate an incident involving Resident 2. The notes indicated Resident 2 stated no recollection of the incident and reported possibility of being hit, possibly during a dream. The facility was informed the matter would be reported to APS (Adult Protective Services). During a concurrent observation and interview on 5/4/26 at 11:35 a.m. in Resident 2's room, Resident 2 was observed with dark discoloration above the left eye, along the bridge of the left side of the nose and underneath the left eye. Resident 2 was asked about her left eye discoloration and Resident 2 stated about 2 weeks ago she was hit by a teenager, a girl. Resident 2 was asked if the girl hit her intentionally and Resident 2 stated, Yes, the teenager was out of control. Resident 2 was asked if she had any type of fall and hit her head. Resident 2 stated she didn't have a fall. During a concurrent record review of the South Unit's Daily Assignment Binder and interview on 5/4/26 at 12:16 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the Body Check by CNA during Shower, form indicated Resident 2's skin was clear on the back and front body diagrams on 4/22/26. CNA 1 stated Clear and a diagonal line is written if the resident doesn't have any new or unusual skin issues. If there is something new, then it is indicated on the form. The form is given to the Charge Nurse for review. During an interview on 5/4/26 at 12:55 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there was a change of condition (COC) for Resident 2 completed on 4/23/26 for left eye discoloration. LVN 1 stated she didn't do the COC for 4/23/26; LVN 3 completed the COC. LVN 1 stated LVN 3 completed an incident report on 4/23/26 for Resident 2's left eye discoloration. During a concurrent interview and record review of the Body Check by CNA during Shower form, dated 4/24/26 with Licensed Vocational Nurse 1 (LVN 1) on 5/4/26 at 12:55 p.m., the form indicated Resident 2's skin was clear on the back body diagram and on the front body diagram was written Around eye discoloration. Circled above the knee on the front body diagram of Resident 2's left thigh, the words Discoloration were written. During an interview with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 2's discoloration was noted by CNA (unidentified) in the morning on 4/23/26 and the treatment nurse was notified, then a skin check assessment was completed. During an interview on 5/4/26 at 1:28 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she completed the COC for Resident 2 after the CNA (unidentified) reported to her the discoloration around Resident 2's eye. LVN 3 stated she reported to her Nurse Supervisor RN 1 about the discoloration on Resident 2's left eye. LVN 3 stated she spoke with the Charge Nurse (NOC shift, not named) and CNA (NOC shift, not named) and they said Resident 2 did not have the discoloration of the left eye on the 4/22/26 NOC shift. LVN 3 stated she had received training in abuse and neglect recognition and reporting during her orientation a month ago. LVN 3 stated she reports any type of abuse to the Administrator (who is the abuse coordinator). LVN 3 stated she did not think the discoloration around the eye was abuse, and stated Resident 2 is on blood thinners. LVN 3 stated she asked Resident 2 if she fell or rubbed her eye, but Resident 2 told her no. LVN 3 stated she did not know what RN 1 reported; LVN 3 acknowledged she did not know if RN 1 reported abuse to the Administrator. During an interview on 5/5/26 at 11:20 a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she noticed Resident 2's left eye discoloration when she returned to work on 4/24/26. CNA 3 stated it was a large discoloration around the left eye. CNA 3 stated she asked Resident 2, What happen to your eye? Did you have a fall? CNA 3 stated Resident 2 just smiled and said no. CNA 3 stated when she completed the Body Check By CNA During Shower form on 4/24/26, she reported the left eye discoloration and left thigh discoloration to the charge nurse (does not remember name of nurse). During an interview on 5/5/26 at 12:42 p.m. with Registered Nurse Supervisor 1 (RN 1), RN 1 stated LVN 3 noted left eye discoloration, big orbital area large, Resident 2 not aware. CNA (unidentified) during breakfast tray delivery noticed left eye discoloration, Resident 2 didn't know until she saw herself in the mirror, no swelling, denied falls, no falls and no injury incidents. RN 1 stated she reviewed Resident 2's medications: anticoagulants: aspirin and apixaban. RN 1 stated Resident 2 has dementia and Resident 2 was asked if Resident 2 slept on her side or rubbed her eyes. RN 1 stated the focus was on Resident 2's left eye discoloration when she completed Resident 2's assessment. RN 1 denied suspicion for abuse when asked about Resident 2's left eye discoloration, and RN 1 stated she was more focused on the initial investigation, which was for left eye discoloration due to anticoagulant medications. RN 1 stated she did not do a full head-to-toe assessment on Resident 2 on 4/23/26. RN 1 stated she worked the next day on 4/24/26 and was unaware that the 4/24/26 CNA shower sheet indicated discoloration on Resident 2's left thigh. RN 1 stated she was sure that LVN 3 completed an incident report on 4/23/26 for Resident 2's left eye discoloration. During an interview on 5/4/26 at 1:11 p.m. with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated she worked on 4/23/26, but left on that day without being notified about Resident 2's left eye or left thigh discoloration. LVN 5 stated she was notified on 4/24/26 about Resident 2's left eye and left thigh discoloration. LVN 5 stated on 4/23/26, LVN 3 only reported Resident 2's had left eye discoloration. LVN 5 stated if skin discoloration for Resident 2 was a new condition, then an investigation should have been done to determine the source. LVN 5 stated the discoloration around Resident 2's left eye is unusual because there were no prior occurrences before for Resident 2. LVN 5 stated the discoloration around Resident 2's left eye should be reported to the supervisor for proper investigation of the injury and to rule out abuse. LVN 5 stated if there is a suspicion for blood thinners causing skin discoloration around the eye, then a full head-to-toe assessment should be completed to identify any other possible areas that are starting or existing. During an interview on 5/5/26 at 4:05 p.m. with Registered Nurse Supervisor 1 (RN 1), RN 1 stated she did not believe Resident 2's left eye discoloration was abuse at time of the 4/23/26 assessment. RN 1 stated she was focused on the injuries due to blood thinners as the cause of the discoloration and did not rule out abuse as a probable cause of Resident 2's left eye discoloration. RN 1 stated she did not have Resident 2 undress to do a full body check on 4/23/26. RN 1 was asked if blood thinners only cause discoloration around the eye. RN 1 stated, No, it can be anywhere on the body. RN 1 acknowledged that a head-to-toe assessment was not performed for Resident 2 on 4/23/26. RN 1 acknowledged that a head-to-toe assessment was important because Resident 2 could have other discolorations on Resident 2's body that indicate abuse and should be reported to the physician (MD) to assist in further medical decision making. During a telephone interview on 5/5/26 at 4:18 p.m. with Registered Nurse Supervisor 2 (RN 2), RN 2 stated RN 2 the facility had a stand-up meeting that same week of when the facility discovered Resident 2's left eye discoloration [4/23/26]. RN 2 stated Resident 2 had an injury of unknown origin, but with a probable cause of anticoagulants and that was reported on 5/2/26. RN 2 stated he completed an investigation that included reviewing Resident 2's electronic medical record [PCC-Point Click Care online], a full interview with Resident 2, any person who may saw what happened [but there were none], and then the case was brought to the department stand-up meetings. RN 2 stated he checked Resident 2's orders and MAR for monitoring or medication that can cause bleeding/bruising. RN 2 stated he checked Resident 2's room environment to see if Resident 2 could have bumped herself on something in the room. RN 2 stated he did not believe at the time he was investigating that it was abuse, based on review of information in Resident 2's medical record. RN 2 stated he was not informed about Resident 2's left thigh discoloration and did not report that on 5/2/26. RN 2 stated blood thinners can cause random discolorations on the body. RN 2 stated he did not have Resident 2 reassessed for a full body head-to-toe after he completed the PCC review and determined blood thinners as a probable cause. RN 2 acknowledged he did not rule out abuse for Resident 2's left eye discoloration. RN 2 acknowledged he has received training and in-services on abuse and neglect recognition and reporting injury of unknow origin. During a concurrent record review of Resident 2's Non-Pressure Sore Skin Problem (NPSS) Report and interview on 5/6/26 at 11:20 a.m. with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated LVN 5 stated she created the NPPS report for Resident 2's left eye discoloration because that was the information reported to her on 4/24/26. LVN 5 stated the charge nurse gets report from the CNA by a skin check report and then the treatment nurse is notified. LVN 5 stated no one informed her on 4/24/26 about the left thigh discoloration on Resident 2's leg. LVN 5 stated the NPSS report indicated under Comments: Noted left orbital eye area with discoloration in place, no noted swelling. Resident able to verbalize needs, does not c/o (complain of) pain or discomfort, skin is intact. Order for monitoring noted and carried out. 6 cm [centimeter, a metric unit of length] in diameter, around eye 3 cm radius extending out from eye. During an interview on 5/6/26 at 3:28 p.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated when she brought the breakfast tray to Resident 2 on 4/23/26, she noticed Resident 2's eye had a large bruise around the left eye. CNA 4 stated she asked Resident 2 what happened, but Resident 2 was unaware of the bruise around the left eye. CNA 4 stated she reported the left eye bruise to the charge nurse. CNA 4 stated Resident 2 had a prior altercation on 4/19/26 with a different roommate (unnamed) and that is why Resident 2 was moved into her current room. During a review of the facility's current Policy & Procedure (P&P) titled, Injury of Unknown Source, no revised date, the P&P indicated Purpose: To ensure that a complete and thorough investigation is conducted for an injury of unknown source.Content:1. An injury should be reported as an injury of unknown source when: The source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident. The injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time.2. The facility shall follow the Abuse Allegation Investigation Policy to complete a thorough investigation of any injury of unknown source.3. The facility shall follow the Abuse Allegation Reporting if the injury meets the definition of an injury of unknown source. During a review of the facility's current Policy & Procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, the P&P indicated, Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility.

Based on observation, interview and record review, the facility staff member failed to notify the responsible party when 1 of 3 sample residents (Resident 1) moved to another room. This failure resulted in lack of timely communication with Resident 1's responsible party regarding changes in Resident 1's Room/environment.During a review of Resident 1's admission Record (AR-Face Sheet), the AR indicated the facility admitted Resident 1 on 2/5/2026, with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury), and Alzheimer's disease (progressive mental deterioration).During a review of Resident 1's History and Physical (H&P), dated 2/7/2026 the H&P indicated, Resident 1 does not have the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/11/2026, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required partial/moderate assistance for activities of daily living. During a review of Resident 1's Nurses Note, dated 3/18/2026, the Nurses note indicated Resident 1 was moved to a different room.During an interview on 4/17/2026 at 1 PM with the Social Service Designee (SSD), the SSD stated Resident 1 was moved from one room to another room, but facility staff did not notify Resident 1's responsible party. The SSD stated Resident 1's responsible party should have been notified.During a review of the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment, revised 2021, indicated that prior to a room change, all parties involved, including the resident and responsible party, are to be given advance notice of the change. The policy indicated that room changes are to be documented in the resident's medical record.

Based on interview and record review, the facility failed to ensure adequate supervision for 1 of 3 sampled residents (Resident 1) who required supervision during showers.This failure resulted in Resident 1 being found in the shower area without staff supervision, placing the resident at risk for injury.Findings:During a review of Resident 1's admission Record (AR-Face Sheet), the AR indicated the facility admitted Resident 1 on 2/5/2026, with diagnoses including dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury), and Alzheimer's disease (progressive mental deterioration).During a review of Resident 1's History and Physical (H&P), dated 2/7/2026 indicated, the H&P Resident 1 does not have the mental capacity to make medical decisions.During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/11/2026, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decisions making was moderately impaired, and required partial/moderate assistance for activities of daily living. During an interview on 4/17/2026 at 1 PM with Resident 1, Resident 1 stated Resident 1 entered the shower and showered by herself. Resident 1 stated staff later instructed her that she is not allowed to shower independently and must wait for staff assistance.During an interview on 4/17/2026 at 1 PM with the Social Service Designee (SSD), the SSD stated Resident 1 was found in the shower area without staff present. The SSD stated Resident 1 required supervision and should not have been showering independently.During an interview on 4/17/2026 at 2 PM with Registered Nurse 1 (RN1), RN 1 stated, Resident 1 required supervision during showers. RN 1 stated staff should be aware of the resident's whereabouts and Resident 1 should not have been in the shower by herself.During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 2017, indicated the facility is responsible for identifying risks and implementing interventions to prevent accidents, including ensuring adequate supervision based on the resident's assessed needs.During a review of the facility's policy and procedure (P&P) titled, Bath, Shower/Tub, revised 2018, indicated staff are to remain with the resident throughout the bath or shower and that residents are not to be left unattended during bathing.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan (individualized document developed to manage a patient's physical, mental, emotional, and social health needs) with interventions (action taken to improve a situation) for three of eight sampled residents (Residents 3, 6 and 7).Findings:1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (disturbance of the brain's functioning that leads to problems like confusion and memory loss) and respiratory failure (serious condition that makes it difficult to breathe, lungs cannot get enough oxygen into the blood).During a review of Resident 3's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 3/28/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 3's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was severely impaired. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort) for eating, oral hygiene, toileting hygiene, and upper body dressing. The MDS indicated Resident 3 required maximal assistance (helper does more than half the effort) for lower body dressing, showering/bathing, and personal hygiene.During a review of Resident 3's Skin Rash Report, dated 1/30/2026, the Skin Rash Report indicated Resident 3 had skin rash on bilateral hands.During a review of Resident 3's medical record, there was no care plan regarding Resident 3's skin rash on bilateral hands. 2. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses that included encephalopathy and chronic kidney disease (gradual loss of kidney function, kidneys are unable to filter wastes and excess fluids from blood).During a review of Resident 6's H&P, dated 12/14/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions.During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 6 required set-up assistance for eating and upper body dressing. The MDS indicated Resident 6 required supervision for oral hygiene, toileting hygiene, putting on/off shoes and lower body dressing. The MDS indicated Resident 6 required moderate assistance for showering/bathing and personal hygiene.During a review of Resident 6's Skin Rash Report, dated 1/28/2026, the Skin Rash Report indicated Resident 6 had skin rash on upper back.During a review of Resident 6's medical record, there was no care plan regarding Resident 6's rash on upper back. 3. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included palliative care (medical care focused on relieving symptoms, pain, and stress from serious illnesses to improve quality of life for patients) and chronic kidney disease.During a review of Resident 7's H&P, dated 2/15/2026, the H&P indicated Resident 7 could make needs known but could not make medical decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 7 required set-up assistance for eating. The MDS indicated Resident 7 required moderate assistance for oral hygiene and upper body dressing. The MDS indicated Resident 7 required maximal assistance for toileting hygiene, showering/bathing, putting on/taking off footwear, lower body dressing and personal hygiene.During a review of Resident 7's Skin Rash Report, dated 9/8/2025, the Skin Rash Report indicated Resident 7 had skin rash on generalized body. The Skin Rash Report indicated Resident 7 complained of itchiness.During a review of Resident 7's medical record, there was no care plan regarding Resident 7's generalized body rash. During an interview on 4/3/2026 at 8:51 a.m. with Infection Prevention Nurse (IPN), IPN stated when a resident had a skin issue it had to be part of the resident's care plan. IPN stated the care plan must indicate monitoring resident's skin, following treatments as ordered by doctor, and maintaining skin moisture. The IPN stated a care plan must be developed to provide nursing staff with a plan on how to care for a resident with a rash.During an interview on 4/3/2026 and 12:16 p.m. with Treatment Nurse (TN), TN stated when a resident developed a skin rash a care plan must be developed. TN stated a care plan needed to be developed to inform nursing staff of the steps for residents to get better. TN stated if there was no care plan the residents would be at risk for not receiving the proper care and symptoms would get worse. TN stated all nurses are allowed to develop care plans for residents when a resident develops a skin rash. TN stated TN was not aware Residents 3, 6 and 7 did not have a care plan for their skin rashes.During the review of facility's Policy and Procedure (P&P) titled Goals and Objectives, Care Plans, dated 4/2009, the P&P indicated care plans would incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The P&P indicated care plan goals and objectives are defined as the desired outcome for a specific resident problem. The P&P indicated goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. The P&P indicated goals and objectives are reviewed and/or revised when there was a significant change in the resident's condition.

Based on interview and record review the facility failed to ensure an adequate amount of Certified Nursing Assistants (CNAs) worked in the South Dementia unit (unit designed to meet the specific needs of residents with dementia [a progressive state of decline in mental abilities]) on the NOC shift (overnight shift from 11 pm to 7 am) on 3/8/2026, 3/11/2026 and 3/21/2026, in accordance with the facility's Facility Assessment Tool (FAT - facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies), dated 3/19/2026. This failure had the potential to result in residents receiving inadequate care and supervision which can lead to falls, elopement, and delayed recognition of residents' significant changes in condition.Findings:During a concurrent interview and record review on 4/2/2026 at 11:30 am with Director of Staff Development (DSD), the FAT, the Nursing Staffing Assignment and Sign-in Sheet from 3/1/2026 to 3/31/2026, and CNA Timecards were reviewed. The FAT, dated 3/19/2026, indicated individual staff assignment 3.3 described how the facility determined and reviewed individual staff member assignments for coordination and continuity of care for residents within and across staff assignments. The FAT indicated CNAs were assigned to a run or round based on census and or resident's request. The FAT also indicated ratios for the NOC shift was one (1) CNA per 13 to 16 residents. DSD stated there should be three CNAs on the NOC shift for the locked unit (South Dementia unit). DSD stated on 3/8/2026, 3/11/2026, and 3/21/2026 there were only two CNAs on the NOC shift in the locked unit which meant the two CNAs had 25 residents each. DSD stated that because of the CNA shortage the residents were at a higher risk for falls, elopement, and there were less safety and security for the residents. DSD stated the facility did not follow the FAT. During an interview on 4/2/2026 at 4 pm with Registered Nurse Supervisor (RNS), RNS stated the DSD oversaw staffing and should be using the FAT which indicated three CNAs for the NOC shift. RNS stated the lack of CNAs affected the residents' safety and the residents were at higher risk of falls, elopement, and unsafe environment. During a review of facility Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 8/2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. 1. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety; b. attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident; c. Assessing, evaluating, planning and implementing resident care plans; and d. responding to resident needs. 5. Nurse aides/nursing assistants are individuals providing nursing or related services to residents in the facility, including those who provide services through an agency or under a contract with the facility. 6. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment. 7. Factors considered in determining appropriate staffing ratios and skills include an evaluation of the diseases, conditions, physical or cognitive limitation of the resident population, and acuity.

Based on interview and record review the facility failed to complete an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form for two of eight sampled residents (Resident 3 and Resident 7) in accordance with the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status when:1. There was no SBAR found in Resident 3's medical record regarding Resident 3's skin rash (abnormal changes in skin color or texture and are typically associated with irritation or swelling) on both hands. 2. There was no SBAR found in Resident 7's medical record regarding Resident 7's generalized body rash.These deficient practices placed Resident 3 and Resident 7 at risk of not receiving appropriate care.Findings: 1. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (disturbance of the brain's functioning that leads to problems like confusion and memory loss) and respiratory failure (serious condition that makes it difficult to breathe, lungs cannot get enough oxygen into the blood).During a review of Resident 3's History and Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 3/28/2026, the H&P indicated Resident 3 did not have the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 3/9/2026, the MDS indicated Resident 3's cognitive skills (reasoning, learning, and problem-solving) for daily decision making was severely impaired. The MDS indicated Resident 3 required moderate assistance (helper does less than half the effort) for eating, oral hygiene, toileting hygiene, and upper body dressing. The MDS indicated Resident 3 required maximal assistance (helper does more than half the effort) for lower body dressing, showering/bathing, and personal hygiene. During a review of Resident 3's Skin Rash Report, dated 1/30/2026, the Skin Rash Report indicated Resident 3 had skin rash on bilateral hands.During a review of Resident 3's medical record, there was no SBAR found in Resident 3's medical record regarding Resident 3's skin rash on both hands.2. During a review of Resident 7's AR, the AR indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included palliative care (medical care focused on relieving symptoms, pain, and stress from serious illnesses to improve quality of life for patients) and chronic kidney disease. During a review of Resident 7's H&P, dated 2/15/2026, the H&P indicated Resident 7 could make needs known but could not make medical decisions.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 7 required set-up assistance for eating. The MDS indicated Resident 7 required moderate assistance for oral hygiene and upper body dressing. The MDS indicated Resident 7 required maximal assistance for toileting hygiene, showering/bathing, putting on/taking off footwear, lower body dressing and personal hygiene. During a review of Resident 7's Skin Rash Report, dated 9/8/2025, the Skin Rash Report indicated Resident 7 had skin rash on generalized body. The Skin Rash Report indicated Resident 7 complained of itchiness.During a review of Resident 7's medical record, there was no SBAR found in Resident 7's medical record regarding Resident 7's generalized body rash. During an interview on 4/3/2026 at 8:51 a.m. with Infection Prevention Nurse (IPN), IPN stated when a resident develops a skin issue, nursing staff must document the change of condition on a change of condition (COC) form (SBAR). IPN stated when a resident has a COC, residents must be monitored more closely, and findings must be reported to their physician. IPN stated documenting a COC (SBAR) was reporting a change in a resident.During an interview on 4/3/2026 and 12:16 p.m. with Treatment Nurse (TN), TN stated when there was a change in a resident, it had to be documented, and their physician had to be notified. TN stated when a resident developed a skin rash, that was a COC and it had to be documented on a COC form. TN stated it was important to document resident's COC because it was a way to communicate a change in a resident and it indicated physician's notification. TN stated if a COC did not get documented, it created a risk for a resident not to receive the proper care for their skin rash and it would potentially get worse.During the review of facility's Policy and Procedure (P&P) titled Change in a Resident's Condition or Status dated 2/2021, the P&P indicated the facility promptly notifies the resident, attending physician, and the resident representative of changes in the resident's medical/mental condition. The P&P indicated a nurse would notify the resident's physician when there was a significant change in the resident's physical/emotional/mental condition. The P&P indicated, Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 3), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and was assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) did not elope from the facility's secured unit (specialized healthcare setting that restricts patient/resident movement and access to promote safety with measures such as locked doors and surveillance) on 4/24/2025, at 7: 06 PM by failing to ensure: 1. Certified Nursing Assistant (CNA) 6 closed/locked the door when CNA 6 exited the facility's secured unit and ascertained (make sure of) Resident 3 did not follow CNA 6 out of the secured unit. 2. Receptionist (RC) 1 clocked and set the alarm on the front door located in the facility's lobby to prevent Resident 3 from leaving the facility without supervision. 3. CNA 7 implemented Resident 3's Care Plan (CP) titled, Elopement Risk, indicating to monitor Resident 3 and to follow the facility's visual check protocol (to check the resident where about with the naked eyes) [Q (every) 15-minute monitoring]. These deficient practices resulted in Resident 3's elopement on 4/24/2025 at 7:06 PM, placing Resident 3 at risk for vehicular accidents due to the facility is located in a busy street with many cars driving by, negative outcome from not receiving Resident 3's medication, and exposure due to extreme temperatures (heat during the day and cold during the night) that could lead to serious injury, serious harm, or death. On 4/28/2025 at 5:20 PM, while onsite at the facility, the State Survey Agency (SSA) identified an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The IJ was called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure the doors to the secured unit were closed after CNA 6 walked out of the secured unit, the front lobby's door was locked and alarmed, Resident 3 was monitored/checked every 15 minutes, and to prevent the elopement of Resident 3 on 4/24/2025. On 4/29/2025 at 3:24 PM, while onsite at the facility, the ADM provided an acceptable IJ Removal Plan (IJRP, a detailed plan that includes interventions to immediately correct the deficient practices in the IJ) for the facility's failure to ensure Resident 3 did not elope from the facility on 4/24/2025 at 7:06 PM. The SSA verified and confirmed the facility's full implementation of the IJRP through observations, interviews, and record reviews, and determined the IJ situation regarding Resident 3's elopement due to lack of supervision, unlocked secured unit door, and no alarm on the front lobby door, were no longer present. The SSA removed the IJ on 4/29/2025 at 5 PM in the presence of the ADM. The acceptable IJRP included the following summarized actions: A. Immediate Corrective Actions: 1. On 4/24/2025, the DON provided a verbal one-on-one in-service (education given to one staff by one educator) via phone regarding the elopement policy to CNA 6, following a disciplinary Performance Correction on 4/25/2025. 2. On 4/25/2025, 4/26/2025, and 4/27/2025, the Registered Nurse Supervisor RNS 1 had contacted the nearby hospitals, and local police department to locate Resident 3. On 4/25/2025 the ADM contacted the private investigators (PI) who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI. 3. On 4/28/2025, the local police found Resident 3 and dropped Resident 3 off at Clinic 1. at approximately 6:30 AM. The DON communicated with Clinic 1's Nurse (CN) 1 who confirmed Resident 3 was currently in Clinic 1 with stable (normal) vital signs (VS, measuring the basic functions of your body temperature, blood pressure, pulse, and respirations). The DON notified Resident 3's Primary Physician/Medical Doctor (MD 1) who instructed to transfer Resident 3 back to the facility. 4. On 4/28/2025, two CNA's (CNAs 1 and 2) picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility at 4:35 PM. 5. On 4/28/2025, RNS 1 conducted a comprehensive assessment of Resident 3 upon Resident 3's return to the facility. Resident 3's VS were stable, no signs or symptoms of major injury were noted. MD 1 ordered to transfer Resident 3 to a General Acute Care Hospital (GACH) for further evaluation on 4/29/2025. Facility staff notified Resident 3's conservator regarding Resident 3 was found. 6. On 4/28/2025, the DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education. 7. Effective 4/28/2025, the facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility. 8. On 4/28/2025, and 4/29/2025, the DON and the Director of Staff Development (DSD) provided in-services to staff members regarding the elopement policy, covering the following topics: a. Supervise and redirect residents who are close to the exits, to mitigate the risk of elopement. b. While entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors. c. The importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision. d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision. e. Elopement Trainings is as follows: e1. As of 4/29/2025, 7 out of 8 RNs, 14 of 14 Licensed Vocational Nurses (LVNs), 36 of 42 CNA's, 20 of 20 department managers and assistants, 4 of 4 activity assistants, 7 of 7 housekeeping and laundry employees, 10 of 11 dietary service staff received the in-service training for elopement. e2. 8 staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. e3. 7 staff were not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return. e4. The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted in developing the IJ removal plan. 9. On 4/29/2025, the facility also installed a new door keypad for safety in the front lobby. B. Identification of other Residents: 1. On 4/28/2025, there were 48 residents residing in the secured unit. 2. On 4/28/2025 and 4/29/2025, the ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified. 3. On 4/27/2025, 4/28/2025, and 4/29/2025. the maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted. C. Systematic Change: 1. Effective 4/29/2025, the DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics: a. Supervise and redirect residents who are close to the exits, to mitigate the risk of elopement. b. While entering or exiting the secured unit, staff members must check/confirm that no residents are exiting the secured unit before walking away from the exit doors. c. The importance of conducting rounds every 15 minutes and as needed for adequate supervision. d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision. 2. The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement. 3. Effective 4/29/2025, the facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision. D. Monitoring Performance: 1. The DON, the DSD or the RNS 1 would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log. 2. The ADM and the DON developed a Quality Assurance and Performance Improvement (QAPI, data driven and a proactive approach to quality improvement) for elopement to address the deficient practice in the IJ findings. Findings: During a review of Resident 3's Admission Record (AR), the AR indicated Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included paranoid (when a person feels distrustful and suspicious of other people) schizophrenia (a serious mental health condition that affects how people think, feel, and behave, characterized by prominent delusions [a belief or altered reality that is persistently held despite evidence or agreement to the contrary] and hallucinations [false perception of objects or events involving the senses]), anxiety disorder (persistent feeling of dread or panic that can interfere with daily life), unspecified convulsions (a sudden, violent, irregular movement of a limb [arm or leg] or of the body), epilepsy [a disorder in which nerve cell activity in the brain is disturbed, causing seizures (a sudden burst of electrical activity in the brain)], cognitive communication deficit (difficulties with communication affecting the ability to understand), and diabetes mellitus (a disease that results in elevated levels of glucose in the blood). During a review of Resident 3's CP, titled Elopement Risk, initiated 8/21/2023 (no revision date indicated), the CP indicated Resident 3 sometimes left the facility without authorization/permission. The CP's interventions indicated for staff to continue to provide frequent visual checks (every 15 minutes) of Resident 3's where abouts (the place or general locality where a person is) in the secured unit, and to follow the protocol for visual checks (check the resident every 15 minutes). During a review of Resident 3's Change of Condition (COC)/Interact Assessment Form (SBAR, a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains), dated 8/30/2024, the COC indicated on 8/30/2024 at 8 AM, Resident 3 showed exit seeking behaviors and increased delusions that someone was waiting for Resident 3 outside of the facility. The COC indicated (on 8/30/2024) at 10 AM, Resident 3 was noted to be walking up and down the hallways looking hypervigilant (being excessively or abnormally alert to potential danger or threat), looking to get out [of the facility], screaming and shouting I need to get out of here now. During a review of Resident 3's Physician Orders (POs) for the month of September 2024, the POs indicated the following orders: 1. Admit Resident 3 to the secured unit, dated 9/9/2024. 2. Humalog Injection Solution [a rapid-acting insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) that starts working faster and works for a shorter period of time than regular/short-acting insulin] 100 unit milliliter (ml, unit of measurement) to inject as per sliding scale (a scale followed, dose of insulin varies based on blood sugar levels), dated 9/20/2024. 3. Lantus Solostar [a long-acting (a type of insulin that works throughout the day and night to provide residents/patients with low levels of insulin all the time) man-made-insulin used to control high blood sugar] subcutaneous (to administer medications between skin and muscle ) solution pen-injector inject (a device that provides a nonelectrically-powered, mechanically-operated method of accurately injecting medication/insulin) 100 unit/ml, administer 15 units at bedtime for diabetes mellitus with hyperglycemia (high blood sugar), check finger stick blood sugar (FSBS, a little poke is make in the finger, and a little teeny, tiny drop of blood is withdrawn to test the blood sugar/glucose) before administration, dated 9/9/2024. 4. Tegretol (carbamazepine, medication used to treat seizures) tablet, 200 milligrams (mg, unit of measurement) administered by mouth, three times a day, dated 9/9/2024. 5. Zyprexa (Olanzapine, medication used to treat schizophrenia) tablet, 10 mg, give 1 tablet by mouth, one time a day, for paranoid schizophrenia manifested by delusion that a judge ordered Resident 3 to take the medication. During a review of Resident 3's History and Physical (H&P), dated 9/10/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Elopement Risk Assessments ([NAME]), dated 9/26/2024, 12/24/2024 and 3/18/2025, the [NAME] indicated Resident 3 was assessed at risk for elopement due to Resident 3 wandered aimlessly (to move around or go to different places without having a particular purpose or direction), had verbally expressed the desire to go home, packed belongings to go home, and stayed near an exit door. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment and care screening tool), dated 3/18/2025, the MDS indicated Resident 3 had moderate impaired cognition (ability to think, remember, and reason). The MDS indicated Resident 3 needed supervision (helper provided verbal cues and/or touching/steadying and/or contact guard assistance as resident completed the activity and may be provided throughout the activity or intermittently) with oral hygiene, toileting, and personal hygiene. During a review of Resident 3's Police Report (PR), dated 4/24/2025, the PR indicated on 4/24/2025 at approximately 9:48 PM, Resident 3 was reported missing. The PR indicated (on 4/24/2025) at around 8 PM, facility staff looked through the entire facility and were unable to locate Resident 3. The PR indicated the facility's surveillance video footage captured Resident 3 walking in the [facility's] hallway (on 4/24/2025) at approximately 6 PM and at 7 PM, Resident 3 was seen standing by the secured unit's double doors. The PR indicated, A medical staff [CNA 6] opened the locked door and walked through the door. The PR indicated Resident 3 held the door open, walked behind CNA 6, then opened the front entrance door, and walked toward the north bound on [T Avenue, street located in front of the facility]. The PR indicated Resident 3 was diagnosed with several medical conditions, required constant medical attention, took prescribed medication, and was unable to care for herself. The PR indicated Resident 3 was a Critical missing person. The PR indicated Resident 3 left the health care facility without anyone [staff] noticing. During an observation on 4/28/2025 at 10:37 AM of the facility's premises. There was double glass doors located at the front of the facility's lobby. The double doors were pushed open to exit the facility. Past the double doors, there was a busy street with multiple cars moving along the road. During a concurrent observation of the facility's surveillance video, dated 4/24/2025, time at 7:06 PM and interview with the DON, on 4/28/2025 at 12:13 PM, the facility's surveillance video indicated Resident 3 exited the facility on 4/24/2025, at 7:06 PM and walked toward the left side of the facility. The video indicated there were multiple cars driving by on the major street located in front of the facility. The DON stated, the facility's surveillance video dated 4/24/2025, timed at 7:06 PM, indicated Resident 3 was in the secured unit's hallway, standing next to the exit door. The DON stated, CNA 6 opened the facility's locked door and walked out of the secured unit. The DON stated, Resident 3 placed Resident 3's hand between the double doors to prevent the doors from closing. The DON stated Resident 3 pushed the double doors open, walked into the facility's lobby, and walked out of the facility. The DON stated there were no staff visible past the secured unit door or in the facility's lobby. The DON stated Resident 3 walked out of the facility's main door, Like a visitor, and the facility located on a busy street with cars constantly driving by. The DON stated the facility's main lobby door was unlocked and no alarm or blinking lights were heard or observed visible in the surveillance video. The DON stated there should have been a staff member (receptionist) at the front desk monitoring who entered or left the facility. The DON stated the front doors should always be locked and the alarm should have turned on [sounded] to alert facility staff when people (staff, residents and or visitors) attempted to enter or exit the facility, as a safety measure to prevent residents (in general) from eloping. During a concurrent observation of the facility's surveillance video, dated 4/24/2025, at 7:06 PM, and an interview with the ADM on 4/28/2025 at 3:06 PM, the surveillance video indicated Resident 3 exited the facility on 4/24/2025, at 7:06 PM. The ADM stated, per the surveillance video, CNA 6 walked out of the facility's secured unit into the facility's lobby. The ADM stated Resident 3 walked behind CNA 6, pushed the lobby front doors open, walked out of the facility, and walked toward the busy street in front of the facility. The ADM stated, according to the surveillance video, no staff were seen at the front desk on 4/24/2025, since 6:30 PM, and the facility's staff members were unaware of Resident 3's elopement (on 4/24/2025, at 7:06 PM). During a review of Resident 3's 3 PM to 11 PM Resident Check (PMRC) log, dated 4/24/2025, completed by CNA 7, the PMRC log indicated Resident 3's where abouts were to be monitored by CNA 7 every 15 minutes. The PMRC log indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank (no indication of Resident 3's location). During a review of Resident 3's PMRC log, dated 4/24/2025 and an interview with CNA 7, on 4/28/2025 at 3:33 PM, The PMRC log indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank. CNA 7 stated all residents resided in the secured unit (including Resident 3) were to be monitored/checked every 15 minutes. CNA 7 stated CNA 7 was supposed to monitor and document the time and location of each resident assigned to CNA 7. CNA 7 stated, on 4/24/2025, (from 3 pm to 11 pm shift) CNA 7 was the primary CNA assigned to care for Resident 3. CNA 7 stated CNA 7 documented Resident 3's where abouts as being in the hallway on 4/24/2025, at 6 PM, 6:15 PM, and at 6:30 PM. CNA 7 stated CNA 7 last saw Resident 3 (on 4/24/2025), at 6:30 PM just before the scheduled smoke break for the smokers (residents who smoke) which lasted until 7 PM. CNA 7 stated it was unrealistic to monitor (check and document the residents [all assigned residents including Resident 3'] location every 15 minutes because CNA 7 was busy assisting and providing care to other residents. During an interview with the DSD, on 4/28/2025 at 3:43 PM, the DSD stated CNA 6 was in-serviced (educated) on the necessary safety steps to take when staff entered and exited the facility's secured units (prior to Resident 3's elopement). The DSD stated, after exiting the secured unit, CNA 6 needed to ensure the secured door was closed shut and residents did not follow CNA 6 or attempted to exit the secured unit. The DSD stated, when these steps [closed the door and made sure residents did not leave the secured unit without supervision] were not taken, residents could elope from the facility and could walk onto the busy street and get hurt. During a telephone interview with CNA 6 on 4/28/2025 at 3:54 PM, CNA 6 stated, on 4/24/2025 at around 7 PM, CNA 6 unlocked the secured unit doors and exited the secured unit. CNA 6 stated CNA 6 did not check if the door closed shut behind CNA 6 upon exiting the secured unit or ensure there were no residents standing close to the doors. CNA 6 stated it was important to ensure the doors were closed shut and locked, upon exiting the secured unit, so the resident (Resident 3) did not elope. During a review of Resident 3's PMRC log, dated 4/24/2025 and an interview with the DON on 4/29/2025 at 3:30 PM, The PMRC log indicated Resident 3's slots on 4/24/2025, from 6:45 PM to 11 PM were left blank. The DON stated Resident 3 was discovered missing on 4/24/2025, between 8:40 PM to 9 PM. During an interview with LVN 4, on 4/29/2025 at 3:40 PM, LVN 4 stated, on 4/24/2025, LVN 4 was the person in charge of the secured unit. LVN 4 stated Resident 3 was observant, smart, and aware of Resident 3's surroundings. LVN 4 stated on 4/24/2025, at around 9 PM, CNA 6 informed LVN 4 Resident 3 was missing. LVN 4 stated the assigned CNA (CNA 6) was responsible for monitoring the whereabouts of Resident 3 every 15 minutes. During a review of the facility's undated policy and procedures (P&P) titled, Missing Resident, the P&P indicated The facility's objective was to prevent possible injury or death to a resident and for wanderers (exit seeking residents) to be checked on a regular basis. During a review of the facility's P&P titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated Resident safety, supervision and assistance to prevent accidents are facility wide priorities. The P&P indicated systems approach to safety included, facility-oriented and resident-oriented approaches to safety are used together to implement a system's approach to safety, which considers the hazards identified in the environment and individual resident risk factors. The P&P indicated to adjust interventions accordingly. During a review of the facility's P&P titled, Wandering and Elopements, revised 3/2019, the P&P indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on observation, interview, and record review the facility failed to limit charges on the personal funds for four of four sampled residents (Residents 1, 2, 3, and 4's) by failing to: 1. Ensure Residents 1, 2, 3, and 4 who were unable to independently make medical and financial decisions were not charged an excessive amount of money (hundreds and thousands of dollars) for items the residents did not request or consent to purchase such as: puzzles, art supplies, iPads, televisions, exercise wrist watch, wireless headphones, and pet supplies. 2. Inform Residents 1, 2, 3, 4, and/or their responsible parties orally and in writing before purchasing any items that were not requested by the residents so the responsible parties would be able to make a decision on the residents' behalf. 3. Involve an advocate for Residents 2 and 3 who did not have a responsible party or family in the decision making prior to the facility staff purchasing items from the resident's funds that the residents did not request. 4. Assess Residents 1, 2, 3, and 4's personal needs and determine reasonable costs prior to facility staff purchasing items from the resident's funds. 5. Ensure Residents 1, 2, 3, and 4, were not charged for items that were not part of the residents' care plans and were not required to achieve the residents' goals. These deficient practices violated the residents' rights by the facility using residents' personal funds without the requests and wishes from the residents or their responsible parties which caused the misuse of the residents' personal funds. On 7/9/2021 at 8 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Director of Nursing (DON), and Business Office Manager (BOM) regarding the facility's failure to misappropriation and spending of resident's funds. On 7/10/2021 at 12 pm, the IJ was lifted after the ADM and Registered Nursing (RN) consultant submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the DON and RN consultant. The acceptable POA was as follows: 1. All residents' personal funds would be used properly. 2. Items would be purchased based on the residents' requests. 3. The Ombudsman (an official appointed to investigate individuals' complaints against maladministration) would be involved in the bioethics meeting (a body of persons established by the facility and assigned to consider, debate, study, take action on, or report on ethical issues that arise in patient care), for residents who were unable to independently make financial decisions. The facility communicated with the ombudsman and requested the ombudsman to participate in the bioethics meeting for residents who were unable to independently make financial decisions. 4. The facility notified the residents and/or family member before facility purchased any items using the residents' personal funds. 5. The facility evaluated the residents' needs and costs prior to purchasing, to avoid unnecessary and excessive purchases. Cross Reference F602 Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on 8/8/2006 and readmitted the resident on 5/6/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/2/2020, indicated Resident 1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Resident Statement Landscape, (personal fund account), indicated Resident 1's personal funds were debited (monies deducted) with the following: 1. On 9/14/2020, $ 1,886.00 was debited for personal needs items, (unidentified items). 2. On 9/28/2020, $384.73 was debited for personal needs items, (unidentified items). 3. On 10/23/2020, $848.36 was debited for personal needs items, (unidentified items). 4. On 10/26/2020, $ 156.50 was debited for personal needs items, (unidentified items). 5. On 11/19/2020, $662.78 was debited for personal needs items, (unidentified items). 6. On 11/27/2020, $606.02 was debited for personal needs items, (unidentified items). 7. On 11/27/2020, $936.02, was debited for personal needs items, (unidentified items). 8. On 11/27/2020, $261.00 was debited for personal needs items, (unidentified items). 9. A total of $1,348.96 was debited for clothing, (unspecified clothing items) from 12/24/2019 to 7/21/2020. A review of Resident 1's Resident Essentials, with an ordered date of 9/30/2020, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] $190.00. The form included other multiple orders for various clothing items and musical products. During an interview 7/8/21 at 10:17 am, the BOM verified there was no documentation in Resident 1's records to indicate the resident or the resident's responsible party requested for the facility or facility staff to make purchases on the resident's behalf for any personal needs items with the resident's personal funds. The BOM stated Resident 1 had enough funds and needed to spend down, to continue to receive Medi-cal benefits (a state medical insurance). b. A review of Resident 2's Admission Record indicated the facility admitted the resident on 7/25/2018 and readmitted the resident on 1/21/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was assessed as being moderately impaired in cognitive skills and poor decision-making. A review of Resident 2's Resident Statement Landscape, indicated Resident 2 received a Social Security check in the amount of $3,4801.00 on 2/7/2019 and $1,244.00 on 3/7/2019. The statement indicated the following were deducted from Resident 2's personal funds: 1. On 3/27/2019, $564.59 was debited for personal needs items, (unidentified items). 2. On 3/27/2019, $433.00 was debited for TV/Antenna. 3. On 4/2/2019, $1034.74 was debited for IPad with insurance. 4. On 4/2/2019, $888.38 was debited for personal needs items, (unidentified items). 5. On 4/2/2019, $280.00 was debited for a cash withdrawal. 6. 4/9/2019, $220.00 was debited for cash personal. During an interview and concurrent record review on 7/9/2021 at 9:21 am, the AD verified there was no documented evidence Resident 2 or the resident's family and/or responsible party approved of the purchases or requested the facility or facility staff to make purchases on the resident's behalf for any personal needs items with the resident's personal funds for the items listed above. c. A review of Resident 3's Admission Record, indicated the facility admitted the resident on 9/25/2019 and readmitted the resident on 11/2/2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident's Interdisciplinary Team Conference (Bioethics) dated 9/26/2019, indicated Resident 3 did not have the capacity to make decisions and did not have a family member or a next of kin with legal authority to make healthcare or financial decisions for the resident. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Resident Statement Landscape, indicated the following were deducted from Resident 3's personal funds: 1. On 6/25/2020, $352.79 was debited for personal needs items, (unidentified items). 2. On 6/25/2020, $329.55 was debited for personal needs items, (unidentified items). 3. On 12/4/2020, $551.13 was debited for personal needs items, (unidentified items). 4. On 12/4/2020, $296.94 was debited for personal needs items, (unidentified items). 5. On 2/18/2021, $768.56 was debited for personal needs items, (unidentified items). 6. On 5/21/2021, $ 1,835.64 was debited for personal needs items, (unidentified items). 7. On 6/17/2021, $42.14 was debited for personal needs items, (unidentified items). 8. On 7/17/2020, $413.20 clothing. 9. From 11/6/2020 to 6/24/2021, $79.00 for snack bar. A review of Resident 3's Original Invoice, dated 5/7/2021, indicated some of the items that were purchased by the facility for Resident 3 were: 1. Storage Caddy in the amount of $55.00 2. Puzzles in the amount of $23.38 3. Pattern Play blocks in the amount of $32.95 4. Set Swirly mats in the amount of $67.95 5. Tempera Stick Flour in the amount of $119.85 6. Brush Bright Canister Collection in the amount of $107.30 7. Art Start in the amount of 32.35 8. Slot Machine in the amount of $22.49 During an observation inside the facility's activity room on 7/8/2021 at 10:10 am the AD stated the items listed above and other items listed in the resident's inventory list dated 5/7/2021, were observed in the activity room marked with Resident 3's name. The AD stated she purchased the items for Resident 3 but did not have a written request from the resident or any family or resident's representative prior to purchasing the items with the resident's personal funds. During an interview on 7/8/21 at 11:52 am, the Business Office Regional Manager (BORM) stated, Residents 1, 2, 3, 4 were supposed to have less than two thousand dollars in the residents' personal funds to ensure the residents did not lose their Medi-cal Benefits. During a facility tour on 7/8/2021 at 1:30 pm, Resident 3 was observed sitting in the wheelchair near the nursing station. An attempt was made to interview the resident, however, the resident was unable to state the date and place of residence. During an observation on 7/8/2021 at 1:57 pm inside Resident 3's room, no television was observed. During an observation conducted with Certified Nursing Assistant 1 (CNA 1) on 7/9/2021 at 2:42 pm, inside Resident 3's room, Resident 3 was observed lying in bed. With the permission of Resident 3, the resident's closet was observed with wireless headphones, one exercise wrist watch, and two pairs of workout pants (resident 3's inventory indicated 10 workout pants), and a large flat screen television mounted on a mobile television mount at the foot of resident's bed (was not observed at the bedside on 7/8/2021). During an interview with 7/9/21 at 2:51 pm, Licensed Vocational Nurse 1(LVN 1) stated Resident 3 was confused. LVN 1 stated, he had not seen Resident 3 use the computer tablet and she would not be able to use the computer tablet without help. LVN 1 stated he had not seen Resident 3 use the Beats headphones, or the exercise wristwatch, he stated that the resident preferred to be outside of the room. d. A review of Resident 4's Admission Record indicated the facility admitted the resident on 11/28/2003 and readmitted the resident on 11/9/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated Resident 4 had moderately impaired memory and cognition that required total assistance with one person assistance with the activities of daily living. A review of Resident 4's Resident Statement Landscape, indicated the following were deducted from Resident 4's personal funds: 1. Clothing in the amount of $324.90 2. Personal need item in the amount of $34.00 During an interview on 7/9/21 at 3:30 pm the BOM stated, the facility was the Representative Payee for residents who were unable to make decisions for themselves, or have a family or a responsible party that did not want to be the resident's Representative Payee. The BOM stated there were about 31 residents the facility managed their personal funds for some of which the funds were more than $2,000.00 dollars because they received stimulus checks and other sources of funds such as residents' pensions. During an interview on 7/9/2021 at 3:45 pm with the Business Office Regional Manager (BORM), stated the facility had up to eight months to spend down, the residents' personal funds to make sure the residents' balances were less than $2,000.00 dollars to maintain the Medi-Cal Benefits, in which the funds could be used to purchase anything such as personal items even jewelry. The BORM stated the facility was aware the vendors had higher prices than other stores, but these were vendors (unidentified) that could legally sell the items. The BORM stated some residents had funds greater than $2,000.00 dollars. The BORM stated there were no written documents in the residents' clinical records that indicated the Social Security Administration office instructed the facility to spend down, the residents' funds. During an interview on 7/9/2021 at 4:43 pm, the ADM stated the facility conducted a Bioethics Committee meeting that consisted of the nursing staff, activity Director, and Social Service Designee and made a list of items prior to making the purchase. The ADM stated she did not have the list of items for Residents 1, 2, 3, and 4 based. ADM stated the facility did not make the purchases based on the residents' care plans. The ADM stated the Bioethics committee met prior to purchasing the items for the residents without their family or responsible parties or the Ombudsman present to advocate for the residents. ADM stated the facility did not inform Residents 1, 2, 3, and 4 in writing or orally what purchases were going to be made from the residents' personal funds. During an interview on 7/13/2021 at 11:18 am, the Deputy of the Public Guardian (DPG) Supervisor stated when the residents received Social Security checks and other personal funds such as pensions, the facility should report to the Medi-Cal office the changes of the finances of the residents in order for the Share of Cost (SOC, the amount of money a resident agrees to pay for health care before Medi-Cal starts to pay), to be adjusted. The DPG stated the facility should report the residents' personal funds to the Medi-Cal office. During a telephone interview on 7/14/2021 at 4:33 pm, Resident 4's family member 2 (FAM 2) stated the facility did not inform her of the resident's balance or the purchases made by the facility for Resident 4 or the amount of stimulus check Resident 4 received. FAM 2 stated the facility informed her that she could not have the information on Resident 4's funds because she was not the legal representative (court ordered to be the legal representative for the resident) for the resident even if she attended the quarterly IDT meetings. She further stated facility staff would ask for her to purchase clothing for Resident 4. During a telephone interview on 7/15/21 at 1:30 pm, the BOM stated there was no documented evidence family (FAM 2) was requested by the facility to be the Representative Payee for Resident 4, and no record to indicate FAM 2 was informed of the balance and activities in the residents' personal funds. During a telephone interview on 7/15/21 at 8:28 am, the Social Services Designee (SSD), stated for the residents who designated the facility as the Representative Payee, she and the other members of the Bioethics Committee did not inform the family or any residents responsible party for what items to be purchased unless they were the legal representative. During a telephone interview with the ADM in the presence of the BOM and BORM on 7/15/2021 at 1:30 pm, the BOM stated, the family or representative were not provided with the balance or purchases of the residents' personal funds unless they were the legal representative. The ADM stated there was no documented evidence that some of the residents' family or representatives were informed to apply as the Representative Payee. A review of the facility's policy and procedure, dated 4/14/2021, titled Resident Trust Fund, (funds that belongs to the residents), indicated if the resident or their responsible party on the resident's behalf chose to establish a resident fund in his or her name, the resident of their authorized agent should sign the resident trust software Authorization and Agreement Form prior to having their funds held in the facility Resident Trust Fund. Resident should have convenient access to their funds held in the trust account. The Trust Funds records should be available for residents to review upon request during normal business office hours.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 1, 2, 3, and 4) were free from misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent, includes all residents' possessions, regardless of their apparent value to others since they may hold essential value to the resident) by failing to: 1. Ensure not to misuse the personal funds of Residents 1, 2, 3, and 4 who were unable to independently make medical and financial decisions by using residents' money to purchase items not being used by the residents such as pet supplies, exercise wristwatch, and computer tablet. 2. Protect residents' personal funds by charging Residents 1, 2, 3, and 4 an excessive amount of money for items not requested by the residents or their responsible parties such as puzzles, art supplies, computer tablet, television, exercise wristwatch, wireless headphones, and pet supplies. These deficient practices had the potential to result in the residents' (including residents who were under the facility payee) failure to exercise their rights to be free from financial abuse, theft, and loss of personal property, and personal funds. On 7/9/2021 at 8 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), Director of Nursing (DON), and Business Office Manager (BOM) regarding the facility's failure of spending residents' funds without reasonable cause and placing the residents for further misappropriation of property. On 7/10/2021 at 12 pm., the IJ was lifted after the ADM and Registered Nursing (RN) consultant submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the DON and RN consultant. The acceptable POA was as follows: 1. All residents' personal funds would be used properly. 2. Items would be purchased based on the residents' requests. 3. The Ombudsman (an official appointed to investigate individuals' complaints against maladministration) would be involved in the bioethics meeting (a body of persons established by the facility and assigned to consider, debate, study, take action on, or report on ethical issues that arise in patient care), for residents who were unable to independently make financial decisions. The facility communicated with the ombudsman and requested the ombudsman to participate in the bioethics meeting for residents who were unable to independently make financial decisions. 4. The facility notified the residents and/or family member before facility purchased any items using the residents' personal funds. 5. The facility evaluated the residents' needs and costs prior to purchasing, to avoid unnecessary and excessive purchases. 6. The facility identified a total of 31 residents who were under the facility payee. 12 of 31 residents did not have the capacity to make decisions, and the facility scheduled bioethics meetings including the participation of the ombudsman. Cross reference F571 Findings: a. A review of Resident 1's Admission Record, indicated the facility admitted the resident on 8/8/2006 and readmitted the resident on 5/6/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/2/2020, indicated Resident 1 had severe impairment in memory and cognition that requiring total assistance with one person to assist with activities of daily living (ADL). A review of Resident 1's Resident Statement Landscape, indicated Resident 1's personal funds were debited (monies deducted) with the following: 1. On 9/14/2020, $ 1,886.00 was debited for personal needs items, (unidentified items). 2. On 9/28/2020, $384.73 was debited for personal needs items, (unidentified items). 3. On 10/23/2020, $848.36 was debited for personal needs items, (unidentified items). 4. On 10/26/2020, $ 156.50 was debited for personal needs items, (unidentified items). 5. On 11/19/2020, $662.78 was debited for personal needs items, (unidentified items). 6. On 11/27/2020, $606.02 was debited for personal needs items, (unidentified items). 7. On 11/27/2020, $936.02, was debited for personal needs items, (unidentified items). 8. On 11/27/2020, $261.00 was debited for personal needs items, (unidentified items). 9. A total of $1,348.96 was debited for clothing, (unspecified clothing items) from 12/24/2019 to 7/21/2020. A review of Resident 1's Resident Essentials, with an ordered date of 9/30/2020, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] $190.00. The form indicated other multiple orders for various clothing items and music products. During an interview 7/8/21 at 10:17 am, the BOM verified there was no documentation in Resident 1's records to indicate the resident or the resident's responsible party requested for the facility or facility staff to make purchases on the resident's behalf for any personal needs items with the residents' personal funds. The BOM stated Resident 1 had enough funds and needed to spend down, to continue to receive Medi-cal benefits (a state medical insurance). b. A review of Resident 2's Admission Record indicated the facility admitted the resident on 7/25/2018 and readmitted the resident on 1/21/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was moderately impaired in cognitive skills and poor decision-making. A review of Resident 2's Resident Statement Landscape, indicated Resident 2 received a Social Security check in the amount of $3,4801.00 on 2/7/2019 and $1,244.00 on 3/7/2019. The statement indicated the following were deducted from Resident 2's personal funds: 1. On 3/27/2019, $564.59 was debited for personal needs items, (unidentified items). 2. On 3/27/2019, $433.00 was debited for TV/Antenna. 3. On 4/2/2019, $1034.74 was debited for IPad with insurance. 4. On 4/2/2019, $888.38 was debited for personal needs items, (unidentified items). 5. On 4/2/2019, $280.00 was debited for a cash withdrawal. 6. 4/9/2019, $220.00 was debited for cash personal. During an interview and concurrent record review on 7/9/2021 at 9:21 am, the Activities Director (AD) verified there was no documented evidence Resident 2 or the resident's family and/or responsible party approved of the purchases or requested the facility or facility staff to make purchases on the resident's behalf for any personal needs items with the residents' personal funds for the items listed above. c. A review of Resident 3's Admission Record, indicated the facility admitted the resident on 9/25/2019 and readmitted the resident on 11/2/2020 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident's Interdisciplinary Team Conference (Bioethics) dated 9/26/2019, indicated Resident 3 did not have the capacity to make decisions and did not have a family member or a next of kin with legal authority to make healthcare and medical decisions for the resident. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had moderate impairment in memory and cognition (ability to think and reason) that required limited ( resident involved in activity) with one person assistance on activities of daily living (ADL). A review of Resident 3's Resident Statement Landscape, indicated the following were deducted from Resident 3's personal funds: 1. On 6/25/2020, $352.79 was debited for personal needs items, (unidentified items). 2. On 6/25/2020, $329.55 was debited for personal needs items, (unidentified items). 3. On 12/4/2020, $551.13 was debited for personal needs items, (unidentified items). 4. On 12/4/2020, $296.94 was debited for personal needs items, (unidentified items). 5. On 2/18/2021, $768.56 was debited for personal needs items, (unidentified items). 6. On 5/21/2021, $ 1,835.64 was debited for personal needs items, (unidentified items). 7. On 6/17/2021, $42.14 was debited for personal needs items, (unidentified items). 8. On 7/17/2020, $413.20 clothing. 9. From 11/6/2020 to 6/24/2021, $79.00 for snack bar. A review of Resident 3's Original Invoice, dated 5/7/2021, indicated some of the items that were purchased by the facility for Resident 3 were: 1. Storage Caddy in the amount of $55.00 2. Puzzles in the amount of $23.38 3. Pattern Play blocks in the amount of $32.95 4. Set Swirly mats in the amount of $67.95 5. Tempera Stick Flour in the amount of $119.85 6. Brush Bright Canister Collection in the amount of $107.30 7. Art Start in the amount of $32.35 8. Slot Machine in the amount of $22.49 During an observation inside the facility's activity room on 7/8/2021 at 10:10 am the AD stated the items listed above and other items listed in the inventory list dated 5/7/2021, were observed in the activity room marked with Resident 3's name. The AD stated she purchased the items for Resident 3 and did not have a written request from the resident or any family or resident representative prior to purchasing the items with the residents' personal funds. During an interview on 7/8/21 at 11:52 am, with Business Office Regional Manager (BORM) stated, Residents 1, 2, 3, 4 were supposed to have less than two thousand dollars in the residents' personal funds to ensure the residents did not lose the Medi-cal Benefits. During a facility tour on 7/8/2021 at 1:30 pm, Resident 3 was observed sitting in the wheelchair near the nursing station. Resident 3 was unable to state the date and place of residence. During an observation on 7/8/2021 at 1:57 pm inside Resident 3's room, no television was observed. During an observation conducted with Certified Nursing Assistant 1 (CNA 1) on 7/9/2021 at 2:42 pm, inside Resident 3's room, Resident 3 was observed lying in bed. With the permission of Resident 3, the resident's closet was observed with wireless headphones, one exercise wrist watch, and two pairs of workout pants (resident 3's inventory indicated 10 workout pants), and a large flat screen television mounted on a mobile television mount at the foot of resident's bed (was not observed at the bedside on 7/8/2021). During an interview with 7/9/21 at 2:51 pm, Licensed Vocational Nurse 1(LVN 1) stated Resident 3 was confused. LVN 1 stated, he had not seen Resident 3 use the computer tablet and she would not be able to use the computer tablet without help. LVN 1 stated he had not seen Resident 3 use the wireless headphones, or the exercise wristwatch, he stated that the resident preferred to be outside the room. d. A review of Resident 4's Admission Record indicated the facility admitted the resident on 11/28/2003 and readmitted the resident on 11/9/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated Resident 4 had moderately impaired memory and cognition that required total assistance with one person to assist with the activities of daily living. A review of Resident 4's Resident Statement Landscape, indicated the following were deducted from Resident 4's personal funds: 1. Clothing in the amount of $324.90 2. Personal need item in the amount of $34.00 During an interview on 7/9/21 at 3:30 pm the BOM stated, the facility was the Representative Payee for residents who were unable to make decisions for themselves, or have a family or a responsible party that did not want to be the resident's Representative Payee. The BOM stated there were about 31 residents the facility managed their personal funds for some of which the funds were more than $2,000.00 dollars because they received stimulus checks and other sources of funds such as residents' pensions. During an interview on 7/9/2021 at 3:45 pm with the Business Office Regional Manager (BORM), stated the facility had up to eight months to spend down, the residents' personal funds to make sure the residents' balances were less than $2,000.00 dollars to maintain the Medi-Cal Benefits, in which the funds could be used to purchase anything such as personal items even jewelry. The BORM stated the facility was aware the vendors had higher prices than other stores, but these were vendors that could legally sell the items. The BORM stated some residents had funds greater than $2,000.00 dollars. The BORM stated there were no written documents in the residents' clinical records that indicated the Social Security Administration office instructed the facility to spend down, the residents' funds. During an interview on 7/9/2021 at 4:43 pm, the ADM stated the facility conducted a Bioethics Committee meeting that consisted of the nursing staff, activity Director, and Social Service Designee and made a list of items prior to making the purchase. The ADM stated she did not have the list of items for Residents 1, 2, 3, and 4. ADM stated the facility did not make the purchases based on the residents' care plans. The ADM stated the Bioethics committee met prior to purchasing the items for the residents without their family or responsible parties or the Ombudsman present to advocate for the residents. ADM stated the facility did not inform Residents 1, 2, 3, and 4 in writing or oral what purchases were going to be made from the residents' personal funds. During an interview on 7/13/2021 at 11:18 am, the Deputy of the Public Guardian (DPG, a person who helps make important decisions for others who cannot decide for themselves) Supervisor stated when the residents received Social Security checks and other personal funds such as pensions, the facility should report to the Medi-Cal office the changes of the finances of the residents in order for the Share of Cost (SOC, the amount of money a resident agrees to pay for health care before Medi-Cal starts to pay), to be adjusted. The DPG stated the facility should report the residents' personal funds to the Medi-Cal office. During a telephone interview on 7/14/2021 at 4:33 pm, Resident 4's family member 2 (FAM 2) stated the facility did not inform her of the resident's balance or the purchases made by the facility for Resident 4 or the amount of stimulus check Resident 4 received. FAM 2 stated the facility informed her that she could not have the information on Resident 4's funds because she was not the legal representative (court ordered to be the legal representative for the resident) for the resident even if she attended the quarterly IDT meetings. She further stated facility staff would ask for her to purchase clothing for Resident 4. During a telephone interview on 7/15/21 at 1:30 pm, the BOM stated there was no documented evidence family (FAM 2) was requested by the facility to be the Representative Payee for Resident 4, and no record to indicate FAM 2 was informed of the balance and activities in the residents' personal funds. During a telephone interview on 7/15/21 at 8:28 am, the Social Services Designee (SSD), stated for the residents who designated the facility as the Representative Payee, she and the other members of the Bioethics Committee did not inform the family or any residents responsible party for what items to be purchased unless they were the legal representative. During a telephone interview with the ADM in the presence of the BOM and BORM on 7/15/2021 at 1:30 pm, the BOM stated, the family or representative were not provided with the balance or purchases of the residents' personal funds unless they were the legal representative. The ADM stated there was no documented evidence that some of the residents' family or representatives were informed to apply as the Representative Payee. A review of the facility's policy and procedure, dated 4/14/2021, titled Resident Trust Fund, (funds that belongs to the residents), indicated if the resident or their responsible party on the resident's behalf chose to establish a resident fund in his or her name, the resident of their authorized agent should sign the resident trust software Authorization and Agreement Form prior to having their funds held in the facility Resident Trust Fund. Resident should have convenient access to their funds held in the trust account. The Trust Funds records should be available for residents to review upon request during normal business office hours. A review of the facility's undated policy and procedure, titled Policy on Patient Abuse, indicated the facility would establish a system to prevent misappropriation of property. The policy indicated the residents should not be subject to abuse by anyone, including but not limited to staff, other residents, consultants, and from other agencies.