Every finding on record at Claremont Heights Post Acute

Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for two of four sampled residents (Resident 1 and Resident 4) whose urinals (a receptacle used to collect urine [a yellowish liquid waste product produced by the kidneys]) were observed half full of urine and were left on top of the resident's dressers.This deficient practice had the potential to result in bacterial growth inside the urinals and infections to Resident 1 and Resident 4.Cross Reference with F550Findings:a. During a review of Resident 1's Face Sheet (FS, admission record), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of long-term lung diseases that block airflow), heart failure (heart muscle doesn't pump blood as well as it should), and morbid (severe) obesity.During a review of Resident 1's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Date Set (MDS, a resident assessment and care-screening tool), dated 3/31/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 needed maximal assistance (helper does more than half the work) with toilet hygiene and moderate assistance (less than half the work) to sit-to-stand and toilet transfers.During an observation and interview on 4/15/2026 at 12:55 PM with Resident 1 inside the resident's room, Resident 1's urinal was halfway full and was located on top of Resident 1's dresser. Resident 1 stated Resident 1 had asked the staff (unidentified) to empty Resident 1's urinal several times.During an observation and concurrent interview on 4/15/2026 at 1:27 PM in Resident 1's room, with Licensed Vocational Nurse 1 (LVN 1), Resident 1's urinal was full of urine and was on top of Resident 1's dresser. LVN 1 stated Resident 1's urinal contained 240 cubic centimeters (cc, a volume of fluid) of urine. LVN 1 stated urinals should be emptied because bacteria could grow inside [the urinals] and for infection control.b. During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI, an infection [the invasion and growth of germs in the body] in the bladder/urinary tract), difficulty walking, and lack of coordination.During a review of Resident 4's H&P, dated 2/11/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was intact. The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort) with toilet hygiene and shower/baths and required maximal assistance (helper does more than half the effort) with sit to lying position.During an interview and concurrent observation on 4/15/2026 at 1:24 PM to 1:27 PM with LVN 1, at Resident 4's bedside, Resident 4's urinal contained urine and was observed on top of Resident 4's dresser. LVN 1 stated Resident 4's urinal was on the top of the dresser and had 240cc of urine inside. LVN 1 stated urinals should be emptied because they could grow bacteria, for infection control.During an interview with the Director of Staff Development (DSD) on 4/15/2026 at 1:59 PM, the DSD stated staff were instructed to empty urinals as soon as possible because [urinals left with urine] became an infection control issue.During an interview on 4/15/2026 at 3:25 PM with the Director of Nursing (DON), the DON stated urinals should not be left with urine and should be emptied as soon as possible to prevent infections and bacterial growth.During a review of the facility's policy and procedure (P&P) titled Infection Control - Policies & Procedures, revised 1/1/2012, the P&P indicated the facility's infection control policies and procedures 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 indicated to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public.

Based on interview and record review, the facility failed to treat two of four sampled residents (Resident 1 and Resident 4) with respect and dignity when on 4/15/2026 Resident 1 and 4's urinals (a receptacle used to collect urine [a yellowish liquid waste product produced by the kidneys]) were half filled with urine and left on top of the resident's dressers.This deficient practice resulted in feelings of embarrassment to Resident 1 and Resident 4.Cross Reference with F880 Findings:a. During a review of Resident 1's Face Sheet (FS, admission record), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a group of long-term lung diseases that block airflow), heart failure (heart muscle doesn't pump blood as well as it should), and morbid (severe) obesity.During a review of Resident 1's History and Physical (H&P), dated 9/9/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Date Set (MDS, a resident assessment and care-screening tool), dated 3/31/2026, the MDS indicated Resident 1's cognition (the ability to think and process information) was intact. The MDS indicated Resident 1 needed maximal assistance (helper does more than half the work) with toilet hygiene and moderate assistance (less than half the work) to sit-to-stand and toilet transfers.During an observation and interview on 4/15/2026 at 12:55 PM with Resident 1 inside the resident's room, Resident 1's urinal was halfway full and was located on top of Resident 1's dresser. Resident 1 stated Resident 1 had asked the staff (unidentified) to empty Resident 1's urinal several times. Resident 1 stated I need the urinal emptied before it overflows, then where would I pee? It's embarrassing. During an observation and concurrent interview on 4/15/2026 at 1:27 PM in Resident 1's room, with Licensed Vocational Nurse 1 (LVN 1), Resident 1's urinal was full of urine and was located on top of Resident 1's dresser. LVN 1 stated Resident 1's urinal contained 240 cubic centimeters (cc, a volume of fluid) of urine. LVN 1 stated for Resident 1's dignity, urinals should not be [left] with urine inside. b. During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI, an infection [the invasion and growth of germs in the body] in the bladder/urinary tract), difficulty walking, and lack of coordination.During a review of Resident 4's H&P, dated 2/11/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was intact. The MDS indicated Resident 4 required moderate assistance (helper does less than half the effort) with toilet hygiene and shower/baths and required maximal assistance (helper does more than half the effort) with sit to lying position.During an interview and concurrent observation on 4/15/2026 at 1:24 PM with LVN 1, at Resident 4's bedside, Resident 4's urinal was full of urine and was located on top of Resident 4's dresser. Resident 4 stated can you please empty my urinal? My family is coming later today, and it's a little embarrassing for them to see that.During an interview on 4/15/2026 at 1:27 PM with LVN 1, LVN 1 stated Resident 4's urinal was on the top of Resident 4's dresser and had 240cc of urine inside. LVN 1 stated urinals should be emptied and concealed for the dignity of the residents.During an interview with the Director of Staff Development (DSD) on 4/15/2026 at 1:59 PM, the DSD stated urinals should be empty because full urinals played a part in the resident's dignity.During an interview on 4/15/2026 at 3:25 PM with the Director of Nursing (DON), the DON stated urinals should be emptied. The DON stated residents (in general) must be treated with respect and dignity to avoid the residents feeling embarrassed.During a review of the facility's policy and procedure (P&P) titled Resident Rights - Accommodation of Needs, revised 1/1/2012, the P&P's purpose indicated to ensure that the facility provides an environment and services that meet resident's individual needs. The P&P indicated the facility's environment is designed to assist the resident in achieving independent functioning and maintaining the resident's dignity and well-being.During a review of the facility's P&P titled Resident Rights - Quality of Life, revised 3/2017, the P&P indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner .

Based on observation, interview, and record review, the facility failed to ensure foods brought in from outside of the facility were stored properly for two of two sampled residents (Resident 105 and Resident 4), in accordance with the facility's policy and procedure (P&P) titled, Food Brought in by Visitors. This deficient practice placed Resident 105 and Resident 4 at risk for serious complications from food borne illnesses (any illness resulting from eating contaminated/spoiled foods).Findings: a. During a review of Resident 105's admission Record (AR), the AR indicated, Resident 105 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a heart disorder which causes the heart to not pump blood efficiently) and essential (primary) hypertension (HTN - high blood pressure). During a review of Resident 105's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/18/2026, the H&P indicated Resident 105 had the capacity to understand and make decisions. b. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening blood infection) and unspecified protein-calorie malnutrition. During a review of Resident 4's H&P, dated 1/15/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 1/20/2026, the MDS indicated Resident 4's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 4 required substantial to maximal assistance with eating, oral hygiene, and personal hygiene and was dependent on toileting, showering, and dressing. During an observation on 2/24/2026 at 9:53 AM, inside Resident 105's room, an unlabeled 3-pound (lb - a unit of weight) container of green seedless grapes was found on Resident 105's dresser. During a concurrent observation and interview on 2/24/2026 at 10:28 AM with Registered Nurse (RN) 2, in Resident 105's room, RN 2 observed an unlabeled 3-pound container of green seedless grapes on Resident 105's dresser. RN 2 stated RN 2 did not know who the grapes belonged to and the grapes should have been labeled with resident's (in general) name and stored in the refrigerator for infection precautions. During a concurrent observation and interview on 2/24/2026 at 12:30 PM with Certified Nursing Assistant (CNA) 9, in Resident 4's room, an unlabeled/undated plastic grocery bag containing an undated plastic container with Spanish labeling was found inside Resident 4's bedside drawer. The undated plastic container with Spanish labeling contained three (3) cookies. CNA 9 stated CNA 9 did not know how old the food (cookies) was. CNA 9 stated foods brought in from outside were supposed to be labeled with resident's name, room number, date (received) and stored in the refrigerator, to know if the food not old. During an interview on 2/24/2026 at 1 PM with CNA 10, CNA 10 stated foods brought in from home were not supposed to be left inside the resident's room and should be labeled with the resident's name and date (received), and stored in the refrigerator for safety, because the food can get old. During an interview on 2/25/2026 at 12:55 PM with Resident 4's family member (FM), the FM stated the food in Resident 4's bedside drawer was brought in by the FM, and it was a papaya salad. The FM stated the facility did not inform the FM of the facility's policy regarding bringing food from home. During an interview on 2/26/2026 at 11:27 AM with RN 1, RN 1 stated staff (in general) were supposed to be informing resident's family regarding the facility's policy regarding bringing food from home. RN 1 stated staff (in general) should be checking resident's food from home for the resident's appropriate diet, label the food with resident's name, room number and date (received) and time to ensure safe consumption. During an interview on 2/26/2026 at 3:25 PM with Resident 105, Resident 105 stated Resident 105's son brought the grapes and cherries and should have been refrigerated to prevent bacteria to get in, and make Resident 105 sick. During a review of the facility's P&P titled, Food Brought in by Visitors, with an effective date of 5/22/2025, the P&P indicated, The facility staff will.provide resident/resident representative with this policy about the use and storage of foods brought in by family/visitors.Place the food in a food container that is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to ensure two of two sampled residents' (Resident 105's and Resident 50's) personal care items were labeled and stored properly. This deficient practice 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 for Resident 105 and Resident 50.Findings:a. During a review of Resident 105's admission Record (AR), the AR indicated Resident 105 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and essential (primary) hypertension (HTN - high blood pressure). During a review of Resident 105's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated [DATE], the H&P indicated Resident 105 had the capacity to understand and make decisions. During a review of Resident 105's Care Plan Report (CPR), initiated on [DATE], the CPR indicated a goal to reduce the risk of MDRO transmission. The CPR interventions included implementing EBP to prevent the spread of infections for specific care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. b. During a review of Resident 50's AR, the AR indicated Resident 50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including sepsis (a life-threatening blood infection) and personal history of other infectious and parasitic (relating to organisms that depend on a host to survive and spread) diseases. During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 50's cognitive skills (ability to think and process information) for daily decision making were intact. The MDS indicated Resident 50 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) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 50's H&P, dated [DATE], the H&P indicated Resident 50 had the capacity to understand and make decisions. During an observation on [DATE] at 9:53 AM, Resident 105 and Resident 50's shared room had an EBP signage posted by the door and a white colored trimmed 3-drawer personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) cart outside of the room. There was an unlabeled 3-pound (lb - a unit of weight) container of green seedless grapes next to multiple unlabeled personal care items such as a deodorant, mouthwash, toothpaste, toothbrush and a wash basin with supply of diapers, stored on the shared dresser of Resident 105 and Resident 50, located across from Resident 105's bed. Resident 105 and Resident 50's shared restroom had an unlabeled pack of XL [NAME] Wipes (brand name) and two (2) unlabeled packs of equate (brand name) wipes on top of the toilet tank and a twenty point three (20.3) fl oz (fluid ounce - a unit of volume), extra repair (brand name) unscented body lotion, a seven point five (7.5) oz Tres Care (brand name) perineal/body wash + shampoo, four (4) fl oz DawnMist (brand name) baby lotion, one point five (1.5) oz freshmint (brand name) toothpaste, a bar of [NAME] spring (brand name) bath soap stored on the top of the pony wall (a short wall that separates the toilet and the shower in a bathroom). During a concurrent observation and interview on [DATE] at 10:28 AM with Registered Nurse (RN) 2 in Resident 105 and Resident 50's shared room, RN 2 observed an unlabeled 3-pound container of green seedless grapes next to multiple unlabeled personal care items such as a deodorant, mouthwash, toothpaste, toothbrush and a wash basin with supply of diapers, stored on the shared dresser of Resident 105 and Resident 50, located across from Resident 105's bed. In Resident 105 and Resident 50's shared restroom, RN 2 observed an unlabeled pack of XL [NAME] Wipes (brand name) and two (2) unlabeled packs of equate (brand name) wipes on top of the toilet tank and a twenty point three (20.3) fl oz (fluid ounce - a unit of volume), extra repair (brand name) unscented body lotion, a seven point five (7.5) oz Tres Care (brand name) perineal/body wash + shampoo, four (4) fl oz DawnMist (brand name) baby lotion, one point five (1.5) oz freshmint (brand name) toothpaste, a bar of [NAME] spring (brand name) bath soap stored on the top of the pony wall. RN 2 stated Resident 105 and Resident 50, ideally, they share half of everything. RN 2 stated labeling resident's (in general) personal care items and storing the personal care items in resident's personal space was important to know who the personal care items belonged to and for infection control. During an interview on [DATE] at 3:06 PM with the Infection Preventionist (IP), the IP stated, resident's personal care items should be labeled with the resident's name and stored close to the resident's side of the room for infection control. The IP stated Resident 105 and Resident 50 could share the dresser as long as the personal care items were not mixed (separated).During an interview on [DATE] at 4:41 PM with Certified Nursing Assistant (CNA) 14, CNA 14 stated personal care items were essential and should be labeled with the resident's name and stored at the resident's bedside. CNA 14 stated labeling and storing personal care items at the resident's bedside was important to prevent residents from sharing, to avoid cross contamination, and for infection control. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program Description, dated [DATE], the P&P indicated the program encompassed employee health and patient safety through resident care practices. The P&P included goals such as to provide a safe, sanitary and comfortable environment, decrease the risk of infections to residents, visitors, guests and staff, monitor for evidence of infection/communicable disease and implement appropriate control measures, create a culture of safety in the facility to promote infection prevention as a focus and identify and correct problems related to infection prevention and control practices. The P&P indicated, the IP would monitor/audit procedures for proper infection prevention and control technique, as indicated and appropriate.

Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, 6, and 54) were treated with dignity when:a. Certified Nursing Assistant (CNA) 6 left Resident 54's lower body exposed. b. CNA 12 stood over in front of Resident 1 while assisting Resident 1 to drink during lunch.C. Speech Therapist (ST) was standing while feeding Resident 6.These deficient practices resulted in Resident 54 feeling uncomfortable, cold and naked and had the potential to cause Resident 1, 6 and 54 feeling humiliated, negatively impacting the residents' psychosocial well-being. Findings: a. During a review Resident 54's admission Record (AR), the AR indicated Resident 54 was admitted to the facility on [DATE]with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness in the arm, leg, and face on one side of the body) following cerebral infarction (stroke – loss of blood flow to a part of the brain) and contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the right and left ankle and left shoulder. During a review of Resident 54's Minimum Data Set (MDS – resident assessment tool), dated 1/24/2026, the MDS indicated Resident 54'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 54 was dependent (helper does all of the effort) with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview with Resident 54 on 2/24/2026 at 1:52 PM, CNA 6 was observed leaving Resident 54's room. Resident 54 was observed lying in bed uncovered only wearing a sweater over a shirt, a diaper and socks. The privacy curtain was not pulled all the way around to cover Resident 54's bed. The privacy curtain was only pulled so that the resident was not visible from the hallway. Resident 54 stated Resident 54 was not cold but felt uncomfortable lying in bed uncovered. During a concurrent observation and interview on 2/26/2026 at 10:23 AM with Resident 54 in the activities room, Resident 54 was observed sitting in the wheelchair covered in a blanket. Resident 54 stated Resident 54 was usually cold and did not like to be uncovered. Resident 54 stated when lying in bed, Resident 54 liked to be covered to stay warm. Resident 54 stated when left in only a shirt, underwear and no blanket, Resident 54 would feel naked. During an interview on 2/26/2026 at 10:39 AM with CNA 7, CNA 7 stated whenever CNA 7 had to step away for whatever reason while assisting a resident (in general), CNA 7 would cover the resident for dignity and respect, and made sure the resident was comfortable and with the call light available. During an interview on 2/26/2026 at 3:26 PM with the Director of Nursing (DON), the DON stated if the CNA (in general) was going to step away from the resident, the CNA should cover the resident. The DON also stated it was important to keep the residents covered for privacy. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/1/2012, indicated, Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.These rights included, but are not limited to, a resident's right to.privacy and confidentiality. b. During a review of Resident 1's AR, the AR indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (adult onset disorder characterized by difficulty in blood sugar control and poor wound healing, muscle weakness (generalized), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills were moderately impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort to complete the activity) to eat and with oral hygiene. During a review of Resident 1's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/2/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a concurrent observation and interview on 2/24/2026 at 1 PM with CNA 10 in the Dining Room, Resident 1was sitting in a wheelchair while being fed by CNA 12 who sat across from Resident 1. CNA 12 stood up in front of Resident 1 every time CNA 12 had to hold and tip the milk for Resident 1 to drink. CNA 10 stated CNA 12 was not supposed to stand up and should sit at Resident 1's side while feeding Resident 1. During an interview on 2/25/2026 at 9:44 AM with CNA 12, CNA12 stated CNA 12 should have been at eye level with Resident 1 while CNA 12 fed Resident 1, for dignity. During an interview on 2/26/2026 at 11:27 AM with Registered Nurse (RN) 1, RN 1 stated staff (in general) should be sitting down at eye level with the resident (in general) during feeding for dignity issues. c. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (loss of blood flow to a part of the brain) and flaccid hemiplegia (total paralysis of one side of the body characterized by muscles that are limp, floppy, and devoid of muscle tone) affecting the right dominant side. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for ADLs. During a concurrent observation and interview on 2/26/2026 at 7:47 AM in Resident 6's room, the ST was observed standing while feeding Resident 6. The ST stated the ST normally stands while feeding residents due to personal preference and residents have not asked the ST to sit down. The ST stated the ST attended an in-service on how to feed residents and had been instructed to sit while feeding residents. During an interview on 2/26/2026 at 8:12 AM with CNA 16, CNA 16 stated facility staff (in general) should sit down while feeding residents to ensure staff can see the residents' faces and make sure, they are not choking. During a review of the facility's P&P titled, Resident's Rights - Quality of Life, dated 3/2017, the P&P indicated each resident should be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and received services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable wellbeing. The P&P indicated facility staff must treat cognitively impaired residents with dignity and sensitivity.

Based on interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Advance Directives, for two of two sampled residents (Resident 4 and Resident 35) when:1. Copies of Resident 4's and Resident 35's advance directives (AD-a legal document that provides instructions for medical care when a person can no longer decide on their own) were obtained and filed in Resident 4's and Resident 35's medical records.2. The Social Services Director (SSD) did not ensure the Durable Power of Attorney (DPOA, a legal document allowing another person to manage one's financial, legal, or medical affairs when one can no longer decide on their own) filed in Resident 35's medical records also covered medical or healthcare decisions.These failures had the potential to result in conflict regarding Resident 4's and Resident 35's choices regarding health care decisions and the residents' medical wishes not to be honored.Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated the facility admitted Resident 4 on 1/13/2026 with diagnoses including fracture of lower end of right femur (a broken bone on the right thigh), subsequent encounter for closed fracture with routine healing (a follow up visit indicating the break is healing normally) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 4's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 1/15/2026, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 1/20/2026, the MDS indicated Resident 4's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 4 required substantial to maximal assistance with eating, oral hygiene, and personal hygiene and was dependent on toileting, showering, and dressing. During a review of Resident 4's Social Services Assessment (SSA), dated 1/14/2026, the SSA indicated Resident 4 had an AD on file. The SSA indicated the AD was uploaded in Resident 4's electronic health record (EHR-a digital version of a patient's medical chart that stores health information). During an interview on 2/25/2026 at 12:30 PM with the Social Services Director (SSD), the SSD stated an AD indicated the residents' (in general) preferences regarding health decisions. The SSD stated Resident 4 should have an AD on file, but the AD was not in Resident 4's medical record. The SSD stated it was important to have Resident 4's AD on file to ensure Resident 4's health decisions were honored. b. During a review of Resident 35's AR, the AR indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (group of conditions that affect movement and posture caused by damage to the brain before birth) and unspecified severe protein-calorie malnutrition. During a review of Resident 35's H&P, dated 11/20/2025, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills were severely impaired (never/rarely made decisions). The MDS indicated Resident 35 was dependent (helper does all the effort to complete the activity) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 35's AD was not completed. During a review of Resident 35's Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be provided to a person in an emergency), dated 9/19/2025, the POLST did not indicate if Resident 35 had an AD and who Resident 35's healthcare agent (proxy, person specifically appointed to make medical treatment decisions when a person can no longer decide on their own) was. The POLST indicated, POLST complements an Advance Directive and is not intended to replace that document (Advance Directive). During a review of Resident 35's DPOA, dated 12/13/1991, the DPOA indicated Resident 35 only granted Resident 35's responsible party (RP, a person who is responsible for guiding, informing, assisting, and advocating for residents in the healthcare system) the DPOA to manage Resident 35's financial affairs. The DPOA did not appoint Resident 35's RP to manage Resident 35's medical or healthcare affairs. During a concurrent interview and record review on 2/25/2026 at 12:30 PM with the SSD, Resident 35's SSA, dated 9/23/2025 and timed at 4:01 PM, was reviewed. The SSA indicated Resident 35 had an AD on file. The SSD stated an AD was a form that would assist residents (in general) to identify who the residents (in general) wanted to decide for them in the event they were not able to make medical decisions for themselves. The SSD stated the POLST was not intended to replace an AD. Resident 35's medical record was reviewed and an AD and/or a DPOA for healthcare was not found in Resident 35's medical record. The SSD stated the SSD and/or Admissions staff were responsible for providing education and acquiring the residents' (in general) AD upon admission. The SSD reviewed Resident 35's DPOA, dated 12/13/1991, and stated the DPOA only covered financial decisions and did not cover medical decisions. The SSD stated the SSD should have read Resident 35's DPOA to ensure the DPOA also covered medical decisions. During a review of the facility's P&P titled, Advance Directives, revised July 2018, the P&P indicated, Upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. A copy of the resident's advance directive will be included in the resident's medical record. An Advance Directive is defined as a resident's written preference regarding treatment options.Upon admission, the Admissions Staff or designee will provide written information to the resident concerning his or her right to make decisions concerning medical care.and the right to formulate advance directives.During the Social Services Assessment process, the Director of Social Services or designee will also ask the resident whether he or she has a written advance directive.If the resident has an Advance Directive, the Facility shall obtain a copy of the document and place it in the resident's medical record. The P&P indicated, the Interdisciplinary Team would review the advance directive with the resident or responsible party annually to ensure that the directive still reflects the wishes of the resident.

Based on interview and record review, the facility failed to develop a Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) for three of three residents (Resident 103, 13, and 67) as evidenced by:Failure to develop a CP for Resident 13's behavior of pulling and removing Resident 13's gastrostomy tube (GT - medical feeding tube inserted through the abdomen directly into the stomach to deliver nutrients, fluids, and medications.)Failure to develop a CP for Resident 67's personal preference to apply tape to the eyelids. Failure to develop a CP for Resident 103's admission to hospice care.These failures had the potential for Resident 103, 13 and 67 to not obtain their highest physical, mental and psychosocial well-being.Findings: A. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including Parkinson's disease (brain disorder in which there is a lack of the chemical messenger dopamine, which helps control muscle movement; leads to muscle stiffness, weakness and trembling) with dyskinesia (difficulty in performing or controlling voluntary movements) with fluctuations, dysphagia (difficulty, discomfort or inability to swallow food or liquids) and encounter for attention to gastrostomy (the surgical creating of an opening in the abdominal wall into the stomach for drainage or a feeding tube.) During a review of Resident 13's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 12/5/2025, the MDS indicated Resident 13 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for toileting and required partial/ moderate assistance (helper does less than half the effort) for mobility. During an interview on 2/26/2026 at 11:38 AM with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 13 wore an abdominal binder and mitten restraints on both hands because Resident 13 had a history of pulling out Resident 13's GT. CNA 8 stated the abdominal binder and mitten restraints are worn while Resident 13 is in bed to prevent Resident 13 from removing the GT. CNA 8 was unsure how many times Resident 13 had pulled out the GT and was only aware of one incident. During an interview on 2/26/2026 at 11:59 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated in the past year, Resident 13 might have removed the GT four to five times. During an interview on 2/26/2026 at 12:14 PM with LVN 4, LVN 4 stated Resident 13 wore restraints because Resident 13 had a behavior or pulling out the GT. LVN 4 stated Resident 13 was strong and persistently attempted to remove the GT. During a concurrent interview and record review on 2/26/2026 at 12:37 PM with the Registered Nurse (RN) 2 Resident 13's CPs were reviewed. RN 2 stated Resident 13 had a history of pulling the GT many times. RN 2 stated prior to implementing mitten restraints, Resident 13 wore an abdominal binder to prevent pulling out the GT but Resident 13 was still able to reach underneath the abdominal binder to remove the GT. RN 2 stated the staff (general) did not develop a CP for Resident 13's behavior of removing the GT. RN 2 stated a CP should have been developed to inform the staff to monitor for the behavior and to indicate interventions and goals for Resident 13. B. During a review of Resident 67's AR, the AR indicated Resident 67 was admitted to the facility on [DATE] with multiple diagnoses including disorder of macular degeneration (gradual loss of vision due to deterioration of nerve tissue in the retina) and disorders of multiple cranial nerves (involve dysfunction of two or more cranial nerves, symptoms depend on the nerves involved ranging from vision changes and facial weakness to swallowing difficulties.) During a review of Resident 67's MDS dated [DATE], the MDS indicated Resident 67 had impaired cognition and required partial/ moderate assistance for toileting hygiene and bathing. During a review of Resident 67's Optometry Notes (ON) dated 1/26/2026, the ON indicated Resident 67 had complete ptosis (drooping of the upper eyelid) with lids taped up and to alternate two to three times per day. During an observation and interview on 2/26/2026 at 10:20 AM with Resident 67, Resident 67 was observed with tape placed vertically from the top of the right eyelid to Resident 67's forehead and the left eye was closed. Resident 67 stated the tape was used to keep Resident 67's right eye open because Resident 67 was unable to keep their eyes open themselves. Resident 67 stated it was their preference to use tape. During an interview on 2/26/2026 at 1 PM with RN 2, RN 2 stated Resident 67 did not have a CP in place for the tape placed on Resident 67's eyelids. RN 2 stated a CP should have been developed to ensure facility staff are checking Resident 67's skin integrity around the eyes and also due to the potential for infection. RN 2 stated it was also important to note that it was Resident 67's preference to have the tape on the eyelids. During an interview on 2/27/2026 at 8:57 AM with the Director of Nursing (DON), the DON stated the importance of a CP is to guide the nurses on how to give care and what needs to be done. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 9/7/2023, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being. C. During a review of Resident 103's admission Record (AR) indicated Resident 103 was admitted to the facility on [DATE] with diagnoses including anoxic brain damage (a severe condition caused by total lack of oxygen reaching the brain, leading to rapid brain cell death with widespread tissue damage), among other diagnoses. During a review of Resident 103's MDS, dated [DATE], the MDS indicated Resident 103's cognitive skills was severely impaired (never/rarely made decisions). During a review of Resident 103's Inter Disciplinary Team (IDT) Note, dated 1/20/2026, the IDT Note indicated Daughter is requesting hospice to get involved. MD and NP was notified of resident's condition and family request. New order received for hospice eval with Hospice company. New order noted and carried out. All Pertinent information faxed to hospice company. During a review of Resident 103's Order Summary, dated 1/21/2026, the Order Summary indicated, to admit the resident under the care of hospice on Routine level of care. DNR (Do Not Resuscitate), Hospice, Dx: Cerebral atherosclerosis, Dementia. During a review of Resident 103's H&P, dated 1/22/2026, the H&P indicated the resident with history of cerebral atherosclerosis (a condition where hardened, narrowed, or clogged arteries in the brain (due to plaque buildup) reduce oxygen-rich blood flow) with vascular dementia (this lack of blood flow damages brain tissue, resulting in a decline in memory, thinking, behavior, and daily functioning), history of hyperlipidemia (the medical term for having too many fats (lipids) – specifically cholesterol and triglycerides – in your blood), history of anoxic brain injury (a severe condition caused by total lack of oxygen reaching the brain, leading to rapid brain cell death with widespread tissue damage), history of psychosis (a mental health symptom, not a specific illness, where a person loses touch with reality), who is declining, and has been referred for hospice services. During a review of Resident 103's H&P, dated 1/27/2025, the H&P indicated that Resident 103 does not have the capacity to understand and make decisions. During an interview on 2/27/2026 at 8:57 AM with the DON, the DON stated she cannot find a hospice care plan and must have missed that one. The importance of a care plan is to guide the nurses on how to give care and what to be done. Hospice company has their own care plans but it is practice for the facility to also make their own care plan. During a review of the facility's revised policy and procedure (P&P) titled, Person-Centered Care Planning revised 4/24/2025, the P&P indicated, 4. Comprehensive Care Plan a. The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: i. The services that re to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. ii. Any services that would otherwise be required under, but are not provided due to resident's exercise of rights, including the right to refuse treatment. During a review of the facility's revised policy and procedure (P&P) titled, Hospice Care of Residents revised 1/1/2012, the P&P indicated, III. If the resident and/or surrogate decision maker decides to utilize hospice care, the Attending Physician will be contacted to make a final determination. B. The Hospice and Facility will collaborate on a Care Plan for the resident.

Based on interview and record review the facility failed to ensure appropriate and necessary care and services were provided for three of three sampled residents (Residents 58, 105 and 29) by failing to:A. Ensure Resident 58's physician order for Tresiba (a once-daily long-acting injectable insulin [a hormone that removes excess sugar from the blood] used to improve blood sugar control) contained administration parameters (specific instructions that must be followed when giving insulin).B. Ensure Resident 58's blood sugar levels were checked prior to administering Tresiba.These deficient practices had the potential to result in serious health complications for Resident 58.C. Ensure non-legend medications (medication that can be purchased over-the-counter [OTC] without a prescription) were not kept at Resident 105's and Resident 29's bedside without a physician's order and without following the facility's process for self-administration (the process where patients manage and take their own medications).This deficient practice had the potential to result in Resident 105 and Resident 29 misusing the OTC drugs posing a safety risk and had the potential for Resident 105 and Resident 29 to share the OTC drugs with other residents such as their roommates.Findings: a & b. During a review of Resident 58's admission Record (AR), the AR indicated the facility originally admitted Resident 58 on 5/6/2025 with a readmission date of 2/5/2026 with diagnoses including end stage renal disease (ESRD-irreversible kidney failure) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 58's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 2/5/2026, the H&P indicated Resident 58 could participate in plan of care. During a review of Resident 58's Minimum Data Set (MDS- a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 58's cognitive (the ability to think and process information) skills for daily decision making were intact. The MDS indicated Resident 58 required setup or clean up assistance with eating, supervision or touching assistance with oral hygiene, partial to moderate assistance with personal hygiene, substantial to maximal assistance with upper body dressing, and was dependent on toileting, showering, and lower body dressing. During a review of Resident 58's Order Summary Report (OSR), dated 2/27/2026, the OSR indicated a physician order (PO), with a start date of 2/6/2026, to inject 70 units (unit of measurement) of Tresiba subcutaneously (just beneath the skin's surface) to Resident 58 one time a day for DM. The OSR indicated there was no PO to check Resident 58's blood sugar level before administration of Tresiba, when to hold the Tresiba, and what to do when Resident 58's blood sugar level was low. During a review of Resident 58's Medication Administration Record (MAR), dated 2/1/2026 to 2/28/2026, the MAR indicated brand name insulin degludec was administered to Resident 58 on 2/6/2026, 2/15/2026, 2/17/2026, 2/18/2026, 2/19/2026, 2/21/2026, 2/24/2026, and 2/25/2026. During a review of Resident 58's Care Plan Report (CPR), initiated on 2/8/2026, the CPR indicated Resident 58 was at risk for altered endocrine status (regulates hormone levels such as insulin) related to DM and gout (a joint condition that triggers sudden pain and swelling). The CPR goal was for Resident 58 to maintain normal blood glucose level until the next CPR review date of 3/2/2026. The CPR interventions included checking Resident 58's fasting blood sugar (blood sugar level after 8-12 hours of no food or no drink [except water]) as ordered by the physician. During a concurrent interview and record review on 2/27/2026 at 10:56 AM with Licensed Vocational Nurse (LVN) 1, Resident 58's Blood Sugar Summary (BSS), printed on 2/27/2026, was reviewed. LVN 1 stated the BSS indicated Resident 58's blood sugar had only been checked four times (2/5/2026, 2/13/2026, 2/20/2026, and 2/25/2026) since Resident 58 was admitted on [DATE]. LVN 1 stated it was the policy of the facility to check residents' (in general) blood sugar level prior to administering long-acting insulin. LVN 1 stated it was important to check Resident 58's blood sugar prior to giving Tresiba to prevent medical complications such as hypoglycemia (low blood sugar). During an interview on 2/27/2026 at 11:05 AM with Resident 58, Resident 58 stated the staff (in general) did not always check Resident 58's blood sugar prior to administering Tresiba. Resident 58 stated Resident 58 was concerned because Resident 58 knew the staff were supposed to check blood sugar levels prior to administering Tresiba. During a concurrent interview and record review on 2/27/26 at 12:09 PM with Registered Nurse (RN) 1 and RN 2, Resident 58's current physician orders were reviewed. RN 1 and RN 2 stated Resident 58's Tresiba order did not include parameters such as checking blood sugar levels and if necessary, when to hold the medication. RN 1 and RN 2 stated there were no orders indicating Resident 58's blood sugar should be checked prior to administering Tresiba. RN 1 stated the doctor's communication phone and Resident 58's medical record did not indicate a doctor (in general) was notified of the Tresiba's missing parameters. RN 1 and RN 2 stated it was important to check Resident 58's blood sugar prior to giving Tresiba to ensure Resident 58 was appropriate to receive the medication. RN 1 and RN 2 stated it was important to obtain parameters for the Tresiba to ensure Resident 58 received proper medical care. During a review of the facility's Policy and Procedure (P&P) titled, Specific Medication Administration Procedures, updated June 2021, the P&P indicated, Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration. c 1. During a review of Resident 105's AR, the AR indicated Resident 105 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and essential (primary) hypertension (HTN – high blood pressure). During a review of Resident 105's H&P, dated 2/18/2026, the H&P indicated Resident 105 had the capacity to understand and make decisions. c 2. During a review of Resident 29's AR, the AR indicated, Resident 29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 29's H&P, dated 8/26/2025, the H&P indicated Resident 29 could make needs known but could not make medical decisions. During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29's cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required). The MDS indicated Resident 29 required partial/moderate assistance (helper does less than half the effort) to set up or clean-up assistance (helper sets up or cleans up; resident completes activity) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 2/24/2026 at 9:53 AM with Resident 105, a twenty (20) oz (ounce – a unit of weight) bottle of Amlactin Daily Healing 12% Lactic Acid Lotion was on Resident 105's bedside drawer. Resident 105 stated Resident 105 got the Amlactin from a membership-only warehouse club that sells a wide variety of products and Resident 105 had the Amlactin for thirty (30) days. Resident 105 stated Resident 105's physician (unnamed) told Resident 105 to get the Amlactin. During a concurrent observation and interview on 2/24/2026 at 10:18 AM with Resident 29, a sixteen (16) oz Eucerin Original Healing Cream was on Resident 29's bedside drawer. Resident 29 stated Resident 29's family member (unnamed) gave the Eucerin to Resident 29 for Resident 29's dry skin and Resident 29 had the Eucerin for awhile. During a concurrent interview and record review on 2/26/2026 at 11:14 AM with Licensed Vocational Nurse (LVN) 3, Resident 105 and Resident 29's physician orders were reviewed. LVN 3 stated Amlactin was a medicated lotion and Eucerin was a dermatological skin care. LVN 3 stated Amlactin and Eucerin were OTC medications and should have been stored at the facility's medication cart unless there were physician orders for them to be stored at the bedside and for Resident 105 and Resident 29 to self-administer medications. LVN 3 stated the process for self-administration involved assessing the resident (in general), reviewing the care plan (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), and obtaining a physician's order. LVN 3 stated it was important for residents' safety for OTC drugs not to be kept at the bedside to avoid the resident sharing the medication with other residents. LVN 3 stated there were no physician orders for Resident 105's Amlactin and Resident 29's Eucerin. During a concurrent interview and record review on 2/26/2026 at 11:27 AM with Registered Nurse (RN) 1, Resident 105 and Resident 29's medical records were reviewed. RN 1 stated Amlactin was a lactic acid lotion and Eucerin was a healing cream and were OTC topical creams. RN 1 stated residents were allowed to keep OTC drugs at the bedside, but residents had to be first evaluated if residents could administer own medication, had to have a physician's order for self-administration, and consented (gave permission) to self-administer, and was care planned. RN 1 stated Resident 105 and Resident 29 did not have physician orders or consents for self-administration of Resident 105's Amlactin and Resident 29's Eucerin. RN 1 stated staff should be inspecting resident's rooms for OTC drugs. During a review of the facility's P&P titled, Self-Administration of Medications, updated 11/2027, the P&P indicated residents who desired to self-administer medications were permitted to do so if the facility's interdisciplinary team had determined that the practice would be safe for the resident and other residents of the facility. The P&P indicated each resident was offered the opportunity to self-administer his or her medications during the routine assessment by the facility's interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.

Based on observation and interview, the facility failed to ensure a safe and clean environment for one of one sampled resident (Resident 76) when the wall in Resident 76's room was observed with a red tinged substance.These failures resulted in Resident 76 living in an unclean environment and had the potential to result in psychosocial decline to Resident 76.Findings:During a review of Resident 76's admission Record (AR), the AR indicated the facility originally admitted Resident 76 on 2/10/22 with a readmission date of 3/10/2025 with diagnoses including nontraumatic intracerebral hemorrhage in cerebellum (a sudden bleed inside the part of the brain that controls balance and coordination) and acute (sudden) respiratory failure with hypoxia (a medical condition that happens when your lungs cannot get enough oxygen [colorless, odorless gas]).During a review of Resident 76's History and Physical (H&P), dated 3/11/2025, the H&P indicated Resident 76 could make needs known but could not make medical decisions.During a review of Resident 76's Minimum Data Set (MDS- a resident assessment tool), dated 2/13/2026, the MDS indicated Resident 76's cognitive (the ability to think and process information) skills for daily decision making were severely impaired (never/rarely makes decisions). The MDS indicated Resident 76 required partial to moderate assistance with upper body dressing, substantial to maximal assistance with eating, oral hygiene, showering, and lower body dressing, and was dependent on toileting and personal hygiene.During an observation on 2/24/2026 at 9:37 AM in Resident 76's room, the wall on the right side of Resident 76's bed was observed with a red tinged substance.During a concurrent interview and observation on 2/25/2026 at 2 PM with the Director of Staffing Development (DSD) the wall next to Resident 76's bed was observed. The DSD stated the substance on Resident 76's wall looked like old food. The DSD stated the dirty wall was potential for infection. Additionally, the DSD stated it was important to maintain a clean room for Resident 76 to ensure a comfortable and homelike environment.During an interview on 2/27/2026 at 12:33 PM with the Director of Nursing (DON), the DON stated the wall next to Resident 76's bed should be clean, The DON states it was important to provide Resident 76 with a clean room because Resident 76 deserved to have a clean and homelike environment.During a review of the facility's Policy and Procedure (P&P) titled, Resident Rooms and Environment, revised January 2012, the P&P's purpose indicated, To provide residents with a safe, clean, comfortable and homelike environment. The P&P's policy indicated, The facility provides residents with a safe, clean, comfortable, and homelike environment. The P&P's procedure indicated, Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: Cleanliness and order.During a review of the facility's P&P titled, Housekeeping-Resident Rooms, revised September 2016, the P&P's purpose indicated, To promote the quality of life for residents by providing clean and sanitary living spaces. The P&P's policy indicated, The housekeeping department coordinates the daily cleaning of all resident rooms. The P&P's procedure indicated, Quarterly (for long-term residents): All surfaces in the room, including all walls and ceilings are thoroughly cleaned.

Based on interview and record review, the facility failed to provide evidence that the use of physical restraints (any manual method, physical or mechanical device, equipment, or material that restricts the resident's freedom of movement or normal access to his/her body) for one of one sampled resident (Resident 13) was a measure of last resort to protect the safety of the resident.This deficient practice had the potential for Resident 13 to be restrained unnecessarily and could negatively impact Resident 13 mentally, psychosocially and increase the risk for impaired skin integrity.Findings: During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including Parkinson's disease (brain disorder in which there is a lack of the chemical messenger dopamine, which helps control muscle movement; leads to muscle stiffness, weakness and trembling) with dyskinesia (difficulty in performing or controlling voluntary movements) with fluctuations, adult failure to thrive (syndrome characterized by unintended weight loss, decreased appetite, poor nutrition, and physical activity and often accompanied by depression and cognitive decline) encounter for attention to gastrostomy (the surgical creating of an opening in the abdominal wall into the stomach for drainage or a feeding tube.)During a review of Resident 13's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/5/2025, the MDS indicated Resident 13 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for toileting and required partial/ moderate assistance (helper does less than half the effort) for mobility.During a review of Resident 13's Change of Condition Evaluation (COC) dated 1/30/2026, the COC indicated Resident 13 dislodged the gastrostomy tube (GT-soft, flexible tube inserted directly into the stomach) GT while in bed.During a review of Resident 13's Change in Condition Evaluation (COC) dated 2/12/2026, the COC indicated upon assessment, Resident 13 was noted with dislodged GT.During a review of Resident 13's Progress Notes (PN) dated 2/13/2026 at 9:53 AM, the PN indicated Resident 13 was awaiting GT reinsertion at bedside with after pulling out the GT. Resident 13 pulled out foley catheter that was in place to keep stoma (surgically created opening on the outside of the body that connects to an organ on the inside) from closing. Resident 13 was sent to a general acute care hospital (GACH) for further evaluation and treatment.During a review of Resident 13's Restrain-Physical (Initial Evaluation) [RPIE] dated 2/14/2026, the RPIE indicated the device in use at the time was bilateral mittens to prevent accidental GT dislodgment on the left and right hands due to interference with specific medical treatments. The RPIE further indicated an abdominal binder had worked in the past to control/limit the behavior/ issue prompting the need for restraint per the resident/family or next of kin. The RPIE indicated Resident 13 was still able to access the GT site even when wearing the binder. The RPIE indicated Resident 13's family requested the restraints.During a review of Resident 13's Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) the CP indicated Resident 13 may have bilateral mittens on to prevent accidental GT dislodgement with interventions to monitor skin integrity every shift dated 2/14/2026. Resident 13's CP further indicated Resident 13 benefitted from use of abdominal binder to prevent GT dislodgement and to monitor skin integrity daily every shift. The CP interventions also included to monitor Resident 13's behavior, attempt to redirect attention if seen attempting to play with tubing dated 2/10/2026. The CP indicated Resident 13's goal was to not have GT dislodgement through the next review.During a review of Resident 13's Order Summary Report (OSR) dated with active orders as of 2/26/2026, the OSR indicated: may have bilateral mittens on to prevent accidental GT dislodgement with start date 2/14/2026. The OSR also indicated to monitor skin integrity every shift related to use of mittens with start date 2/14/2026.During an interview on 2/26/2026 at 11:59 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 13 was impulsive and had pulled the GT four to five times in the past year. LVN 2 stated Resident 13's last removed the GT on 2/13/2026 and a foley catheter (thin, flexible tube usually used to drain urine from the bladder by way of the urethra) was inserted to prevent Resident 13's gastrostomy from closing but Resident 13 also pulled out the foley catheter before it could be replaced with another GT. LVN 2 stated Resident 13 was then taken to a general acute care hospital (GACH) on 2/13/2026 for GT reinsertion. During an interview on 2/26/2026 at 12:14 PM with LVN 4, LVN 4 stated Resident 13 had restraints due to pulling on the GT and Resident 13 was strong and persistent in the behavior. LVN 4 stated Resident 13 used the restraints all day and the physician order did not specify when to place the restraints and when to remove them. LVN 4 stated the purpose of specifying when Resident 13 needed the restraints was for resident safety and to prevent skin breakdown. LVN 4 stated while using restraints, the resident's skin should be checked every two hours but it was not documented.During an interview on 2/26/2026 at 12:37 PM with the Registered Nurse (RN) 2, RN 2 stated Resident 13 had a history of pulling the GT many times. RN 2 stated nurses (general) have a responsibility to make suggestions to the doctor for certain interventions and Resident 13's doctor was informed of Resident 13's behavior and approved the order for restraints. RN 2 stated Resident 13's order for restraints did not indicate the how long the restraints should be on and only indicated to monitor to prevent dislodgement every shift.During an interview on 2/26/2026 at 1:07 PM with the Director of Nursing (DON), the DON stated Resident 13's family requested to have the bilateral mitten restraints on because the restraints had been useful in the past at a different facility. The DON stated Resident 13 had pulled out the GT up to six times in the past year.During an interview on 2/26/2026 at 2:03 PM with the DON, the DON stated the facility attempted to monitor the behavior and redirect if Resident 13 was seen attempting to play with the tubing. The DON stated Resident 13 had a behavior of pulling on the GT for at least one year. The DON stated there had been no interdisciplinary department team (IDT) meeting about Resident 13's behavior. The DON stated there was no documentation to show interventions that were attempted prior to implementing restraints. The DON stated there was no documented evidence that the facility had used the least restrictive method of managing Resident 13's behavior. The DON stated the nursing staff (general) should document restrain monitoring, restraint application and assessment. The DON stated that when restraints are in use, there should be a plan to reduce the use of restraints as much as possible but there was no current plan in place to reduce use of the restraints. The DON stated if other methods of managing behavior are not used first, the facility could be restraining a person unnecessarily which could affect them mentally, psychosocially and could increase the risk for impaired skin integrity.During a review of the facility's policy and procedure (P&P) titled, Restraints, dated 3/27/2024, the P&P indicated the facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Restraints require a physician order and are used as a last resort to be used only when deemed necessary by the IDT, and in accordance with the resident's assessment and Plan of Care. If restraints are used, the least restrictive alternative is used for the least amount of time, and only under carefully monitored circumstances. Every attempt will be made to avoid a decline in the resident's physical functioning.

Based on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 35'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), was revised after Resident 35 had a significant weight loss (5% in 1 month or 10% in 6 months of total body weight). This deficient practice had the potential to result in the continued implementation of an ineffective or inadequate CP interventions to prevent Resident 35 from further unplanned weight loss. Findings: During a review of Resident 35's admission Record (AR), the AR indicated Resident 35 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of conditions that affect movement and posture, caused by damage to the developing brain) and unspecified severe protein-calorie malnutrition. During a review of Resident 35's History & Physical Examination (H&P, physician's clinical evaluation and examination of the resident), dated 11/20/2025, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 12/17/2025, the MDS indicated Resident 35's cognitive skills (ability to think and process information) were severely impaired (never/rarely made decisions). The MDS indicated Resident 35 was dependent (helper does all of the effort) for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) including eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). The MDS indicated Resident 35 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. During a review of Resident 35's Nutritional Risk Assessment (NRA), dated 12/6/2025 and timed at 12:45 PM, the NRA indicated Resident 35 was at increased nutritional risk and had a fifteen (15) pound (lb- a unit of weight) weight loss in one (1) month and fourteen (14) lb weight loss in three (3) months. During a review of Resident 35's Change in Condition Evaluation (COC), dated 12/6/2025 and timed at 9:57 PM, the COC indicated Resident 35 had a weight loss of sixteen (16) lbs or one hundred thirty nine percent (139%) in one (1) month. During a review of Resident 35's Weights and Vitals Summary (WVS), dated 9/19/2025 to 2/23/2026, the WVS indicated Resident 35's weights as follows: 9/19/2025=114 lbs10/20/2025=115 lbs11/21/2025=109 lbs12/22/2025=99 lbs1/19/2026=100 lbs1/14/2025=97 lbs2/16/2026=98 lbs The WVS indicated Resident 35 had a significant weight loss of -14.04 % in the last 6 months. During a concurrent interview and record review on 2/26/2026 at 11:27 AM with Registered Nurse (RN) 1, Resident 35's AR, WVS and CP titled, [Resident 35] has nutritional problem or potential nutritional problem r/t (related to) ., date initiated 9/23/2025 were reviewed. RN 1 stated Resident 35 was on the skinny side, was at risk for malnutrition and weight loss. RN 1 stated Resident 35 had a significant weight loss. RN 1 stated a CP was how to take care of residents (in general) and consisted of a problem, interventions and goal. RN 1 stated Resident 35's CP was revised on 2/24/2026 and should have been revised when Resident 35 started losing weight in 12/2025. RN 1 stated revising Resident 35's CP timely was important to address the problem and update the plan of care since the initial CP was not effective. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, with revision date of 4/24/2025, the P&P indicated comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. During a review of the facility's P&P titled, Change in Condition, with revision date of 8/25/2025, the P&P indicated a change in weight (change = gain or loss) of five pounds or more within a 30-day period or 10% or more in the past 6 months was a change in condition and the care plan must be updated to reflect the resident's current status, if applicable.

Based on interview and record review, the facility failed to ensure the nursing staff had the appropriate competencies and skills sets necessary to care for residents' needs and related services when the facility:a. Failed to provide documentation indicating nursing staff (general) had been trained in the use of physical restraints (any manual method, physical or mechanical device, equipment, or material that restricts the resident's freedom of movement or normal access to his/her body) while one of one sampled residents (Resident 13) used bilateral mitten restraints (specialized glove that covers the fingers and palm designed to limit the ability to grip or pull at medical lines and devices) and an abdominal binder (compressive, elastic garment worn to reduce access to medical devices.b. Failed to ensure one of three Certified Nursing Aides' (CNA 15) employee personnel file had documentation of a recent background check (a screening process used by employers to verify a candidate's history) upon hire and a current CPR (cardiopulmonary resuscitation - an emergency treatment that's done when someone's breathing or heartbeat has stopped) certification. These deficient practices had the potential for nursing staff to be inadequately trained in the use of physical restraints and had the potential for nursing staff to provide unsafe and inadequate care to Resident 13. These deficient practices also had the potential for the facility to hire a CNA who had a criminal background and was not trained in CPR which could compromise the residents' safety.Findings: a. During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dysphagia (difficulty swallowing) and encounter for attention to gastrostomy (the surgical creating of an opening in the abdominal wall into the stomach for drainage or a feeding tube). During a review of Resident 13's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], the MDS indicated Resident 13 had severely impaired cognition (ability to understand and process information) and was dependent (helper does all of the effort) on staff for toileting hygiene. The MDS indicated Resident 13 required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and/or contact guard assistance as resident completes activity) for personal hygiene. During a review of Resident 13's Order Summary Report (OSR), with active orders as of [DATE], the OSR indicated a physician order (PO), dated [DATE], that Resident 13 may have bilateral mittens on to prevent accidental gastrostomy tube (G-tube, a feeding tube inserted through the abdomen that brings nutrition directly to the stomach) dislodgement. During a concurrent observation and interview on [DATE] at 9:09 AM with the Director of Staff Development (DSD) in Resident 13's room, Resident 13 was observed with bilateral mitten restraints and an abdominal binder. The DSD stated Resident 13 had a behavior of pulling out the gastrostomy tube and wore the mittens and abdominal binder to prevent Resident 13 from reaching and pulling out the gastrostomy tube. During an interview on [DATE] at 11:38 AM with Certified Nursing Assistant (CNA) 8, CNA 8 stated CNA 8 received an in-service about restraints the week prior from the Director of Staff Development before the start of CNA 8's shift to care for Resident 13. CNA 8 stated the DSD informally instructed CNA 8 how to correctly place mitten restraints so they're not too tight and how to remove them. During an interview on [DATE] at 11:59 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated LVN 2 had received an in-service on restraints before but could not recall who led the in-service or when it took place. During an interview on [DATE] at 12:14 PM with LVN 4, LVN 4 further stated LVN 4 had received an in-service on restraints in the past but could not remember when. LVN 4 stated the topic of restraints was not covered during the facility's annual skills fair that took place the week prior. During an interview on [DATE] at 1:12 PM with the DSD, the DSD stated the DSD had not given any in-services on restraints in the past month that the DSD had been employed as the Director of Staff Development. During a review of the Facility Assessment (FA), dated [DATE], the FA indicated the facility held an annual nursing skills competency fair from [DATE] to [DATE]. The FA indicated the nursing skills competency fair covered the following topics: wound care, medication pass, foley catheters, Hoyer lift, transfers, oxygen, nebulizers, peri care, Heimlich maneuver, vital signs, ambulation, position on side, low air loss mattress (LALM), feeding, international dysphagia diet standardization initiative (IDDSI), and diet textures. During an interview on [DATE] at 2:38 PM with the Director of Nursing (DON), the DON stated the DON had been employed at the facility for less than one year and had not conducted any in-service on restraints to licensed staff and did not have any documentation to show that staff had been previously trained in the use of restraints. During a review of the facility's policy and procedure (P&P) titled, Training Requirements, dated [DATE], the P&P indicated the facility must develop, implement, and maintain an effective training program for new and existing staff, individual providing services under a contractual agreement, and volunteers, consistent with their expected roles. The facility must determine the amount and types of training necessary based on a facility assessment and special needs of the residents. b. During a concurrent interview and record review on [DATE] at 11:41 AM with the DSD, CNA 15's employee personnel file was reviewed. CNA 15's background check was dated [DATE]. The DSD stated CNA 15 was hired on [DATE]. The DSD stated background checks were conducted prior to employment to ensure the candidate was eligible for the job applied for and to check for criminal background. The DSD stated a criminal offense could have happened, we don't know all the information, between CNA 15's hiring date of [DATE] and the background check dated [DATE]. CNA 15's CPR card on file indicated the CPR certification was from BLS National CPR Foundation, dated [DATE] and was valid for two (2) years. The DSD stated CNAs (in general) at the facility were required to be CPR certified and CNA 15's CPR card was expired, and a current card should have been on file. The DSD stated having a current CPR card on file was important as part of the facility's requirement to work at the facility. During a concurrent interview on [DATE] at 2:05 PM with the DSD and the Training Instructor (TI), the TI stated the TI came to the facility to provide the CPR class and CNA 15 took the CPR class on [DATE]. The TI stated CNA 15's current CPR card was an e-card (electronic card sent over the internet) sent directly to CNA 15 by the TI. The DSD stated CNA 15's current CPR card, dated [DATE], should have been filed in CNA 15's employee file. A review of the facility's policy and procedure (P&P) titled, Hiring and Employment Verification, effective date [DATE], indicated ongoing monitoring of all licenses and certifications would be re-verified prior to expiration and the DSD would maintain a tracking system to alert for renewals The P&P indicated copies of all verified licenses and certifications would be kept in the employee's personnel file and the facility would maintain records of all verifications and screenings including license and certification verification to be updated regularly and retained throughout the employee's tenure.

Based on interview and record review, the facility failed to ensure one of three Certified Nursing Assistant's (CNA 15's) performance review was completed at least once every 12 months. This deficient practice resulted in the facility not assessing and evaluating the necessary skills and competencies of CNA 15 and placed residents assigned to CNA 15 at risk for inadequate and unsafe care.Findings: During a concurrent interview and record review on 2/27/2026 at 11:41 AM with the Director of Staff Development (DSD), CNA 15's employee personnel file was reviewed. The DSD stated CNA 15 was hired on 2/8/2015 and the last performance review on CNA 15 on file was dated 6/8/2024. CNA 15's Employee Performance Review (EPR), dated and signed 6/8/24 was reviewed. The EPR was incomplete. The DSD stated completing a performance review annually was important to ensure CNAs (in general) were aware of how the CNAs were doing with their skills and what to improve on to ensure the CNAs provided quality of care. During a review of the facility's Employee Handbook (EH), edition dated January 2024, the EH indicated employees may receive periodic performance reviews and would generally be conducted by their supervisor. The first performance evaluation may be after completion of the Introductory Period and after that review, performance evaluations may be conducted annually, on or around their anniversary date. The EH indicated performance evaluations were designed to help employees become aware of progress, areas for improvement and objectives or goals for future work performance.

Based on observation, interview, and record review the facility failed to ensure medications were not left at the bedside for one of one sampled resident (Resident 73) when Resident 73's Calcium Carbonate oral chewable tablet (generic for Tums, over the counter medication containing calcium carbonate designed to relieve heartburn, sour stomach, acid indigestion and upset stomach) was found on Resident 73's bedside table on 2/24/2026.This failure had the potential for Resident 73 to choke or take more medication than prescribed.Findings:During a review of Resident 73's admission Record (AR), the AR indicated Resident 73 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia (total paralysis) and hemiparesis (weakness) following cerebral infarction (condition where blood flow to a part of the brain is blocked or reduced, causing brain tissue to die due to lack of oxygen) affecting left non-dominant side. During a review of Resident 73's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/19/2026, the MDS indicated Resident 73 had intact cognition (ability to understand and process information) and required supervision or touching assistance (helper provides verbal cues and/or touching/ steadying and /or contact guard assistance as resident completes activity) for toileting and personal hygiene.During a concurrent observation and interview on 2/24/2026 at 10:13 AM with Certified Nursing Assistant (CNA) 8 in Resident 73's room, a large, white, round pill imprinted with G 127 was observed in a medicine cup on top of Resident 73's bedside table. CNA 8 stated the medication was Tums and CNA 8 knew it was Tums because Resident 73 took it every day.During a concurrent observation and interview on 2/24/2026 at 10:24 AM with Licensed Vocational Nurse (LVN) 5 in Resident 73's room, a large, white, round pill imprinted with G 127 was observed in a medicine cup on top of Resident 73's bedside table. LVN 5 stated LVN 5 had not administered that medication to Resident 73 today and did not know how long the medication had been left on Resident 73's bedside table. LVN 5 stated medications are not kept at the bedside because they needed to be administered by the nurse unless the residents had been approved by the doctor to self-administer. LVN 5 stated Resident 73 did not have approval to self-administer medications. LVN 5 stated medications are not safe to leave at the bedside and a resident could choke or end up taking a different dose than what is ordered and become unstable.During a review of Resident 73's Order Summary Report (OSR) dated with active orders as of 2/25/2026, the OSR indicated calcium carbonate oral tablet, give one tablet by mouth every six hours as needed for heart burn with start date of 6/2/2025.During an interview on 2/26/2026 at 8:44 AM with Resident 73, Resident 73 recalled the Tums left on the bedside table and stated Resident 73 had asked for the medication the night before to have it nearby. Resident 73 stated Resident 73 sometimes woke up with acid reflux (common condition where stomach acid flows back up into the throat causing a burning sensation in the chest) at nighttime and wanted the medication just in case.During an interview on 2/26/2026 at 12:58 PM with Registered Nurse (RN) 2, RN 2 stated it was never acceptable to keep medication at the bedside unless an assessment was completed indicating the resident could self-administer medication. RN 2 stated leaving medication at the bedside could lead to someone being over medicated or another resident could enter the room and take the medication that was not prescribed to them.During an interview on 2/26/2026 at 1:05 PM with the Director of Nursing (DON), the DON stated Resident 73 should not have had medication at the beside for safety reasons and if a staff member does not watch the resident take their medications, the resident could choke.During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 8/2019, the P&P indicated B. only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are allowed access to medications and C. all medications dispensed by the pharmacy are stored in the box, bag or other container with the pharmacy label.

Based on interview and record review, the facility failed to implement the facility's protocol for antibiotic stewardship for one of one sampled resident (Resident 106). Resident 106 was screened for pneumonia (an infection that causes the lungs to fill with fluid or pus) and prescribed levofloxacin (a strong broad-spectrum antibiotic used for bacterial infections like pneumonia) without meeting the necessary criteria.This deficient practice had the potential for Resident 106 to develop antibiotic resistance.Findings:During a review of Resident 106's admission Record (AR), the AR indicated Resident 106 was admitted to the facility on [DATE] with multiple diagnoses including quadriplegia (partial or total paralysis of all four limbs and the torso), pneumonia, and solitary pulmonary nodule (area of abnormal growth on the lungs).During a review of Resident 106's Patient Report (PR) dated 2/24/2026, the PR indicated Resident 106's chest x-ray (noninvasive imaging test that uses a small amount of radiation to create pictures of the heart, lungs, airways, blood vessels, and chest bones) results and indicated opacities (area of increased density) in the right upper lung, concerning for pneumonia.During a review of Resident 106's OSR, the OSR indicated a physician order for levofloxacin tablet 500 milligrams (mg- unit of weight) give 1 tablet by mouth in the evening for pneumonia for 5 days with start date 2/25/2026.During a review of Resident 106's Progress Notes (PN) dated 2/25/2026 at 9:31 AM, the PN indicated abnormal x-ray results: opacities in the right upper lung. The PN further indicated Resident 106's chest x-ray results were provided to Medical Doctor (MD) 2 and MD 2 prescribed levofloxacin tablet 500 mg, give 1 tablet by mouth in the evening for pneumonia for five days, orders carried out. The PN indicated upon assessment Resident 106 stated complicated pneumonia upon admission caused right upper pain to chest and Resident 106 felt short of breath at times.During a review of Resident 106's Order Summary Report (OSR) with active orders as of 2/27/2026, the OSR indicated Resident 106 was capable of making healthcare decisions.During a concurrent interview and record review on 2/27/2026 at 8:11 AM with the Infection Preventionist (IP), Resident 106's Surveillance Data Collection Form (SDCF) dated 2/26/2026, was reviewed. The SDCF indicated under Respiratory Tract Infections: Pneumonia, that all three criteria must be present:1. Interpretation of chest radiograph as demonstrating pneumonia or the presence of new infiltrate2. At least one of the following respiratory sub-criteria:New or increased coughNew or increased sputum productionO2 saturation <94% of room air or a reduction in O2 saturation of >3% from baselineNew or changed lung examination abnormalitiesPleuritic chest painRespiratory rate of 25 breaths/ min3. At least one of McGeer's constitutional criteria (table 1)The IP stated the checkmarks indicated what criteria applied to Resident 106. The IP stated the SDCF had one checkmark under number 1 and the IP stated Resident 106 had pleuritic chest pain and check marked 2e. The SDCF indicated the treatment for pneumonia was levofloxacin 500 mg, give one tablet by mouth in the evening for pneumonia with start date 2/25/2026. The IP stated MD 2 ordered the levofloxacin based on Resident 106's x-ray results on 2/24/2026.During a concurrent interview and record review on 2/27/2026 at 11:00 AM with the IP, Resident 106's SDCF was reviewed. The IP stated the SDCF used McGeer's criteria (standardized, evidenced based definitions used for surveillance of infection in longer term care facilities to distinguish true infections from non-infectious, age-related symptoms) to determine if residents (general) met the criteria of an infection and need for an antibiotic. The IP stated McGeer's criteria is based on signs of symptoms of the infection as well as labs and imaging depending on the type of infection. The IP stated based on Resident 106's SDCF, Resident 106 did not meet McGeer's criteria. The IP stated if a resident does not meet McGeer's criteria, the doctor should be informed so the doctor could decide whether to continue with antibiotics. The IP stated the IP did not inform MD 2 that Resident 106 did not meet McGeer's criteria and MD 2 should have been notified so that MD 2 could make an informed decision. The IP stated if the doctor does not have all the information, the doctor could be prescribing unnecessary antibiotics which could lead to antibiotic resistance.During an interview on 2/27/2026 at 2:43 PM with the Director of Nursing (DON), the DON stated a resident's (general) doctor should be informed if the resident does not meet McGeer's criteria to ensure the resident does not get unnecessary medication. The DON stated if the resident receives an antibiotic that is not needed, it could lead to antibiotic resistance.During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship dated 5/20/2021, the P&P indicated the IP is responsible for tracking the following antibiotic stewardship processes: C. whether or not the resident's condition met McGeer's Criteria when the antibiotic was ordered.

Based on observation, interview, and record review, the facility failed to implement a care plan's (CP) interventions to keep bilateral (both sides) floor mats next to the bed for one of two sampled residents (Resident 2).This deficient practice had the potential to result in unmet individualized needs for Resident 2 and the potential to affect the resident's physical well-being.Findings:During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 8/11/2020, with diagnoses that included dementia (a progressive state of decline in mental abilities) and lack of coordination.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 10/22/2025, the MDS indicated Resident 2 had severe cognitive (the ability to think and process information) deficit. The MDS indicated Resident 2 required maximal assistance (Helper lifts or hold trunk or limbs and provides more than half the effort) with walking 10 feet, sitting to standing, chair/bed-to- chair transfers, and with toilet transfers.During a review of Resident 2's CP titled risk for falls related to impaired mobility, initiated 10/26/2025, the CP indicated Resident 2 may have the bed in the lowest position with bilateral floor mats while in bed due to getting up unassisted.During a review of Resident 2's CP titled risk for falls related to impaired mobility and weakness, initiated 10/26/2025, the CP's interventions indicated to apply floor mats next to [Resident 2's bed] as appropriate.During a review of Resident 2's Fall Risk Evaluation, dated 12/10/2025, the evaluation indicated Resident 2 's score was 16 (a total score of 10 or greater is considered a high risk for potential falls) and Resident 2 was at high risk for falls.During an observation on 1/23/2026 at 4:36 PM, Resident 2 was lying in bed, and the bed was in a low position. A bed alarm was in place, and a fall mat was located on the right side of the bed.During a concurrent interview and record review on 1/23/2026 at 4:39 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2's [at risk for falls] CP indicated bilateral fall mats. LVN 1 stated Resident 2 needed fall mats on both sides of Resident 2's bed to prevent injuries in the event of a fall.During a concurrent observation and interview on 1/23/2026 at 4:49 PM with the Director of Nursing (DON), the DON stated fall mats needed to be in place on both sides [of Resident 2's bed]. The DON entered Resident 2's room and found the left fall mat placed against the wall toward the right side of Resident 2's bed. The DON stated the fall mat needed to be in place to prevent injury in case of a fall.During a review of the facility's Policy and Procedure (P&P) titled Person Centered Care Planning dated 5/22/2025, the P&P indicated the facility must develop and implement a comprehensive person-centered care plan.

Based on observation, interview and record review, the facility failed to ensure that Certified Nursing Assistant 1 (CNA 1), CNA 2, and Licensed Vocational Nurse 1 (LVN 1) responded in a timely manner to requests for assistance to the bathroom for one of one resident (Resident 4). This deficient practice resulted in Resident 4 having unmet needs. Findings: During a review of Resident 4' s admission Record (AR), the AR indicated the facility admitted Resident 4 on 11/6/2025, with diagnoses that included traumatic hemorrhage of the cerebrum (bleeding in the brain), muscle weakness, and lack of coordination. During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/13/2025, the MDS indicated Resident 4 had moderately impaired cognition (a level of cognitive decline). The MDS indicated Resident 4 was dependent with rolling left and right, chair/bed-to-chair transfer. During an observation on 1/8/2026 from 1:16 PM to 1:25 PM, Resident 4 was sitting in a wheelchair at the foot of the bed, facing away from the door, and was yelling repeatedly, Can I go to the bathroom, 16 times. During an observation on 1/8/2026 at 1:18 PM, CNA 1 entered Resident 4's room, looked around the room, while Resident 4 was yelling, Can I go to the bathroom, CNA 1 did not communicate with Resident 4 and left the room. During an observation on 1/8/2026 at 1:21 PM, CNA 2 entered Resident 4's room, but did not assist Resident 4 with toileting. CNA 2 did not communicate with Resident 4 and left the room. Resident 4 continued to repeatedly yell, Can I go to the bathroom. I just want to go to the bathroom. Resident 4 stated, I would make a mess and you going to be stuck with it. During an observation on 1/8/2026 at 1:24 PM, LVN 1 was standing in front of the medication cart located in the hallway close by Resident 4's room while Resident 4 continued to call out, Can I go to the bathroom. LVN 4 started to prepare medications and then entered Resident 4's room to administer medications. During an observation on 1/8/2026 at 1:27 PM, the Director of Nursing (DON) stated staff needed to assist Resident 4 once they heard him asking for assistance to the bathroom. The DON stated that they need to stop and notify the assigned CNA. The DON stated if the staff member who heard the resident calling was not the staff assigned to Resident 4, they needed to inform the assigned staff. During an observation on 1/8/2026 at 1:30 PM, the DON approached CNA 2, and CNA 2 went to Resident 4's room and asked Resident 4 what the resident needed. Resident 4 stated the resident needed to have a bowel movement. CNA 2 stated the CNA would help the resident and asked resident to wait a few minutes. During an observation on 1/8/2026 from 1:30 PM to 1:35 PM, Resident 4 was sitting in a wheelchair and was no longer yelling. During an interview on 1/8/2026 at 1:40 PM, LVN 1 stated that LVN 1 was preoccupied with the medication pass. LVN 1 stated that when a resident would call out to use the bathroom, LVN 1 needed to check on the resident and page the staff assigned to that resident. During an interview on 1/8/2026 at 2:06 PM, CNA 1 stated that at the time CNA 1 went to Resident 4's room, CNA 1 was taking out meal trays. CNA 1 stated that Resident 4 could get very persistent, and that there were not a lot of things that would keep Resident 4 happy. During a review of the facility's Policy and Procedure (P&P), titled Resident Rights - Quality of Life, revised in March 2017, the P&P indicated demeaning practices and standards of care that compromise dignity are prohibited. Facility Staff promote dignity and assist residents as needed by:B. Promptly responding to the resident's request for toileting assistance.

Based on observation, interview, and record review, the facility failed to ensure the call light system was functioning to allow one of one resident (Resident 4) to call for staff assistance. This deficient practice had the potential for Resident 4 to have unmet needs.Findings: During a review of Resident 4' s admission Record (AR), the AR indicated the facility admitted Resident 4 on 11/6/2025, with diagnoses that included traumatic hemorrhage of the cerebrum (bleeding in the brain), muscle weakness, and lack of coordination. During a review of Resident 4's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/13/2025, the MDS indicated Resident 4 had moderately impaired cognition (a level of cognitive decline). The MDS indicated Resident 4 was dependent with rolling left and right, chair/bed-to-chair transfer. During an observation on 1/8/2026 from 1:16 PM to 1:25 PM, Resident 4 was sitting in a wheelchair at the foot of the bed, facing away from the door, and was yelling repeatedly, Can I go to the bathroom, 16 times. The call light button was next to the resident, taped on top of the bottom rail. During an observation on 1/8/2026 at 1:20 PM, Resident 4 pressed the call light button placed near him; the call light bulb outside the door did not turn on and there was no audible sound outside the door. During an observation and interview on 1/8/2026 at 1:21 PM, CNA 2 confirmed that the call light outside Resident 4's room did not light up when Resident 4 pressed the call light button and that there were no audible sound and light outside the door. CNA 2 stated CNA 2 would call maintenance for the call light. During an observation on 1/8/2026 at 1:26 PM, the Maintenance Staff (MS) entered Resident 4's room to activate the call light. The MS stated the light bulb outside the door was not working. The MS stated MS did not receive a report Resident 4's call light needed to be checked until now. During an interview on 1/8/2026 at 1:59 PM, LVN 2 stated the call light needs to be working properly for residents to be able to reach staff when they need help. During a review of the facility's Policy and Procedure (P&P), titled Communication - Call System, dated 10/9/2024, the P&P indicated the facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities to ensure that residents have a means of contacting Facility staff for assistance. The P&P indicated if the call alert system is defective, it will be reported to maintenance for immediate repair.

Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) immediately notified the physician and the family for one of six sampled residents (Resident 2) after Resident 2's unwitnessed fall on 11/12/2025 at 6:30 pm. This failure had the potential for Resident 2 to receive inappropriate care and had the potential to delay the assessment and treatment of Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/30/2018 with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), dementia (a progressive state of decline in mental abilities), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 2's History and Physical (H&P), dated 3/8/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data set (MDS - a resident assessment tool), dated 12/2/2025, the MDS indicated Resident 2's cognition (thinking, knowing, and being aware) was severely impaired. The MDS indicated Resident 2 had impaired movement of both upper and lower extremities and was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and to move around in bed. During a review of Resident 2's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 11/14/2025, the SBAR indicated while an unidentified staff provided care to Resident 2, Resident 2's right knee was observed to be swollen and Resident 2 did not complain of pain. The SBAR indicated Resident 2's physician was informed Resident 2's change in condition on 11/14/2025 at 4:13 am and Resident 2's family was informed on 11/14/2025 at 4:20 am. During a review of Resident 2's SBAR, dated 11/17/2025, the SBAR indicated Resident 2 had a discoloration behind both knees and back of thighs. The SBAR indicated Resident 2's family was informed on 11/17/2025 at 4 pm and Resident 2's physician was informed on 11/17/2025 at 5:30 am. During a review of Resident 2's SBAR, dated 11/20/2025, the SBAR indicated Resident 2 had a displaced (bone is out of alignment) comminuted (bone is broken into pieces) fracture (break in the bone) of the left thigh bone and an acute oblique fracture (sudden angled break) in the lower part of the right thigh bone. The SBAR indicated Resident 2's physician and family were notified on 11/20/2025 at 6 am. During a review of Resident 2's physician order (PO), dated 11/20/2025 and timed at 11:26 am, the PO indicated to send Resident 2 to General Acute Care Hospital 1 (GACH 1) for further evaluation and treatment of Resident 2's right and left thigh fractures. During a review of Resident 2's Discharge/Transfer Documentation (DTD) from GACH 1, dated 11/21/2025, the DTD indicated Resident 2 underwent surgical intervention that included intramedullary nailing (insertion of a metal rod to repair bone fractures) of Resident 2's left and right thigh bones fracture. During an interview on 12/16/2025 at 1:27 pm with the Director of Nursing (DON), the DON stated Resident 2 slid out of bed and was found on the floor during the 3 pm to 11 pm shift on 11/12/2025. Resident 2 was assessed and was not in pain. The DON stated Resident 2's family and physician were not informed on 11/12/2025 after Resident 2 was found on the floor. During a concurrent interview and record review on 12/16/2025 at 3:53 pm with the DON, the DON reviewed Resident 2's medical record and stated there was no SBAR or Change of Condition (COC) note in Resident 2's medical record regarding Resident 2's fall on 11/12/2025. The DON stated the DON did not know Resident 2 fell on [DATE] until LVN 3 told the DON on 11/20/2025. Resident 2's physician was informed on 11/20/2025 that Resident 2 fell on [DATE]. During a phone interview on 12/17/2025 at 11:46 am with LVN 3, LVN 3 stated LVN 3 did not take care of Resident 2 during the 3 pm to 11 pm shift on 11/12/2025. LVN 3 stated on 11/12/2025 at 6:30 pm, LVN 3 assisted LVN 4 and Certified Nursing Assistant 8 (CNA 8) to put Resident 2, who was sitting on the floor mat by Resident 2's bed, back to bed. During a concurrent interview and record review on 12/17/2025 at 3:02 pm with the DON, the facility's policy and procedure (P&P) titled Change of Condition Notification, dated 4/1/2025, was reviewed. The P&P indicated, A licensed nurse will notify the resident's attending physician and legal representative or an appropriate family member when there is an incident/accident involving the resident. The DON stated the Change of Condition Notification policy applied to Resident 2's unwitnessed fall on 11/12/2025. The DON stated Resident 2's physician and family should have been notified on 11/12/2025 regarding Resident 2's fall. During a phone interview on 12/17/2025 at 3:12 pm with LVN 4, LVN 4 stated on 11/12/2025, while LVN 4 worked the 3 pm to 11 pm shift, CNA 8 informed LVN 4 that CNA 8 found Resident 2 on the floor mat by Resident 2's bed at around 6:30 pm. LVN 4 stated LVN 4, LVN 3, and CNA 8 assisted Resident 2 back to bed. LVN 4 stated LVN 4 did not report to anyone and did not document Resident 2's fall because Resident 2 did not have any injury. LVN 4 stated if Resident 2 had an injury or was in distress then LVN 4 would have reported Resident 2's fall.

Based on interview and record review, the facility failed to provide a safe environment and protect one of six sampled residents (Resident 3) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) and mistreatment when Certified Nursing Assistant 6 (CNA 6) roughly placed Resident 3 into a wheelchair, brushed Resident 2's hair roughly, and yelled at Resident 3 on 11/25/2025. This deficient practice had the potential to place Resident 3 at risk for physical and psychosocial harm.Findings: a. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was readmitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P, physician's clinical evaluation and examination of the resident), dated 3/19/2025, 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 11/19/2025, the MDS indicated Resident 3's cognition (thinking, knowing, and being aware) was severely impaired. The MDS indicated Resident 3 required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). b. During a review of Resident 4's AR, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The AR indicated Resident 4 stayed in the same room as Resident 3. During a review of Resident 4's H&P, dated 6/4/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of the facility's Interview Record (IR) with Resident 4, dated 11/25/2025, the IR indicated Resident 4 was interviewed by the facility regarding her observations made while CNA 6 was providing care to her roommate, Resident 3. The IR indicated Resident 4 stated that while CNA 6 was assisting Resident 3 with personal care, Resident 4 noticed that CNA 6 was speaking to Resident 3 in a loud and firm voice, repeatedly telling Resident 3 not to get up. Resident 4 stated that CNA 6 appeared to be holding Resident 3 tightly by the hands and guided Resident 3 to the wheelchair in a manner that Resident 4 described as fast and rough. Resident 4 further reported that while CNA 6 was combing Resident 3's hair, Resident 4 observed CNA 6 brushing Resident 3's hair hard enough that it seemed like it was pulling Resident 3's hair, which caused Resident 4 to become concerned for Resident 3's comfort. During a review of the facility's IR with the Director of Staff Development (DSD), dated 11/25/2025, the IR indicated that at approximately 3:25 pm while in the DSD's office, a CNA (unknown) came to report to the DSD that the CNA heard another CNA yelling at a resident (Resident 3). The IR indicated the CNA told the DSD to ask Resident 4 because Resident 4 heard it as well. The DSD spoke with Resident 4 who was under the care of CNA 6. The IR indicated Resident 4 told the DSD CNA 6 was rough with Resident 3 when CNA 6 grabbed Resident 3 by the arms and placed Resident 3 down (in the wheelchair). Resident 4 stated that when CNA 6 brushed Resident 3's hair CNA 6 was rough and yelled at Resident 3. During a review of the facility's IR with CNA 5, dated 11/26/2025, the IR indicated that CNA 5 stated that CNA 5 believed reporting the incident was the appropriate action. The IR indicated CNA 5 observed that Resident 3 appeared uncomfortable while CNA 6 was providing care and noted that CNA 6 spoke to Resident 3 in a loud tone of voice. CNA 5 stated that CNA 5 would not feel comfortable if CNA 5's own grandmother or family member were treated in that manner and this prompted CNA 5 to report the incident. During an interview on 12/15/2025 at 2:19 pm with Resident 3, Resident 3 stated Resident 3 did not remember the incident between Resident 3 and CNA 6. During an interview on 12/15/2025 at 2:25 pm with Resident 4, Resident 4 stated CNA 6 would practically throw Resident 3 into the (wheel)chair and would pull on Resident 3's hair while combing the knots out of Resident 3's hair. Resident 4 stated Resident 4 refused to have CNA 6 take care of Resident 4. During an interview on 12/16/2025 at 9:36 am with Social Worker Director (SWD), the SWD stated that on 11/25/2025 she went to speak to Resident 3 and Resident 3 stated the ugly and rude nurse (CNA 6) assisted Resident 3 to the restroom and yelled at Resident 3 not to get up, then CNA 6 got Resident 3 up and placed Resident 3 hard on the chair. Resident 3 stated Resident 3 did not like CNA 6. The SWD stated Resident 3's roommate, Resident 4, witnessed the incident and stated it happened between 3:30 pm and 4 pm on 11/25/2025. During an interview on 12/16/2025 at 11:39 am with the DSD, the DSD stated Resident 4 had requested not to have CNA 6 because CNA 6 has too much attitude and Resident 4 did not want CNA 6 to care for Resident 4. During an interview on 12/16/2025 at 1:27 pm with the Director of Nursing (DON), the DON stated there were 2 residents who requested not to be cared for by CNA 6 including Resident 4. The DON also stated there was only one recorded grievance between CNA 6 and Resident 3 and the decision to let CNA 6 go had to do with Resident 4's statement because the facility believed an incident did occur. The DON stated CNA 5 also overheard CNA 6's tone of voice when CNA 6 spoke to Resident 3. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 5/30/2024, indicated, The facility does not condone any form of resident abuse.and/or mistreatment.The facility identifies, corrects, and intervenes in situations in which abuse, neglect.and/or mistreatment is more likely to occur.

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), who had diagnosis of dementia (loss of memory and other mental abilities severe enough to interfere with daily life), had a history of fall (unintentionally coming to rest on a lower-level surface) on 6/1/25, and was assessed at a high fall risk on 6/1/25, received care needs and services to prevent a fall on 6/19/25 by failing to ensure:Licensed Vocational Nurse (LVN) 2 monitored (observed and checked) and promptly (quickly/rapidly/immediately) redirected Resident 1 (direct Resident 1 to a new or different place or purpose) when Resident 1 got up from Resident 1's wheelchair unassisted while Resident 1 was at Nurses' Station 1 on 6/19/25 [at around 10 am].As a result, on 6/19/25, at approximately 10 am, Resident 1 fell out of Resident 1's wheelchair, in front of Nurses' Station 1. Resident 1 sustained fractures (break in the bones) of the left 8th, 9th, and 10th ribs (are commonly referred to as false ribs [12 paired bones which form a cage to protect the lungs and the heart]. Unlike the first seven ribs, which directly connect to the sternum [breastbone]). Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included dementia, a history of falling, cognitive (ability to think and understand information) communication deficit (communication difficulties stemming from impaired cognitive functions rather than direct speech or language problems), difficulty in walking and impulse disorder (inability to resist urges and impulses [acting without forethought]).During a review of Resident 1's untitled Care Plan (CP), dated 8/8/24, revised 5/9/25, the CP indicated Resident 1 was at risk for falls related to dementia, the aging process, poor safety awareness, and a history of falls. The CP interventions included anticipating and meeting Resident 1's needs, promptly response to all of Resident 1's requests for assistance and removing any potential causes of falls if possible.During a review of Resident 1's History and Physical (H&P, physician examination of a resident), dated 1/27/25, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had an unstable gait (abnormal walking pattern characterized by a lack of coordination [the ability to use different parts of the body together smoothly and efficiently]), balance, or stability, and increasing the risk of falls.During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 3/25/25, the MDS indicated Resident 1's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) from staff for transfers (moving from bed to chair or wheelchair), and walking.During a review of Resident 1's Fall Risk Evaluation (FRE), dated 6/1/25, the FRE indicated Resident 1's fall risk score was 15 due to Resident 1 required the use of assistive devices (cane, wheelchair, walker, furniture) while standing and walking, and had one to two falls in the past 3 months. The FRE indicated a score of 10 or higher, placed Resident 1 at high risk for fall. The FRE indicated Resident 1 was considered at high risk for potential falls (an increased likelihood of a person experiencing a fall, which can lead to injuries) when Resident 1's fall risk score was 10 or greater. The FRE indicated for nursing staff (in general) to focus on Resident 1's risk for falls with a goal for Resident 1 to be free of falls, and interventions to assist Resident 1 with ambulation (the ability to walk from place to place) and transfers.During a review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 6/1/25 and timed at 11:50 pm, the SBAR indicated Resident 1 had a fall, was unresponsive to verbal questions, and sustained an open skin tear to the left side of Resident 1's face due to the fall. During a review of Resident 1's Risk for Falls Care Plan (CP), dated 6/1/25, indicated Resident 1 was transferred to General Acute Care Hospital (GACH) 2 Emergency Department (ED) (on 6/1/25) due to a fall on 6/1/25. The CP interventions included assisting Resident 1 with walking, transferring, and placing Resident 1 in front of the Nurses' Station for monitoring (observing and checking) [Resident 1's behavior to prevent falls].During a review of Resident 1's Fall Investigation Report (IR), dated 6/19/25 and timed 10:16 am, the IR indicated on 6/19/25 at 10 am, Resident 1 got up from Resident 1's wheelchair and fell on the floor in front of Nurses' Station 1. The IR indicated LVN 2 was on the computer with the Activities Director (AD) in Nurses' Station 1 on 6/19/25 [at 10 am]. The IR indicated LVN 2, and the AD saw Resident 1 walking towards Nurses' Station 1 unassisted, but LVN 2 and the AD were not able to get to Resident 1 in time due to the incident happened too fast. During a review of Resident 1's SBAR Form, dated 6/19/25 and timed at 10:25 am, The SBAR indicated [on 6/19/25, at 10 am], Resident 1 got up from Resident 1's wheelchair and fell on the floor in front of Station 1.During a review of Resident 1's SBAR Form, dated 6/20/25, and timed at 7:15 pm, the SBAR indicated Resident 1 was observed grimacing (to distort one's face in an expression usually of pain) in pain (pain was unrated) upon palpation (hands and fingers used to examine the body) of Resident 1's left lower quadrant (LLQ- the area below the belly button and to the left of the midline [the vertical line that runs down the center of the abdomen]). The SBAR indicated Resident 1's Primary Physician/Medical Doctor (MD) 1 recommended Resident 1 to get an X-ray (picture of the inside of the body).During a review of Resident 1's X-ray Report, dated 6/21/25, the X-ray Report indicated the reason MD 1 ordered an X-ray of Resident 1's ribs was due to Resident 1 having acute pain (a short-lived, sharp, and sudden onset pain that typically arises from a specific injury) due to trauma (physical injury due to violence or an accident). The X-ray Report indicated Resident 1 had an acute nondisplaced fracture (a break in a bone where the broken pieces of bone are still lined up correctly) of the left 8th, 9th, and 10th ribs.During an interview, on 6/26/25, at 10:06 am, with LVN2, LVN 2 stated Resident 1 was a fall risk and Resident 1 had a history of getting up (from bed and or wheelchair) unassisted. LVN 2 stated, on 6/19/25, at approximately 10 am, LVN 2 and the AD, were on the computer in Nurses' Station 1 looking for some information. LVN 2 stated, while looking for information on the computer, LVN 2 and the AD heard another resident (unidentified) make a sound to alert others that something was about to happen. LVN 2 stated LVN 2 and the AD went outside of Nurses' Station 1 and found Resident 1 lying on Resident 1's left side, on the floor. LVN 2 stated Resident 1 complained of pain (unable to rate the pain) but Resident 1 was not able to state where Resident 1's pain was. LVN 2 stated Resident 1 was placed near Nurses' Station 1 so LVN 2 could monitor Resident 1's behavior of getting up from Resident 1's wheelchair due to Resident 1 being at a high risk for falls and having behavior of getting up while sitting on wheelchair.During an interview, on 6/26/25, at 3 pm, with LVN 1, LVN 1 stated Resident 1 was constantly (always, continuously over a period of time) trying to get up from Resident 1's bed and or wheelchair, unassisted. LVN 1 stated Resident 1 needed one-to-one care (1:1, one staff caring for/supervising one resident). LVN 1 stated Resident 1 would get up out of the wheelchair unassisted even when a staff (in general) was sitting in front of Resident 1. LVN 1 stated, on 6/19/2025, (unable to recall exact time), Resident 1 was taken to the activity room for the morning activities (doing something such as action, movement, exercise), but Resident 1 was brought back in front of Nurses' Station 1 quickly (for additional monitoring) due to Resident 1 tried to get up (in the activity room) while sitting in Resident 1's wheelchair.During an interview, on 6/26/25, at 3:46 pm, with the Activities Director (AD), the AD stated, on 6/19/25 (unable to remember exact time), the AD walked up to Nurses' Station 1 and saw Resident 1 in Resident 1's wheelchair in front of Nurses' Station 1. The AD stated the AD went inside Nurses' Station 1 and asked LVN 2 for assistance with the AD on the computer. The AD stated while looking for information on the computer with LVN 2, the AD heard a crashing noise. The AD stated the AD walked around to the front of Nurses' Station 1 and saw Resident 1 lying on Resident 1's left side on the floor. The AD stated Resident 1 liked to stand up a lot and forgot to use Resident 1's wheelchair.During a concurrent interview and record review, on 6/26/25, at 3:53 pm, with the Assistant Director of Nursing (ADON), Resident 1's Physician's Order, dated 1/24/25, was reviewed. Resident 1's Physician' s Order, dated 1/24/25, indicated for staff to monitor Resident 1 for episodes of getting up from the wheelchair and the bed unassisted every shift (each and every designated work period within a 24-hour cycle). The ADON stated Resident 1 had a history of getting up from Resident 1's wheelchair unassisted and needed to be monitor [for the behavior of getting up from the wheelchair unassisted].During an interview, on 6/26/25, at 5:56 pm, with the Director of Nursing (DON), the DON stated, it was important to determine the root cause analysis (problem solving method used to identify the underlying reasons why a problem or event occurred) for Resident 1's fall [on 6/1/25] to prevent further fall and injuries [on 6/19/25].During a review of the facility's policy and procedure (P&P) titled, Dementia Care, dated 10/2017, the P&P indicated, The Interdisciplinary Team (IDT, a group of healthcare professionals who collaborate to provide comprehensive care for residents) would seek to identify and address the root cause of challenging resident behaviors to determine whether there is a medical, physical, environmental cause of the behavior. The P&P indicated the IDT would develop plans of care and implement interventions to understand and address behaviors as a form of communication and modify the environment and daily routines to meet the resident's needs/preferences.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) and CNA 2 provided two-person physical assistance (help from two person) to transfer Resident 1 from the bed to a shower chair using a Hoyer Lift (mechanical lift, a device used by staff to transfer residents from a bed to a chair or other similar places). 2. Ensure CNA 1 and CNA 2 followed the facility ' s Policy and Procedure (P&P) on Fall Management Program, How to Safely Lift A Patient Into A Patient Lift/Hoyer Lift, and Total Mechanical Lift. As a result, on 12/21/2022, at 9:10 a.m., Resident 1 fell from the Hoyer Lift. Resident 1 experienced severe generalized body pain and was transferred to a General Acute Care Hospital (GACH) Emergency Department (ED) via 911 (emergency services) and was found to have fracture of the right kneecap (a flat movable bone forming the front part of the knee) and right lower leg. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified quadriplegia (paralysis that affects a person ' s limbs and body from the neck down), cerebral palsy (a physical disability which affects movement and posture), muscle weakness, abnormalities of gait (manner of walking or moving on foot), and mobility (ability to move). A review of Resident 1 ' s Fall Risk Evaluation dated, 9/10/2021, indicated Resident 1 was at risk for falls due to the resident being chairbound, had balance problem while standing, walking, decreased muscular coordination, and required the use of assistive devices (cane, wheelchair, walker, furniture). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/17/2021, indicated Resident 1's cognition (ability to think and process information) was severely impaired (significantly limited). The MDS indicated Resident 1 was totally dependent on two or more persons physical assist to transfer the resident from or to bed, chair, wheelchair. A review of Resident 1 ' s Change in Condition Evaluation (COC) dated 12/21/2022, timed at 9:30 a.m., indicated on 12/21/2022, at 9:10 a.m., CNA 2 called Licensed Vocational Nurse 1 (LVN 1) to come to Resident 1 ' s room. The COC indicated LVN 1 found CNA 1 with Resident 1 on the floor underneath the Hoyer Lift. LVN 1 noted Resident 1 ' s right side of the forehead was bleeding with a laceration (deep cut to the skin). LVN 1 noted Resident 1 had discoloration (change in color in a bad way) and swelling of the right knee, and redness of right shoulder. Resident 1 complained of 8/10 (severe/intense) generalized body pain on a scale of 0-10 (0 means no pain and 10 means the worst possible pain). Resident 1's Primary Physician (MD 1, Doctor of Medicine) was notified, and MD 1 recommended for Resident 1's transfer to the GACH ED for further evaluation. A review of Resident 1 ' s Facility to Hospital Transfer Form, dated 12/21/2022, timed at 9:15 a.m., indicated Resident 1 was transferred to a GACH ED via ambulance. A review of Resident 1 ' s Progress Notes, dated 12/21/2022, timed at 11:13 a.m., indicated the facility transferred Resident 1 to the GACH due to a fall. A review of CNA 1 ' s Interview Report, dated 12/21/2022, indicated CNA 2 lifted Resident 1 up on the Hoyer lift. The report indicated CNA 1 was by Resident 1 ' s side (side not specified) and holding Resident 1 while CNA 2 was standing behind and maneuvering (moving skillfully or carefully) the Hoyer lift. The report indicated CNA 2 walked away from the Hoyer lift to get the shower chair and CNA 1 walked away from Resident 1 ' s side to the back to maneuver the Hoyer Lift. Resident 1 started to cough, leaned forward, and fell off the Hoyer Lift. A review of Resident 1 ' s GACH ED Provider Note, dated 12/21/2022, indicated the GACH ED Physician (MD 2) irrigated (cleansed/washed) and anesthetized (administered medication to prevent sensation or eliminate pain) on Resident 1 ' s laceration on the right side of the forehead. MD 2 repaired the laceration with Vicryl sutures (sterile surgical threads used to repair cuts) and discussed Resident 1's case with the Orthopedic Physician (a doctor who specializes on injuries and diseases affecting the bones, muscles, and joints), who recommended to apply a splint (a rigid or flexible device that maintains in position a displaced or movable part) to prevent knee rotation (prevent movements of the knee to prevent further knee injury). A review of Resident 1's GACH X-ray (photographic or digital image of a body part) Report, dated 12/21/2022, indicated Resident 1 sustained an acute (severe and sudden onset) transverse (across) fracture (condition in which bones crack or break into pieces) of the lower patella (knee cap), acute oblique fracture (when the bone is broken at an angle) of proximal (nearer to the center of the body) tibial shaft (one of the bones of the lower leg), prepatellar (the front of the knee cap) and pretibial (the front of the large bone of the lower leg) edema (swelling), and severe osteopenia (when bones are weaker than normal). A review of Resident 1 ' s GACH Orthopedic Physician Note, dated 12/23/2022, at 3:53 p.m., indicated Resident 1 may need a cast treatment (a protective shell of fiberglass, plastic, or plaster, and bandage that is molded to hold a fractured bone in place while it heals), versus surgical fixation (a surgical procedure that stabilizes and joins the ends of fractured bones by mechanical devices such as metal). During an observation and concurrent interview with Resident 1 on 1/5/2023, at 1:19 p.m., Resident 1 was in the bed awake and alert. Resident 1 ' s forehead had a reddish colored and healed dry laceration with one staple (a piece of thin wire to fasten an open wound) on the right side of the resident ' s forehead. Resident 1 ' s right lower leg was covered with a bandage (a strip of material used to bind a wound or to protect an injured part of the body) in ace wrap dressing (elasticated bandage) and a splint. Resident 1 ' s right lower leg was elevated on a pillow. Resident 1 was unable to respond to the questions during the interview. During an interview with CNA 1 on 1/5/2023, at 2:06 p.m., CNA 1 stated on 12/21/2022, while Resident 1 was cradled (placed) in the sling (flexible strap used to support or raise the resident) on the Hoyer Lift, CNA 1 maneuvered the Hoyer Lift and CNA 2 left the Hoyer Lift to move the shower chair closer to Resident 1. CNA 1 stated Resident 1 was coughing hard. CNA 1 stated Resident 1 tried to spit her saliva by leaning forward and Resident 1 fell . CNA 1 stated Resident 1 fell fast, and the resident ' s face hit the floor. CNA 1 stated Resident 1 ' s right side of the head was bleeding. CNA 1 stated she applied pressure on Resident 1 ' s forehead while CNA 2 ran out of the room to notify the charge nurse (LVN 1). During an interview with CNA 2 on 1/5/2023, at 2:39 p.m., CNA 2 stated she left the resident while on the Hoyer Lift ' s sling and went to get the shower chair by the foot of Resident 1 roommate ' s bed next to Resident 1 ' s bed. CNA 2 stated when she turned her back on Resident 1 and CNA 1, she heard Resident 1 coughed and CNA 1 screamed, she fell . CNA 2 stated as she turned around, she saw Resident 1 on the floor. During an interview with CNA 2 on 1/25/2023, at 10:33 a.m., CNA 2 stated initially when Resident 1 was sitting on the Hoyer lift ' s sling, CNA 2 stood behind the Hoyer lift and maneuvered the lift. CNA 2 stated she left to get the shower chair located next to Resident 1 roommate ' s bed. CNA 2 left CNA 1 by herself, standing next to Resident 1 while Resident 1 was on the Hoyer Lift ' s sling. CNA 2 stated CNA 1 left Resident 1 ' s side and walked behind to take control of the Hoyer Lift and prepared to position Resident 1 on to the shower chair. CNA 2 stated one staff (in general) should be at Resident 1 ' s side, close to Resident 1 at all times while Resident 1 was on the Hoyer Lift ' s sling to prevent accidents and falls. During an observation of Resident 1 in Resident 1 ' s room on 1/25/2023, at 11:10 a.m., with CNA 2, Resident 1 was lying in bed, awake. Resident 1 had a laceration on Resident 1 ' s right side of the forehead with pinkish discoloration. Resident 1 had a splint on the right lower leg. Resident 1 complained of pain on her right foot. During a concurrent interview with LVN 1 on 1/25/2023, at 3:08 p.m. and a review of Resident 1 ' s COC Evaluation, dated 12/21/22, LVN 1 stated there was a lot of bleeding on Resident 1 ' s laceration on the right side of the forehead. LVN 1 stated Resident 1 ' s right knee had swelling with pinkish discoloration and Resident 1 complained of pain. LVN 1 stated Resident 1 said, I ' m pain. A review of Resident 1 ' s undated Care Plan, titled Safety, indicated resident will remain safe. One of the interventions in the care plan indicated safety measures for the resident including for staff to implement strategies to reduce the risk of falls, injury as appropriate. A review of the facility ' s undated P&P, titled Fall Management Program, indicated to provide residents a safe environment that minimizes complications associated with falls. The policy indicated the facility will implement a fall management program that supports providing an environment free of fall hazards. A review of the facility ' s undated P&P, titled Total Mechanical Lift, indicated a mechanical lift is used appropriately to facilitate transfers of residents. The policy indicated at least two people are present while resident is being transferred with the mechanical lift. A review of the facility undated P&P, titled How To Safely Lift A Patient Into A Patient Lift/Hoyer Lift, indicated for staff to know how to use the Hoyer lift correctly can prevent patient falls from lifts, which may cause injuries, including head trauma, fractures and death.

Based on observation, interview, and record review, the facility failed to ensure residents requiring [MEDICAL TREATMENT] (a [MEDICAL TREATMENT] machine and a special filter called an artificial kidney, or dialyzer (an apparatus for performing [MEDICAL TREATMENT]), are used to clean the blood in people whose kidneys do not function. To get the blood into the dialyzer, a surgeon will make access or entrance, into the blood vessels), received care and services consistent with professional standards of practice, policies, and the plan of care, for one of four sampled residents (Resident 1). Resident 1 had a recent (on [DATE]) complication of bleeding (hemorrhage) from the right upper arm [MEDICAL TREATMENT] (an arteriovenous (AV) shunt, a surgical connection between an artery and a vein to create an AV fistula (an abnormal connection between two hollow spaces, such as blood vessels) that can handle the needles that allow blood to flow out to and return from the [MEDICAL TREATMENT] machine). The facility failed to: 1. Ensure Resident 1 was closely monitored and assessed after (post) [MEDICAL TREATMENT] treatment to identify complications, including bleeding from the [MEDICAL TREATMENT] access. 2. Implement immediate interventions to stop Resident 1's bleeding from the right arm AV shunt on [DATE], at 6:02 p.m., when Resident 1 was found unresponsive with profuse bleeding. The nurses did not apply pressure to the bleeding [MEDICAL TREATMENT] and did not use a tourniquet (a device for stopping the flow of blood through a vessel, typically by compressing a limb with a cord or a tight bandage) to prevent further bleeding. This deficient practice resulted in Resident 1 bleeding out of the right upper arm AV shunt and paramedics (911, emergency services), were unable to resuscitate Resident 1. Resident 1 was pronounced dead at the facility the same day, [DATE], at 6:52 p.m. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-planning tool) dated [DATE], indicated Resident 1's cognition (ability to think and process information) was moderately impaired, the resident was able to communicate to make needs known, and required extensive assistance for bed mobility, transfers, and personal hygiene. Resident 1 used a wheelchair for mobility and was receiving [MEDICAL TREATMENT] treatments. A review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. A review of Resident 1's Care Plan Report, effective date [DATE], indicated resident was receiving [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. The care plan interventions included assessing the [MEDICAL TREATMENT] for signs/symptoms of infection and bleeding every shift, and goals included episodes of low blood pressure, pain, and bleeding will be minimized through next review on [DATE] goal date. A review of Resident 1's Pre and Post-[MEDICAL TREATMENT] Assessment form dated [DATE] (Thursday - [MEDICAL TREATMENT] day) timed at 3 p.m., indicated Resident 1's access site was dry post [MEDICAL TREATMENT]. A review of Resident1's (MONTH) (YEAR) Orders, indicated on [DATE], during the 3 p.m. to 11 p.m. shift, the licensed nurse did not assess Resident 1's [MEDICAL TREATMENT] site condition or the status of the right arm AV shunt including presence of bleeding. A review of the SBAR (Situation Background Assessment Report) Communication form dated [DATE], (Friday - non-[MEDICAL TREATMENT] day) indicated Resident 1 had 60 cubic centimeter (cc) of blood loss from the AV shunt and at 1 a.m. Resident 1's blood pressure was ,[DATE] millimeters of mercury (mmHg - blood pressure below ,[DATE] mmHg is considered low and may cause inadequate blood flow to the heart, brain, and other vital organs). A review of the Licensed Personnel Weekly Progress Notes dated [DATE], timed at 2 a.m., indicated Resident 1 had blood draining from the AV shunt and Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) Emergency Department via paramedics. A review of the Pre-hospital Care Report Summary (paramedics report), dated [DATE], noted paramedics arrived at 1:54 a.m. for bleeding/wound and the narrative included the resident was found in with a (one) cubic centimeter (cc) of bleeding from shunt. A review of GACH 1 Clinical Notes Report, dated [DATE] at 2:50 a.m., indicated Resident 1 presented to the emergency department due to right arm [MEDICAL TREATMENT] shunt bleeding but with no active bleeding. Resident 1 was discharged to the facility the same day at 5:18 p.m. A review of GACH 1 Assessment Report, dated at 2:55 a.m., indicated Resident 1's blood pressure was ,[DATE] and resident was able to obey commands. A review of GACH 1 Hematology (laboratory result), dated [DATE] at 3:07 a.m., indicated Resident 1's hemoglobin (hgb) was 6.3 grams per deciliter (g/dl) (normal level 11.4 to 15.9 g/dl) and hematocrit (hct) was 19.7 % (normal level 33.3 % to 45.7 %). A review of GACH 1 [MEDICAL TREATMENT] Flow Sheet, date [DATE], indicated Resident 1 had [MEDICAL TREATMENT] from 8:50 a.m. to 11:50 a.m. at the right upper arm access site. Resident 1's second unit of packed red blood cells (PRBC) was given at 9:20 a.m. A review of Resident 1's Care Plan dated [DATE], developed for Resident 1's [MEDICAL TREATMENT] and risk for complications related to [MEDICAL TREATMENT] and bleeding AV shunt, indicated the interventions included monitoring [MEDICAL TREATMENT] (AV shunt) for signs and symptoms of infection and bleeding and to apply pressure for bleeding. A review of the Resident 1's (MONTH) (YEAR) Orders, dated [DATE] for the 11 p.m. to 7 a.m. shift (night of [DATE] and the day of [DATE]) indicated the licensed nurse did not assess Resident 1's [MEDICAL TREATMENT] site condition or the status of the right arm AV shunt including presence of bleeding. A review of the Pre and Post-[MEDICAL TREATMENT] Assessment form dated [DATE], the Pre-[MEDICAL TREATMENT] section, timed at 8 a.m., indicated Resident 1 had a blood transfusion at GACH 1 on [DATE] due to the AV shunt bleeding. A Review of the POS [REDACTED]. A review of the Pre and Post-[MEDICAL TREATMENT] Assessment form dated [DATE], indicated the Post-[MEDICAL TREATMENT] section was not completed. The licensed nurses did not check Resident 1's vital signs (blood pressure, heart rate, respiration, and temperature) and did not assess the condition of the A-V shunt after Resident 1 returned from [MEDICAL TREATMENT] after 1 p.m. A review of the Licensed Personnel Weekly Progress Note dated [DATE] completed by Licensed Vocational Nurse 3 (LVN 3) indicated, at 6 p.m., Certified Nursing Assistant 2 (CNA 2) reported Resident 1 was bleeding from the A-V shunt and was unresponsive. The licensed nurse called 911 at 6:02 p.m. Resident 1 was pronounced dead at 6:52 p.m. at the facility. LVN 3 did not document nursing staff applied immediate interventions to stop Resident 1's bleeding, including pressure or application of a tourniquet to the right arm AV shunt. A review of the Pre-hospital Care Report Summary (paramedics report), dated [DATE], noted paramedics arrived at the facility at 6:36 p.m. Resident 1 had no blood pressure, pulse, or respiration at 6:38 p.m. Paramedics' resuscitation attempts were unsuccessful. The narrative included blood drenching the bedding, shunt right arm bleed out, and estimated over one liter of blood loss. The Report Summary indicated severe blood loss as the presumed etiology of [MEDICAL CONDITION]. A review of Resident 1's Certificate of Death indicated the immediate cause of death was a probable acute [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). During an interview, on [DATE] at 9:49 a.m., the Director of Nursing (DON) stated after the incident of Resident 1's bleeding the facility implemented the use of an emergency kit (four gauzes, one tape, and one tourniquet, inside a clear plastic bag) placed at the bedside of residents on [MEDICAL TREATMENT]. During a facility tour observation and concurrent interview, on [DATE] at 9:57 a.m., no [MEDICAL TREATMENT] emergency kit observed in resident's rooms (room [ROOM NUMBER], 23, and 25) on [MEDICAL TREATMENT]. Licensed Vocational Nurse 1 (LVN 1) stated emergency kit were stored in the treatment cart. On [DATE] at 12:58 p.m., during an interview, Housekeeper 4 stated, on [DATE], Resident 1 was bleeding, and there was blood on the floor, wall, bed, and mattress. During an interview, on [DATE] at 2:52 p.m., Licensed Vocational Nurse 3 (LVN 3) stated on [DATE], CNA 2 told her Resident 1 was bleeding. LVN 3 ran to Resident 1's room and tried to arouse Resident 1 and called code blue (a term often used to refer to a [MEDICAL CONDITION] to initiate emergency response). During an interview, on [DATE] at 3:08 p.m., LVN 3 stated, on [DATE], Resident 1 had no pulse, and there was a puddle of blood on the floor. LVN 3 stated blood was coming out from underneath the bandage on the [MEDICAL TREATMENT] and which was intact. LVN 3 stated 911 was called and started cardiopulmonary resuscitation (CPR, an emergency procedure that combines chest compressions and ventilation to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [MEDICAL CONDITION]). During an interview, on [DATE] at 4:20 p.m., the Director of Nursing (DON) stated the nurse conducts an assessment of a [MEDICAL TREATMENT] patient before and after (pre and post) a [MEDICAL TREATMENT] treatment and every shift after that. The nurse checks the access site for redness, bleeding, swelling, pain, thrill (a vibratory sensation felt on the skin overlying an area of turbulence), bruit (a sound heard over an artery or vascular channel reflecting turbulence of flow), and documents the assessment on a [MEDICAL TREATMENT] Communication sheet and documents the assessment for each shift in a form called, Orders. A review of the facility's policy and procedure titled, [MEDICAL TREATMENT] Care, revised date [DATE], indicated AV shunt site will be inspected for functionality and sign and symptoms of complication. The policy and procedure indicated monitor site for redness, vascular (blood vessel) access, tenderness, bleeding, and drainage.

Based on interview and record review, the facility failed to implement their written policies and procedures to protect 1 of 23 sample residents (Resident 6) from verbal abuse from Certified Nursing Assistant (CNA 2) and lack of intervention to prevent CNA 2 from creating an environment of fear for Residents 6 by failing to: -Immediately remove from the premises the staff member (CNA2) accused of verbal abuse. -Ensure the alleged verbal abuse by CNA 2 was immediately investigated. - Conduct investigations to individuals or residents under the care of CNA 2 who may have information relevant to the abuse allegation that included Resident 10 and Resident 7. -Report the incident to local law enforcement within 24 hours and a written report made to the local ombudsman and the California Department of Public Health. An immediate jeopardy was called on 7/31/16 at 1:18 PM, in the presence of the Regional Vice President (VPO), Administrator, and Director of Nursing (DON), by failing to protect Resident 6 from verbal abuse and the facility's lack of intervention to prevent Resident 6 from a fearful environment for 17 days after the allegation of abuse was made. The facility submitted an acceptable plan of correction on 8/1/16, as follows: The Director of Nursing (DON) and Quality Assurance (QA) Nurse met with Resident 6 to assure the resident of her safety and that an abuse incident will not reoccur. Interviews of all alert and oriented residents and/or responsible parties by leadership personnel were to be completed by 8/1/16. In-services will be initiated for all employees regarding abuse and reporting with a plan to complete in-servicing to all employees by 8/3/16. The administrator will monitor for future compliance through active education with the facility staff during monthly staff meetings. Upon an allegation of abuse by a facility staff member, the facility staff member will be suspended and removed immediately from the premises during the investigation. The investigation process will include a written, signed, and dated statement from the person(s) reporting the incident, the person allegedly committing the incident, and any witnesses of the incident. The administrator will report the alleged incident to local law enforcement within 24 hours of the observation, knowledge, or suspicion of abuse. In addition, a written report will be made to the local ombudsman and the California Department of Public Health. Department managers will review results of interviews, resident council meeting notes, and grievance logs during meetings in order to prevent future occurrences of failure to report, failure to remove harm, and to ensure the residents are protected. On 8/1/16, at 8:30 PM, the facility submitted an acceptable plan of correction. The survey team verified the plan of correction and verbally notified the VPO and DON the IJ was abated. Findings: Resident 6's admission record indicated Resident 6 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. The admission Minimum Data Set Assessment on 1/11/16 (MDS is a comprehensive assessment of a resident's mental status, behaviors, likes and dislikes, activities of daily living, medical conditions) indicated Resident 6 had a Brief Interview for Mental Status (BIMS) score of 15 . A score of 15 suggested that the resident is cognitively intact, which means that Resident 6 was able to understand others and to make herself understood. Resident 6 had no signs or symptoms of [MEDICAL CONDITION] (confusion), required assistance with personal care and hygiene needs and was incontinent of bowel and bladder ( inability to hold urine or feces). During a resident quality of life Interview on 7/31/16 at 8:15 AM., Resident 6 stated, CNA 2 yelled at me at the top of his lungs two weeks ago (on 7/14/16) when she asked CNA 2 to clean her after an episode of urinary incontinence. Resident 6 stated she waited 55 minutes for CNA 2 to answer the call light to come into her room to change her. Resident 6 stated CNA 2 yelled, You're not the only one I have to take care of, I had to change somebody . Resident 6 stated CNA 2 cleaned her using cold water. Resident 6 stated I was afraid, and thought he was going to hit me . Resident 6 stated I started to get upset and I vomited. During the ongoing interview, Resident 6 began to cry and stated, Every time CNA 2 works since the verbal abuse occurred, I try to stay awake until the evening shift, is over. I don't trust him and I am afraid he might come into my room. Resident 6 also stated she told LVN 4 about the verbal abuse on 7/14/16 after CNA 2 yelled at her. Resident 6 also stated during the interview, during the evening shift (3-11 pm) on 7/16/16, CNA 2 was involved in a verbal altercation with another staff member, in the hallway outside her room; they were very loud and yelling. Resident 6 stated that she was very scared. The Police Report dated 7/16/16 at 7 p.m., indicated the police responded to a call regarding an altercation between two male staffs at the facility. According to the facility's schedule and time card records, CNA 2 continued to work the 3 PM to 11 PM shift on 7/15/16, 7/16/16, 7/17/16, 7/18/16, 7/21/16, 7/22/16, 7/27/16, 7/28/16, 7/29/16, and on 7/30/16. On 7/31/16, CNA 2 was not available for an interview due to being suspended when the IJ was called on 7/31/16 at 1:18 PM During an interview with Resident 10, Resident 6's roommate, on 7/31/16 at 9:26 AM, Resident 10 stated CNA 2 came into the room two weeks ago (7/14/16) and; He was screaming at my neighbor (Resident 6). The yelling lasted three (3) minutes, I felt bad and I was scared of CNA 2 yelling at Resident 6. Resident 6 vomited after the incident. A review of Resident 10's clinical record indicated Resident 10 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 10's admission [DIAGNOSES REDACTED]. A review of Resident 10's MDS dated [DATE] indicated Resident 10 was able to understand others and to make herself understood. The MDS indicated there were no signs or symptoms of [MEDICAL CONDITION]. During an interview with the Director of Nursing (DON) on 7/31/16 at 9:38 AM, the DON stated there were no allegations of abuse reported to her during the month of July. During an interview with the Social Services Director (SSD) on 7/31/16 at 10:21 AM, the SSD found a grievance that was filed by Resident 6 stored within a binder in the social services office. The grievance was filed on 7/15/16 for an event that occurred on 7/14/16 involving CNA 2 and Resident 6. The allegation on the grievance indicated Resident reported to (LVN 4) that (CNA 2) yelled at the resident because she needed to be changed & was waiting for 55 min & the CNA said you're not my only patient. The grievance report indicated that the Assistant Social Services Director interviewed Resident 6 on 7/15/16 regarding the abuse allegation. The grievance report also indicated on 7/22/16 (7 days later), CNA 2 was interviewed by the Director of Staff Development (DSD). CNA 2 indicated Resident 6 asked him why it took so long to get to her and that she had been waiting for over an hour to get help. CNA 2's response to the grievance indicated I'm sorry for the delay and offered her assistance she needed. I apply new diaper, call light in reach and make sure she is fine that evening. The grievance response signed by the Administrator and DSD on 7/22/16 and Social Services Director (SSD) signed on 7/28/16 indicated CNA needed to be careful when speaking with the patient. Staff on the floor to answer the call light. Charge Nurse (CN) & Supervisor to monitor needs to be met. During the interview with the SSD on 7/31/16 at 10:21 AM, stated she did not report the abuse allegation to the Department of Public Health, the local ombudsman, or the local authorities. The SSD indicated that if they were contacted, it would have been specified in the grievance report. There was no documentation that anyone had contacted any public agencies in the grievance report. The SSD indicated in her written statement on 7/31/16 that she reported the results of the grievance report to Resident 6. The SSD indicated Resident informed that the DSD spoke with CNA 2 about speaking properly with the resident and that the CNA 2 did not yell at the resident in his interview record. CNA 2's interview in the grievance report did not have a confirmation or denial that CNA 2 yelled at Resident 6. During an interview with the Director of Staff Development (DSD) on 7/31/16 at 10:35 AM, The DSD confirmed that she interviewed CNA 2 on 7/22/16. The DSD stated that she interviewed LVN 4 over the phone. The DSD confirmed there was no documentation of the phone interview. The DSD confirmed during the interview that she did not report the allegation to any of the mandated public entities (the Department of Public Health, the local ombudsman, and the local authorities. The DSD stated the allegation filed in the grievance was verbal abuse. The DSD indicated in a written statement on 7/31/16 that I got hold of the grievance report on 7/21/16 in the morning after a staff meeting. The DSD conducted an interview and obtained a signed written statement from CNA 2 on 7/22/16. During an interview with the DON on 7/31/16 at 10:48 AM, the DON was asked if she had received any complaints from Resident 6 during the month of July. The DON stated she did not. The DON was asked if any allegations of abuse were reported by the facility to the mandated agencies. The DON stated Not that I can recall. Any allegation of abuse will go through the Administrator and the DON and should be reported to the mandated agencies within 24 hours. During an interview with the Administrator on 7/31/16 at 11:05 AM, the Administrator stated no staffs were suspended for an abuse allegation during the month of July. The Administrator stated CNA 2 did not have any disciplinary actions on file for the month of July. The Administrator confirmed that she signed the grievance form on 7/22/16 for Resident 6's abuse allegation and confirmed she did not report the abuse allegation to any of the mandated agencies. The administrator verbalized during an ongoing interview she failed to suspend CNA 2, investigate and report Resident 6's abuse allegation . During an interview with a randomly selected resident (RSR 7) on 7/31/16 at 12:05 PM, Resident 7 was asked if he had any problems with any male staff members. Resident 7 stated he has had a previous negative encounter with CNA 2. Resident 7 stated CNA 2 had used foul language (curse words) with him in the past me and him have had some words, he's got a bad temper, let's put it that way. Resident 7, who resided down the hall from Resident 6, was admitted on [DATE] and readmitted on [DATE]. Resident 7 was admitted with heart failure, high blood pressure, osteo[DIAGNOSES REDACTED] (infection of the bone), [MEDICAL CONDITION] (disease of the nerves), and [MEDICAL CONDITION] ([MEDICAL CONDITION], a disease of the lungs). According to Resident 7's MDS dated [DATE], Resident 7 has a BIM score of 15. Resident was able to make himself understood and was able to understand others. There was no indication of any signs or symptoms of [MEDICAL CONDITION] documented. A review of the facility's policy and procedure indicated: - 1.A. When the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, or injuries of an unknown source, the Administrator or designee, will initiate an investigation immediately. The policy indicates under 1.A.ii. That the facility will not inhibit staff from their mandated reporter obligations. The policy indicates under 1.A.iv. If appropriate, call law enforcement. -2.A. Immediate Action: The Administrator or designee will provide for a safe environment for the resident as indicated by the situation. The policy indicates under 2.A.ii. That if the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation . -3.A. Interview: The administrator/designee conducting the investigation will interview individuals who may have information relevant to the allegation. The policy indicates under 3.A.i. that individuals who may have information relevant to the incident are the resident, witnesses to the incident, other residents under the care of the staff member involved, roommates, family, visitors, etc. The only interviews documented, in the grievance, were from CNA 2 and Resident 6. -5.A. Notification of Outside Agencies of Abuse when No Serious Bodily Injury: