Every finding on record at Courtyard Health Care Center

Based on observation, interview, and record review, the facility failed to ensure physician orders were obtained and implemented for the assessment, monitoring, and care of a newly created ostomy (a surgically created opening on the belly that allows waste from the body to leave through an opening) for one (Resident 1) out of three sampled residents.This failure had the potential to result in inconsistent ostomy management, delayed identification of stoma ( small opening on the abdomen that the surgeon creates so stool or urine can leave the body), skin breakdown, infection, leakage, and pain.Findings:Review of Resident 1's admission Record (AR), indicated Resident 1 was admitted 7/2026 with diagnosis including Ulcerative Colitis (a long-term disease that causes swelling, irritation, and small open sores called ulcers on the inner lining of the large intestine and rectum) and rectal bleeding, Ileostomy (a surgical operation that connects the final part of the small intestine to a hole in the belly, so waste can leave the body without using the colon or rectum.)Review of Resident 1's Minimum data set (MDS- a federally mandated resident assessment tool), indicated, Resident 1 had intact cognition (memory).Review of Resident 1's Treatment Administration Record (TAR- an official checklist that shows the treatment a patient needs) dated July 2026, indicated, no physician order obtained and no provision of treatment care, for Ileostomy.Review of an outside hospital emergency room medical decision making (ER MDM- a doctor's written record of their clinical reasoning, problem-solving, and treatment plans during an emergency visit) notes for Resident 1 dated 7/19/26, indicated, .Brought to ER with complaint of abdominal pain and rash.Abdomen: Erythematous (red, reddened, inflamed), moist, and friable tissue on right lower quadrant (RLQ- the lower right section of the belly) surrounding the ostomy. Ostomy does not have normal output but draining on the skin. The tissue does appear excoriated and related to the stool contents that was noted to be leaking on her skin.During an interview on 7/31/26 at 9:25 a.m. with Licensed Nurse (LN) 1, LN 1 stated, she has not seen the stoma since Resident 1 does her own ostomy care. LN 1 further stated, . all I do was to gather supplies and give it to her (no care provision).During a concurrent observation and interview on 7/31/26 at 9:45 a.m., with Resident 1, in Resident 1's room, Resident 1 stated, she just finished taking a shower and changed her ileostomy bag herself. Resident 1 stated she had to call the ostomy representative to do ostomy self-care because she could not get the help she needed in the facility, which was why she was doing it herself.During a concurrent interview and record review on 7/31/26 at 3 p.m. with Assistant Director of Nursing (ADON), Resident 1's Physician orders were reviewed. ADON confirmed that there were no documented Physician Orders for Resident 1's ostomy care. ADON stated, her expectation was that ostomy orders were written so that appropriate care were provided for Resident 1.During a review of the undated facility's policy and procedure titled, Ostomy Care- C (colostomy (a surgery that creates an opening on the abdomen so stool can leave the body), Urostomy (a surgery that creates an opening on the abdomen so urine can leave the body), Ileostomy, indicated, .It is the policy of this facility to ensure that residents who require . ileostomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on observation, interview, and record review the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards of food service for a census of 104 Residents when:1.Two ovens were observed with blackened, burnt debris on the bottom and doors;2.Food items in Freezer #1 were opened and undated;3.Food items in the dry storage area were placed in bowls unlabeled and undated; and,4. Meal trays were observed being delivered to residents with uncovered food. These failures had the potential to cause food borne illness among a vulnerable resident population. Findings: 1.During a concurrent observation and interview on 7/7/26 at 8:46 a.m., with the Dietary Manager (DM) and the Registered Dietician (RD), the 2 kitchen ovens were observed to have blackened and burnt debris on the bottom and the oven doors. DM confirmed the above findings and stated she expected the oven to be cleaner. The RD stated that if the oven is not kept clean, it could affect the cooking temperature of the food. Review of the facility's policy and procedure (P&P), titled, Ranges and Ovens, dated 2023, the P&P indicated, Oven's cleaning procedure.clean weekly or as often and necessary.in manufacture directions. Review of the oven owner's manual for Restaurant Series Ranges, dated 2012, the owner's manual indicated for Oven Maintenance-Daily: 1. Wipe the inside of the oven. 2.During a concurrent observation and interview on 7/7/26 at 9 a.m. with the DM and RD, in freezer #1 the following items in gallon containers were opened and undated: Mayonnaise, Sesame dressing and Pickle relish. The DM confirmed the above findings and stated her expectation would be that the dietary staff date the item when they open it. The RD stated that if the food does not have an open date there is no way to tell how long the food has been there. The RD further stated that it could affect the taste of the food and cause food borne illness. Review of the facility's policy and procedure (P&P), titled Procedure for Freezer Storage, dated 2023, the P&P indicated, All frozen foods should be labeled and dated. 3.During a concurrent observation and interview on 7/7/26 at 9:20 a.m. with the DM and RD in the dry storage area, observed eight covered serving bowls of cereal that were unlabeled and undated. DM confirmed the above finding and stated her expectation is that the cereal bowls should have a date that they were prepared. The RD stated that it could affect the taste of the cereal. Review of the facility's policy and procedure (P&P), titled, Storage of food and Supplies, dated 2023, indicated, dry food items which have been opened.such as cereal.will be labeled and dated. 4.During a concurrent observation and interview on 7/7/26 at 12:21 p.m. with Certified Nursing Assistant (CNA) 8 in the hallway outside the dining room, CNA 8 removed a tray containing an uncovered brownie and salad from the dining room food cart and proceeded to bring the tray to the memory care dining room. CNA 8 confirmed that the brownie and salad did not have covers. During a concurrent observation and interview on 7/7/26 at 12:27 p.m. with CNA 8 in the hallway outside the dining room, CNA 8 took a tray containing an uncovered brownie from the dining room food cart and proceeded to walk the tray to the resident's room in the C hallway. CNA 8 confirmed that the brownie was uncovered. During a concurrent observation and interview on 7/7/26 at 12:35 p.m. with CNA 6, CNA 6 was observed with a tray containing an uncovered brownie coming from the kitchen hallway. CNA 6 stated that she took the tray from the food cart in B hallway, went to the kitchen to confirm that the food was okay to be served, and was walking the tray back to the resident's room in B hallway. During a concurrent observation and interview on 7/7/26 at 12:33 p.m. outside the dining room, Resident 65's food tray containing an uncovered brownie was left on top of the dining room food cart. At 12:36 p.m. CNA 1 placed the tray back inside the food cart. At 12:37 p.m., CNA 8 removed the tray from the food cart and walked it back to Resident 65's room in Hallway C. CNA 8 confirmed that the brownie was uncovered. At 12:38 p.m., CNA 1 confirmed that the tray that had been left on top of the cart belonged to Resident 65. During an observation on 7/8/26 at 12:35 p.m., observed lunch trays being passed on B hall with uncovered food. The tray cart was outside of the dining room and a tray was passed by the Director of Staff Development (DSD) to room B17 with an uncovered fruit cup. The tray cart was then moved to B17, and a lunch tray was brought to a resident in room B15 by CNA 6 with an uncovered fruit cup and bean salad. CNA 6 stated that the food should have been covered. During an interview on 7/8/26 at 12:45 p.m. with the DSD, the DSD confirmed these findings and stated that the food should have been covered. The DSD further stated that the tray cart should be directly outside of a resident's room when a food tray is being delivered. During an interview on 7/8/26 at 1:20 p.m. with the RD, the RD stated that if a meal tray is being delivered to a resident's room from a tray cart in the hallway the food on the tray should be covered because there is risk of food contamination. During a review of the facility's P&P titled, Covering Food During Transport, undated, the P&P indicated 1. Meal trays will be delivered in carts. All foods will be covered in trays if not in an eclosed or covered cart.2. If tray leaves the dining room not in a cart and is being delivered to patient rooms, all food on the tray needs to be covered.7. Carts may be parked outside of the residents' doors in hallway as trays are delivered to adjacent rooms; minimizing transport of food through a common area to protect it from contamination while it is uncovered.

Based on interview and record review, the facility failed to ensure five residents (Residents 1, 3, 4, 12, and 91) out of 26 sampled residents were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors), when they received psychotropic medications while nursing staff did not implement nonpharmacological (non-drug, behavioral interventions). This failure had the potential to result in the unnecessary use of psychotropic medications and to not utilize the lowest effective dose of medication.1. A review of Resident 12's medical record indicated she was admitted to the facility in September 2023 with diagnoses which included seizures, major depressive disorder (an illness where one experiences persistent feeling of emptiness, hopelessness, and a total loss of interest in activities), and schizoaffective disorder (a chronic mental health condition that combines the symptoms of two distinct illnesses: schizophrenia [losing touch with reality] and a mood disorder such as depression). A review of Resident 12's physician's orders indicated the following orders:- Risperidone (an antipsychotic medication) 0.5 milligram (mg, a unit of measurement) tablet: Give 1 tablet by mouth two times a day for schizoaffective disorder m/b (manifested by) hallucinations, ordered 8/6/25- Sertraline (a medication to treat depression) 100 mg tablet: Give 1 tablet by mouth one time a day for depression m/b SI (suicidal ideation, the thought of killing oneself) & tearfulness. Give with 25 mg tablet to total 125mg, dated 10/7/25- Sertraline 25 mg tablet: Give 1 tablet by mouth one time a day for depression m/b SI & tearfulness. Give with 100 mg tablet to total 125mg, dated 11/11/25- Trazodone (a medication to treat depression and insomnia) 50 mg tablet: Give 50 mg by mouth at bedtime for depression m/b inability to sleep, dated 10/21/25 During a concurrent interview and record review on 7/9/26 at 2:24 p.m. with the Director of Nursing (DON), the DON stated the first response to resident who displayed behaviors was always behavioral interventions. He stated nursing staff were expected to document the intervention that was implemented. He stated behavioral interventions were expected to be routine and implemented every shift. The DON stated once a resident was started on a psychotropic medication, nonpharmacological interventions were implemented if a medication was scheduled to be administered as needed and not routine. The DON reviewed the Resident 12's record and stated he did not see non drug interventions 2. A review of Resident 4's medical record indicated he was admitted to the facility in February 2026 with diagnoses which included major depressive disorder. A review of Resident 4's physician's orders indicated the following orders:- Aripiprazole oral solution 1 mg/milliliter (mg/ml, a unit of measurement): Give 15 mg via PEG-Tube (Percutaneous Endoscopic Gastrostomy, a soft, flexible feeding tube that is placed directly through the skin of the belly into the stomach) one time a day for MDD (major depressive disorder) m/b self isolation, dated 5/6/26- Escitalopram (an antidepressant to treat depression) 10 mg tablet: Give 1 tablet via PEG-Tube at bedtime for MDD m/b verbalization of sadness, dated 5/5/26 During a concurrent interview and record review on 7/9/26 at 2:36 p.m. with the DON, Resident 4's medical record was reviewed. The DON stated social services and activities created care plans that were specific to a resident's likes and dislikes to help direct staff on what nonpharmacological interventions to implement. The DON reviewed Resident 4's medical record and confirmed there was no documentation that behavioral interventions were implemented. 3. A review of Resident 91's medical record indicated she was admitted to the facility in December 2022 with diagnoses which included anxiety disorder and major depressive disorder. A review of Resident 91's physician's orders indicated the following orders:- Fluoxetine (an antidepressant to treat depression) 20 mg/5 ml oral solution: Give 2.5 ml by mouth one time a day for anxiety m/b compulsive skin picking, dated 9/10/25- Seroquel (an antipsychotic medication) 25 mg tablet: Give 0.5 tablet by mouth two times a day for behavioral disturbance m/b agitation, dated 6/15/26 During a concurrent interview and record review on 7/9/26 at 2:59 p.m. with the DON, Resident 91's physician's orders and documentation for behavioral interventions were reviewed. The DON confirmed Resident 91's medical record did not indicate that nonpharmacological interventions related to her anxiety and agitation were implemented because her psychotropic medications were administered routinely, not as needed. 4. A review of Resident 3's medical record indicated he was admitted to the facility in April 2022 with diagnoses which included major depressive disorder and anxiety disorder. A review of Resident 3's physician's orders indicated an order for the following:- Ativan (a psychotropic medication to treat anxiety) 0.5 mg tablet: Give 1 tablet by mouth every 8 hours as needed for anxiety/inability to relax for 14 days hold for sedation, RR (respiratory rate) less than 12, SBP (systolic blood pressure, a measurement of the maximum pressure of blood pushing against artery walls when the heart beats and pumps blood out to the body) less than 90, or new confusion or delirium, ordered 7/7/26- Sertraline 25 mg tablet: Give 1 tablet by mouth one time a day for depression m/b social isolation, dated 5/24/26 During a concurrent interview and record review on 7/9/26 at 3:01 p.m. with the DON, Resident 3's psychotropic medication orders and behavioral interventions were reviewed. The DON stated Resident 3's medical record did not indicate nursing staff implemented behavioral interventions for his psychiatric conditions and confirmed the record indicated he was only monitored for behaviors related to the sertraline and Ativan. 5. A review of Resident 1's medical record indicated he was admitted to the facility in November 2023 with diagnoses which included major depressive disorder and anxiety disorder. A review of Resident 1's physician's orders indicated an order for venlafaxine (a medication to treat depression) 37.5 mg tablet, give 2 tablet by mouth in the morning for anxiety disorder m/b worrying about dying, feeling fatigue, dated 5/28/26. During a concurrent interview and record review on 7/9/26 at 3:03 p.m. with the DON, Resident 1's medical record was reviewed for behavioral interventions related to his anxiety disorder. The DON confirmed Resident 1's record did not indicate that any non-drug interventions were implemented for anxiety in an effort to use the lowest effect dose of venlafaxine. During a review of the facility's policy and procedure (P&P) titled Care and Treatment, revised 2/2025, the P&P indicated, Based on a comprehensive assessment of a resident, the facility will ensure that: 1. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Procedures. 6. Upon initial comprehensive assessment, SSD [Social Services Director] and/or nursing designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the Psychiatrist to ensure. g. Review of plan of care shows individualized, person-centered care approaches to manage behavior with non-pharmacological interventions.

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed for four residents (Residents 1, 3, 4, and 12) out of 26 sampled residents when: 1. Resident 3 did not receive appropriate pain management services during wound care treatment;2. Resident 12's physician's order to discontinue medication was not carried out;3. Resident 4's opioid (a potent medication to treat pain) medication was not administered by nursing staff according to the physician's order; and,4. Nursing staff did not routinely check Resident 1's blood sugar (BS) prior to administration of (brand name for semaglutide)(a medication to treat type 2 diabetes). These failures resulted in Resident 3 to exhibit severe pain and not attain his highest practicable well-being and had the potential to result in Residents 12, 4, and 1 to receive unnecessary medication and exposure to unwanted side effects such as sedation or hypoglycemia (low blood sugar). Findings: 1.During a review of Resident 3's admission Record (AR-front page of the chart that contains a summary of basic information about the resident, part of medical record), the AR indicated Resident 3 was admitted to the facility in April 2022 with multiple diagnoses which included chronic pain syndrome and pain in thoracic (mid-back between neck and lower back) spine (provides structural support for posture, bending, and movement). During a review of Resident 3's Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident, physician orders), Resident 3 received multiple daily wound treatments for pressure ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) located to right lower buttock and deep tissue injury (DTI- a severe type of pressure sore that develops deep within the soft tissue or muscle near a bone, presenting as a localized area of persistent, non-blanchable deep red, maroon, or purple skin) located to left and right heel. During a review of Resident 3's Order Summary Report (OSR, physician orders), dated 7/7/26, indicated, Morphine (pain medication) 15 mg (milligram, unit of measurement) give 1 tablet by mouth every 8 hours for pain management. During a review of Resident 3's OSR, dated 7/7/26, indicated, acetaminophen (pain medication) 325 mg .give 2 tablet by mouth every 6 hours as needed for mild pain (1-3 on the pain scale) . During a review of Resident 3's OSR, dated 7/7/26, indicated, licensed nurse (LN) to document Pain-Record highest level of pain every shift. During a concurrent observation, interview and record review on 7/7/26 at 1:24 p.m. in the hallway in front and outside of Resident 3's room, Resident 3 was observed moaning and yelling, .ow, ow, it hurts! LN 2 confirmed the wound doctor and LN 1 were inside providing treatment for Resident 3. LN 2 stated that Resident 3 was always complaining he was in pain and per review of Resident 3's medical record, was given only morphine at 6 a.m. and not given acetaminophen. LN 2 further stated that Resident 3's yelling in pain was his baseline. LN 2 acknowledged that administration of pain medication was important to keep Resident 3 comfortable during wound treatment. During a review of Resident 3's Medication Administration Records (MARs, physician orders), the MARs indicated Resident 3 had 21 episodes of pain greater than 2 in June 2026 with 21 missed opportunities to administer acetaminophen. In July 2026, Resident 3 had 5 episodes of pain greater than 2 with 5 missed opportunities to administer acetaminophen. No documented evidence that acetaminophen was offered, refused or given. During a concurrent observation and interview on 7/9/26 at 10 a.m. in Resident 3's room, Certified Nursing Assistant (CNA )1 and CNA 2 assisted Resident 3 with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting). Resident 3 was observed continuously grimacing, groaning, moaning and yelling ow, ow it hurts. LN 1 did not ask Resident 3 what his pain level was. Resident 3 continued to moan and yell ow! This surveyor prompted LN 1 at 10:20 a.m. to ask Resident 3 what his pain level was and Resident 3 stated 10/10 pain. LN 1 exited room and reported pain level to LN 3. LN 1 came back, and CNA 1 and CNA 2 continued wound treatments without any pain medication administered to Resident 3. Resident 3 continued to moan and yell ow! LN 1, CNA 1 and CNA 2 exited Resident 3's room at 10:55 a.m. Resident 3 was heard moaning inside the room from outside of the hallway. During a concurrent interview and record review on 7/9/26 at 11:13 a.m. with LN 3, LN 3 confirmed Resident 3 had 10/10 (highest) pain scale. LN 3 also confirmed no documented evidence of pain assessment and pain medication administration prior to Resident 3's wound treatment. Resident 3's MAR was reviewed and indicated a new pain medication started on 7/7/26, oxycodone (pain medicine) Give 5mg every 4 hours as needed for moderate pain, then give 10mg every 4 hours as needed for severe pain AND Give 2 tablet by mouth every 4 hours as needed for Severe Pain (7-10/10). Review of Resident 3's Medication Audit Report and MAR indicated, LN 3 administered oxycodone at 11:15 a.m., which indicated pain medication was given not prior to but after the wound treatment. During a review of facility's Class attendance Roster, dated 4/16/26, indicated that CNA 1 attended an in-person in-service for pain and pain management: CNA responsibilities. During a review of facility's Class attendance Roster, dated 6/26/26, indicated that LN 2 and LN 3 attended an in-person in-service for pain management, pain assessment, pain parameters, and PRN pain medication. During a review of Resident 3's care plan intervention for pain, initiated on 9/9/25, indicated, .will not have discomfort.anticipate need for pain relief and respond immediately to any complaint of pain.reassess for pain meds PRN. During an interview on 7/10/26 at 9:30 a.m. with the Director of Nursing (DON), the DON stated it was the expectation of LNs to pre-medicate resident (prior to care provision), and if resident was in pain during wound treatment, to administer as needed pain medication as soon as possible and come back when the pain has alleviated. The DON further stated that a pain scale assessment should be used to assess pain. During a review of the facility's policy and procedure (P&P), titled, Pain Recognition and Management , revised May 2007, indicated, .recognize when a resident is experiencing pain and identify circumstances when pain can be anticipated .manages or prevents pain, consistent with assessment and plan of care, current professional standards of practice.using a scale of 1-10. During a review of the facility's P&P, titled Wound Care, undated, indicated, Review the resident's care plan to assess for any special needs of the resident.a. For example, the resident may have a PRN order for pain medication to be administered. 2. During a review of Resident 12's medical record indicated she was admitted to the facility in September 2023 with diagnoses which included seizures, depression (an illness where one experiences persistent feeling of emptiness, hopelessness, and a total loss of interest in activities), and schizoaffective disorder (a chronic mental health condition that combines the symptoms of two distinct illnesses: schizophrenia (losing touch with reality) and a mood disorder (like depression or bipolar disorder). A review of Resident 12's medical record indicated a physician's order for melatonin (a lab-made version of a natural hormone produced by the brain that regulates the sleep and wake cycle) 5 milligrams (mg, a unit of measurement), give one tablet at bedtime for inability to sleep, dated 8/3/25. During a concurrent interview and record review on 7/9/26 at 2:18 p.m. with the DON, Resident 12's physician's orders, psychiatry note dated 6/15/26, and physician's note dated 6/15/26 were reviewed. The DON confirmed the psychiatry note indicated, Concern for medical contribution to altered mental status and sedation. Discussed case with nursing staff regarding current presentation including increased sedation. Recommendations: Medication Management: Discontinue melatonin 5 mg. The DON reviewed the physician's note in response to the recommendations made by psychiatry and stated the note indicated the order for melatonin should have been discontinued but had not been. 3. During a review of Resident 4's medical record indicated he was admitted to the facility in February 2026 with diagnoses which included type 1 diabetes (a condition where the body does not make enough insulin, a hormone that allows the body to utilize sugar from ingested food or can't use it properly), muscle weakness, and dysarthria following cerebral infarct (slurred or slowed speech caused by muscle weakness following a stroke [when blood flow to a part of the brain is suddenly cut off or a blood vessel in the brain bursts]). A review of Resident 4's physician's orders indicated an order for oxycodone (an opioid medication to treat pain) 5 mg tablet, give one tablet via PEG tube (percutaneous endoscopic gastrostomy, a flexible medical feeding tube inserted directly through the abdominal wall into the stomach) every 8 hours as needed for severe pain (7-10) (pain scale of 0 to 10, with 10 being the highest level of pain), dated 5/5/26. During a concurrent interview and record review on 7/9/26 at 2:52 p.m. with the DON, Resident 4's oxycodone order and MARs dated June to July 2026 were reviewed. The DON confirmed Resident 4's oxycodone order indicated to be administered only for a pain score of 7 to 10. The DON reviewed Resident 4's June and July MARs and confirmed nursing staff administered oxycodone for pain scores outside of the physician's parameters for the following dates and pain levels: 6/7/26 pain level 5, 6/10/26 pain level 5, 6/18/26 pain level 6, 6/20/26 pain level 0, and 7/7/26 pain level 5. The DON stated nursing staff were expected to contact the physician to change an order if the needs of a resident were different than what was indicated in the order. He stated otherwise, nursing staff were expected to administer medications according to the order. 4. During a review of Resident 1's medical record indicated he was admitted to the facility in November 2023 with diagnoses which included type 2 diabetes (a condition where the body does not make enough insulin, a hormone that allows the body to utilize sugar from ingested food or can't use it properly). A review of Resident 1's physician's orders indicated an order for (brand name of semaglutide) 14 milligrams (mg, a unit of measurement) tablet, give one tablet by mouth one time a day for diabetes 30 minutes before breakfast, give with no more than four ounces of water, Hold if BS (blood sugar) less than 100 mg/dl (milligrams/deciliter, a unit of measurement), dated 5/16/26. During a concurrent interview and record review on 7/9/26 at 3:03 pm. with the DON, Resident 1's (brand name of semaglutide) order and blood sugar test results dated May to July 2026 were reviewed. The DON reviewed the (brand name of semaglutide) order and stated Resident 1 was administered the medication daily at 5:45 a.m. The DON stated Resident 1 had blood sugar checks before each meal, but his blood sugar was not routinely checked prior to administration of (brand name of semaglutide) to confirm it was not less than 100 mg/dl. During a review of the facility's P&P titled, Medication Administration, revised 1/2020, the P&P indicated, Policy: It is the policy of this facility to accurately prepare, administer and document oral medications. Procedures. Administering Unit Doses and Previously Prepared Drugs. 3. Read resident's medication sheet and select appropriate drugs from unit dose drawer. 4. Take vital signs if required. Hold drugs if indicated.14. If there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage.

Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control measures were implemented for a census of 104 when:1. Nursing Staff did not maintain hand hygiene in accordance with accepted professional standards; 2. Resident 18's, Resident 65's and Resident 104's oxygen tubing were on the floor;3. Licensed Nurse (LN) 1 did not change gloves between two different wound sites during wound treatment for Resident 106; 4. Resident 106's PICC (Peripherally inserted central catheter- a long tube inserted into a vein in the upper arm for intravenous access for medications) line dressing was not intact; and,5. Facility staff provided care without wearing all the required personal protective equipment (PPE) for Resident 28 and Resident 59 who were on Enhanced Barrier Precaution (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that requires gown and glove use). These failures had the potential to cause the spread of infection among a vulnerable resident population. Findings: 1.During a concurrent observation and interview on 7/8/26 at 10:21 a.m. with Licensed Nurse (LN) 9, LN 9 was observed preparing medications for a resident. LN 9 was observed with ungloved hands and approximately one quarter inch long polished, artificial nails on her fingers. LN 9 stated she had forgotten to remove her artificial nails and that nursing staff were expected to keep nails natural and short. During a concurrent observation and interview on 7/8/26 at 10:30 a.m. with LN 10, LN 10 was preparing to pass medications. LN 10 was observed with approximately one quarter inch long polished, artificial nails on her fingers. She confirmed her responsibilities included passing medications and performing direct resident care. LN 10 stated it was permissible to have artificial nails with some length. She stated it was important for the nails to not be too long so that a resident would not be injured during care. LN 10 stated she would occasionally double glove when she performed direct resident care, such as when inserting a suppository, to avoid injuring a resident. During a concurrent observation and interview on 7/8/26 at 10:38 a.m. with LN 11 at Medication Cart A, LN 11 was observed with approximately one quarter inch long polished, artificial nails on her fingers. LN 11 confirmed her responsibilities included preparing and passing medications to residents and performing direct resident care. LN 11 stated her understanding was that one quarter inch long nails were acceptable for nursing staff but artificial nails were not. During an interview on 7/8/26 at 10:51 a.m. with Infection Preventionist (IP) and Director of Staff Development (DSD), DSD stated nursing staff were expected to keep nails natural and short, so they did not extend past the fingertip. She stated fingernail polish was acceptable so long as it was not chipped. DSD stated short nails prevented the spread of germs and long nails, even if gloved, could poke through and injure a resident. During an interview on 7/8/26 at 10:55 a.m. with the Director of Nursing (DON), the DON stated as a professional standard, nursing staff were expected to keep nails short. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, undated, the P&P indicated, Policy Interpretation and Implementation. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 9. The use of gloves does not replace hand washing/hand hygiene.11. Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and fingernails must also be kept clean, neatly trimmed, and well-groomed. A review of an article published by the CDC titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, the article indicated, Maintain fingernail and jewelry safety: Natural nails should not extend past the fingertip. Do not wear artificial fingernails or extensions when having direct contact with high-risk patients. Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html; accessed 6/23/26) A review of World Health Organization's (WHO, the specialized agency of the United [NAME] responsible for international public health) Guidelines on Hand Hygiene in Health Care guidelines on hand hygiene in health care, dated 2009, the guidelines indicated, II. CONSENSUS [a general, widespread agreement among a group of people] RECOMMENDATIONS. 7. Other aspects of hand hygiene A. Do not wear artificial fingernails or extenders when having direct contact with patients. B. Keep natural nails short (tips less than 0.5 cm long or approximately 1/4 inch). 2.During a review of Resident 18's admission Record (AR), the AR indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (CRF-long term condition where lung cannot properly get enough oxygen into the blood) with hypoxia (body's tissue and organs do not receive enough oxygen to function properly), CRF with hypercapnia (too much carbon dioxide in the bloodstream), and obstructive sleep apnea (OSA-sleep disorder where breathing repeatedly stops and starts while sleeping). During a review of Resident 18's OSR (OSR – a list of a person's current medical orders or instructions from their healthcare provider), indicated Resident 18 had an order for Oxygen may titrate up to 5L [liters, unit of measurement] . via NC [Nasal cannula- a small, soft plastic tube with two short prongs that sit inside the nostrils to deliver oxygen] continuous every shift for oxygen. During a concurrent observation and interview on 7/7/26 at 9:52 a.m. with LN 5 in Resident 18's room, Resident 18's oxygen tubing was on the floor. LN 5 confirmed that the oxygen tubing was on the floor and stated that it should not have been on the floor. During a review of Resident 65's AR, indicated Resident 65 was admitted to the facility on [DATE] with diagnoses that included CRF with hypercapnia and OSA. During a review of Resident 65's OSR, indicated Resident 65 had an order for Oxygen at 2 LPM [liters per minute – a measurement] via NC continuous every shift. During a concurrent observation and interview on 7/7/26 at 10:01 a.m. with LN 5 in Resident 65's room, Resident 65's oxygen tubing was on the floor. LN 5 confirmed that the oxygen tubing was on the floor. During a review of Resident 104's admission Record (AR), indicated the resident was admitted to the facility with diagnosis including Acute and Chronic Respiratory Failure (a medical emergency when the lungs suddenly stop working well enough to help the individual breathe properly.) During a review of Resident 104 OSR, the OSR indicated, May titrate oxygen up to 3 LPM via NC. During an observation on 7/7/2026 at 10:46 a.m. in Resident 104's room, Resident 104 was being administered with oxygen at 2 liters per minute via nasal cannula. A portion of the nasal cannula tubing was observed to be on the floor. During an interview on 7/7/26 at 10:50 a.m., with Certified Nurse Assistant (CNA) 2, CNA 2 was asked to come into Resident 104's room. CNA 2 confirmed that the oxygen tubing was on the floor. CNA 2 stated oxygen tubing should be kept off the floor for infection prevention. During an interview on 7/9/26 at 1:39 p.m. with IP, IP stated that oxygen tubing should not touch the floor for infection control purposes because the floor could contain germs that could cause infection. The facility did not provide a policy and procedure (P&P) addressing oxygen tubing contacting the floor upon request. 3. During a review of Resident 106's AR, indicated Resident 106 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection), cellulitis (common, potentially serious bacterial infection of the skin) of left lower limb, type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by long term high blood sugar) and acquired (not present at birth) absence of left toe(s). During a review of Resident 106's OSR, indicated Resident 106 had an order for .Tx (treatment): L (left) shin trauma wound: clean with NS (normal saline), pat dry, apply xeroform and cover with dry dressing every day shift. and .Tx: TMA (trans metatarsal amputation) site venous ulcer (slow healing open sore): clean with NS, pat dry, apply Medi honey gel, cover with abd (abdominal pad) and wrap in kerlix then ace bandage. During an observation on 7/9/26 at 9:13 a.m. in Resident 106's room during wound treatment, observed with a pair of gloves LN 1 with removed a wet gauze from a medicine cup and cleaned the shin wound. LN 1 discarded the gauze, removed another wet gauze from the same medicine cup, and cleaned the TMA wound (different wound site) without changing gloves between the wound sites. With a new pair of gloves, LN 1 removed a dry gauze from the clean field on the overbed table, patted the shin wound dry, then removed another dry gauze to pat the TMA wound dry without changing gloves. During an interview on 7/9/26 at 9:34 a.m. with LN 1, LN 1 confirmed that she used the same gloves to clean the shin wound and the TMA wound and also used the same gloves to dry both wound sites. LN 1 stated different gloves should be used for each wound site. LN 1 stated that using different gloves helped prevent cross-contamination. During an interview on 7/9/26 at 1:39 p.m. with IP, the IP stated that wound treatment should be completed one wound site at a time. IP stated that if wound treatment was not completed one wound site at a time, a different pair of gloves should be used for each wound site to help prevent infection because bacteria from one wound site could transfer to another site. During a review of the facility's policy and procedure (P&P) titled, Wound Care, undated, the P&P indicated, 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 4. Review of Resident 106's admission Record (AR), the AR indicated that Resident 106 was admitted to the facility on 8/2025 with diagnoses including osteomyelitis (infection of the bone) and cellulitis of left lower limb (bacterial infection of the skin's deeper layers). Review of Resident 106's OSR dated 7/8/26, indicated, .IV Device Type PICC: Gauge 4 fr (French-a unit of diameter measurement) .Change catheter site RUE (right upper extremity) with transparent dressing.every week and as needed complications; observe site.dressing dislodgement . Review of Resident 106's Care Plan (CP) dated 6/30/26, indicated, .Focus: Is on antibiotic therapy related to osteomyelitis and cellulitis and an intervention that included PICC line per facility policy . During a concurrent observation and interview on 7/8/26 at 9:30 a.m. with LN 6 in Resident 106's room, observed Resident 106 lying in bed with a right upper arm PICC line. The PICC dressing had drops of dried blood underneath, the right corner and left side of the dressing was not intact. LN 6 confirmed the above findings and stated the dressing should be checked each shift. During an interview on 7/8/26 at 9:40 a.m. with LN 7 in Resident 106's room, LN 7 stated that she was concerned that there was dried blood under the dressing and the PICC site looked a little red. LN 7 acknowledged the PICC dressing needed to be changed and if the dressing was not intact the PICC could become dislodged (pulled out of its proper place) and there was an increased risk of infection. During an interview on 7/9/26 at 9:18 a.m. with the IP, the IP stated, it is the facility's policy that the PICC dressing be checked every shift. IP further stated if any part of the dressing is not intact there is an increased risk of infection. Review of the facility's policy and procedure (P&P) tilted Midline and Peripherally Inserted Catheter Dressing Changes, undated, the P&P indicated, 1. Change the Midline/PICC line dressing.if not in Inserted tact or compromised in any way. 5.During a review of Resident 28's AR, the AR indicated, Resident 28 was admitted to the facility on 2/2026 with diagnosis including Cerebral Infarction (Loss of blood flow to a part of the brain.), Aphasia (a disorder that makes it difficult to speak), and Gastrostomy tube ( G-tube/GT- a device to allow feedings to be administered directly to the stomach common people with swallowing problems). During a review of Resident 28's OSR dated 5/22/26, the OSR indicated, .Place Resident on EBP (Enhance Barrier Precaution) . During an observation on 7/10/26 at 9:06 a.m. outside of Resident 28's room, a sign was posted, Enhanced Barrier Precaution. A storage compartment was observed to contain blue gowns, gloves available for the staff to use. Resident 28 was in bed with a G-tube. During a concurrent observation and interview on 7/10/26 at 9:10 a.m., CNA 4 entered Resident 28's room without putting on a gown. CNA 4 assisted Resident 28 for incontinence care. CNA 4 confirmed she forgot to wear the Personal Protective equipment (PPE – a clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments.) CNA 4 stated, wearing a gown, and gloves must be worn when caring for Resident 28 (who was placed on EBP) to prevent infection and protect the resident. During a review of Resident 59's AR, the AR indicated Resident 59 was admitted to the facility in June 2026 with diagnosis of Endocarditis (inflammation of the heart's inner lining and valves). During an observation on 7/7/26 at 12:30 p.m. outside of Resident 59's room, a sign was posted under Resident name card with an orange sticker which indicated, Enhanced Barrier Precaution. A hanging storage compartment was observed to contain blue gowns and gloves available for the staff to use. Resident 59 was observed laying in bed with a PICC to the right arm. During a concurrent observation and interview on 7/7/26 at 12:55 p.m., CNA 3 entered Resident 59 without putting on a gown. CNA 3 assisted Resident 59 to the bathroom. CNA 3 then began to fix Resident 59's bed linen. CNA 3 confirmed that she did not wear a gown when transferring, assisting and handling bed linens. CNA 3 confirmed that proper PPE for Resident 59 was to wear gown and gloves. CNA 3 further stated that it was important to wear proper PPE for EBP to protect the residents. During a review of Resident 59's care plan (CP), dated 6/25/26, the CP indicated, Resident is on enhanced barrier precautions (EBP) related to PICC line.direct care staff and visitors to follow EBP. During an interview on 7/9/26 at 2:50 pm. with the IP, the IP stated that the expectation for staff was to wear gloves and gown with residents on EBP precautions. Gowns and gloves were to be worn while staff was in close contact with EBP residents. IP further stated that the CNA should have worn proper PPE to not spread infection to other residents. During a review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, dated 6/2021, the P&P indicated, .use of gown and gloves during high-contact resident care activities.(e.g. residents with.indwelling medical devices.examples of high contact resident care activities requiring gown and glove use.transferring.changing linens.

Based on observation, interview, and record review, the facility failed to ensure a medication error rates of less than 5 percent when four medication errors out of 37 opportunities were observed during a medication pass for two of six Residents (Residents 59 and 100) observed for a census of 104. These failures resulted in 10.81% medication error rates, and in medications not given in accordance with the prescriber's order and the potential to negatively affect residents' clinical conditions. During a medication pass observation on 7/7/26 at 8:43 a.m. with Licensed Nurse 8 (LN 8), LN 8 was observed preparing five medications for Resident 100, including levothyroxine (a medication to treat an underactive thyroid gland, to restore metabolism, energy levels, and normal body temperature) 25 micrograms (mcg, a unit of measurement), 1 tablet. A review of Resident 100's medical record indicated a physician's order for levothyroxine 25 mcg, give one tablet by mouth one time a day for hypothyroidism (also known as an underactive thyroid), dated 7/2/26. During a concurrent interview and record review on 7/7/26 at 12:44 p.m. with LN 8, Resident 100's levothyroxine order was reviewed. LN 8 stated the medication was scheduled to be administered at 9 a.m. and that it was to be given with food. During an interview on 7/8/26 at 9:54 a.m. with the Director of Nursing (DON), the DON stated levothyroxine was to be administered on an empty stomach, 30 minutes to one hour before breakfast so it could be absorbed by the body. A review of the manufacturer's labeling for levothyroxine sodium tablets, revised 3/2024, indicated, Important Administration Instructions: Administer levothyroxine sodium tablets as a single daily dose, on an empty stomach, one-half to one hour before breakfast. During a medication pass observation on 7/7/26 at 9:43 a.m. with LN 2, LN 2 was observed preparing nine medications for Resident 59, including calcium 600 milligrams (mg, a unit of measurement) with vitamin D 10 micrograms (mcg, a unit of measurement), 1 tablet, timolol (a medication to lower the pressure in the eye) 0.5% eye drop, and brimonidine (a medication to lower the pressure in the eye) 0.2% eye drop. During an observation on 7/7/26 at 9:55 a.m. with LN 2, LN 2 administered Resident 59's calcium with vitamin D tablet. LN 2 then instilled one drop timolol into Resident 59's right eye, waited approximately 30 seconds, then instilled one drop brimonidine into the same eye. Resident 59 refused brimonidine drops to be administered in his left eye. A review of Resident 59's medical record indicated a physician's order for the following:- Calcium 600 mg with vitamin D 5 mcg tablet: Give one tablet twice daily, ordered 6/30/26- Timolol 0.5% eye drop: Instill one drop in the right eye every 12 hours for glaucoma (a disease where there is increased pressure in the eye), ordered 6/24/26- Brimonidine 0.2% eye drop: Instill one drop in both eyes every 12 hours for glaucoma, ordered 6/24/26 During a concurrent observation, interview, and record review on 7/7/26 at 12:49 p.m. with LN 2, LN 2 reviewed Resident 59's calcium with vitamin D order. LN 2 removed the calcium with vitamin D from the medication cart that she had prepared and administered to Resident 59 and confirmed the strength of vitamin D did not match the physician's order. LN 2 reviewed the labeling on the timolol and brimonidine eye drops and confirmed the labeling indicated to wait five minutes between the eye drops. LN 2 stated she should have waited longer between the administration of the two different eye drops. A review of an article published by the American Academy of Ophthalmology (the world's largest association of eye physicians and surgeons) titled, How to Put in Eye Drops, dated 5/5/23, the article indicated, If you need to take more than one type of eye drop at the same time, wait 3 to 5 minutes between the different kinds of medication. During an interview on 7/8/26 at 9:51 a.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to wait five minutes between the administration of different eye drops for them to be effective. The DON stated supplements administered to residents should match the physician's order. He stated if the supplement ordered was not available, nursing staff were expected to notify the physician to change the order. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, revised 1/2020, the P&P indicated, Policy: It is the policy of this facility to accurately prepare, administer and document oral medications.

Based on observation, interview, and record review, the facility failed to ensure: 1. One of four emergency kits (E-kit, a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after removal of medication; and,2. One of four E-kits had the contents clearly listed on the exterior in accordance with facility policy and procedure (P&P). These failures had the potential to result in emergency medications not available when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions for a census of 103.During a concurrent inspection and interview on [DATE] at 1:14 p.m. of the Station 1 Medication Storage Room with the Director of Nursing (DON), a refrigerated E-kit was identified with a red plastic tie indicating it had been opened by nursing staff. The DON opened the E-kit and the emergency kit log (a document completed by nursing staff whenever a medication is removed from the emergency supply) was dated [DATE], 20 days prior. The DON stated whenever nursing staff opened an E-kit and removed medication, the log was to be filled out and faxed to the supplier pharmacy to notify them. The DON stated it was important to have E-kits replaced timely so medications were available for administration in the event of an emergency or when waiting for a new resident's medications to be delivered from the pharmacy. During a concurrent inspection and interview on [DATE] at 1:38 p.m. of the Station 2 Medication Storage Room with the DON, a large white opaque E-kit was identified without a list of contents affixed to it. The DON confirmed the finding and stated it should have had a list of contents on the outside in order to know what was available for use and when the E-kit expired. During a review of the facility's P&P titled, Emergency Medications, undated, the P&P indicated, Policy Statement: The facility shall maintain a supply of medications typically used in emergencies. Policy Interpretation and Implementation. 4. The contents of each emergency medication kit will be clearly listed. 9. Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order.

Based on observation, interview and record review, the facility failed to ensure three residents (Resident 9, Resident 28 and Resident 102) out of 26 sampled residents, were assisted with their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when:Resident 9 was observed with long toenails and dry thickened heels; Resident 28 was observed with long fingernails containing brown debris underneath, an oily face and hair, dried crusting inside both nostrils, long toenails, dry thickened skin surrounding the toenails and thick, dry, cracked heels; and,Resident 102 was observed with long fingernails containing brown debris underneath.These failures had the potential to result in poor personal hygiene, skin breakdown, discomfort, unpleasant odor and diminished dignity and well-being. Findings: 1. During a review of Resident 9's admission record (AR), indicated Resident 9 was admitted to the facility on 5/2026 with diagnoses including sepsis (sepsis- blood infection), bacteremia (bacteria in the blood stream), and generalized muscle weakness. During a review of Resident 9's Minimum Data set (MDS – a federally mandated resident assessment tool), dated 5/17/26, the MDS indicated, Resident 9 had intact cognition. The MDS also indicated Resident 9 required maximal assistance (maximal assistance -helper [staff] does more than half of the effort) with shower, bed bath and maximal assistance with personal hygiene. During a review of Resident 9's care plan initiated on 5/14/26, there was no evidence of a person-centered care plan related to self-care deficit and ADLs including nail care. During a review of Resident 9's bathing tasks for June 2026 indicated, Sponge bath (SB) on June 3 and June 10; Shower June 6; Resident Refused (RR) June 13, June 20, the rest of the dates in June were noted as Not Applicable (NA). July 2026 bathing tasks indicated, Shower July 1; RR July 4, NA for July 2,3,5,9. No documentation written for July 7, 2026. During the initial tour observation on 7/7/26 at 10:03 a.m. in Resident 9's room, Resident 9 was observed to be in bed, with her feet uncovered. Resident 9's toenails observed to be long, and her heels were thick and dry, the skin at her bilateral lower extremities were scaly dry, with fragments of the dry flaked skin were on the bed. During a concurrent observation and interview on 7/8/26 at 9:50 a.m. with Resident 9, in Resident 9's room, Resident 9 remained to have long toenails and dry skin and dry thickened heels. Resident 9 stated, she'll agree for her nails to be trimmed when the staff have the chance to do it. During a concurrent observation and interview on 7/10/26 at 9:55 a.m. with Licensed Nurse (LN) 4 in Resident 9's room, LN 4 stated, nails must be kept clean and trimmed. Toenails should be checked during sponge bath or showers. CNAs are allowed to clip their nails if needed and can clip toenails if the resident was not diabetic. LN 4 confirmed that Resident 9's toenails were long, her skin in her bilateral lower extremities were dry and scaly, and her heels were cracked and dry. LN 4 confirmed Resident 9 was agreeable for her toenails to be clipped. 2. During a review of Resident 28's AR, indicated, Resident 28 was admitted to the facility on 2/2026 with diagnosis including Cerebral Infarction (Loss of blood flow to a part of the brain), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), Aphasia (a disorder that makes it difficult to speak.) During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 was unable to perform the Brief Interview for Mental status (BIMs- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of a resident) due to the cerebral infarction and aphasia. The Staff Assessment for Mental status indicated his cognitive skills for daily decision making are moderately impaired. The MDS also indicated Resident 28 required dependent assistance (dependent- helper does all the effort) in shower, in bed bath, and in personal hygiene. During a review of Resident 28's care plan initiated on 2/21/26, there was no evidence of a person-centered care plan related to self-care deficit and ADLs including nail care. During a review of Resident 28's bathing tasks for June 2026 indicated, Sponge Bath (SB) June 15, 18, 22, 29; Full-body bath (FB) June 1, 4,7, 8, 26. The rest of the dates in June were noted as NA. July 2026 bathing tasks indicated, SB July 6, RR July 9, NA for July 1,2,3,4,5,8. No documentation written for July 7, 2026. During an observation on 7/7/26 at 10:14 a.m. in Resident 28's room, Resident 28 was observed lying in bed with greasy hair, and with a greasy face. Dried, crusted nasal mucus were present in both nostrils. Resident 28 was observed scratching his scalp, and behind his left ear. Resident 28's fingernails were long with brown debris underneath. The toenails were long, and the surrounding skin appeared dry and thickened. Both heels were dry, thickened, and had visible cracks. During a concurrent observation and interview on 7/10/26 at 9:10 a.m. with Certified Nurse Assistant (CNA) 4 in Resident 28's room, CNA 4 confirmed Resident 28's nails were long and had brown debris underneath the fingernails. CNA 4 confirmed that Resident 28's toenails were long, with bilateral thick dry heels and visible cracks. During a concurrent observation and interview on 7/10/26 at 9:43 a.m. with LN 4 at Resident 28's room, LN 4 confirmed Resident 28's nails were long and had brown debris underneath, his toenails were long and had thick skin around the nails and bilateral thick dry heels and with visible crack. Resident 28 nodded his head when asked if he wanted his nails trimmed. During a concurrent interview and record review on 10/10/26 at 10:10 a.m. with Director of Staff Development (DSD), the bathing tasks for Resident 9 and Resident 28 were reviewed for the last 30 days. DSD confirmed that the Not Applicable or NA documentation meant that the tasks were not performed. The DSD further stated that every resident should be showered two times every week, full body bath or sponge bath in between shower day as part of the residents' morning care. During the shower, skin check and nails should be checked. DSD stated, fingernails and toenails can be trimmed by the CNA as long as the resident does not have diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). During an interview on 7/10/26 at 11:30 a.m. with Director of Nursing (DON), DON stated, his expectations for ADLs were as follows: Showers two times a week, bed bath or full body bath in between shower days. Skin check and nails checked by CNA during shower days. Nail care and toenail care should be done by the CNA unless otherwise contraindicated. 3. Review of Resident 102's admission Record (AR), indicated Resident 102 was admitted to the facility on 7/2026 with diagnoses including nontraumatic intercerebral hemorrhage (a bleeding in the brain tissue that occurs without a head injury or external trauma), hemiplegia and hemiparesis (near complete paralysis of one side of the body and weakness or partial loss of strength on one side of the body) affecting the left dominant side, muscle weakness and need for assistance with personal care. Review of Resident 102's MDS dated [DATE], the MDS indicated that Resident 102 had intact cognition. Review of Resident 102's Care Plan (CP) dated 7/4/26, the CP indicated a focus of Risk for Self-Care Deficit: Bathing, Dressing and Feeding and an intervention included: Provide assistance with ADLs. During a concurrent observation and interview on 7/7/26 at 9:45 a.m. with Resident 102 and CNA 6, Resident 102 was observed lying in bed with long fingernails and a dark brown substance under his fingernails on his right hand. Resident 102 stated that it bothered him because he cannot use his phone when they are long and he is not able to use his left arm because he had a stroke. CNA 6 confirmed that Resident 102's fingernails had a brown substance underneath and stated they needed to be trimmed. During an interview on 7/9/26 at 9:34 a.m. with CNA 7, CNA 7 stated that Resident 102 had some left sided weakness. Resident 102 was dependent on the left upper extremity and required partial assistance using right upper extremity for ADL care. During an interview on 7/9/26 at 9:40 a.m. with the Infection Preventionist (IP), the IP stated that she would expect that residents' fingernails be clean and trimmed. The IP stated that if they are not clean it has the potential to spread germs and is an infection control problem. During a review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting undated, indicated, .appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with consent of the resident.including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, oral, finger and toe nail care.

Based on observation, interview and record review, the facility failed to ensure communication needs for one resident (Resident 28) of 26 sampled residents was accommodated, when staff did not use communication board for Resident 28 per resident's care plan. Resident 28 speaks mainly Hmong and has limited ability to communicate. This failure limited the resident's ability to express discomfort during care, contributed to frustration and affected the resident's dignity.Findings: During a review of Resident 28's admission Record (AR), the AR indicated, Resident 28 was admitted to the facility on 2/2026 with diagnosis including Cerebral Infarction ( stroke, loss of blood flow to a part of the brain), and Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body.)During a review of Resident 28's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 5/27/26, the MDS indicated Resident 28 was unable to perform the Brief Interview for Mental status (BIMs- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of a resident) due to the stroke. The Staff Assessment for Mental status indicated his cognitive skills for daily decision making are moderately impaired.During a review of Resident 28's communication care plan revised 5/22/26, indicated, . Use alternative communication tool.such as communication board, pictures, signs.During an observation on 7/9/26 at 1:55 p.m. in Resident 28's room, Licensed Nurse (LN)1 was observed preparing supplies to change the dressing around Resident 28's gastrostomy tube ( GT- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common to people with swallowing problems). LN 1 began removing Resident 28's old dressing, when Resident 28 began crying. LN 1 continued the dressing change without asking Resident 28 why she was crying. LN 1 did not use a communication board and no communication board was observed at bedside.During a concurrent observation and interview on 7/10/26 at 9:43 a.m. with LN 4 in Resident 28's room, LN 4 confirmed that Resident 28's communication board was not within reach (not used) and was tucked underneath the bedside drawer.During an interview on 7/10/26 at 11:30 a.m. with Director of Nursing (DON), DON stated, communication board must always be within reach (to use). DON further stated, Communication Board should be treated like it was a call light. Always within reach.A review of the facility's policy and procedure titled, Resident's Rights, undated, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: b. Be treated with respect, kindness and dignity; f. communication with and access to people and services, both inside and outside the facility.

Based on observation, interview and record review, the facility failed to promote dignity and respect for two residents (Resident 48 and Resident 104) out of 26 sampled residents, when:1. Certified Nursing Assistant (CNA) 5 remained standing while assisting and feeding Resident 48 with lunch and,2. The privacy curtain between the two residents was not closed during wound treatment for Resident 106.These failures had the potential to impact the two residents' self-esteem and self-worth.Findings:1. During a review of Resident 48's admission Record (AR), the AR indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord) and dysphagia (difficulty swallowing).During a review of Resident 48's Care Plan (CP), the CP indicated, EATING: Requires assistance to eat.During an observation on 7/7/26 at 12:26 p.m. in the dining room, Resident 48 was seating in a wheelchair while CNA 5 stood over him while feeding him lunch with a spoon.During an interview on 7/9/26 at 1:43 p.m. with Director of Staff Development (DSD), DSD stated that staff were expected to sit while assisting residents with eating to promote resident dignity.During a review of the facility's policy and procedure (P&P) titled, Dignity, undated, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.residents are treated with dignity and respect at all times.when assisting with care, resident are supported exercising their rights. resident are provided with a dignified dining experience.2. During a review of Resident 106's AR, the AR indicated Resident 106 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by long term high blood sugar) and acquired (not present at birth) absence of left toe(s).During a review of Resident 106's Order Summary Report (OSR), the OSR indicated Resident 106 had an order for Tx (treatment): L (left) shin trauma wound. and Tx: TMA (trans metatarsal amputation) site venous ulcer (slow healing open sore) .During an observation on 7/9/26 at 9:13 a.m. with Licensed Nurse (LN) 1 in Resident 106's room, LN 1 performed wound treatment for Resident 106 while the privacy curtain between Resident 106 and the roommate remained open throughout the procedure.During an interview on 7/9/26 at 9:34 a.m. with LN 1, LN 1 stated that during wound treatment, staff provided privacy by closing the privacy curtains around the resident, including the curtain separating the two residents. LN 1 confirmed that she did not close the curtain between Resident 106 and the roommate. LN 1 stated that providing privacy promoted the resident's dignity and respect and helped the resident feel comfortable during wound treatment.During a review of the facility's P&P titled, Dignity, undated, the P&P indicated 12. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview and record review, the facility failed to store resident food in a sanitary manner in the resident refrigerator for a census of 104 when an 8 oz. (ounce, a unit of measurement) package of cheese, and two plastic bags with take-out food did not have residents' name and were undated.These failures had the potential to cause food borne illness in a vulnerable population.During a concurrent observation and interview on 7/7/26 at 12:47 p.m. , with the Director of Staff Development (DSD), observed in the resident refrigerator in the memory care unit with an opened package of cheese and two bags with take-out food. These items were undated and were not labeled with the residents' names. The DSD confirmed that she would not be able to tell who the food items belonged to and they should be dated. The DSD stated that the takeout food should be thrown out after seventy-two hours.During an interview on 7/8/26 at 11:10 a.m., with the Registered Dietician (RD), the RD stated that the food in the resident's refrigerator should be dated. If the food is not dated, staff can't determine how long it has been there or when it should be discarded. RD further stated that if spoiled or expired food is not discarded there is a risk for food borne illness.Review of the policy and procedure (P&P), titled, Foods Brought by Family or Visitor, dated 7/21/21, the P&P indicated, Resident food will be stored at the facility.all foods shall be labeled, with the resident's name, location and date.perishable food will be checked by activities staff and discarded after 72 hours.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident 3) out of 26 sampled residents received appropriate pain management services consistent with professional standards of practice and facility's policy and procedure (P&P), when Resident 3's pain was not managed during wound care treatment. This failure resulted in Resident 3 to exhibit severe pain and not attain his highest practicable well-being.Findings:During a review of Resident 3's admission Record (AR-front page of the chart that contains a summary of basic information about the resident, part of medical record), the AR indicated Resident 3 was admitted to the facility April 2022 with multiple diagnoses which included chronic pain syndrome and pain in thoracic spine.During a review of Resident 3's Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident, physician orders). Resident 3 received multiple daily wound treatments for pressure Ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) located to right lower buttock and deep tissue injury (DTI- a severe type of pressure sore that develops deep within the soft tissue or muscle near a bone, presenting as a localized area of persistent, non-blanchable deep red, maroon, or purple skin) located to left and right heel. During a review of Resident 3's Order Summary Report (OSR, physician orders), dated 7/7/26, indicated, Morphine (pain medication) 15 mg (milligram, unit of measurement) give 1 tablet by mouth every 8 hours for pain management.During a review of Resident 3's OSR, dated 7/7/26, indicated, acetaminophen (pain medication) 325 mg .give 2 tablet by mouth every 6 hours as needed for mild pain (1-3 on the pain scale) .During a review of Resident 3's OSR, dated 7/7/26, indicated, licensed nurse (LN) to document Pain-Record highest level of pain every shift.During a concurrent observation, interview and record review on 7/7/26 at 1:24 p.m. in the hallway in front and outside of Resident 3's room, Resident 3 moaned and yelled, .ow, ow, it hurts! LN 2 confirmed the wound doctor and LN 1 were inside providing treatment for Resident 3. LN 2 stated that Resident 3 was always complaining he was in pain and per review of Resident 3's medical record, was given only morphine at 6 a.m. and not given acetaminophen. LN 2 further stated that Resident 3's yelling in pain was his baseline. LN 2 acknowledged that administration of pain medication was important to keep Resident 3 comfortable during wound treatment. During a review of Resident 3's Medication Administration Records (MARs, physician orders), the MARs indicated Resident 3 had 21 episodes of pain greater than 2 in June 2026 with 21 missed opportunities to administer acetaminophen. In July 2026, Resident 3 had 5 episodes of pain greater than 2 with 5 missed opportunities to administer acetaminophen. No documented evidence that acetaminophen was offered, refused or given. During a concurrent observation and interview on 7/9/26 at 10 a.m. in Resident 3's room, Certified Nursing Assistant (CNA )1 and CNA 2 assisted Resident 3 with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting). Resident 3 was observed continuously grimacing, groaning, moaning and yelling ow, ow it hurts. LN 1 did not ask Resident 3 what was his pain level. Resident 3 continued to moan and yell ow! This surveyor prompted LN 1 at 10:20 a.m. to ask Resident 3 what his pain level was and Resident 3 stated 10/10 (10 is highest level) pain. LN 1 exited room and reported pain level to LN 3. LN 1 came back and CNA 1 and CNA 2 continued wound treatments without any pain medication administered to Resident 3. Resident 3 continued to moan and yell ow! LN 1, CNA 1 and CNA 2 exited Resident 3's room at 10:55 a.m. Resident 3 was heard moaning inside the room from outside of the hallway. During a concurrent interview and record review on 7/9/26 at 11:13 a.m. with LN 3, LN 3 confirmed Resident 3 had 10/10 (highest) pain scale. LN 3 also confirmed no documented evidence of pain assessment and pain medication administration prior to Resident 3's wound treatment. Resident 3's MAR was reviewed and indicated a new pain medication started on 7/7/26, oxycodone (pain medicine) Give 5mg every 4 hours as needed for moderate pain, then give 10mg every 4 hours as needed for severe pain AND Give 2 tablet by mouth every 4 hours as needed for Severe Pain (7-10/10). Review of Resident 3's Medication Audit Report and MAR indicated, LN 3 administered oxycodone at 11:15 a.m., which indicated pain medication was given not prior to but after the wound treatment. During a review of Resident 3's care plan intervention for pain, initiated on 9/9/25, indicated, .will not have discomfort.anticipate need for pain relief and respond immediately to any complaint of pain.reassess for pain meds PRN.During an interview on 7/10/26 at 9:30 a.m. with the Director of Nursing (DON), the DON stated it was the expectation of LNs to pre-medicate resident (prior to care provision), and if resident was in pain during wound treatment, to administer as needed pain medication as soon as possible and come back when the pain has alleviated. The DON further stated that a pain scale assessment should be used to assess pain. During a review of the facility's policy and procedure (P&P), titled, Pain Recognition and Management , revised May 2007, indicated, .recognize when a resident is experiencing pain and identify circumstances when pain can be anticipated .manages or prevents pain, consistent with assessment and plan of care, current professional standards of practice.using a scale of 1-10.During a review of the facility's P&P, titled Wound Care, undated, indicated, Review the resident's care plan to assess for any special needs of the resident.a. For example, the resident may have a PRN order for pain medication to be administered.During a review of the facility's P&P, titled Resident Rights, undated, indicated, .Employees shall treat all residents with.dignity.these rights include the residents' right to a dignified existence.

Based on observation, interview and record review the facility failed to ensure resident environment remained free of accident hazards for two residents (Resident 18 and Resident 91) out of 26 sampled residents when:1. A portable oxygen cylinder tank in Resident 18's room was not secured in a stand/cart; and,2. Resident 91's floormat (fall mat, a cushioned floor pad designed to help prevent injury should a person fall) was placed underneath the bed not beside the bed.These failures had the potential to result in accident and injury.Findings:1. During an observation on 7/7/26 at 9:49 a.m. in Resident 18's room, a portable oxygen cylinder was positioned on the right side of the bed, in front of the oxygen concentrator, and was not secured in a cylinder stand or carrier.During an interview on 7/10/26 at 10:44 a.m. with Director of Nursing (DON), DON stated that portable oxygen cylinders should be secured in an oxygen carrier to prevent them from falling and causing injury/accident.During a review of the facility's policy and procedure (P&P) titled, Oxygen Safety, dated 8/1/25, the P&P indicated, Oxygen storage.cylinders will be properly chained or supported in racks or other fastenings (i.e. sturdy portable carts, approved stands) to secure all cylinders from falling, whether connected, unconnected, full, or empty.2. During a review of Resident 91's admission Record (AR), indicated Resident 91 was admitted to the facility on [DATE] with diagnoses that included vascular dementia (a progressive state of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D) without current pathological fracture.During a review of Resident 91's Care Plan (CP), the CP indicated Resident 91 was a risk for fall which was identified on 8/3/25.During a review of Resident 91's Long Term Care Eval Progress Note (PN) dated 7/4/26, the PN indicated, the resident's safety interventions included half side rails, a low bed and a bedside (fall) mat.During a review of Resident 91's Physician Progress Note (PPN) dated 6/16/26, the PPN indicated that the plan for Alzheimer's disease included continuing safety measures. The plan for age-related osteoporosis included maintaining fall precautions and providing supportive care to minimize the risk of fractures.During a concurrent observation and interview on 7/7/26 at 10:13 a.m. with Certified Nursing Assistant (CNA) 9 in Resident 91's room, Resident 91 was lying in bed, and the floormat was located underneath the bed. CNA 9 confirmed the floor mat was under the bed and stated the floormat was part of Resident 91's fall precaution and should have been placed beside the bed.During an interview on 7/9/26 at 1:43 p.m. with Director of Staff Development (DSD), DSD stated that floor mats should be placed beside the bed as part of the resident's fall precautions to prevent or lessen injury.During a review of the facility's policy and procedure (P&P) titled, Fall and Fall Risk, Managing, undated, the P&P indicated 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.3. Examples of initial approaches might include.fall mats etc.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from abuse for one of five sampled residents (Resident 2) when facility staff witnessed Resident 1 hit Resident 2.This failure resulted in Resident 2 not being free from abuse and had the potential for Resident 2 to be harmed. Findings:During a review of Resident 1's clinical record, Resident 1 had been admitted in June 2022 with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (an intense, excessive, and persistent feeling of fear, dread, or uneasiness), and psychosis (a collection of symptoms characterized by a loss of contact with reality).During a review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 4/22/26, Resident 1 had a Brief Interview for Mental Status (BIMS-a tool to assess cognition) score of 0 out of 15, which indicated Resident 1 had severely impaired cognition.During a review of Resident 2's clinical record, Resident 2 had been admitted in July 2021 with diagnoses that included dementia, anxiety, bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Resident 2's MDS, dated [DATE], Resident 2 had a BIMS score of 0 out of 15, which indicated Resident 2 had severely impaired cognition.During a concurrent review of Resident 1 and Resident 2's progress note, dated 5/16/26, the progress notes indicated Resident 1 and Resident 2 had been involved in an altercation (a noisy argument or disagreement). Facility staff witnessed Resident 1 hit Resident 2 in the back with a closed hand.During an interview on 6/11/26 at 9:32 a.m. with Resident 2, Resident 2 confirmed he had been hit in the back by another resident and stated he felt angry that he had been hit.During an interview on 6/11/26 at 11:57 a.m. with the Restorative Nurse Assistant (RNA), the RNA stated she witnessed Resident 1 hit Resident 2 on the back with a closed hand.During an interview on 6/11/26 at 12:03 p.m. with the Director of Nursing (DON), the DON stated that the expectation is to keep residents safe. The facility has a duty to keep the resident safe.During a review of the facility's Policy and Procedure (P&P) titled Abuse Prevention of and Prohibition Against, revised 8/2025, the P&P indicated, It is the policy of this Facility that each resident has the right to be free from abuse.

Based on interview and record review, the facility failed to ensure the results of an abuse allegation investigation was reported within the required time frame for one (Resident 1) out of five sampled residents.Failure to report in a timely manner may delay state agency oversight and intervention potentially allowing on-going abuse and placing residents at risk for harm.Findings:Review of Resident 1's admission Record indicated Resident 1 was admitted [DATE] with several diagnosis including fracture of the right shoulder and end stage renal failure (a condition where the kidneys can no [NAME] filter waste, balance fluids or maintain electrolytes).Review of SBAR (SBAR-situation, background, assessment, a recommendation-a communication tool used by healthcare workers when there is a change in condition among residents) notes dated 4/13/26, the SBAR indicated, Resident and her roommate were in the lobby. Roommate was to load up for dialysis, and she was on the phone. They began cussing at each other. When resident was on the gurney leaving roommate punched resident on the body. During a concurrent interview and record review on 4/30/26 at 3:53 p.m. with the Administrator (ADM), review of an email sent to CDPH indicated the 5-day summary was sent on 4/21/26. The ADM confirmed that the SOC 341 was sent on 4/13/26 and the 5-day summary was sent on 4/21/26. ADM further stated that the expectation would be that the results of abuse allegation investigation should be sent in 5 business days.During a review of the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revision dated 8/2025, the P&P guidance indicated, .Results of all investigations of alleged violations - [report] within 5 working days of the incident.

Based on interview and record review, the facility failed to ensure corrective action was taken to protect residents from abuse for two of six sampled residents (Resident 1 and Resident 2) when:The facility did not report the results of all investigations to California Department of Public Health (CDPH) within 5 working days for Resident 1 and Resident 2, andThe facility did not do an assessment of Resident 2 after abuse allegations.These failures had the potential to result in ongoing abuse for Resident 1 and Resident 2.Findings:1.During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was admitted to the facility in September 2025 with multiple diagnosis including surgical aftercare. During a review of Resident 2's Face, the Face Sheet indicated Resident 2 was admitted to the facility in December 2024 with multiple diagnosis including respiratory failure.During a review of the facility's incident reports received by CDPH on 1/26/26 and 1/28/26 respectively, the incident reports indicated Resident 1 and Resident 2 reported to staff that they were physically abused by a Certified Nursing Assistant (CNA). During a review of the facility's 5-day investigation report for the incident reports dated 1/26/26 and 1/28/26, CDPH received results of the 5-day investigation on 2/10/26, which was more than five working days. During an interview, on 2/10/26 at 1:34 p.m. with the Administrator (ADM), the ADM confirmed the facility had reported an allegation of abuse concerning Resident 1 on 1/26/26 and Resident 2 on 1/28/26 to CDPH and the results of the facility's investigation had not been provided to CPDH within 5 working days.During a review of the facility's policy and procedure (P&P) titled, Abuse: Prevention of and Prohibition Against, dated 11/2017, the P&P indicated, .allegation of abuse.will be reported.to.State or Federal agencies in the applicable timeframes, per.applicable regulations.2.During a review of Resident 2's medical record, there was no documentation indicating Resident 2 was assessed by a nurse after allegations of abuse on 1/28/26.During an interview with the Director of Nursing (DON) on 2/10/16 at 12:00 p.m., DON confirmed an assessment for Resident 2 was not done after allegations of abuse on 1/28/26. DON stated the expectation was for an assessment to be done.During a review of the facility's P&P, titled Abuse: Prevention of and Prohibition Against, dated 11/2017, the P&P indicated, .a licensed nurse will immediately examine the resident upon receiving reports of alleged physical.abuse. The findings of the examination shall be recorded in the resident's medical record.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of three sampled residents (Resident 1) when Resident 1 reported to nursing staff that she was injured by facility staff during patient care. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety. During a review of Resident 1's face sheet (a document containing patient information), Resident 1 was admitted to the facility in August 2025 with multiple diagnoses which included chronic kidney disease (decreased kidney function), Schizophrenia (mental health condition that affects how people think, feel and behave), and Bipolar Disorder (mental health condition that causes extreme mood swings). A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 1/21/26, indicated Resident 1 was cognitively intact. During a review of a facility's investigation document titled, 5 Day Summary from Abuse Investigation from Resident allegation of abuse on 1/14/2026, indicated, On 1/14 (1/14/26) at approximately 2330 (11:30 p.m.), a Charge Nurse noted purple and yellow tinted discoloration on residents right cheek.When interviewed resident stated that a Certified Nursing Assistant (CNA) assigned to her, hit her in the face and pulled her hair after she touched the CNA without notice. Resident unable to recall date and time of event and whom the assigned staff was.During a review of the facility's investigation documents contained an Interview Record, dated 1/15/26 that indicated CNA 2 was aware of Resident 1's abuse allegation on 1/13/26 but had not reported it. Review of the Interview Record, dated 1/15/26 indicated on 1/13/26 Resident 1 asked CNA 2 if she saw the bruise on Resident 1's face. CNA 2 stated, Yeah, what happened? Resident 1 stated the CNA in the middle of night last night hit me and pulled my hair. CNA 2 stated she didn't know what to do with the information and didn't believe Resident 1 because of the things she says, so she waited and asked Resident 1 again the next day Wednesday 1/14/26 and the story remained the same .During an interview on 2/2/26 at 10:58 a.m. with Resident 1 she stated the CNA thought she was acting out in aggression. The CNA grabbed her hands, hit me in my face and pulled my hair. Resident 1 was asked how this made her feel she stated, Scared me and hurt that they did that to me. During a telephone interview on 2/19/26 at 1:49 p.m. with the Executive Director (ED), he stated this was a reportable incident and his expectation would be for the staff member to report the allegation to their charge nurse within the required timeframe.During a review of the facility's policy and procedure (P&P) titled, Abuse: Prevention of and Prohibition Against, revised 8/2025 indicated, under the section Identification that Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The P&P also indicated under the section Reporting/Response that All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator.

Based on observation, interview, and record review, the facility failed to store clean dishes in a sanitary manner for a census of 109 residents, when: 1. A dirty dish with half-eaten food on it was found on the shelves of clean dishes; and 2. A hot water jug stored in the clean dish area was found with dark brown residue on it. These failures decreased the facility's potential to prevent foodborne illness among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/29/25 at 10:32 a.m. with the Dietary Manager (DM) in the facility's kitchen, a half-eaten food item in a dirty cup was observed on a clean dish storage shelf. The cup was placed next to clean dishes used by residents. DM confirmed the dirty cup with half-eaten food was not supposed to be left in the clean dish storage area. DM further stated cross contamination could have been an issue as well as pest control. 2. A review of an admission record indicated Resident 1 was admitted to the facility in June 2023. A review of Resident 1's Minimum Data Set (MDS; an assessment tool), dated 2/26/25, indicated Brief Interview of Mental Status score was 15 out of 15 with intact cognition. During an interview on 9/29/25 at 11:30 am with Resident 1, Resident 1 stated her fork for breakfast had a dried crusty residue on it. During a concurrent observation and interview on 9/29/25 at 10:35 a.m. with DM in the facility's kitchen, a hot water jug stored with clean dishes was observed with dark brown residue in its crevices. DM confirmed the jug should not have been stored with the clean dishes and stated he did not know what the dark brown residue was, and crevices such as where the dark brown residue was seen, could have had the potential to harbor bacteria. A review of the facility's undated policy and procedure titled, Dishwashing, indicated, All dishes will be properly sanitized through the dishwasher. Gross food particles shall be removed by careful scraping and pre-rinsing in running water. Flatware is to be pre-soaked in a solution of water and detergent per manufacturer's instructions . Pay close attention to prevent cross-contamination of workers going from handling dirty dishes and then clean . Wash hands and change gloves whenever cross-contamination occurs. A review of the facility's undated Inservice titled, Cleaning and Sanitizing Dishes, Utensils, Pots and Pans, indicated, Cleaning and sanitizing food handling equipment, utensils, food contact surfaces, and food storage areas are vital in keeping food wholesome and safe to consume. The Inservice further indicated, Cleaning is the removal of soils, tarnishes, or stains from countertops, equipment, pots, pans, or dishes . Sanitizing is the process of reducing the number of microorganisms on a surface to safe levels so that they cannot cause disease or food spoilage . Everything in your operation must be kept clean; however, any surface that comes in contact with food must also be cleaned and sanitized.

Based on observation, interview, and record review, the facility failed to follow a therapeutic diet plan to one of three sampled residents (Resident 2), when Resident 2 was served a hard to chew chicken burger at lunch. This failure had the potential to negatively impact Resident 2's nutritional status.Findings: A review of an admission record indicated Resident 2 was admitted to the facility in October 2024 with diagnoses including moderate protein-calorie malnutrition (a condition that occurs when a person does not consume enough protein to meet their body's needs), dysphagia (a medical condition characterized by difficulty swallowing), and adult failure to thrive (a condition characterized by a significant decline in weight, muscle mass, and overall health in adults). A review of Resident 2's Minimum Data Set (MDS; an assessment tool), dated 7/23/25, indicated Brief Interview of Mental Status score was 15 out of 15 with intact cognition. During an observation on 9/29/25 at 1:20 pm for the B-unit lunch tray pass, Resident 2's tray contained a burger bun with a large, breaded piece of chicken, tomato slice, lettuce, macaroni salad, juice, and pudding. During an interview on 9/29/25 at 1:30 pm with Resident 2, Resident 2 stated she did not eat her lunch because she could not chew it and her upper teeth were broken, which made it hard to eat the chicken burger. Resident 2 further stated the chicken meat was not tender enough to bite for her, and the meat was hard and chewy. A review of Resident 2's therapeutic diet plan, dated 9/3/25, indicated Resident 2 was to be served a regular diet easy to chew level 7 texture. A review of Resident 2's care plan, dated 9/23/25, indicated Resident 2 had a swallowing problem and a potential nutritional risk related to underweight, protein calorie malnutrition, dysphagia, and adult failure to thrive. During an interview on 9/29/25 at 3:58 pm with the Dietary Manager (DM), DM stated if a therapeutic diet plan was not followed correctly, then there could have been a chance that Resident 2 would have not eaten enough, and not eating enough could have caused a lack of proper nutrition. DM further stated if resident 2 was not able to chew the food properly, then it could have been a possible risk of choking. A review of the facility's policy and procedure (P&P) titled, Level 7 Regular Easy to Chew for Adults, dated 1/2019, indicated, Do not use foods that are: hard, tough, chewy, fibrous, have stringy textures, pips/seeds, bones or gristle. P&P further indicated, Meat cooked until tender, if you cannot serve soft and tender, serve meat Minced and Moist.

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner for a census of 108 residents, when:Clean Utensils were found with food particles and water residuals and utensil holders had multiple small black particles; andDietary Aide 3 (DA 3) did not wash hands before handling clean kitchenware.These failures had the potential to result in foodborne illness among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/8/25 at 11:05 a.m. with the Dietary Manager (DM) and Registered Dietician (RD), the kitchen's utensils and utensil holders were observed. Multiple small black particles were observed on the utensil holders. Three forks and three spoons had food particles and water residuals. DM and RD confirmed six utensils were dirty and stated clean utensils should have no food particles on it. DM further stated it was unsafe to use uncleaned utensils for residents.2. During a concurrent observation and interview on 9/8/25 at 12:28 p.m. with DA 3, DA 3 was manually washing the kitchenware (containers) with soap and water. Next, DM removed the cleaned kitchenware from the dishwasher. DA 3 continued to wash more kitchenware from the dirty side. There was no hand hygiene observed before touching the cleaned kitchen containers. DA 3 confirmed he was the only one doing dishwashing and should have washed hands before touching the cleaned side of the dishwashing area.During an interview on 9/8/25 at 12:33 p.m. with the RD, RD stated there should be two people doing dishwashing at a time and DA 3 should have washed his hands before touching the clean side of the dishwashing area to prevent contamination. A review of the facility's undated policy and procedure titled, Dishwashing, indicated, All dishes will be properly sanitized through the dishwasher. Gross food particles shall be removed by careful scraping and pre-rinsing in running water. Flatware is to be pre-soaked in a solution of water and detergent per manufacturer's instructions. Pay close attention to prevent cross-contamination of workers going from handling dirty dishes and then clean . Wash hands and change gloves whenever cross-contamination occurs.

Based on observation, interview, and record review the facility failed to ensure one of 30 sampled residents (Resident 43) received services to maintain mobility when Restorative Nursing Aide services (RNA, provides residents with exercises to improve or maintain mobility and independence) were not provided to Resident 43 as recommended by a Physical Therapist (PT, a healthcare professional who specializes in helping residents improve their physical functioning). This failure resulted in Resident 43 not receiving services to maintain her highest practicable physical level of functioning and psychosocial well-being. Findings: A review of Resident 43's admission record, indicated Resident 43 was readmitted in December of 2023, with diagnoses which included spinal stenosis (space around spinal cord becomes too narrow and can cause pain or weakness in arms or legs), dorsopathy (disease of the spine), osteoarthritis (joint pain and stiffness), history of falling, muscle weakness, and abnormalities of gait (a manner of walking) and mobility. A review of Resident 43's Minimum Data Set (MDS, an assessment tool), dated 12/18/23, indicated Resident 43 had moderate cognitive impairment, used a walker (a device used for balance and support while walking) and wheelchair (WC), was able to walk at least 10 feet with partial moderate assistance (helper does less than half the effort) with a goal to be able to walk 10 feet with supervision or touching assistance. A review of Resident 43's MDS, dated [DATE], indicated Resident 43 used a walker and WC and once standing Resident 43 could walk at least 150 feet and make two turns with supervision or touching assistance. A review of Resident 43's self-care deficit care plan (CP), initiated 12/15/23, indicated, .Resident will participate with ADL's [Activities of Daily Living: fundamental skills required to independently care for oneself such as eating, bathing, and mobility] and ADL status will improve by target date . target date 6/25/24 . PT/OT [physical therapy/occupational therapy: physical therapy focuses on the resident's ability to move their body whereas occupational therapy focuses on improving the resident's ability to perform ADLs] evaluation and treatment as per MD [Medical Doctor] orders .[and] .encourage the resident to participate to the fullest extent possible with each interaction . A review of Resident 43's safety CP, initiated 12/21/23, indicated, .Goal: Resident will remain safe .Encourage use of prescribed assistive devices . A review of Resident 40's Order Summary Report, dated 5/24/24 indicated Physical Therapy Clarification Order for skilled PT services for Tx [treatment] Plan .to achieve LTG [long term goal]: SBA [stand by assistance] functional mobility with appropriate use of AD [assistive device] . During a concurrent interview and observation on 5/21/24 at 10:33 a.m. with Resident 43 in her room, Resident 43 was sitting up in a WC with a walker leaning against a wall in her room. Resident 43 explained when she was getting PT, she was doing well walking with the walker. Resident 43 added since PT stopped, no staff have assisted her with using her walker. Resident 43 expressed anger and frustration because without assistance her ability to use her walker has declined and she cannot walk with her walker now. During a concurrent interview and record review on 5/23/24 at 11:45 a.m. with the Area Director of Rehabilitation (ADOR), Resident 43's PT discharge summary dated 4/22/24, was reviewed. The ADOR stated a resident would be discharged from PT when the resident has reached maximum progress in PT, and added, a physical therapist would assess the resident's needs and could make a recommendation for the resident to receive RNAs when discharged from PT. The ADOR stated Resident 43's PT discharge summary from 4/22/24 indicated Resident 43 met her maximum potential when she surpassed her goals for using a walker for 30 feet with minimal assist/contact assist. The ADOR confirmed Resident 43's discharge summary included a recommendation for Resident 43 to start RNAs. During a concurrent interview and record review on 5/23/24 at 12:07 p.m., with the Minimum Data Set Licensed Nurse (MDS LN), Resident 43's CPs and assessments were reviewed. The MDS LN stated she is overseeing the RNAs program for the facility and added, residents could be entered into the RNAs when they are discharged from PT with a recommendation for RNAs. The MDS LN stated the RNAs included providing residents with exercise sessions to maintain/restore their upper and lower body abilities. The MDS LN stated residents who have been recommended to RNAs should have a restorative therapy referral under the assessments tab in the electronic health record (EHR) and an exercise plan on their CP. The MDS LN reviewed Resident 43's CP and assessments in the EHR and stated there was no restorative therapy referral and Resident 43 had not been started on RNAs. During a concurrent interview and record review on 5/23/24 at 12:22 p.m. with the ADOR, Resident 43's PT discharge summary dated 4/22/24 and assessments in EHR were reviewed. The ADOR stated when a resident is recommended to RNAs the MDS LN would be notified by a restorative therapy referral under the assessments tab in the EHR. The ADOR stated there was no referral for restorative therapy in Resident 43's assessments. The ADOR reviewed Resident 43's PT discharge summary and stated the discharge summary indicated Resident 43 could ambulate 30 feet with a walker with supervision/touching assistance and Resident 43's prognosis to maintain her current level of function at PT discharge was good with consistent staff follow-through. The ADOR clarified the prognosis was good if Resident 43 had assistance from Certified Nursing Assistants (CNAs) and RNAs. The ADOR stated a resident who does not receive the RNAs as recommended after their PT discharge could have declines in their level of functioning. During a concurrent interview and record review on 5/23/24 at 12:37 p.m. with the MDS LN, Resident 43's PT discharge summary dated 4/22/24, was reviewed. The MDS LN confirmed Resident 43's PT discharge summary indicated Resident 43 was recommended to start RNAs on 4/22/24 and should have been initiated into the RNAs by 5/23/24. The MDS LN acknowledged a resident who does not received the recommended RNAs could have declines in functioning. The MDS LN disclosed that Resident 43 was not happy with her current level of functioning because she cannot walk and will not be able to walk. An interview on 5/23/24 at 1:01 p.m., the ADOR stated she expected CNAs to tell the PT team if residents are requiring more assistance or experience declines in functioning. An interview on 5/23/34 at 1:37 p.m., the Assistant Director of Nursing (ADON) stated she expected residents who are recommended to start RNAs from PT should be initiated into RNAs before a month has elapsed. The ADON acknowledged residents who do not receive RNAs as expected after PT discharge would be at risk for physical declines. An interview on 5/24/24 at 9:43 a.m., CNA 4 stated Resident 43 cannot walk with a walker. An interview on 5/24/24 at 9:47 a.m., CNA 5 stated she has worked with Resident 43 for about two months, stated Resident 43 used to be able to use a walker when she was getting PT but added she has not seen or helped Resident 43 use a walker in over a month. A review of the facility's policy and procedure (P&P) titled, Restorative Nursing Programs, revised 12/2021, indicated, It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level .'Restorative nursing program' refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible .Residents .will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include .passive or active range of motion .training and skill practice in transfers or walking .Residents may receive restorative nursing services .upon discharge from therapy .candidates for restorative nursing services may be identified through one or more of the following processes .specialized rehabilitation assessments .in-house referrals .The Restorative Nurse is responsible for maintaining a current list of resident who require nursing services, and for ensuring that all elements of each resident's program are implemented .

Based on interview and record review the facility failed to ensure an environment was free of accident hazards for one resident (Resident 1) when Resident 1 fell off a wheelchair, for a census of 86. This failure led to Resident 1's death. Findings: A review of the facility's document titled Admission Record, dated [DATE], indicated Resident 1 was admitted in [DATE] with diagnoses including acquired absence of left leg above knee and right leg above knee. A review of a Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated Resident 1 had no memory problems, normally used a wheelchair to move around, and had no history of falls. A review of a care plan initiated on [DATE] indicated Resident 1 had [CONDITION(S)] (a disease that thins and weakens the bones) and [CONDITION(S)] (a condition in which the body's immune system attacks its own tissue and joints). The goal of the care plan was for Resident 1 to remain free of injuries. Staff interventions and tasks included, Monitor/ document for risk of falls. Educate .caregivers on safety measures that need to be taken in order to reduce risk of falls . A review of a care plan initiated on [DATE], indicated Resident 1 was at risk for falls and injuries related to medications Resident 1 was taking. The goal of the care plan was to decrease the risk of fall and/or minimize injuries from falls for 90 days. A review of a fall report, dated [DATE] at 12:28 p.m., indicated Resident 1 fell from a wheelchair during a physical therapy session on the facility's patio when Resident 1 propelled the wheelchair over the door's threshold (a strip of wood or metal formed at the bottom of a doorway and crossed when entering a building) and resulted in swelling to the back of the head. Resident 1 was sent to the hospital for further evaluation. A review of the hospital's physician note, dated [DATE] at 12:47 p.m. indicated, The history provided by the [Resident 1] and EMS [Emergency Medical Services] personnel .[Resident 1] was wheeling herself on her wheelchair, when the wheels got caught on the rug causing patient to fall backwards and hitting her head . A review of the hospital's physician notes, between [DATE] and [DATE], indicated Resident 1 obtained compression fractures in the thoracic (middle) and lumbar (lower) spine and hemorrhages (ruptured blood vessels) in three layers of the brain. Resident 1 died on [DATE]. In an interview on [DATE] at 12:58 p.m., the Physical Therapy Assistant (PTA) stated, .[Resident 1] attempted to cross the threshold of the door .he heard [Resident 1] yell as she was falling back, the wheelchair tilted back .[Resident 1] hit her head on the ground . A review of the facility's document titled Order Summary Report, dated [DATE], indicated Resident 1 was unable to bear weight on both legs and had a fair rehabilitation potential. In an interview on [DATE] at 10:30 a.m., the PTA stated, They [he and Resident 1] were outside coming in. A mat was .outside .[Resident 1] was on the wheelchair .the front of the wheelchair was right behind the mat .[Resident 1] had an impulse to propel herself .It must have been the mat. In an interview on [DATE] at 10:01 a.m., the PTA confirmed there was a mat in front of door from patio to therapy room when the resident fell . A review of a facility policy titled Fall Management, dated ,d+[DATE], indicated, .PURPOSE .To evaluate risk factors and provide interventions to minimize, risk, injury, and occurrences.

Based on observation, interview and record review the facility failed to ensure each resident was free from sexual abuse (unwanted sexual contact, usually perpetrated by force or by taking advantage of a person not able to give consent) for two of two sampled residents (Resident 1 and Resident 2) from sexual abuse when: 1. Resident 3 was found lying naked on top of Resident 1, and 2. Resident 3 was found naked in bed touching Resident 2 inappropriately. This failure resulted in the sexual abuse of Resident 1 and Resident 2 causing psychosocial harm to vulnerable residents. Findings: Review of the undated Admission Record indicate Resident 3 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 3's medical record documents titled Progress Notes revealed the following: - 6/29/18 at 1:15 p.m., Continues to be monitored for increased aggressive behaviors occurring yesterday involving him hitting another resident with a closed fist in the face .He was monitored 1:1 (constant visual, arms reach observation for immediate or impulsive behavior that may be harmful to self or others) through the day shift. Per SSD (Social Services Director) will be transferred .out of the memory care unit . - 6/30/18 at 12:11 a.m., . (Resident 3) is visual being monitored (sic), for he has shown tendency to wander into other resident's rooms. - 6/30/18 at 4:28 a.m., In 'C' HALL dancing and removing clothes. - 7/1/18 at 12:11 p.m., (Resident 3) was by kitchen trying to get out doors. Ignoring all staff that attempted to talk or redirect (resident). - 7/2/18 at 11:19 a.m., Resident was reported to have difficulty using the toilet properly; there is ongoing concerns raised regarding BM (bowel movement) messes on the bathroom floor, around or near the toilet . an OT (Occupational Therapy) referral for further toilet training . 7/2/18 at 3:50 p.m., Supervisor alerted nursing (Resident 3) was observed at station 1 standing from his w/c (wheelchair) and attempted to hit CNA (Certified Nursing Assistant) as employee was speaking to another co-worker during shift change. Resident became enraged and stated 'I'll knock you out'. Employee removed himself from area to de-escalate situation, but resident then proceeded to throw a plant onto the ground with his hand that was on the counter of the nurses' station .He was heard mumbling 'I'll knock you out.' Again as he wheeled off .Floor supervisor talked to him 1:1 to provide reassurance .visuals in place, continue to monitor. -7/3/18 at 6:56 a.m., Resident up in his w/c, restless, wandering, re-oriented by nursing staff, tried to get out of w/c and get into nurse's purse and get scissors out. Was immediately stopped, scissors were confiscated safely by nursing staff. - 7/5/18 at 12:48 p.m., (Resident 3) attempted to hit a female resident in the dining room as she was sitting in her w/c . He stated 'Leave me alone or I'm going to start swinging.' .1:1 in his room .continue to monitor. - 7/10/18 at 8:19 p.m., Resident continuously going into other resident's rooms and making a mess in their bathrooms. - 7/14/18 at 3:19 p.m., (Resident 3) took liberty in accessing the personal toiletries .of his room mate (sic) and also put them on the floor. Several urine puddles were noted on various aspects of this area on and around the personal belongings. His room mates spirometer was laid in a puddle of urine. There were also clothing items that were saturated in urine . Note further indicated Resident 3 was moved to another room. - 7/20/18 at 23:15 p.m., .(Resident 3) continues to exhibit negative behaviors by wandering around facility, entering other (residents') rooms, and tossing objects to the floor. Redirection to room and reminding resident where his bathroom is multiple times. Visual checks by staff at all times .Staff encouraged to keep visual checks on (Resident 3) through the night . -7/24/18 at 2:25 a.m., (Resident 3) found without clothes in female resident's (Resident 1) bed. (Resident 3) removed from female resident's room, clothed, redirected. One on one supervision/ monitoring initiated. Review of the facility report faxed to the Department on 7/24/18, indicated the following: 1. Resident 3 was found naked on top of Resident 1 on 7/24/18 at 2:30 a.m., and 2. Resident 3 was found naked in bed with Resident 2 on 7/24/18 at 5:35 a.m. after being placed on 1:1 supervision. 1. Review of SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 7/24/18 and electronically signed by Licensed Nurse (LN) 1, indicated Resident 1 was the victim of sexual abuse on 7/24/18 at 2:30 a.m. by another resident, that Resident 1 is not oriented to person, place or time and does not have the capacity to make decisions. It further indicated Resident 3 was found lying on top of (Resident 1) with his pants down pass (sic) his buttocks, with genitals exposed. No erection observed, no body fluids observed. Resident (1) was wearing gown, brief, and covered with two blankets. Review of a summary report submitted by the facility dated 7/27/18 indicated the following: - Resident 3 has limited mental capacity and a history of behaviors .has exhibited baseline behaviors with periodic outbursts .Occasional incidents noted of propelling into resident's rooms near his own. (Resident 3) has made verbalizations of a sexual nature in the past, but nothing physical in nature. - Resident 1 has Dementia with Behavioral Disturbances .is not alert and oriented . - Statement from (CNA 1) While doing rounds, found (Resident 3) in the adjacent room lying on (Resident 1) with his pants down showing his buttock and genitals. His shirt was still on. (Resident 1) still had blankets over her. (CNA 1) told (Resident 3) to get off of (Resident 1) and when she attempted to remove him he swung at her multiple times and she ran to the nurse's station for help. (LN 1) and (LN 2) and (CNA 2) ran to the room to assist and got (Resident 3) off the bed, pulled his pants up and walked him back to his room and put him to bed. - Statement from CNA 2 was at the nurse's station when (CNA 1) asking could we help with a resident that was in another resident's room .When they arrived at the room (Resident 3) was at the edge of the bed with his buttocks exposed. (LN 1) and (LN 2) were able to remove (Resident 3) from the room and put him to bed. - Follow up Actions taken included Resident 3 on 1:1 observation all shifts. Review of the undated Admission Record indicated Resident 1 was admitted to the facility in 2008 with [DIAGNOSES REDACTED]. Review of Resident 1's Progress Notes, dated 7/24/18 at 3:00 a.m. and signed by LN 1, indicated Certified Nursing Assistant (CNA) 1 found Resident 3 lying on top of (Resident 1) with his pants down to buttocks and genitals showing. The progress note further indicated Resident 1 was dressed and under the covers. 2. Review SBAR, dated 7/24/18 and electronically signed by LN 2, indicated Resident 2 was the victim of sexual abuse on 7/24/18 at 5:35 a.m. by another resident, that Resident 2 is oriented to person and place. It further indicated Resident 3 was found naked lying beside (Resident 2). (Resident 2) states that (Resident 3) rubbed her chest down to her private area. Resident stated he 'touched me all over.' Review of a summary report submitted by the facility dated 7/27/18 indicated the following: - Resident 2 is an alert and oriented resident whose significant other visits daily .Initial statement regarding the incident by (Resident 2) to (CNA 2) was that (Resident 3) got into bed with her naked and that he touched her, rubbing her body from the neck down. - Resident 3 has limited mental capacity and a history of behaviors .has exhibited baseline behaviors with periodic outbursts .Occasional incidents noted of propelling into resident's rooms near his own. (Resident 3) has made verbalizations of a sexual nature in the past, but nothing physical in nature. -Statement from CNA 2 was instructed by (LN 2) to check on (Resident 3) every 10 minutes following the first incident that occurred earlier in the morning. Last time she saw (Resident 3) he was in his own room lying in bed. Performed rounds and when she returned (Resident 3) was not in his room and found him sitting on the edge of (Resident 2's) bed, naked wrapped in a blanket .took him back to his room while nursing staff stayed with (Resident 2). (Resident 2) stated (Resident 3) got in bed with her naked and touched her rubbing her body from the neck down. -Statement from LN 1, (CNA 2) came to nurse's station . (Resident 3) had already been removed from the room and LN 2 stayed with (Resident 2) to calm her . - Follow up Actions Taken included 1:1 with (Resident 3) all shifts and Facility staff inserviced (sic) on 1:1 supervision vs. monitoring residents. During a concurrent observation and interview on 7/25/18 at 8:50 a.m., Resident 3 was lying in bed, clothed. Resident 3 stated he could be better because he was looking for his head and he would be better when(NAME)is here. Does not remember changing rooms yesterday and stated he does not have family that visits him. During an interview on 7/27/18 at 8:45, CNA 4 stated she was assigned to 1:1 observe Resident 3 since 6:30 this am. Stated resident reported to not sleep much and he takes off his pajamas at night to be nude and pees on the floor. During a telephone interview on 7/27/18 at 4:40 p.m., CNA 3 confirmed the incident with Resident 1 and added there was urine on Resident 3's floor so she went to help CNA 1 clean up the floor. She stated she went back to the nurse's station to chart. At 3:45 a.m. she stated she covered CNA 2 for lunch on the hall where Resident 3 resided. CNA 3 stated, the LN asked me to sit by his door .didn't tell me he was a 1:1, we were short that night, I had 30 patients myself .I couldn't have been a sitter for him. When asked if she had any training regarding being a sitter or watching someone who was a 1:1, CNA 3 stated Not here, but at other places I worked I have .If I am being a sitter, then I am in the room by the bed .patient is always in my view. During a telephone interview on 8/1/18 at 5:05 p.m., CNA 1 stated she was caring for the residents across the hallway from Resident 1. When she was walking by, she saw Resident 3 lying on top of Resident 1 with his pants down, tried to get him off but he tried to hit her so she went to get help. CNA 1 further stated Resident 1 cannot talk so they do not know what Resident 3 did to her. CNA 1 additionally stated Never a 1:1 issued to her knowledge. On 8/2/18 at 2:25 p.m., during a telephone interview, CNA 2 stated she walked in and found Resident 3 sitting on Resident 2's bed wrapped in a blanket butt naked. CNA 2 stated she stayed with (Resident 3) 1:1 until 7:00 a.m. She stated prior to the incident with Resident 2, Resident 3 was being checked on every 10 to 15 minutes. During a telephone interview on 8/3/18 at 11:29 a.m., LN 1 stated she helped CNA 1 remove Resident 3 from Resident 1's bed and return him to his room, and asked CNA 1 to stay with him. She stated later in the morning about 5:30 a.m., CNA 2 called for help, Resident 3 was naked on Resident 2's bed. Resident 2 was upset, shaking and crying. LN 1 further stated Resident 3 should have been a 1:1 because that is our policy, after the first incident. During an 8/3/18 at 2:05 p.m. telephone interview, LN 2 stated she helped CNA 1 and LN 1 remove Resident 3 from Resident 1's bed. She confirmed Resident 3 was at the foot of Resident 1's bed when she came in and that his pants were down, exposing his genitals and buttocks. LN 2 stated CNA 2 returned from her break and LN 2 instructed her to sit outside his door in case he came out. She added, to prevent Resident 3 from entering Resident 1's and Resident 2's room through the adjoining bathroom, a wheelchair with the brakes on, was placed to block the door. LN 2 related at 5:50 a.m., CNA 2 called for help because Resident 3 was naked on Resident 2's bed. LN 2 stated he pushed the wheelchair out of the way to enter the room. Review of the facility provided policy titled Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, last revised (MONTH) (YEAR), indicated The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .The facility is responsible for assuring resident safety by prohibiting verbal, mental, sexual, or physical abuse, .Have evidence that all alleged violations are thoroughly investigated and prevent further potential abuse .while the investigation is in progress .The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, neglect, exploitation and misappropriation and mistreatment such as: Physical aggression or self-injurious behaviors, Verbally abusive behavior towards others, Socially inappropriate or disruptive behaviors, Wandering into the rooms or personal spaces of others, Those requiring heavy nursing care and/or are fully dependent on staff To protect residents and employees from harm or retaliation during an investigation, the facility shall: Take prompt measures to remove any resident from harm, .Take reasonable measures to separate residents involved in Resident-to-Resident abuse or altercations .