Every finding on record at Del Rosa Villa

Based on interview and record review, the facility failed to maintain an effective training program for One of three sampled Certified Nursing Assistants (CNA 3), when the facility was unable to provide documented evidence to show CNA 3 completed the required Continued Education Units (CEUs -mandatory ongoing training hours required to maintain and renew an active certification). This failure limited the facility's ability to ensure staff met the mandatory training requirements and had the potential to result in staff not receiving essential education needed to provide safe and competent resident care.During an interview on May 15, 2026, at 10:14 AM, with CNA 3, CNA 3 stated she had completed the 48 hours of CEU required for renewal license but the Director of Staff Development (DSD) can't [cannot] find the in-services [training provided to employees while on the job].During a concurrent interview and record review on May 15, 2026, at 10:49 AM, with the Director of Nursing (DON), the DON reviewed CNA 3's training records, dated from January 2024, through December 2024. DON stated she was not able to verify some of the training records for 2024 because either CNA 3 never signed, or never attended the training, we don't [do not] have proof that CNA 3 did it, whomever gave the in service didn't [did not] write a topic on that, or CNA 3 didn't fill it out properly. The DON stated that the current Director of Staff Development (DSD) can only verify what she has.During an interview on June 3, 2026, at 2:58 PM, with the DSD, the DSD stated the facility is responsible for maintaining the training records.During a follow-up interview on June 4, 2026, at 12:20 PM, with the DSD, the DSD stated in the email that the facility does not have a specific policy on maintaining in-service trainings and the DSD was unable to provide one.During a review of the facility's document titled, Job Description: Director of Staff Development (JD), (undated), the JD indicated under subheading Essential Duties one of the DSD duties to be Maintain records of In-Services as required by regulations.

Based on observation, interview and record the facility failed to ensure resident's needs and preferences were met when: An appropriate bed mattress was not accommodated upon request for 1 of 20 sampled residents (Resident 107) after returning from the hospital to maintain comfort. An evaluation for a power wheelchair was not coordinated upon request for 1 of 20 sampled residents (Resident 116) to accommodate her inability to self propel a manual wheelchair.These failures resulted in Resident 107 experiencing discomfort and the inability to sleep in his bed and the potential for loss of independence for Resident 116 when their needs were not met. Findings:1.During a review of Resident 107's face sheet (demographic data), Resident 107 was readmitted to the facility on [DATE] with diagnoses which included fluid overload, and hypoxemia (low oxygen levels in the blood). During a review of Resident 107's admission Minimum Data Set (MDS- assessment tool), MDS assessment indicated Resident 107 has intact cognition. During a concurrent observation and interview on 2/8/26 at 10:10 a.m. and on 2/9/26 at 9:30 a.m. with Resident 107 in the room, Resident 107 was observed sitting up in his wheelchair. Resident 107 stated he reported his bed mattress was uncomfortable, and he had informed different staff about the issue since returning from the hospital. Resident 107 stated that due to the discomfort, staff were aware that he had been sleeping in a chair every night in the lobby and had not slept in his bed since his hospital discharge and no interventions were initiated to resolve the issue. During an interview on 2/9/26 at 9:49 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she was not aware of Resident 107's issue with the bed mattress. However, LVN 1 confirmed Resident 107 was observed sitting in his wheelchair most of the time. During a concurrent interview and record review on 2/9/2026 at 9:51 a.m. with Environmental Services Director (ESD), the work order request logbook dated 2/1/26 to 2/8/26 indicated no evidence a request for a bed mattress was made. The ESD stated that he was not informed about Resident 107's bed mattress issue. During a review of the facility's policy and procedure titled Quality of Care/Accommodation of Needs dated March 2021 indicated Our facility 's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. Policy Interpretation and implementation.g. providing a variety of types. furniture in rooms.so that residents with.mobility can independently arise to standing position. 2. During a review of Resident 116's Face Sheet (Demographics) dated 2/11/26, the Face Sheet indicated Resident 116 was admitted to facility on 8/12/24 with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During an interview on 2/9/26 at 9:50 a.m. with Resident 116, Resident 116 stated she requested the staff for a powered wheelchair to use to be more independent because she cannot use a manual wheelchair by herself due to her diagnoses. Resident 116 stated she requested the powered wheelchair from multiple staff since her admission and there had been no follow up information regarding the status of her request. During an interview on 2/10/26 at 3:05 p.m. with Director of Rehab (DOR), DOR stated the Rehab department performs screenings and provides the physician with recommendations for a powered wheelchair for residents in the facility. She stated she was not informed by nursing staff that Resident 116 requested a powered wheelchair and staff should notify her of a resident's request by leaving a written note or verbally in person. During an interview on 2/11/26 at 9:50 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the nursing staff is responsible for communicating a resident's concerns or requests with the appropriate departments. During an interview on 2/11/26 at 10:15 a.m. with Social Services Director (SSD), SSD stated she is involved in coordinating and ordering specialized equipment for resident's use, but nursing staff had not informed her of Resident 116's request for powered wheelchair. During a review of Resident 116's Individual Psychotherapy Progress Note, dated 1/26/26, the progress note indicated, Encouraged communication with staff regarding mobility options and equipment needs. Motivation to increase activity and social engagement was evident. Coordinate with nursing and rehabilitation staff regarding wheelchair evaluation and mobility planning. During a review of policy and procedure (P&P) titled, Assistive Devices and Equipment, dated January 2020, the P&P indicated, Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents.

Based on observation, interview and record review, the facility failed to keep the environment safe and free from hazards for 1 of 20 sampled residents (Resident 28) when safety interventions to prevent falls were not implemented. These failures placed Resident 28 at risk for potential falls and injuries. During a review of Resident 28's Face Sheet (Demographics), the Face Sheet indicated Resident 28 was readmitted to the facility on [DATE] with diagnoses which included Encephalopathy (brain dysfunction that often results in altered mental state), Multiple Sclerosis (MS- a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord).During an observation on 2/8/26 at 10:30 AM, in Resident 28's room, Resident 28 was resting in bed, with the bed elevated in a high position from the ground. Resident 28 was wearing a wristband that indicated Fall Risk.During a concurrent observation and interview on 2/9/26 at 9:30 a.m. with Certified Nursing Assistant (CNA) 4 in Resident 28's room, Resident 28 was resting in bed which was again raised in a high position from the floor. The Resident's call light was found underneath the bed on the floor. CNA 4 confirmed bed was in a high position and stated Resident 28 was considered a high risk for fall and the bed should be lowered to prevent injury. CNA 4 stated the call light should be within the resident's reach and was not when it was found under Resident 28's bed.During an interview on 2/10/26 at 10 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 28 was a fall risk and safety interventions should be in place to prevent falls, including keeping her bed in a low position and having the call light within reach.During a review of Resident 28's care plan Falls dated 12/18/24, the care plan indicated goals were to minimize risk for falls and the interventions included, Keep bed in low position. Keep call light within reach.During a review of the facility's policy and procedure (P&P) titled, Falls/Fall Risk Management, dated September 2012, the P&P indicated, . the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling.

Based on observation, interview and record review, the facility failed to develop and implement individualized care plan interventions related to actual needs for two of 20 sampled residents (Resident 6 and 73) when: Multiple observation over several days showed Resident 6 had long, visibly dirty fingernails.For two consecutive days, Resident 73 remained in bed without participation in activities.These failures resulted in staff not being provided with interventions to deliver individualized care and placed residents at risk of unmet needs. Findings: During a review of Resident 6 face sheet (demographic data) and quarterly Minimum Data Set (MDS- assessment tool) dated 1/4/26, the face sheet showed Resident 6 was admitted to the facility on [DATE] with diagnoses which included dementia (decline in memory function). During a concurrent observation and interview on 2/8/26, at 10:56 a.m. with Resident 6 in the dining room, Resident 6 was observed with long, visibly dirty fingernails.During a meal observation on 2/8/26 at 12:02 p.m. Resident 6 was seen eating and touching her food with both hands. When asked about the condition of her fingernails, Resident 6 stated I know.During a concurrent observation and interview on 2/9/26 at 11:02 a.m. in Resident 6's room, with Certified Nursing Assistant (CNA) 1, Resident 6 fingernails remained long and dirty. CNA 1 stated she did not notice the condition of Resident 6's fingernails.During an interview on 2/9/26 at 9:52 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CNAs were responsible for cutting/cleaning residents' fingernails.During a concurrent observation and interview on 2/10/26 at 8:50 a.m. with CNA 2, Resident 6 remained with long dirty fingernails. CNA 2 stated she did not observe the condition of Resident 6's fingernails.During a review of the Activities of Daily Living (ADL) care plan dated 2/14/24 and last reviewed 1/13/26, indicated At risk for decline in self-care and mobility skills. However, the care plan showed no individualized goals or interventions addressing hygiene needs, including nail care.During an interview on 2/12/26 at 9:22 a.m. with Minimum Data Set (MDS- assessment tool) Coordinator 1, MDS 1 stated care plans should be individualized according to residents' needs, specific goals and interventions.During a review of the facility's policy and procedure (P&P) titled Care Planning-Interdisciplinary Team with a revised date of September 2013, indicated Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 2. During a review of Resident 73's face sheet (demographic data) and quarterly Minimum Data Set (MDS- assessment tool) dated 1/27/26, the face sheet indicated Resident 73 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis on one side of the body). MDS assessment indicated Resident 73 had severe cognitive impairment.During observation on 2/8/26 from 10:27 a.m. to 11 a.m. and on 2/9/26 at 10:12 a.m. to 11 a.m., Resident 73 was in bed without participation in activities or offered activities for two consecutive days.During an interview on 2/9/26 at 10:25 AM with Certified Nursing Assistant (CNA 1), CNA 1 stated she did not ask or offer Resident 73 to be up in the Geri-chair (medical chair for individuals with limited mobility).During an interview on 2/9/26 at 10:41 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 73 did not have a physician's order to be up in a Geri-chair; however, LVN 1 stated that CNAs could still get her up.During an interview on 2/9/26 at 3:34 p.m. with the Activity Director (AD), Activity Director stated staff should provide Resident 73 with 1:1 activities such as Spanish music and read Spanish books while in room and up in the dining room.During a review of Resident 73's Activity care plan dated 5/5/21, indicated One/One: resident needs one on one activity visits to provide social interaction and mental/sensory stimulation.; however, the interventions did not address the music and the books as part of the activity's plan.During an interview on 2/12/26 at 9:16 a.m. with MDS 1, MDS 1 stated care plans should be individualized according to residents' needs, specific goals and interventions.During a review of the facility's policy and procedure (P&P) titled Care Planning-Interdisciplinary Team with a revised date of September 2013, indicated Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, interview and record review, the facility failed to ensure a safe, sanitary, and comfortable environment for one of 20 sampled residents (Resident107) when Resident 107 did not receive education/training in infection control practices when emptying his urinary bag.These failures had the potential to place Resident 107 at risk for infection, and contamination that could affect his overall health condition.Findings: During a review of Resident 107's face sheet (demographic data) and admission Minimum Data Set (MDS- assessment tool), Resident 107 was readmitted to the facility on [DATE] with diagnoses which included fluid overload, and hypoxemia (low oxygen levels in the blood). MDS assessment indicated Resident 107 has intact cognition.During a concurrent observation and interview on 2/8/26 at 10:10 a.m. with Resident 107, Resident 107 was observed with urinary drainage bag with covering attached to his wheelchair and he stated the staff were not coming in to empty the urinary bag and had been emptying the urine by himself. Resident 107 was observed removing the drainage port, showing how to empty it, and replacing the port without gloves or performing hand hygiene before and after the task.During an interview on 2/9/26 at 9:43 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 107 was not his regular assigned resident, and he was not aware of the urinary bag.During an interview on 2/9/26 at 9:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated CNAs were responsible for emptying urinary bags. LVN 1 could not state if Resident 107 was screened to perform self-emptying the urinary bag.During an interview on 2/11/26 at 10:08 a.m. with Infection Preventionist (IP), IP could not confirm if there was documentation indicating Resident 107 was assessed as capable of managing his own catheter care, nor any documentation of resident education, supervision or competency evaluation related to catheter-bag emptying.During a review of the facility's policy and procedure titled Infection Prevention and Control Program with revised date of October 2018, indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program, when staff failed to report the presence of flying insects in room [ROOM NUMBER] shared bathroom. This failure had the potential to pose significant health risks to residents, visitors and staff.Findings:During an interview conducted on 2/9/26 at 10:56 a.m. with Resident 14, Resident 14 stated there was a lot of bugs inside his bathroom. Resident 14 stated he informed staff about the bugs last week but they did nothing about it. Resident 14 stated he could not remember the staff name or the specific date when he told staff.During an observation on 2/9/26 at 10:57 a.m. in room [ROOM NUMBER] shared bathroom, there was large amount of small dark colored flying insects inside the bathroom and large amount that were resting around the toilet seat.During a concurrent observation and interview on 2/9/26 at 11 a.m. with the Administrator and Environmental Service Director (ESD) in room [ROOM NUMBER] bathroom, the Administrator and the ESD stated they were unaware of the bugs issue inside the bathroom. The Administrator and the ESD confirmed the large amount of flying insects.During a concurrent interview and record review on 2/10/26 at 9:56 a.m. with the ESD, the ESD stated he was not notified by any staff regarding the insects inside room [ROOM NUMBER] bathroom. The ESD provided a communication folder (a folder used by facility staff to report maintenance issues) for review. The folder indicated there was no documented evidence that staff reported or communicated the issue.During a review of the facility's policy and procedure (P&P) titled, Pest Control with a revision date of May 2008, the P&P indicated, Our facility shall maintain an effective pest control program.

Based on observation, interview and record review, the facility failed to provide necessary assistance for one of 20 sampled residents (Resident 6) with personal hygiene specifically nail care. This failure resulted in Resident 6 not being provided and receiving necessary activities of daily living (ADL) assistance to maintain personal hygiene. Findings:During a review of Resident 6's face sheet (demographic data), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included dementia (decline in memory function).During a review of Resident 6's quarterly Minimum Data Set (assessment tool) dated 1/14/26, Resident 6 required assistance in her personal hygiene.During a concurrent observation and interview on 2/8/26, at 10:56 a.m. with Resident 6 in the dining room, Resident 6 was observed with long, visibly dirty fingernails.During a meal observation on 2/8/26 at 12:02 p.m., Resident 6 was seen eating and touching food with both hands. When asked about the condition of her fingernails, Resident 6 stated I know.During a concurrent observation and interview on 2/9/26 at 11:02 a.m. in Resident 6's room, with Certified Nursing Assistant (CNA 1), Resident 6 fingernails remained long and dirty. CNA 1 stated she did not notice the condition of Resident 6's fingernails.During an interview on 2/9/26 at 9:52 a.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated CNAs were responsible for cutting/cleaning residents' fingernails.During a concurrent observation and interview on 2/10/26 at 8:50 a.m. with CNA 2, Resident 6 remained with visibly long dirty fingernails. CNA 2 stated she did not observe the condition of Resident 6's fingernails.During an interview on 2/12/26 at 9:05 a.m. with Director of Nursing (DON), DON stated CNAs were responsible for maintaining and providing ADL assistance to the residents.During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting dated March 2018, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, the facility failed to ensure hot food was served at an acceptable temperature (above 135 degrees Fahrenheit [F- measurement of temperature]) to be appetizing for two of 20 sampled residents (Resident 67 and Resident 116).This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents.During an interview on 2/8/26 at 11 a.m. with Resident 67 in the resident's room, Resident 67 stated the food was not good and she did not like to eat the food served. Resident 67 stated the food would also be delivered cold, which did not make it appetizing to eat and she would often not finish her meal because of it.During an interview on 2/8/26 at 3:30 p.m. with Resident 116 in the resident's room, Resident 116 stated she did not like the food that was served because it was not palatable when the food tray was cold by the time it was delivered to her room.During a review of the facility's menu titled, February 9-15, 2026, the menu for Monday 2/9/26 indicated the lunch meal of Regular diet included Fish with Tarragon, Cajun Country Rice, Creamed Spinach, Sweet Corn Salad, and Fruit Bavarian Cream.During a test tray observation and interview on 2/9/26 at 12:28 p.m. with the Dietary Supervisor (DS) in the dining room, a food tray of the regular diet was removed from the last meal cart for delivery to the residents' rooms and the temperatures of the food were taken. On the regular tray, the entree of Fish with Tarragon was 126.8 degrees F and the Cajun Country [NAME] was 127.8 degrees F when the temperature was taken with a thermometer. The DS acknowledged the low food temperatures of the food and stated it should be served warmer.During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 3-501.16 titled, Time/Temperature Control for Safety. Holding, FDA Food Code indicated, Food shall be maintained. held at a temperature of 54 degrees Celsius (130 degrees F) or above.During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, undated, the P&P indicated, Proper hot and cold temperatures are maintained during food distribution and service.

Based on observation, interview and record review the facility failed to provide necessary respiratory care and services for two of 20 sampled residents (Resident 5 and Resident 107) when: Resident 5's oxygen cannula tubing (medical device to deliver oxygen) was not changed for twelve days (12 days) past the required time frame.Resident 107 did not receive the prescribed respiratory treatments following his return to the facility.These failures placed Resident 5 and Resident 107 at risk for compromised respiratory health status and avoidable decline in health. Findings:During a review of Residents 5's face sheet (demographic data), Resident 5 was readmitted to the facility on [DATE] with diagnosis including pneumonia (lung infection).During a concurrent observation and interview on 2/8/26 at 10:04 a.m. with Resident 5, there was an oxygen cannula tubing with a date label of 1/27/26 at bedside. Resident 5 stated the oxygen was used two (2) days ago (on 2/6/26).During an interview on 2/9/26 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated all cannula oxygen tubing should be replaced every three (3) days and the charge nurses were responsible for changing oxygen tubing.During an interview on 2/12/26 at 9:05 a.m. with Director of Nursing (DON), DON stated charge nurses were responsible for changing the oxygen cannula tubing and Infection Preventionist (IP) was responsible for overseeing that the task was done.During a review of the facility's policy and procedure (P&P) titled Prevention of Infection Respiratory Equipment with revised date of November 2011, indicated The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff.Change the oxygen cannula and tubing every seven (7 days) or as needed.2. During a review of Resident 107 face sheet (demographic data), Resident 107 was readmitted to the facility on [DATE] with diagnoses which included fluid overload, and hypoxemia (low oxygen levels in the blood).During a review of Resident 107's admission Minimum Data Set (MDS- assessment tool) dated 11/13/2025, MDS assessment indicated Resident 107 was cognitively intact.During a review of the physician's order dated 2/4/26 indicated [name of medication] to inhale orally via nebulizer (medical device that turns liquid medicine into a mist that can be inhaled) every 6 hours as needed for shortness of breath, hypoxia (a condition where body tissues do not receive enough oxygen); Initiate Incentive Spirometer (medical device used to measure lung volume and speed of air in between respiration) three times a day for 5 to 10 breath cycle or as tolerated for 10 days. During a concurrent observation and interview on 2/8/26 at 10:10 a.m. and 2/9/26 at 9:30 a.m. with Resident 107, a nebulizer machine was observed without set-up and there was no Incentive Spirometer found at bedside. Resident 107 was observed to have coughs and stated he was experiencing slight shortness of breath in between his activities.During an interview on 2/10/26 at 9:20 a.m. with Resident 107, Resident 107 stated he had not received any breathing treatments since his readmission. Resident 107 further stated the Incentive Spirometer was not provided since returning from the acute hospital.During an interview on 2/10/26 at 9:35 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 107 had orders of respiratory treatments; however, LVN 1 stated the respiratory prescribed treatments were not administered/provided on 2/9/26 to 2/10/26 during her shift. LVN 1 also confirmed the nebulizer machine had no set up and there was no Incentive Spirometer equipment at bedside,During a review of the Medication Administration Record (MAR) dated February 2026, there was no documentation indicated that the prescribed respiratory medication via nebulizer were administered, offered, attempted or refused by Resident 107.During an interview on 2/12/26 at 9:05 a.m. with Director of Nursing (DON), the DON stated all respiratory medications should have been administered according to physician's order.During a review of the facility's policy and procedure titled Respiratory Treatment dated 8/1/24, indicated It is the policy of this center that residents receive respiratory treatments and monitoring per their physician's orders, standards of practice and plan of care.

Based on observation, interview, and record review, the facility failed to conduct an assessment for one of four sampled residents (Resident 1) to evaluate her status and needs at the time of the proposed return from the hospital.This failure had the potential for the facility to miss important changes in Resident 1's current behavior or condition that could have informed an appropriate and individualized discharge decision. A review of Resident's 1 admission Record (a document containing clinical and demographic information data) indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included quadriplegia (severe medical condition characterized by the partial or total loss of function in all four limbs and the torso), Schizoaffective disorder (mood disorder symptoms such as depression and mania), and cannabis dependence (overpowering desire to use marijuana).During a review of Resident 1's history and physical (H&P- a resident assessment that includes medical past and current symptoms), dated August 21, 2024, indicated Resident 1 had the capacity to make decisions.During a concurrent observation and interview on August 12, 2025, at 7:29 AM, Resident 1 was not present at the facility. License Vocational Nurse (LVN 1) stated Resident 1 was no longer a resident in the facility. During a review of Resident 1's Order Summary (list of doctor's orders), dated August 8, 2025, the Order Summary indicated, Resident may sent [send] to acute for evaluation d/t [due to] to behavior (danger to other).During a review of the hospital document titled, ED [emergency department] Physician notes, dated August 8, 2025, indicated Resident 1 arrived at the emergency room by ambulance, and was examined by the provider on August 8, 2025, at 6:26 PM. During a telephone interview on August 11, 2025, at 4:04 PM, with the hospital Social Worker (SW), the SW stated, Attempts were made to return the resident [Resident 1] to her previous facility after evaluation by a psychiatrist and cleared for discharge. However, the facility declined to accept the resident [Resident 1] back due to her [Resident 1's] history of attempting to harm others. During a review of Resident 1's hospital Discharge Planning Progress Note, dated August 12, 2025, at 2:10 PM, the note indicated, .Pt [Resident 1] from [name of the facility] and they decline to accept her back due to behavior. Pt [Resident 1] has been there custodial [non-medical assistance provided to individuals who require help with daily living activities] for 10 years.During a review of Resident 1's hospital discharge order, titled Ordering Information, dated August 13, 2025, at 9:13 AM, the order indicated, When: Now; Disposition: Skilled Nursing Facility; Special Instruction: Custodial.During a telephone interview on August 12, 2025, at 9: 53 AM, with the facility's Director of Community Relations (Director), the Director was asked if there was any documentation to show Resident 1 was fully evaluated to determine is she is appropriate for transfer back to the facility? The director stated, There is no documentation since I did not evaluate the resident because the Director of Nursing (DON) and the Administrator informed me that she [Resident 1] was no longer considered appropriate for admission to the facility.During a concurrent interview and record review on August 12, 2025, at 11:25 AM, with the DON, the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated October 2022 was reviewed. The P&P indicated, .Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred. During a subsequent interview and record review on August 12, 2025, at 11:27 AM, with the DON, the facility's P&P titled Transfer or Discharge Notices, dated March 2025, was reviewed. The P&P indicated, .If discharge is initiated by the facility after an emergency transfer to the hospital, the reason for discharge is based on the resident's status at the time the resident seeks return to the facility (not at the time the resident was transferred to acute care) . When the DON was asked if the facility's P&Ps were followed, the DON did not provide a direct answer.

Based on interview, and record review, the facility failed to protect against verbal abuse for one of three sampled residents (Resident 1) when a Certified Nursing Assistant 1 (CNA 1) called Resident 1 a B**ch! when Resident 1 was voicing criticism of CNA 1's perineal care (the cleaning and maintenance of the perineum, the area between the anus and the genitals) indicating rough handling with pain.This failure caused Resident 1 to suffer pain, fear, and anxiety.Findings:An unannounced visit was made to the facility on August 13, 2025, at 11:18 AM, to investigate a facility reported incident regarding an allegation of verbal abuse.A review of Resident 1's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of July 6, 2025. Resident 1 had diagnoses that included stroke and left sided paralysis (complete or partial loss of muscle function). Resident 1 was discharged home on August 6, 2025.A review of Resident 1's victim statement dated August 2, 2025, indicated, . [Resident 1] expressed that [CNA 1] was changing her with another [CNA 2]. During the cares she expressed being hurt by the turning, [CNA 1] was not acknowledging the concerns. [CNA 2] addressed them, and [CNA 1] responded with so [?] Cares were completed, [CNA 1] stayed behind conversing with [Resident 1] back forth. [Resident 1] stated that she was telling [CNA 1] she does not want her to do her cares anymore and then [CNA 1] responded with you are [a B**ch!] and then [Resident 1] proceeded to say I'm going to report you. [CNA 1] left immediately after.Resident 1 was unavailable for interview due to discharge on [DATE].A review of CNA 2's witness statement dated August 2, 2025, indicated, [CNA 2] reports he was asked to assist in changing [Resident 1] with another CNA [CNA 1]. [CNA 2] entered the room, and [CNA 1] was already there arranging linens and a brief for changing. They were changing [Resident 1] and she was saying she was experiencing some pain while moving during cares. [CNA 2] asked the other [CNA 1]to be more careful, [CNA 1] responded nonchalantly saying so[?] [CNA 2] expressed that [CNA 1] needs to be mindful [about] changing [Resident 1] and positions. Cares were completed and [Resident 1] stated she needed no more assistance, [CNA 2] was exiting the room. [CNA 1] was still [at] bedside conversing back and forth with [Resident 1] then [CNA 2] heard [CNA 1] say [ B**ch!] towards [Resident 1] while [CNA 2] was leaving room.CNA 2 was unavailable for interview.A review of CNA 1's statement of events dated August 12, 2025, indicated, . [CNA 1] admitted to calling [Resident 1] a [ B**ch!]CNA 1 was unavailable for interview.During an interview with the Director of Nursing (DON) on August 13, 2025, at 11:30 AM, the DON stated she interviewed CNA 1, CNA 2 and Resident 1 and they all confirmed CNA 1 had called Resident 1 a B**ch! The DON stated her investigation concluded CNA 1 used profanity directed at Resident 1. The DON stated Resident 1 had the right to be free from verbal abuse and it was the responsibility of the facility to protect Resident 1 from abuse.A review of the facility's policy and procedure titled, Residents' Rights, dated December 2016, indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. 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; c. be free from abuse, neglect, misappropriation of property, and exploitation; .

Based on observation, interview, and record review, the facility failed to ensure two residents (Residents 1 and 2) were treated with dignity and respect when a Certified Nursing Assistant (CNA 1) used profanity in the immediate presence of the residents, while in the resident's room. This failure resulted in both Residents 1 and 2 to feel disrespected as both residents believed the staff member was directing the profanity toward them in a demeaning manner. Findings: During a review of Resident 1's Admission Record (contains medical and demographic information), the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and behavior), chronic pain, and alcoholic polyneuropathy (a neurological disorder that occurs when the nerves are damaged due to chronic alcohol use). During a review of Resident 1's Minimum Data Set Assessment (MDS - a standardized evaluation of a nursing home resident's health and functional abilities), dated January 27, 2025, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 15 (13-15 = cognition is intact). During a review of Resident 2 ' s Admission Record, the Admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included morbid (severe) obesity, muscle weakness, major depressive disorder, bipolar disorder, and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and kidney failure. During a review of Resident 2 ' s MDS assessment, dated January 3, 2025, the MDS indicated Resident 2 had a BIMS score of 15. During an interview on January 29, 2025, at 11:40 AM, with Resident 1, Resident 1 stated she had her call light on because she needed to have her diaper changed when CNA 1 came into her room and told her Your about to wear me the f**k [a derogatory curse word, profanity] out. Resident 1 stated the reply she received from CNA 1 made her feel horrible and disrespected. During an interview on January 29, 2025, at 11:50 AM, with Resident 2, Resident 2 stated Resident 1 was sitting in feces and needed to be cleaned up when CNA 1 came into the room and said Your about to wear me the f**k out, Resident 2 further stated the incident occurred at approximately 9:30 PM on Monday the 27 of January 2025. During an interview on January 29, 2025, at 12:20 PM, with the Director of Nursing (DON), the DON stated she interviewed CNA 1 regarding the allegation made by Resident 1 and CNA 1 told her she went into Resident 1 ' s room and said I 'm f**king frustrated The DON further stated CNA 1 should never have cursed in front of the residents. During a review of Resident 1 ' s medical record, a progress note dated January 28, 2025, the progress note indicated, PT [patient] on monitor [sic] for emotional distress r/t [related to] staff using foul language in residents presence . During a review of the facility document titled, [name of facility] Room Assignment for PM Shift, dated January 27, 2025, the document indicated for the PM shift on January 27, 2025, CNA 1 was assigned to the room where Resident 1 and Resident 2 resided. During an interview on March 6, 2025, at 4:15 PM, with CNA 1, CNA 1 stated she was in Resident 1 and Resident 2 ' s room on January 27, 2025, when she said out loud I ' m f**king frustrated. CNA 1 further stated she was having a hectic day on that day and there was a million call lights going off, CNA 1 further stated she was standing in the middle of Resident 1 and Resident 2 ' s room when she said, I ' m f**king frustrated, as she was preparing to change one of the residents in the room. CNA 1 stated what she should have done instead was left the room and taken a time out to gather herself. During a review of the facility ' s policy and procedure titled, Resident Rights revised February 2021, the policy indicated, Policy Statement - Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. A dignified existence; b. be treated with respect, kindness, and dignity .

Based on interview and record review the facility failed to follow its Change of Condition (COC) and Documentation Policies for 1 of 3 sampled residents (Resident 1) when: 1. Resident 1 had a (COC), and responsible party was not notified, left as unreachable. 2. No documentation of when responsible party was notified of COC. This failure placed a clinically compromised Resident (Resident 1) health and safety at risk by causing a delay in notification and family involvement. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: rhabdomyolysis (breakdown of muscle tissue damaging protein released into the blood), Cirrhosis (liver disease causing liver failure) , hepatic encephalopathy (liver, buildup of toxins in blood), type 2 diabetes mellitus ( body does not make enough insulin or does not use insulin well), Hepatitis C (infection caused by virus affecting the liver). During a review concurrent interview and record review of Resident 1 ' s Medical Record with the Director of Nursing (DON) reviewed are as follows: 1. Change of Condition (COC)Note dated February 07, 2025, Altered Level of Consciousness (ALOC), Confusion: Resident noted to be having more confusion than normal. Resident noted to be talking gibberish. Vital Signs were taken, noted to be as follow, Blood pressure 145/85, Heart Rate 83, Respirations 18, Temperature 97.9, Oxygen 92% room air. MD made aware. Received orders .Orders noted and carried out. doctor notified February 07, 2025, at 7:00PM .Responsible Part [name] called February 07, 2025, at 10:00PM (unreachable). 2. No Progress Note provided by facility of follow up call or notification to Responsible Party of COC from February 07, 2025. During an interview on February 27, 2025, with the License Vocation Nurse (LVN), the LVN stated, The responsible party [name] did call Saturday February 08, 2025, I told her about Friday (COC) of resident being confusion, but this day Saturday he was back to his normal self, his normal self was him cussing at staff. CNA was checking on him in showers. She thanked me and to please encourage him to take him medications. When asked, did you document the notification of the COC? LVN states, no, I did not document the conversation, I got busy, I did tell her about the COC from Friday, I should have documented but I didn ' t. During an interview on February 27, 2025, with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), ADON states, there was a COC February 07, 2025, the responsible party was called, but we were not able to get ahold of her, the nurse talked to her but did not document the notification of COC, I agree it should have been documented. DON states, there was a COC, we called the doctor, and he ordered labs and to increase lactulose (medication to reduce amount of ammonia is in the blood). We did call responsible party, but they were not able to get ahold of her, it says unreachable. There is no documentation of notification of the COC, the nurse did talk to her the following day. Facility has no documentation of the conversation. DON does agree there it should have been documented. During a review of the facility ' s policy and procedure titled, Change in a Resident ' s Condition or Status (COC),revised [February 2021], the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and or status.4.Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when: b. there is a significant change in the residents physical, mental or psychosocial status. During a review of the facility ' s policy and procedure titled, Charting and Documentation, revised [July 2017], the policy and procedure indicated, All services provided to the resident, progress towards the care plan goals, or any changes in the resident ' s medical, physical, functional or psychological condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. 7.e. Notification of family, physician, or other staff, if indicated .

Based on observation, interview, and record review, the facility failed to follow the menu when: 1. six (6) of six (6) Residents on pureed diet (a diet of smooth, blended foods that require no chewing) was served 2/3 cup of pureed Jambalaya instead of one cup that the menu called for during lunch on January 21, 2025. 2. 33 of 33 Residents on regular carbohydrate controlled (CCHO-consistent, constant, or controlled carbohydrate [sugars, starches and fiber]) diet, were served one whole slice of garlic bread instead of half a slice the menu called for during lunch on January 21, 2025. This failure had the potential to compromise residents' nutritional status when menus were not followed for 39 of 39 Residents on a Pureed and CCHO diet. Findings: 1. During tray line (when cook serves food on plates for each resident according to the menu) observation on January 21, 2025, at 11:50 AM in the kitchen, the Dietary [NAME] served a pureed Chicken Jambalaya using a 2/3 cup scoop to Resident 4 receiving a pureed diet, instead of one cup as indicated on the facility approved menu. During an interviewed with the cook on January 21, 2025, at 3:05 PM, the cook acknowledged that during the tray line she was not aware of the portion size listed on the menu and served only 2/3 cup instead of one cup of pureed Jambalaya for lunch on January 21, 2025, to all residents on pureed diet. The cook further acknowledged that the cook's spreadsheet winter menu dated January 21, 2025, indicates pureed Chicken Jambalaya one cup. During a review of the facility's document titled, Cooks Spreadsheet Winter Menu, dated January 21, 2025, the Winter Menu indicated, Chicken Jambalaya one cup for pureed diet and half a slice garlic bread for regular CCHO diet. 2. During tray line observation on January 21, 2025, at 11:50 AM in the kitchen, the Dietary [NAME] served one whole slice of garlic bread to Resident 548 and Resident 2 receiving regular CCHO diet, instead of a half slice of garlic bread as indicated on the facility approved menu. During an interviewed with the cook on January 21, 2025, at 3:05 PM, the cook acknowledged that during the tray line she was not aware of the portion size listed on the menu and served one whole slice of garlic bread instead of half a slice for lunch to all residents on a regular CCHO diet. The cook further acknowledged that the cook's spreadsheet winter menu dated January 21, 2025, indicates Garlic Bread: 1/2 (half) slice (small), 1/2 slice (regular), and 1 (one) Slice (large). During an interview with the Registered Dietician Nutritionist (RDN) on January 21, 2025, at 3:20 PM, the RDN stated the recipe, and the cook spreadsheet winter menu should be followed. During a review of facility's policy and procedure (P&P) titled, Menu Planning, dated 2023, the P&P indicated, .the menus are planned to meet nutritional needs of residents in accordance with established national guidelines .

Based on interview, and record review, the facility failed to ensure a copy of the notice of transfer or discharge were sent to the Ombudsman for one (1) of three (3) sampled residents (Resident 63) reviewed for hospitalization s when: 1. Resident 63 was sent to the hospital on February 16, 2024, and there was no copy of notice of transfer or discharge sent to the Ombudsman. 2. Resident 63 was sent to the hospital on July 6, 2024, and there was no copy of notice of transfer or discharge sent to the Ombudsman. This failure had the potential for Resident 63 to be inappropriately transferred or discharged . Findings: 1. A review of Resident 63's clinical record, the Admission Record (a document that gives a summary of resident's information), indicated Resident 63 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis (weakness or unable to move one side of the body) following cerebral infarction affecting left non-dominant side (parts of the brain dies when the blood flow is reduced) and dysphagia (difficulty swallowing). During a review of Resident 63's physician order (a set of instructions written by a doctor for the care of a resident), dated February 19, 2024, it indicated, May be sent out to hospital for further evaluation. May have 7-day bed hold. During a subsequent review of Resident 63's hospitalization paperwork, dated February 16, 2024, there was no record of the notice of transfer or discharge sent to the Ombudsman found. During an interview on January 24,2025, at 4:20 PM, with the Social Worker (SW), the SW stated, I cannot find the notice of transfer or discharge sent to the Ombudsman. It was not sent. 2. During a review of Resident 63's physician order, dated July 6, 2024, at 2:18 PM indicated, May go to acute care with a 7-day bed hold. During a subsequent review of Resident 63's hospitalization paperwork, dated July 5, 2024, there was no record of the notice of transfer or discharge sent to the Ombudsman found. During an interview on January 24, 2025, at 4:45 PM here, with the SW, the SW stated, I cannot find the notice of transfer or discharge sent to the Ombudsman for this hospitalization date. It was not sent. During a concurrent interview and record review on January 24, 2025, at 5:25 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Transfer or Discharge notice, dated March 2024, was reviewed. The P&P indicated .4. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: d. An immediate transfer or discharge is required by the resident's urgent medical needs; and/or e. The resident has not resided in the facility for thirty (30) days .6. For Facility-Initiated discharges, a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative . The DON stated the P&P was not followed and further stated the Ombudsman should have been notified and was not.

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the facility's policy and procedure (P&P) for one (1) of 92 residents (Resident 75) when five tablets were found in a medication cup, on the bedside table, unattended by staff. This failure had the potential to cause ineffective drug therapy, significant side effects, and adversely affect the health and safety of Resident 75. Findings: During a review of Resident 75's clinical records, the Admission Record (contains demographic and medical information) indicated, Resident 75 was admitted to the facility on [DATE], with diagnoses of traumatic subarachnoid hemorrhage without loss of consciousness (bleeding in the brain without passing out), and displaced fracture of body of right talus subsequent encounter for fracture (a break of the bone that connects the ankle to the foot, and the neck area). During a concurrent observation and interview on January 21, 2025, at 12:42 PM, with Resident 75, inside Resident 75's room, five medication tablets were found in a medication cup, on-top of the beside table next to the lunch meal tray. Resident 75 stated, These are the morning medications, and I haven't gotten around to taking it yet. Resident 75 proceeded to grab the medication cup and swallowed the tablets. During a concurrent interview and record review on January 21, 2025, at 1:01 PM with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 went inside Resident 75's room and Resident 75 confirmed LVN 2 was the nurse who gave him the medication in the morning. LVN 2 reviewed the picture taken of the five tablets in the medication cup and she stated she was not sure if that was Resident 75's morning medications. LVN 2 stated she did not remember seeing if Resident 75 took his medication this morning at 9:00 AM but verified she was the nurse who gave his morning medications. LVN 2 further stated it was important to make sure medications are taken by the resident at the time of the prescribed time and to make sure the residents swallow the medications handed to them. During a concurrent interview and record review on January 21, 2025, at 2:34 PM, with the Director of Nursing (DON), the facility's P&P titled, Administering Medications, dated April 2019, was reviewed. The P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . The DON stated that the P&P was not followed and further stated it was important to make sure medication tablets are not laying around unattended and that residents are medicated as prescribed by the physician.

Based on observation, interview, and record review, the facility failed to store residents' food according to professional standards for food service safety when a dark brownish-reddish frozen spill was found on the bottom part of the freezer of the residents' refrigerator on January 21, 2025. This failure had the potential for bacteria to growth and to cause foodborne illness in residents who store food in the the residents' refrigerator. Findings: During an observation of the residents' refrigerator on January 21, 2025, at 10:55 AM, a dark brownish-reddish frozen spill was on the bottom part of the freezer. During an interview with the Registered Nurse 1 (RN 1) on January 21, 2025, at 10:57 AM, RN 1 stated that usually the Licensed Vocational Nurse on duty or the housekeeping is responsible for cleaning the residents' refrigerator and does not know why the freezer is dirty. During an interview with the Dietary Supervisor (DS), on January 23, 2025, at 10:49 AM, the DS stated his expectation is that the residents' refrigerator is clean with no frozen spills. The DS stated he wasn't aware the freezer was dirty and that he should have checked it for cleanliness. During a concurrent Interview and record review with the Director of Nursing (DON) on January 24, 2025, at 2:09 PM, the facility's P&P titled, Facility Resident Refrigerators was reviewed. The P&P states, this facility will ensure safe refrigerator maintenance, temperatures, and sanitation, and will observe food expiration guidelines .Weekly cleaning and maintenance on refrigerator Refrigerators will be kept clean and maintained with a disinfectant . When asked if this P&P was followed, the DON stated, If someone would have told housekeeping about the frozen spill, they would have cleaned it. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated (C) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . in addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-are a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs- germs that resist treatment with more than one antibiotic]) were maintained for one (1) of five (5) sampled residents (Resident 97) when one Certified Nurse Assistant (CNA 1) did not wear a gown when providing incontinence care. This failure had the potential to result in an increased risk of cross-contamination (the transfer of harmful bacteria) to 92 highly vulnerable residents whose health conditions are already compromised. Finding: During an observation on January 22, 2025, at 9:50 AM, in Residents 97's room, there was a sign outside the room indicating Resident 97 was on EBP precautions. Resident 97 was lying in bed while CNA 1 was changing the incontinence brief without wearing a gown. During an interview on January 22, 2025, at 9:55 AM, with CNA 1, CNA 1 stated she should have worn a gown for a resident on EBP. CNA 1 stated, I forgot to wear a gown. I should have worn one to prevent the risk of spreading disease, but I was in a rush because other residents also needed assistance. During a review of Active orders dated January 21, 2025, for Resident 97, the order indicated, enhanced barrier precautions [EBP] during high contact resident care activities secondary to wound to right leg. During a review of Resident 97's clinical record, the Admission Record (contains demographic and medical information and the admitted ), the Admission Record indicated Resident 97 was admitted to the facility on [DATE], with diagnoses of Leukocytoclastic Vasculitis (LCV- a disease that causes inflammation of small blood vessels), Cellulitis (a skin infection that usually appears as a red, inflamed area of skin) of right and left lower limbs, and non-pressure chronic ulcer (sores that develop on the skin and take a long time to heal) of unspecified part of left lower leg. During a concurrent interview and record review on January 22, 2025, at 11:30 AM with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, dated September 2022, was reviewed. The P&P indicated, Enhanced Standard Precautions .wear gowns and gloves while performing the following high-contact tasks .Any care where close contact with the resident is expected to occur such as bathing, peri-care, assisting with toileting, changing incontinence briefs, respiratory care . The DON stated CNA 1 did not show compliance with the P&P and should have due to risk of resident's safety throughout the facility.

Based on interview and record review, the facility failed to prevent elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) by one of eight residents (Resident 1) with a wander guard system (a wander guard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts with an audible sound) when Resident 1, who was at risk for elopement, did not have close monitoring of his whereabouts and eloped from the facility through a parking lot gate which automatically opened to vehicles entering and exiting from the facility's parking lot. This failure had the potential to cause Resident 1 to suffer from harm, injury, or possible death while being unsupervised outside of the facility from November 4, 2024, through November 8, 2024. Findings: An unannounced visit was made to the facility on [DATE], at 1:48 PM, to investigate a facility reported incident regarding a resident elopement. A review of Resident 1's face sheet (a document that gives a summary of resident information), undated, indicated an admitted [DATE], with diagnoses that included: encephalopathy (a group of conditions that cause brain dysfunction such as confusion, memory loss, and personality changes), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 1's Elopement and Wandering Risk Observation/Assessment, dated September 28, 2024, indicated, Reason for the Evaluation, Instructions: Evaluate/Assess the resident status in the seven clinical areas listed below. If the total score is 10 or greater, the resident would be considered At Risk for Wandering or Elopement . Resident 1's score was 18. A review of Patient 1's care plan indicated, Elopement: Resident is at risk for elopement/exit seeking/wandering related to: difficult to redirect, exit seeking behaviors, mood or behavior disorders, psychotropic/mood-altering medications, cognitive deficit-poor safety awareness, impulsivity, wander guard placed on [left] ankle, as per order. Date Initiated: [June 24, 2024], Revision on: [November 6, 2024]. Interventions: Monitor environment for hazards which may increase supervision requirements. Date Initiated: [June 24, 2024], Monitor whereabouts frequently. Date Initiated: [June 24, 2024], Provide redirection as needed. Date Initiated: [June 24, 2024]. Wander alarm as ordered. Date Initiated: [June 24, 2024]. During an interview with the Assistant Director of Nursing (ADON) on November 6, 2024, at 1:52 PM, the ADON stated Resident 1 was last observed at the facility on November 4, 2024, at approximately 9 PM and around 10:40 PM, a Certified Nursing Assistant (CNA 1) noticed Resident 1 was not in his room. The ADON stated a search of the facility, the surrounding parking lot area and five-mile radius in the community was conducted but Resident 1 was not located. The ADON stated Resident 1 was admitted on [DATE], and had been assessed as an elopement risk and a wander guard bracelet was placed on his left ankle. The ADON stated the wander guard system was activated on all the facility's exit doors and the automatic parking lot gate; when a resident with a wander guard bracelet went through an exit door or the automatic parking lot gate, an alarm would sound. The ADON stated CNA 1 reported seeing Resident 1 in the outside smoking area around 9 PM and the smoking area was open to the parking lot area. The ADON stated Resident 1 could have walked freely to the automatic parking lot gate and walked through when a vehicle entered or exited because staff did not continuously monitor the automatic parking lot gate. The ADON stated Resident 1's wander guard should have alarmed inside the facility if Resident 1 had walked through the automatic parking lot gate, but staff did not report hearing the alarm on November 4, 2024, between 9 PM and 10:40 PM. The ADON stated Resident 1 could have cut off his wander guard, but the staff did not locate the remains of a wander guard during their search of the facility. During a test of the wander guard system on November 6, 2024, at 2:26 PM, with the ADON, a facility exit door, a few rooms down from Resident 1's room, did not alarm. The ADON confirmed the door did not alarm when tested . During an interview with CNA 1 on November 7, 2024, at 1:10 PM, CNA 1 stated she brought Resident 1's dinner tray to his room for dinner on November 4, 2024, around 6:30 PM and Resident 1 asked her where his coffee was, and she said it was on the dinner tray. CNA 1 stated she checked on Resident 1 at approximately 9 PM and Resident 1 was sitting in the outside smoking area, just sitting there, not smoking, and around 10:40 PM she checked on Resident 1 again and I don't see him. She searched for him in the facility and outside and then she informed the nurse Resident 1 was missing. CNA 1 stated she did not see Resident 1 go outside to the smoking area and did not notice any other residents with him. CNA 1 stated Resident 1 liked to be alone and outside most of the time, and she did not hear the alarm for the automatic parking lot gate sound on November 4, 2024, between 9 PM and 10:40 PM. CNA 1 stated she was surprised Resident 1 was sitting in the smoking area because his usual activity was to walk quickly around the parking lot area, which brought him close to the automatic parking lot gate. During an interview with Resident 1 on November 12, 2024, at 12:30 PM, Resident 1 stated he left the facility through the parking lot gate because he thought the facility was going to send him away to a mental health facility and he did not want to go, so I left. Resident 1 stated he decided to come back because the facility was not going to send him away anymore. A review of the facility's policy and procedure titled Wandering and Elopements, dated March 2019, indicated, Policy Statement: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. An Immediate Jeopardy (IJ-a situation with the potential to harm the health and safety of the patients) was called under 42 CFR S483.25(d)(2) F 689 Each resident receives adequate supervision and assistance devices to prevent accidents, on November 7, 2024, at 1:45 PM, in the presence of the Administrator (Admin) and the Assistant Director of Nursing (ADON). The Admin and ADON were verbally notified of the IJ situation identified based on the facility's failure to protect Resident 1 from elopement. The facility submitted a corrective action plan which was reviewed and accepted on November 8, 2024, at 1:42 PM, in the presence of the Administrator (Admin). The facility's corrective action plan indicated the following: This letter constitutes a credible allegation by [name of the facility] that the Immediate Jeopardy identified by the California Department of Public Health on [November] 7, 2024 due to the identified resident who eloped from the facility on [November 4, 2024] and currently resident is not located. Immediate Plan of Action for the removal of Immediate Jeopardy 1. The administrator assigned a staff member to monitor the entrance gate of the facility by the parking lot for 24 hours, [seven] days a week to ensure no other residents could exit from parking lot main gate. The area will be monitored [every]-shift. The assigned staff member will redirect residents to safety. The staff member will contact another staff member to assist as needed, so the area is not left unmonitored. 2. There are 7 [seven] residents identified as high risk for elopement risks and these residents are still using a wander guard alarm system 3. Assigned Staff checks for the presence of the wander guard as well as the functionality of the wander guard daily. 4. IPN [Infection Preventionist Nurse], Case Manager and MDS [Minimum Data Set] staff conducted reassessment on the 7 residents for elopement risks and clarified the orders to reflect Licensed Nurses monitoring of the presence of the wander guard device every shift and notified the responsible party and attending physicians accordingly. 5. Assigned Staff to monitor and log the expiration date of the wander guard device weekly. 6. The Administrator initially in-serviced staff on [November 6, 2024] regarding Monitoring of Residents on wander guard. In-servicing of staff will continue effective [November 7, 2024]. 7. The facility created elopement binders for each nursing station and 1 [one] by the receptionist with the resident's photo, face sheet and redirect residents who are wandering in the unit. 8. Maintenance Staff removed the air curtain on door 3 [three] so it doesn't interfere with the functionality of the wander guard system. The acceptable corrective action plan was verified with the facility to be implemented through observation, interview, and record review. The IJ was removed on November 12, 2024, at 12:54 PM, in the presence of the Admin and ADON.

Based on interview and record review, the facility failed to protect against verbal abuse for one of three sampled residents (Resident 1) when a Physical Therapy Assistant (PTA 1) yelled Get the f**k up! at Resident 1 when Resident 1 was uncooperative during a transfer. This failure caused Resident 1 to suffer fear, confusion and anxiety. Findings: An unannounced visit was made to the facility on [DATE], at 9:54 AM, to investigate a facility reported incident regarding an allegation of verbal abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admitted [DATE]. Resident 1 had diagnoses that included stroke and left sided paralysis (complete or partial loss of muscle function). During an interview with a Certified Nursing Assistant (CNA 1) on September 24, 2024, at 12:02 PM, CNA 1 stated she was walking down the hall and saw Resident 1 on the floor next to her bed. CNA 1 stated she entered the room to assist Resident 1 to her bed and a Physical Therapy Assistant (PTA 1) walked by the door and asked if she needed assistance. CNA 1 stated she told him Yes. CNA 1 stated PTA 1 entered the room, checked if Resident 1 had any injuries and then told Resident 1 to get to her knees. CNA 1 stated Resident 1 did not respond to the request and PTA 1 got frustrated and yelled at Resident 1 Get the f**k up! Resident 1 did not respond to the command or expletive and continued to lay on the floor. CNA 1 stated after PTA 1 yelled the command and expletive PTA 1 back away from Resident 1 and CNA 2 and CNA 3 came into the room and PTA 1 left the room. CNA 1 stated she held the wheelchair for safety while CNA 2 and CNA 3 transferred Resident 1 back to her bed. CNA 1 stated a Licensed Vocational Nurse (LVN 1) was in the doorway doing medication pass and witnessed what had happened. CNA 1 stated LVN 1 told her Resident 1 ' s roommate ' s (Resident 3) husband had heard what PTA 1 had yelled. During an interview with a Certified Nursing Assistant (CNA 2) on September 24, 2024, at 12:20 PM, CNA 2 stated she was walking by the door and saw PTA 1 trying to lift Resident 1 by himself, so she went in the room to assist. CNA 2 stated PTA 1 was saying Get on your knees! and Resident 1 was not understanding because she was a very confused resident. CNA 2 stated PTA 1 got frustrated and loudly said Get the f**k up! LVN 1 was unavailable for interview. CNA 3 was unavailable for interview. PTA 1 was unavailable for interview. During an interview with the Director of Nursing (DON) on September 24, 2024, at 1:05 PM, the DON stated she interviewed all four witness LVN 1, CNA 1, CNA 2 and CNA 3 and they all stated PTA 1 had yelled Get the f**k up! at Resident 1. The DON stated her investigation concluded PTA 1 used profanity directed at Resident 1. The DON stated Resident 1 had the right to be free from verbal abuse and it was the responsibility of the facility to protect Resident 1 from abuse. A review of the facility ' s policy and procedure titled, Residents ' Rights, dated December 2016, indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. 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; c. be free from abuse, neglect, misappropriation of property, and exploitation; .

Based on interview and record review, the facility failed to ensure supervision for 1 of 43 unsampled residents (Unsampled Resident 15), 6 Sampled Residents (Residents 20, 21, 22, 23, 24, and 25) who were wearing wander guards (A censored device used to alert the staff and alarms when a resident goes beyond a certain area within the facility grounds and alerts the staff) in a universe of 94 by failing to provide: 1. A system to evaluate, analyze and monitor the effectiveness of the wander guard devices (A censored device used to alert the staff and alarms when a resident goes beyond a certain area within the facility grounds and alerts the staff) was developed for 6 sampled residents who were wearing wander guards, (Residents 20, 21, 22, 23, 24, and 25) and for 1 of 43 unsampled residents (Unsampled Resident 15), who eloped (to leave from the facility without notifying staff) twice (once while wearing a wander guard) in a universe of 94. 2. A policy and procedure was developed to evaluate, analyze, and monitor all residents who required a wander guard device; and 3. A system to evaluate and analyze the wander guard system's effectiveness and its function was developed. These failed practices, resulted in Unsampled Resident 15 eloping twice from the facility, once while wearing a wander guard device, and had the potential to result in 6 of 6 Sampled Residents who were wearing wander guard devices to not be adequately supervised which could affect the health and safety of the residents. Findings: During a record review, on April 9, 2014, of an Unsampled Resident (Resident 15 - who was reported by the facility as being missing) clinical record, it indicated the resident was admitted to the facility from a general acute care hospital on March 12, 2014. The [DIAGNOSES REDACTED].{extremely energetic/high spirits} and depressive episodes {loss of interest/low in spirits}). During a record review, on April 9, 2014, of the "Nursing Care Notes," dated March 12, 2014, noted Unsampled Resident 15 was easily redirected when signs and symptoms of confusion were displayed. During a review on April 9, 2014, of Unsampled Resident 15's clinical record, the following were noted: a. "Nursing Care Notes" dated March 13, 2014 at 3 PM and 4:30 PM, indicated that Unsampled Resident 15 had periods of confusion. b. "Narrative Nurse Assistant Notes," dated March 13, 2014, indicated that Unsampled Resident 15 was "Seen outside with no clothes on". c. "Nursing Care Notes" dated March 13, 2014 at 7:30 AM noted that Unsampled Resident 15 was missing. The notes also indicated that Unsampled Resident 15 had been seen earlier that day in the smoking area, wearing a gown down to his waistline and then took it off and was nude. The entry also documented "There was a chair noted in front of building next to the wall - where it would be possible for resident to have jumped over the fence. Staff went around surrounding area - unable to locate resident - call placed to the San Bernardino Police Department (SBPD) at 5 AM..." Further documentation indicated that Unsampled Resident 15 was found (1.8 miles away from the facility), picked up by facility staff and returned to the facility on the same day, March 13, 2014 at 12 PM. d. "Nursing Care Notes," dated March 13, 2014 at 4:30 PM, indicated the resident was confused about where he had been for the past few days. A cane was provided to assist him with walking and a wander guard device order was obtained and placed on the Unsampled Resident 15. e. "Nursing Care Notes," dated March 17, 2014 at 3:50 AM indicated that a LVN documented "Resident was noted to be missing searched entire facility - unable to locate resident - called LVN from last shift to see what resident was wearing...LVN last saw (Unsampled Resident 15) at 10:30 PM on 3/16/14. This LVN was notified by CNA (Certified Nurse Assistant) at 12:25 AM on 3/17/14 of resident missing. Was unable to locate resident and call placed to SBPD..." Additional documentation on the same day (March 17, 2014) at 3 PM indicated Unsampled Resident 15 was "Still missing from facility." f. "Narrative Nursing Assistant Notes", dated March 18, 2014 and March 19, 2014, it was identified that Unsampled Resident 15 was still missing. An interview was conducted on April 9, 2014 at 11:45 AM, with the Administrator who stated that Unsampled Resident 15 had eloped twice from the facility. The first elopement occurred on March 13, 2014 (at approximately 7:30 AM), but Unsampled Resident 15 was found and returned to the facility at 12 PM on the same day. After this first incident (March 13, 2014), Unsampled Resident 15 agreed to wear a wander guard device. The Administrator also stated that Unsampled Resident 15's second elopement from the facility, was on March 16, 2014. "This was the second elopement and it was Against Medical Advice" (AMA -leaving without informing the facility and against the medical doctors advise) and had not been found. During an interview with the Administrator on April 11, 2014 at 4:30 PM, he stated, when Unsampled Resident 15 went missing on March 16, 2014, (the second time that he eloped) it was not investigated by the facility, no interviews were conducted to determine how the resident eloped, and the incident was not reported to the California Department of Public Health (CDPH). The Administrator also stated, "This incident should have been investigated and reported to CDPH. Resident 15 has not found to date". During an interview with the Director of Nurses (DON) on April 11, 2014 at 5:30 PM, she stated, the wander guard device that was placed on Resident 15 had also not been found and the facility had no system in place to evaluate or analyze the wander guard device's function or the effectiveness of the wander guard system. The DON stated, "We should have a system". The DON stated that she did not maintain a log to keep track of when she tests the wander guards and stated "I keep it all in my head." Additionally, she stated, that the facility had no policy and procedure to analyze, evaluate or monitor the wander guard device and that the facility also did not have a system to evaluate or monitor the effectiveness of the facility's supervision of the residents who required the use of the wander guard devices. The (DON) stated, "We should have a policy and procedure to monitor and evaluate the wander guard system". The DON confirmed that as of April 11, 2014, the facility had 6 Sampled Residents (20, 21, 22, 23, 24 and 25), who had wander guard devices and had no systems in place to evaluate or analyze the wander guard device's function or the effectiveness of the wander guard system. During an interview, on April 14, 2014 at approximately 5 PM, with a Licensed Vocational Nurse (LVN 5), he stated that he was not sure if the facility had a process in place to address residents who required the use of the wander guard devices. He also stated that he thought that the wander guards were supposed to be checked during the day shift to determine if they are working properly. During an interview, on April 15, 2014 at 10:45 AM, with a Quality Assessment & Assurance Committee Member (QAA - a committee that serves a preventative function by reviewing and improving systems), she stated that she was not aware of a facility policy/process that evaluates or monitors the use of the wander guard device. She also stated, "Yes, there should be a policy". The (QAA) member was asked, if there was a process/system for supervising any resident, including Sampled Residents 20, 21, 22, 23, 24 and 25 which required the use of a wander guard device. She replied, "Residents should be checked every 2 hours regularly even if they do not have a wander guard." An Immediate Jeopardy (IJ - a crisis situation which has threatened or is likely to threaten the health and safety of a resident) was called under Quality of Care 483.25(h) Free of Accidents Hazards/Supervision/Devices, tag F323 - Accidents & Supervision on April 11, 2014 at 8:00 PM, in the presence of the facility's Administrator, Director of Nurses (DON), Director of Staff Development (DSD). The facility failed to ensure: 1. A system to evaluate, analyze and monitor the effectiveness of the wander guard devices was developed for 6 sampled residents (Residents 20, 21, 22, 23, 24, and 25), 1 Unsampled Resident 15 (who eloped from the facility twice) and for all residents who would require a wander guard device in a universe of 94. 2. A policy and procedure was developed to evaluate, analyze, and monitor all residents who required a wander guard device; and 3. A system to evaluate and analyze the wander guard system's effectiveness and its functioning was developed. The IJ was abated in the presence of the facility's Administrator on April 14, 2014 at 5:05 PM after a plan of correction was accepted by the survey team.