Every finding on record at Dept of State Hospitals - Metropolitan SNF

Based on interviews and record review, the facility failed to ensure that an alleged violation of neglect was reported within 24 hours to the administrator and that the SOC 341 ( Report of Suspected Dependent Adult/Elder Abuse - a mandated California Department of Social Services form used by professionals to report suspected abuse and neglect) was initiated timely when an alleged staff was observed asleep while performing Line of Sight (LOS-a safety intervention requiring continuous direct visual) observation to Resident 1.This failure had the potential to delay the initiation of a timely investigation and implementation of interventions to ensure Resident 1's safety.Findings:During a review of Resident 1's Face Sheet (demographics), dated 4/29/2026, the record indicated Resident 1 was admitted to the facility on [DATE] with a history of diagnoses that included: schizophrenia (a chronic, severe brain disorder that causes individuals to interpret reality abnormally, characterized by symptoms like hallucinations, delusions, and disorganized thinking), other epilepsy - not intractable - without status epilepticus (a seizure disorder that is manageable with medication and does not involve prolonged, continuous seizing) and benign neoplasm of cerebral meninges (a slow growing, noncancerous tumor arising from the protective membranes surrounding the brain).During an interview on 4/29/26 at 9:42 a.m. with Nursing Coordinator (NC), NC stated that on 4/13/26 at approximately 9:00 a.m. he received an email from the Acting after-hours Supervisor Registered Nurse (ASRN) 1 regarding an incident on 4/4/26 alleging the Registry Registered Nurse (RRN) 1 fell asleep while assigned to provide line-of-sight (LOS) observation to Resident 1. NC stated that staff were expected to have reported the incident and should have completed an SOC 341 at time of incident as the incident was considered neglect. NC further stated that SOC 341 was not completed until 4/13/26.During an interview on 4/29/26 at 10:07 a.m. with Supervising Registered Nurse (SRN) 1, SRN 1 stated Resident 1 had been on LOS for danger to self (DTS) behaviors that included throwing herself down to the ground and injuring self.During an interview on 4/29/26 at 8:20 p.m. with ASRN 1, ASRN 1 confirmed he worked the overnight (NOC) shift on 4/3/26. ASRN 1 stated he was contacted in the early morning of 4/4/26 by Registered Nurse (RN) 1, who notified him that RRN 1 fell asleep while assigned to provide LOS observation to Resident 1. ASRN 1 stated this incident would be considered neglect because RRN 1 was asleep and unable to pay attention and watch Resident 1 's safety. ASRN 1 confirmed that he did not initiate an SOC 341 at time of the incident.During an interview on 4/30/26 at 6:10 a.m. with RN 1, RN 1 confirmed she worked the NOC shift on 4/3/26. RN 1 stated she went to do her rounds (every 15/30 minute observation of residents) and noticed RRN 1's eyes appeared closed and appeared to be asleep. RN 1 stated she went up to RRN 1 and called out her name with no response and heard what sounded like sleeping sounds. RN 1 stated this was potential neglect because Resident 1 was on LOS observation for safety and RRN 1 was asleep and did not watch Resident 1. RN 1 stated that she notified ASRN 1 but did not know an SOC 341 needed to be completed. RN 1 confirmed an SOC 341 was not initiated at time of incident.During a review of Resident 1's Interdisciplinary Note, dated 4/13/26 at 10:38 a.m., the record indicated that on 4/13/26 at approximately 9:20 a.m. information was obtained that an employee assigned to monitor a patient on line of sight (LOS) during 4/3/25 NOC shift was noted sleeping while on the assignment.During a review of Resident 1's Treatment Plan, dated 4/9/26, the record indicated on 4/3/26 Resident 1 had a mini team meeting where it was determined Resident 1 would remain on LOS for DTS. Record indicated that Resident 1 had open focus (care plan - written document outlining a person's specific health needs, goals, and the actions healthcare providers will take to meet them) 3.1 Dangerousness and Impulsivity related to history of aggressive and self-injurious behaviors in response to experience of auditory hallucinations. High risk behaviors include throwing body against the wall and floor, banging head and physical assault of others. Interventions include staff monitor Resident 1 daily for proper use of coping skills that will assist in preventing self-injurious behaviors.During a review of Resident 1's Physician's Orders, dated 4/3/26 at 9:00 a.m., the record indicated that Resident 1's LOS order was renewed for 72 hours.During a review of facility's Report Of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 4/13/26, the report indicated neglect of Resident 1 occurred on 4/4/26 between the times of 0200-0400 and 0600-0700 hours. The record further indicated that the incident was not reported to law enforcement until 4/13/26.During a review of the facility's policy and procedure (P&P) titled, Supervision for High Risk Patients, dated 6/18/2024, the P&P indicated, .It is the policy of [Facility Name] to provide time-limited enhanced observation of patients for the safety of patients. Line of Sight Patients (LOS Patients) shall always be in the field of vision of an assigned staff person who will be able to notice and intervene if a dangerous incident occurs.During a Review of facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/2025, the P&P indicated, .Neglect - failure to provide care or service. protection from health and safety hazards. General Rules 5.1 Any mandated reporter who, in their professional capacity, or within the scope of their employment, has observed or has knowledge of an incident that reasonably appears to be physical abuse. or neglect. shall report the known or suspected instance of abuse to the Office of Protected Services (OPS) / Department of Police Services (DPS) local law enforcement agency, by telephone or through a written report immediately or as soon as practicably possible. All staff must report any observed or suspected cases. or who is informed and reasonably believe that an individual has experienced behavior constituting. neglect. 5.3 When a hospital employee observed suspected patient abuse, or receives an allegation of patient abuse from another person, they shall immediately:. 5.3.5 Complete a Report of Suspected Dependent Adult/Elder Abuse (Form SOC 341) and attach the form to the completed incident report by end of shift.9.3 All alleged violations involving abuse, neglect,. which occurred in Skilled Nursing units. do not involve abuse and/or do not result in serious bodily injury, the report should be submitted to CDPH no later than within 24 HOURS.

Based on observation, interview, and record review, the facility failed to develop written policies and procedures (P&P) that clearly defined all forms of abuse to include resident-to-resident abuse. This failure resulted in the facility's inability to recognize and identify three of three sampled incidents involving resident-to-resident physical and alleged sexual assault as abuse when1. Resident 2 punched Resident 1 in the face while Resident 1 slept and Resident 2 alleged sexual assault and stated he [Resident 1] tried to have sex with me.2. Resident 3 kicked Resident 4 in the buttocks and Resident 4 punched Resident 3 in the face three times.3. Resident 5 allegedly punched Resident 6 in the chin after a verbal altercation.Consequently, the facility failed to prevent abuse, protect residents from abuse, conduct abuse investigations, report timely, and accurately train staff. This oversight put 53 of 53 residents at risk of unreported and unmitigated abuse, potentially leading to serious harm and/or psychological trauma.Cross reference to F600, F609, F610 and F943. Findings: 1. During a review of Resident 1's Quarterly Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 11/28/2025, the MDS indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of absence of the left eye, tracheostomy (a surgical hole in the throat to help with breathing), gastrostomy tube (a surgical opening into the intestines to administer nutrition and medications via a tube), and need for assistance. MDS further indicated Resident 1 had difficulty communicating his needs and required the use of a wheelchair for ambulation. During a review of Resident 2's Treatment Plan, dated 1/29/2026 the Treatment Plan indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of schizophrenia (chronic, serious brain disorder that causes people to interpret reality abnormally, often resulting in hallucinations, delusions, and disorganized thinking) and a criminal history of assault by means of force likely to produce great bodily injury. The Treatment Plan further indicated Resident 2 was evaluated to be a moderate risk for violence against others. During a concurrent interview and record review on 2/12/2026 at 10 a.m. with Standards Compliance Supervising Registered Nurse (SCSRN), Resident 1's Interdisciplinary Notes (IDN), dated 2/7/2026 was reviewed. The IDN indicated on 2/7/2026, Resident 1 was punched in the face by Resident 2, resulting in a 1.2 cm (centimeter- unit of measurement) laceration to the right upper eyebrow that required medical attention. The IDN further indicated Resident 2 informed staff that I punched him early in the morning because he tried to have sex with me. SCSRN confirmed the incidents were reported to CDPH three days after on 2/10/2026, and stated the facility did not consider resident-to-resident physical or sexual assault to constitute as abuse, therefore the facility did not have to report to CDPH within 2 hours. SCSRN further stated both physical and alleged sexual assault were not investigated due to not meeting the facility's requirement for the definition of abuse. During a concurrent observation and interview on 2/12/2025 at 10:23 a.m. in Resident 1's room, Resident 1 was lying in bed, Resident 1 was without a left eye and had a tracheostomy tube for breathing. Resident 1 had a noticeable laceration above the right eyebrow accompanied by bruising. Resident 1 had to cover his tracheostomy tube with his hand to communicate, spoke in a whisper, and frequently struggled to catch his breath while speaking. Resident 1 stated, He [Resident 2] attacked me in my sleep and it was unprovoked. During an interview on 2/12/2025 at 10:28 a.m. with Resident 2, Resident 2 confirmed he punched Resident 1 in the face. During an interview on 2/12/2026 at 11:19 a.m. with Registered Nurse (RN) 1, RN 1 stated he went into Resident 1's room, to take vital signs, and seen dried blood above Resident 1's right eyebrow. RN 1 stated Resident 1 informed him that Resident 2 punched Resident 1 in the face while he was sleeping. RN 1 further stated he interviewed Resident 2 and Resident 2 stated I hit him because he wanted to have sex with me. RN 1 stated Resident 2 punching Resident 1 in the face was considered a physical altercation and not abuse, and Resident 2 alleging Resident 1 of trying to have sex with him was not considered sexual assault or abuse. During an interview on 2/12/2026 at 11:26 a.m. with Registered Nurse Shift Lead (RNSL), RNSL stated resident to resident physical or sexual assault was not abuse and staff to resident physical or sexual assault was considered abuse. During an interview on 2/12/2026 at 12:09 p.m. with Program 6 Program Director (PD), the PD stated resident on resident physical or sexual assault was not considered abuse and only staff can be a perpetrator (the person who commits a harmful or illegal act such as a crime, wrongdoing or violent act), therefore the incidents between Resident 1 and Resident 2 were not investigated as abuse and a SOC 341 (Form to report Suspected Dependent Adult/Elder Abuse) was not completed. During an interview on 2/12/2026 at 2:27 p.m. with RNSL, RNSL stated she was not surprised by this incident because in October 2025, Resident 2 attempted to punch a staff member. RNSL further stated, approximately 10 days prior to 2/7/2026, Resident 2 punching Resident 1 in the face, Resident 2 removed the footrest from a wheelchair and repeatedly hit the plexiglass window of the nurses' station requiring emergency assistance from multiple staff members to subdue the resident. RNSL stated Resident 2 was scary because he was violent, had aggressive behaviors and was very unpredictable. RNSL stated on 2/9/2026 Resident 2 informed the Psychiatrist (Psych) 1 that he will continue to hit others until he gets out of the facility. During an interview on 2/17/2026 at 2:36 p.m. with Psych 2, Psych 2 stated he was covering the on-call shift on 2/7/2026 and was informed by unit staff of Resident 2 punching Resident 1 in the face. Psych 2 further stated he did not go to the unit to evaluate both residents and was not aware Resident 2 made an allegation of sexual abuse. Psych 2 stated he should have gone and evaluated Resident 1 and Resident 2.During an interview on 2/19/2026 at 10:18 a.m. with the Social Worker (SW), SW stated she was concerned for the safety of all residents on the same unit as Resident 2 due to his aggressive behaviors and lack of insight. SW confirmed with the most recent Treatment Plan dated 1/29/2026, there was no plan of care or intervention in place to prevent Resident 2's aggressive behaviors towards other residents, or to protect other residents from physical harm. 2. During a review of Resident 3's Treatment Plan, the Treatment plan indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses of gastrostomy status (a surgical opening into the intestines to administer nutrition and medications via a tube) and pulmonary fibrosis (chronic lung disease when the tissue becomes thickened, stiff and scarred making it difficult to breathe). The Treatment Plan further indicated Resident 3 required maximum assistance (patient requires significant help/dependency from a caregiver normally a minimum of 2 staff members for helping) for transferring and was a nonfunctional ambulator (an individual is unable to walk). The Treatment Plan further indicated Resident 3 was evaluated to be a high risk for violence against others. During a review of Resident 4's Treatment Plan, the Treatment Plan indicated Resident 4 was admitted to the facility on [DATE] with the diagnoses of unsteadiness on feet, blindness of left eye and fracture of left femur (broken left thigh bone) with routine healing. The Treatment Plan further indicated Resident 4 was evaluated to be a low risk for violence against others but had a history of DTO (danger to others) behaviors in the past. During a review of Resident 3's Interdisciplinary Notes (IDN), dated 2/28/2026, the IDN indicated, On 2/28/2026 at approximately 1205 [Resident 3] was watching TV in the day hall when [Resident 4] was trying to walk in front of him using his front wheel walker. [Resident 3] kicked [Resident 4] on his buttocks area x1. [Resident 4] retaliated, turned around and started punching [Resident 3] with closed right hand fist x3, hitting [Resident 3] on his right side of the face.During a concurrent observation and interview on 3/4/2026 at 3:57 p.m. with Registered Nurse Shift Lead (RNSL) and Standards Compliance Registered Nurse (SCRN) in the day hall, Resident 3 was shouting and yelling out to surveyor. RNSL stated Resident 3 just received a PRN (as needed) antipsychotic medication (drug given to treat psychosis-a disconnection from reality) due to aggression and agitation. RNSL and SCRN recommended not interviewing Resident 3 due to safety concerns.During an interview on 3/4/2026 at 4:30 p.m. with Standards Compliance Director (SCD), SCD confirmed with the facility's abuse P&P that the definitions in the P&P do not include resident-to-resident as a possibility for abuse. SCD stated there is not another P&P for protection and prevention of abuse to include resident-to-resident abuse. SCD further stated the physical altercations between Resident 3 and Resident 4 were not reported to state survey agency (California Department of Public Health-CDPH) until 2 days after the incident on 2/28/2026 and stated it should have been reported within 2 hours.During an interview on 3/5/2026 at 4:15 p.m. with the Social Worker (SW), SW stated she was not aware of Resident 4 receiving any enhanced monitoring after the incident with Resident 3 to prevent further abuse and to protect other residents. SW further stated Resident 4 was transferred to a different unit on 3/4/2026 due to aggressive behaviors and not meeting skilled nursing needs anymore.During an interview on 3/5/2026 at 5:51 p.m. with the Unit Supervisor (US), the US confirmed with Resident 4's medical records, that Resident 4 did not receive a medication change or enhanced monitoring after the physical altercation with Resident 3. The US stated her recommendation would have been to put Resident 4 on enhanced monitoring to protect other residents in case he had another aggressive outburst and confirmed with an IDN that Resident 4 had a second aggressive outburst two days after the physical altercation with Resident 3, on 2/28/2026, with a staff member.3. During a review of Resident 5's Treatment Plan, the Treatment Plan indicated Resident 5 was admitted to the facility on [DATE] with diagnosis of back fracture and epilepsy (recurrent, unprovoked seizures- abnormal electrical activity in the brain). The Treatment Plan further indicated Resident 5 was evaluated to be a moderate risk for violence against others due to significant history of DTO (danger to others) behaviors towards other residents and staff.During a review of Resident 6's Treatment Plan, the Treatment Plan indicated Resident 6 was admitted to the facility on [DATE] for diagnoses to include. The Treatment Plan further indicated Resident 6 was evaluated to be a moderate risk for violence against others due to verbalizing thoughts of harming another resident. During a review of Resident 6's Interdisciplinary Notes (IDN), dated 2/28/2026, the IDN indicated, At approximately 0900 staff heard yelling coming from the day hall. Staff in the nursing station immediately responded and observed [Resident 5] and [Resident 6] next to each other in the day hall having a verbal altercation when [Resident 5] struck [Resident 6] . When [Resident 6] was asked what happened, patient stated, I don't know. I didn't do anything. [Resident 6] stated [Resident 5] hit him in the chin x1.During an interview on 3/4/2026 at 3:40 p.m. with Resident 5, Resident 5 stated Resident 6 started cursing and yelling at him so with a closed fist Resident 5 touched Resident 6's chin to shut him up.During an interview on 3/4/2026 at 4:30 p.m. with Standards Compliance Director (SCD), SCD confirmed with the facility's abuse P&P that the definitions in the P&P do not include resident-to-resident as a possibility for abuse. SCD stated there is not another P&P for protection and prevention of abuse to include resident-to-resident abuse. SCD further stated the physical altercations between Resident 5 and Resident 6 were not reported to state survey agency (California Department of Public Health-CDPH) until 2 days after the incident on 2/28/2026 and stated it should have been reported within 2 hours. SCD confirmed with SOC 341 (Form to report Suspected Dependent Adult/Elder Abuse), that the SOC 341 was not completed until today, 3/4/2026, and should have been completed by the end of shift on the day of the incident, 2/28/2026.During an interview on 3/6/2026 at 7:59 a.m. with Psychologist (Psych) 3, Psych 3 confirmed she was made aware of the verbal and physical altercation between Resident 5 and Resident 6 when she returned to work on 3/3/2026. Psych 3 stated Resident 6 had an extensive history of verbal aggression towards all residents and staff with two other previous incidents that resulted in alleged physical altercation, and Resident 6 did not have a behavioral care plan and he needed one. Psych 3 further stated Resident 4 had aggressive incidents on his previous unit, and his behavioral care plan had not been updated in over a year. Psych 3 stated Resident 4 informed her that his intent was to harm Resident 3.During a review of the facility's P&P titled, Treatment Plan, dated 7/10/2024, the P&P indicated, Each patient will have a focused, individualized Treatment Plan, based on the integrated assessment. Treatment shall be designed to address each patient's needs. Mini-Team conferences shall be held after an episode of aggression. The treatment plan shall discuss and document the patient's current mental status. interventions, response to interventions, and any risks. The treatment plan shall address any specific individualized risk(s) of the patient including but not limited to risk of danger to self, danger to others.During a review of the facility's P&P titled, Incident Management, dated 5/9/2025, the P&P indicated, . [facility name] will use the definitions of incidents to be reported and investigated listed in the Appendix A. Incidents that Involve Allegations of Abuse or Neglect- When a hospital employee observes suspected patient abuse or receives an allegation of patient abuse from another person, they shall. Refer to AD 3308 [facility's policy and procedure] Reporting Patient Abuse and Neglect for additional information. During a review of the facility's P&P attachment titled, Appendix A- Definitions, undated, the document indicated, Alleged Patient abuse- physical: any intentional interaction or physical contact, motion, or action that is directed toward a patient by someone other than another patient. Alleged Patient Abuse- Psychological: Any act by someone other than another patient that causes or could reasonably be expected to cause mental suffering. Alleged Sexual Abuse: An employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients. During a review of the facility's P&P titled, AD 3308: Reporting Patient Abuse and Neglect, dated 1/3/2023, the P&P indicated, .Definitions. Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. Psychological abuse- any act by someone other than another patient. Verbal abuse- any language by someone other than another patient. Sexual abuse- an employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients. Training. What constitutes abuse, neglect and misappropriation of resident property. Prevention. identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. When a hospital employee observes suspected patient abuse, or receives an allegation of patient abuse, they shall immediately . Complete a Form SOC 341 . Immediate supervisor responsibilities . provide protection to the patient in all instances when there is an allegation of abuse. This includes providing the patient with counseling and debriefing . Notify the Patient's Rights Advocate . Standards compliance responsibilities . all alleged violation involving abuse . which occurred in Skilled Nursing units shall be reported by SCD [Standards Compliance Department]/Designee to CDPH [California Department of Public Health] immediately but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse . SCD shall submit to CDPH within 5 working days of the incident the result of investigations and/or a follow up report . Training- all employees are required to complete annual patient abuse prevention training. Train employees through orientation and on-going sessions on issues related to abuse prohibition practices such as: What constitutes abuse. Prevention . Identify, correct, and intervene in situations in which abuse is more likely to occur. This includes an analysis of: The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors . During a review of the facility's power point training titled, Recognizing and Reporting Abuse, Neglect and Suspected Criminal Conduct, dated 12/2/2025, the training indicated, This training is designed to assist you in improving your recognition of, and response to incidents of abuse . The training will cover processes and procedures, definitions . ensure employees understand their ongoing legal and ethical responsibility to recognize and report suspected cases of abuse . Definitions- Physical Abuse- Any interaction or physical contact, motion, or action that is directed toward a patient by someone other than another patient . Psychological abuse- any act by someone other than another patient . verbal abuse- any language by someone other than another patient . sexual abuse- an employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients, one of whom is not consenting . When an incident or allegation of abuse, neglect or serious bodily injury has occurred, Recognition is key . On 3/5/2026 at 1:08 p.m., the survey team called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident), related to the lack of facility's written policies and procedures for prohibiting and preventing abuse to include resident-to-resident abuse, staff competency in identifying resident-to-resident abuse, preventing, screening, investigating, protecting and reporting abuse, at F 607 [CFR S 483.12(b)], in the presence of the Director of Nursing, Standards Compliance Director, Nursing Coordinator and Standards Compliance Supervising Registered Nurse.On 3/6/2026 at 4:08 p.m., the Standards Compliance Director provided the team with a Plan of Action which included the following actions to be completed and/or started immediately:a.) Physical altercations, sexual allegations, possible mental, psychological and exploitation in SNF area will be treated as potential abuse allegations.b.) SOC 341 form will be completed for each allegation of abuse incident. Completion of SOC 341 will be verified by RN Health Services Specialist/Supervising Registered Nurse prior to end of shift.c.) The hospital updated its reporting of unusual occurrences practice related to any possible abuse incidents to ensure compliance with the 2-hour reporting requirement. 0700-1630 Program VI management/Unit Shift Lead will notify Standards immediately upon identification of a possible abuse incident to ensure reporting requirements are completed within 2 hours. 1630-0700, on weekends and holidays Program VI manager on call/unit shift lead will notify CNS [Central Nursing Staff] for HSS [Health Service Specialist] to complete reporting within 2 hours.d.) Program Director issued a written memorandum for all SNF nursing staff outlining federal regulatory requirements related to abuse recognition, screening and reporting. The memo references CMS State Operations Manual definition of possible abuse including physical, verbal, possible mental/psychological, sexual, and exploitation and clarifies the resident to resident must be treated as potential abuse. The memo and education includes CMS SOM reference, recognition and identification of potential abuse including resident-to-resident, Screening (VRISK-10), prevention strategies and resident protection measures, including expectations for early intervention and behavioral monitoring for residents at risk, investigation requirements and documentation, reporting requirements, SOC 341 completion. SRN will attest that staff can verbalize understanding. Training will be tracked via tracking log. SRN will provide clarification as needed to ensure staff understand the abuse screening and reporting process.e.) Central Nursing Staff Department/Nursing Administrator issued a written memorandum for all registry nursing staff outlining federal regulatory requirements as listed above in (d).f.) Training via memorandum of the non-nursing clinical staff (psychiatry, psychology, rehabilitation therapy, social work, medical services) and ancillary staff (housekeeping, plant operations, nutrition services) will be directed by each department chief/discipline seniors. The training will include federal regulatory requirements as listed above in (d).g.) Additional staff training to provide directions regarding intervention protocols to enhance behavioral monitoring and interventions strategies for residents identified as high risk for behavioral escalation or aggression. Training will include identification of high-risk residents for behavioral escalation, enhanced monitoring and supervision strategies, early interventions and de-escalation techniques, implementation of individualized behavioral interventions, documentation and communication of behavioral concerns to the interdisciplinary team.h.) Identify, correct and intervene in situations in which possible abuse, neglect and/or misappropriation of resident property is more likely to occur an analysis of the following is conducted: physical environment, sufficient staffing, supervision of staff to identify triggers, the assessment, care planning and monitoring of resident.i.) An update to Administrative Directive 3308 to include resident-to-resident physical and verbal assaults, possible mental/psychological abuse, sexual allegations, and exploitation to be treated as potential abuse. The updated directive will include expectations for abuse screening, investigations and reporting requirements.j.) Program VI management will conduct an ongoing review of all incident reports (IRs) involving resident-to-resident altercations or allegations to ensure: SOC 341 reports are completed, reporting timelines are met.On 3/7/2026 at 5:28 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the team accepted the Plan of Action and removed the Immediate Jeopardy in the presence of Registered Nurse 3.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact) by another resident for one of six sampled residents (Resident 1) when Resident 2 punched Resident 1, in the face while Resident 1 slept. The facility failed to implement adequate supervision, environmental interventions, and behavioral interventions for Resident 2, who the facility had previously identified as a moderate risk for violence against others to prevent foreseeable harm. These failures resulted in Resident 1, a medically fragile resident, sustaining a laceration to his eyebrow requiring medical attention and experiencing a loss of safety and subsequently placed all other residents at risk for potential abuse. The facility census was 53.Cross reference to F607, F609, F610 and F943.Findings:During a review of Resident 1's Quarterly Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 11/28/2025, the MDS indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of absence of left eye, tracheostomy (a surgical hole in the throat to help with breathing), gastrostomy tube (a surgical opening into the intestines to administer nutrition and medications via a tube), and need for assistance. MDS further indicated Resident 1 had difficulty communicating his needs and required the use of a wheelchair for ambulation. During a review of Resident 2's Treatment Plan, dated 1/29/2026 the Treatment Plan indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of schizophrenia (chronic, serious brain disorder that causes people to interpret reality abnormally, often resulting in hallucinations, delusions, and disorganized thinking) and a criminal history of assault by means of force likely to produce great bodily injury. The Treatment Plan further indicated Resident 2 was evaluated on 1/22/2026 to be a moderate risk for violence against others.During a concurrent observation and interview on 2/12/2026 at 10:23 a.m. in Resident 1's room, Resident 1 was lying in bed, Resident 1 was without a left eye and had a tracheostomy tube for breathing. Resident 1 had a noticeable laceration above the right eyebrow accompanied by bruising. Resident 1 had to cover his tracheostomy tube with his hand to communicate, spoke in a whisper, and frequently struggled to catch his breath while speaking. Resident 1 stated, He [Resident 2] attacked me in my sleep and it was unprovoked. During an interview on 2/12/2026 at 10:28 a.m. with Resident 2, Resident 2 confirmed he punched Resident 1 in the face. Resident 2 displayed pre-aggression tendencies and RN 1 recommended to stop the interview.During an interview on 2/12/2026 at 11:19 a.m. with Registered Nurse (RN) 1, RN 1 stated he went into Resident 1's room, to take vital signs, and seen dried blood above Resident 1's right eyebrow. RN 1 stated Resident 1 informed him that Resident 2 punched Resident 1 in the face while he was sleeping. RN 1 further stated he interviewed Resident 2 and Resident 2 stated I hit him because he wanted to have sex with me.During an interview on 2/12/2026 at 2:27 p.m. with Registered Nurse Shift Lead (RNSL), RNSL stated Resident 2's medical conditions had drastically improved since admission, and now Resident 2 was highly ambulatory and no longer medically fragile. RNSL stated she was not surprised by this incident because in October 2025, Resident 2 attempted to punch a staff member. RNSL further stated, approximately 10 days prior to 2/7/2026, Resident 2 punching Resident 1 in the face, Resident 2 removed the footrest from a wheelchair and repeatedly hit the plexiglass window of the nurses' station requiring emergency assistance from multiple staff members to subdue the resident. RNSL stated Resident 2 was scary because he was violent, had aggressive behaviors and was very unpredictable. RNSL stated on 2/9/2026 Resident 2 informed the Psychiatrist (Psych) 1 that he will continue to hit others until he gets out of the facility.During an interview on 2/13/2026 at 11:02 a.m. with the Psychiatrist (Psych) 1, Psych 1 confirmed she was aware of Resident 2 having an aggressive history to include attempting to punch staff, hitting a trash can in the common area and hitting the nurses' station window with a wheelchair footrest, and stated Resident 2 was a high risk for violence against others. Psych 1 further stated on 2/10/2026 Resident 2 informed Psych 1 that he wanted to punch everyone and anyone until he got out of the facility. Psych 1 confirmed with the current treatment plan that there was no care plan in place to address Resident 2's aggressive behaviors toward others or interventions to protect other residents from Resident 2.During an interview on 2/17/2026 at 9:45 a.m. with Unit Supervisor (US), US confirmed with the Violent Risk Assessment completed on 1/22/2026, that the Psychiatrist determined Resident 2 needed to be closely monitored due to aggressive outbursts. US confirmed with the treatment plan completed on 1/29/2026, for 16 days after identifying Resident 2's need to be closely monitored, Resident 2 received the same level of monitoring as all other residents in the facility and was not placed on any enhanced monitoring interventions. US stated there was not a plan of care developed to address Resident 2's aggressive behaviors towards others or interventions implemented to address Resident 2's aggressive outbursts and protect other residents from Resident 2.During a concurrent interview and record review on 2/18/2026 at 10:05 a.m. with SNRL, Resident 2's Treatment Plan, dated 1/29/2026 was reviewed. The Treatment Plan indicated Resident 2 had a documented history of identified violent risk to others and there was no behavioral plan of care to address Resident 2's aggressive behaviors toward others or interventions implemented to safeguard other residents. SNRL stated there should have been a behavioral plan of care with interventions to address Resident 2's violent behaviors.During an interview on 2/19/2026 at 9:49 a.m. with Psych 1, Psych 1 confirmed with the treatment plan, completed on 1/29/2026, there were no mini treatment plan conferences held after Resident 2's episodes of aggression on 10/28/2025 and 1/9/2026. Psych 1 stated there should have been a behavioral plan of care to address Resident 2's aggressive behaviors and implementation of interventions.During an interview on 2/19/2026 at 10:18 a.m. with the Social Worker (SW), SW stated she was concerned for the safety of all residents on the unit with Resident 2 because he is demonstrating such aggressive behaviors and lack of insight.During a review of Resident 2's Special Incident Report (SIR), dated 1/30/2026, the SIR indicated on 10/28/2025 Resident 2 was aggressive towards staff and lunged (sudden, forceful movement forward) at staff with a closed fist, in attempts to punch staff.During a review of Resident 2's Monthly Psychiatric Progress Note, dated 1/31/2026, the Monthly Psychiatric Progress Note indicated Resident 2 was continuously verbally abusive. On 10/23/2025 Resident 2 had worsening behaviors and was verbally abusive to staff, on 10/28/2025 he had an aggressive stance with a closed fist towards staff, and on 1/21/2026 he hit a trash can and then the nurses' station plexiglass window. The Monthly Psychiatric Progress note further indicated Resident 2 has a history of assaulting staff and others, and his risk for violence against others should be carefully monitored.During a review of Resident 2's Interdisciplinary Notes (IDN), dated 1/21/2026, the IDN indicated Resident 2 was banging his fists on the trash can in the common area and staff were unable to redirect Resident 2 and he continued to bang on the trash can. IDN further states Resident 2 walked over to a wheelchair and removed one of the footrests, then walked over to the nurses' station's plexiglass window and repeatedly hit the window with the footrest.During a review of Resident 2's Violence Risk Screening (V-Risk), dated 1/22/2026, the V-Risk indicated Resident 2 was a moderate risk for violence against others due to multiple aggressive incidents such as verbal and physical aggression towards staff and property. The V-Risk further indicated the psychiatrist recommendations were [Resident 2's name] should be carefully monitored as he has a demonstrated history of violent behaviors. [Resident 2's name]'s risk will be carefully monitored and changed accordingly.During a review of Resident 2's Physician Progress Note, dated 1/23/2026, the Physician Progress Note indicated, He [Resident 2] is telling the staff that he is hearing voices to hurt others, that way he can be out here.During a review of Resident 2's IDN, dated 2/7/2026, the IDN indicated Resident 2 punched Resident 1 in the face while Resident 1 was asleep. The IDN further indicated Resident 1 required wound care as a result of his injuries.During a review of Resident 2's Physician Progress Note, dated 2/9/2026, the Physician Progress Note indicated, I was called by staff to address his [Resident 2] aggressive behaviors. Pt [patient] attacked another peer and caused an injury. He said I will keep doing that till I'm out of here.During a review of Resident 2's Physician Progress Note, dated 2/10/2026, the Physician Progress Note indicated, Yesterday pt [Resident 2] verbalizing he wanted to hit people until he got out of here.During a review of the facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/2025, the P&P indicated, Abuse or neglect of patients is not condoned and shall not be tolerated. Physical abuse: Any of the following (a) Assault, as defined in Section 240 of the Penal Code.During a review of California's Penal Code (PC) Section 240, PC Section 240 defines assault as attempt to commit a violent injury on the person of another.During a review of the facility's P&P titled, Treatment Plan, dated 7/10/2024, the P&P indicated, Each patient will have a focused, individualized Treatment Plan, based on the integrated assessment. Treatment shall be designed to address each patient's needs. Mini-Team conferences shall be held after an episode of aggression. The treatment plan shall discuss and document the patient's current mental status. interventions, response to interventions, and any risks. The treatment plan shall address any specific individualized risk(s) of the patient including but not limited to risk of danger to self, danger to others.

Based on interview and record review the facility failed to ensure all staff received adequate training on the recognition, prevention, and reporting of all forms of abuse, including resident-to-resident abuse in accordance with Federal regulations. This failure resulted in staff's inability to recognize incidents involving resident-to-resident physical and alleged sexual assault as abuse for two of six sampled residents (Resident 1 and Resident 2).Cross reference F600, F607, F609 and F610.Findings:During a concurrent interview and record review on 2/12/2026 at 10 a.m. with Standards Compliance Supervising Registered Nurse (SCSRN), Resident 1's Interdisciplinary Notes (IDN), dated 2/7/2026 was reviewed. The IDN indicated Resident 1 was punched in the face by Resident 2, resulting in a 1.2 cm (centimeter- unit of measurement) laceration to the right upper eyebrow that required medical attention. The IDN further indicated Resident 2 informed staff that I punched him early in the morning because he tried to have sex with me. SCSRN stated the facility did not consider resident-to-resident physical or sexual assault to constitute as abuse due to not meeting the facility's requirement for the definition of abuse. During an interview on 2/12/2026 at 10:33 a.m. with Registered Nurse (RN) 2, RN 2 stated he received annual abuse training to include only staff-to-resident abuse, reporting and prevention.During an interview on 2/12/2026 at 11:19 a.m. with RN 1, RN 1 stated he went into Resident 1's room, to take vital signs, and seen dried blood above Resident 1's right eyebrow. RN 1 stated Resident 1 informed him that Resident 2 punched Resident 1 in the face while he was sleeping. RN 1 further stated he interviewed Resident 2 and Resident 2 stated I hit him because he wanted to have sex with me. RN 1 stated Resident 2 punching Resident 1 in the face was considered a physical altercation and not abuse, and Resident 2 alleging Resident 1 of trying to have sex with him was not considered sexual assault or abuse. RN 1 confirmed he received annual abuse training.During an interview on 2/12/2026 at 11:26 a.m. with Registered Nurse Shift Lead (RNSL), RNSL stated resident-to-resident physical or sexual assault was not considered abuse, only staff-to-resident physical or sexual assault was considered abuse. RNSL confirmed she received annual abuse training.During an interview on 2/12/2026 at 12:09 p.m. with Program 6 Program Director (PD), the PD stated resident-to-resident physical or sexual assault was not considered abuse and only staff can be a perpetrator (the person who commits a harmful or illegal act such as a crime, wrongdoing or violent act). PD confirmed she received annual abuse training. During an interview on 2/12/2026 at 12:19 p.m. with Program 6 Nursing Coordinator (NC), NC confirmed he received annual abuse training and stated the incidents with Resident 1 and Resident 2 were not considered abuse because the perpetrator wasn't a staff member.During a review of the facility's power point training titled, Recognizing and Reporting Abuse, Neglect and Suspected Criminal Conduct, dated 12/2/2025, the training indicated, This training is designed to assist you in improving your recognition of, and response to incidents of abuse . The training will cover processes and procedures, definitions . ensure employees understand their ongoing legal and ethical responsibility to recognize and report suspected cases of abuse . Definitions- Physical Abuse- Any interaction or physical contact, motion, or action that is directed toward a patient by someone other than another patient . Psychological abuse- any act by someone other than another patient . verbal abuse- any language by someone other than another patient . sexual abuse- an employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients, one of whom is not consenting . When an incident or allegation of abuse, neglect or serious bodily injury has occurred, Recognition is key .During a review of the facility's policy and procedure (P&P) titled, Incident Management, dated 5/9/2025, the P&P indicated, . [facility name] will use the definitions listed in the Appendix A. Incidents that Involve Allegations of Abuse or Neglect- When a hospital employee observes suspected patient abuse or receives an allegation of patient abuse from another person, they shall. Refer to AD 3308 [facility's policy and procedure] Reporting Patient Abuse and Neglect for additional information. During a review of the facility's P&P attachment titled, Appendix A- Definitions, undated, the document indicated, Alleged Patient abuse- physical: any intentional interaction or physical contact, motion, or action that is directed toward a patient by someone other than another patient. Alleged Patient Abuse- Psychological: Any act by someone other than another patient that causes or could reasonably be expected to cause mental suffering. Alleged Sexual Abuse: An employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients. During a review of the facility's P&P titled, Reporting Patient Abuse and Neglect, dated 1/3/2023, the P&P indicated, .Definitions. Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. Psychological abuse- any act by someone other than another patient. Verbal abuse- any language by someone other than another patient. Sexual abuse- an employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients. Training. What constitutes abuse, neglect and misappropriation of resident property . Training- all employees are required to complete annual patient abuse prevention training. Train employees through orientation and on-going sessions on issues related to abuse prohibition practices such as: What constitutes abuse .

Based on interview and record review, the facility failed to identify all forms of abuse to include resident-to-resident abuse for three of three sampled allegations, when:1. Resident 2 punched Resident 1 in the face, alleging that Resident 1 attempted to engage in unwanted sexual activity with Resident 2.2. Resident 3 kicked Resident 4 in the buttocks and in retaliation Resident 4 punched Resident 3 in the face three times.3. Resident 6 reported an allegation that Resident 5 punched him in the chin.These failures resulted in the required authorities, patients' rights advocate (PRA-designated individual that helps patients navigate the healthcare system, ensuring their legal, civil and human rights are upheld) and the state survey agency (CDPH- California Department of Public Health) not being notified immediately, but not later than 2 hours after the allegation was made.Cross reference to F600, F607 and F610.Findings:1.During a review of the facility's Report of Unusual Occurrence, dated 2/10/2026, the report indicated on 2/7/2026, three days prior to notifying State Agency, Resident 1 was punched in the face by Resident 2, which resulted in a laceration above the resident's right eyebrow and Resident 2 alleged Resident 1 attempted to engage in sexual activity with him.During an interview on 2/12/2026 at 10 a.m. with Standards Compliance Supervising Registered Nurse (SCSRN), SCSRN confirmed Resident 1 was punched by Resident 2 on 2/7/2026 and Resident 2 reported an sexual assault allegation against Resident 1. SCSRN stated the department of standards and compliance were not open over the weekend, therefore they would not be able to report abuse within 2 hours. SCSRN further stated she does not consider resident-on-resident physical and/or sexual assault as abuse; therefore, it was not mandated to be reported within 2 hours of incident. During an interview on 2/17/2026 at 1:43 p.m. with the PRA, the PRA stated he had not received any notification of physical and/or sexual assault or abuse from the facility regarding Resident 1 and Resident 2.During a review of the facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/2025, the P&P indicated, Abuse of Dependent Adult/Elder: Includes physical. as defined as . Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. (e) Sexual assault.Standards compliance responsibilities. all alleged violations involving abuse. which occurred in Skilled Nursing units shall be reported by SCD/Designee to CDPH IMMEDIATELY but not later than 2 HOURS after allegation is made.2. During a review of the facility's Report of Unusual Occurrence, dated 3/2/2026, the report indicated on 2/28/2026, two days prior to notifying State Agency, Resident 3 kicked Resident 4 in the buttocks unprovoked and in retaliation Resident 4 punched Resident 3 in the face three times.During an interview on 3/4/2026 at 4:30 p.m. with Standards Compliance Director (SCD), SCD confirmed the physical altercations between Resident 3 and Resident 4 were not reported to CDPH until 2 days after the incident on 2/28/2026 and stated it should have been reported within 2 hours.During an interview on 3/6/2026 at 11:31 a.m. with the PRA, the PRA stated he had not received any notification of physical abuse for Resident 3 and/or Resident 4.During a review of the facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/2025, the P&P indicated, Abuse of Dependent Adult/Elder: Includes physical. as defined as . Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. Standards compliance responsibilities. all alleged violations involving abuse. which occurred in Skilled Nursing units shall be reported by SCD/Designee to CDPH IMMEDIATELY but not later than 2 HOURS after allegation is made.3. During a review of the facility's Report of Unusual Occurrence, dated 3/2/2026, the report indicated on 2/28/2026, two days prior to notifying State Agency, Resident 5 allegedly punched Resident 6 in the chin after a verbal altercation.During an interview on 3/4/2026 at 4:30 p.m. with Standards Compliance Director (SCD), SCD confirmed the alleged physical altercation between Resident 5 and Resident 6 was not reported to CDPH until 2 days after the incident on 2/28/2026 and stated it should have been reported within 2 hours.During an interview on 3/6/2026 at 11:31 a.m. with the PRA, the PRA stated he had not received any notification of a physical abuse allegation for Resident 6.During a review of the facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/2025, the P&P indicated, Abuse of Dependent Adult/Elder: Includes physical. as defined as . Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. Standards compliance responsibilities. all alleged violations involving abuse. which occurred in Skilled Nursing units shall be reported by SCD/Designee to CDPH IMMEDIATELY but not later than 2 HOURS after allegation is made.

Based on interview and record review, the facility failed to ensure all alleged violations that involved abuse, including alleged sexual assault and physical abuse, were thoroughly investigated for 2 of 6 sampled residents (Resident 1 and Resident 2) when:Resident 2 alleged sexual assault and stated he [Resident 1] tried to have sex with me.Resident 1 was physically assaulted by Resident 2 while he was sleeping.Consequently, the facility failed to report the results of all investigations to the State Survey Agency (SA) within 5 working days of the incident. These failures resulted in the investigations not being conducted and placed Resident 1 and Resident 2 at risk for further harm.Cross reference to F600, F607 and F609.Findings:1. During a review of Resident 2's Treatment Plan, dated 1/29/2026 the Treatment Plan indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of schizophrenia (chronic, serious brain disorder that causes people to interpret reality abnormally, often resulting in hallucinations, delusions, and disorganized thinking). During a concurrent interview and record review on 2/12/2026 at 10 a.m. with Standards Compliance Supervising Registered Nurse (SCSRN), Resident 1's Interdisciplinary Notes (IDN), dated 2/7/2026 was reviewed. The IDN indicated Resident 1 was punched in the face by Resident 2, resulting in a 1.2 cm (centimeter- unit of measurement) laceration to the right upper eyebrow that required medical attention. The IDN further indicated Resident 2 informed staff that I punched him early in the morning because he tried to have sex with me. SCSRN confirmed the incidents were reported to CDPH three days after 2/7/2026, on 2/10/2026, and stated the facility did not consider resident-to-resident physical or sexual assault to constitute as abuse, therefore the facility did not have to report to CDPH within 2 hours. SCSRN further stated alleged sexual assault was not investigated due to not meeting the facility's requirement for the definition of abuse. During an interview on 2/12/2026 at 10:33 a.m. with Registered Nurse (RN) 2, RN 2 stated he was informed by RN 1 that Resident 2 punched Resident 1 in the face resulting in a laceration to the right upper eyebrow. RN 2 stated he interviewed Resident 2 and Resident 2 informed RN 2 that he hit Resident 1 because he was trying to have sex with me. RN 2 further stated, I didn't ask any further questions.During an interview on 2/12/2026 at 12:09 p.m. with Program 6 Program Director (PD), PD stated she spoke with the nursing staff and treatment team and none of the staff/team believed there was validity to Resident 2's statement of alleged sexual assault, and it was decided from the treatment team the allegation was a delusion. PD further stated alleged sexual assault with the perpetrator being another resident does not constitute as abuse, therefore was not investigated nor completed a SOC 341 (Form to report Suspected Dependent Adult/Elder Abuse).During a concurrent interview and record review on 2/12/2026 at 2:03 p.m. with Standards Compliance Registered Nurse (SCRN), Resident 2's medical records were reviewed. Resident 2's medical record did not include a physician report after Resident 2 made sexual assault allegation against Resident 1 on 2/7/2026. SCRN confirmed there was not a physician report.During an interview on 2/13/2026 at 11:02 a.m. with Psychiatrist (Psych) 1, Psych 1 confirmed she was temporarily the primary psychiatrist for Resident 2 and stated she did not see or evaluate Resident 2 until three days after the incident. Psych 1 further stated she did not address or focus on the sexual assault allegation.During an interview on 2/17/2026 at 1:43 p.m. with the Patients' Rights Advocate (PRA), the PRA stated he was not notified of Resident 2's allegation of sexual assault.During an interview on 2/17/2026 at 2:36 p.m. with Psych 2, Psych 2 stated he was covering the on-call shift on 2/7/2026 and he did not go to the unit to evaluate Resident 2 after the allegation of sexual abuse. During a review of the facility's policy and procedure (P&P) titled, Rape or Sexual Assault of Elder/Dependent Adult (Actual or Alleged), dated 4/1/2025, the P&P indicated, Sexual assault victims (male or female) shall receive immediate medical attention and sensitive supportive counseling from clinical staff as soon as the assault is brought to the attention of hospital staff. Every effort shall be made to ensure the victim's physical and emotional well-being, and to gather evidence. Prompt medical attention is necessary for victims of alleged sexual assaults. Medical attention is required to assess the psychological reaction to the event. Procedures to be implemented immediately upon the discovery of a case of alleged sexual assault. complete Form SOC-341. unit staff/personnel discovering assault. comfort patient. The unit physician or MOD [medical on call doctor] will fill out the Physicians Report section of the Incident Report.During a review of the facility's P&P titled, Reporting Patient Abuse and Neglect, dated 1/3/2023, the P&P indicated, .Definitions. Physical abuse: Any of the following. Sexual abuse- an employee engages in sexual contact with a patient. An employee encourages or allows sexual contact between patients. When a hospital employee observes suspected patient abuse, or receives an allegation of patient abuse, they shall immediately . Complete a Form SOC 341 . Immediate supervisor responsibilities . provide protection to the patient in all instances when there is an allegation of abuse. This includes providing the patient with counseling and debriefing . Notify the Patient's Rights Advocate . Standards compliance responsibilities . all alleged violation involving abuse . which occurred in Skilled Nursing units shall be reported by SCD [Standards Compliance Department] /Designee to CDPH [California Department of Public Health] immediately but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse . SCD shall submit to CDPH within 5 working days of the incident the result of investigations and/or a follow up report . 2. During a review of Resident 1's Quarterly Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 11/28/2025, the MDS indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of absence of the left eye, tracheostomy (a surgical hole in the throat to help with breathing), gastrostomy tube (a surgical opening into the intestines to administer nutrition and medications via a tube), and need for assistance. MDS further indicated Resident 1 had difficulty communicating his needs and required the use of a wheelchair for ambulation. During a concurrent interview and record review on 2/12/2026 at 10 a.m. with Standards Compliance Supervising Registered Nurse (SCSRN), Resident 1's Interdisciplinary Notes (IDN), dated 2/7/2026 was reviewed. The IDN indicated Resident 1 was punched in the face by Resident 2, resulting in a 1.2 cm (centimeter- unit of measurement) laceration to the right upper eyebrow that required medical attention. The IDN further indicated Resident 2 informed staff that I punched him early in the morning because he tried to have sex with me. SCSRN confirmed the incidents were reported to CDPH three days after the incident, on 2/10/2026, and stated the facility did not consider resident-to-resident physical or sexual assault to constitute as abuse, therefore the facility did not have to report to CDPH within 2 hours. SCSRN further stated physical assault was not investigated due to not meeting the facility's requirement for the definition of abuse. During an interview on 2/12/2026 at 12:09 p.m. with Program 6 Program Director (PD), the PD stated resident on resident physical assault was not considered abuse and only staff can be a perpetrator (the person who commits a harmful or illegal act such as a crime, wrongdoing or violent act), therefore the incidents between Resident 1 and Resident 2 were not investigated as abuse and a SOC 341 (Form to report Suspected Dependent Adult/Elder Abuse) was not completed. During an interview on 2/13/2026 at 11:02 a.m. with Psychiatrist (Psych) 1, Psych 1 stated she seen Resident 1 four days after the incident, Resident 2 punching Resident 1 in the face while he was asleep, on 2/7/2026. Psych 1 further stated during her visit with Resident 1 she was accompanied by Medical Doctor (MD) and the visit was solely for medical issues regarding his tracheostomy, and not the physical assault.During an interview on 2/17/2026 at 1:43 p.m. with the Patients' Rights Advocate (PRA), the PRA stated he was not notified of Resident 1's physical assault.During an interview on 2/17/2026 at 2:36 p.m. with Psych 2, Psych 2 stated he was covering the on-call shift on 2/7/2026 and was informed by unit staff of Resident 2 punching Resident 1 in the face. Psych 2 further stated he did not go to the unit to evaluate Resident 1 and Resident 2. During a review of the facility's P&P titled, Reporting Patient Abuse and Neglect, dated 1/3/2023, the P&P indicated, .Definitions. Physical abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. When a hospital employee observes suspected patient abuse, or receives an allegation of patient abuse, they shall immediately . Complete a Form SOC 341 . Immediate supervisor responsibilities . provide protection to the patient in all instances when there is an allegation of abuse. This includes providing the patient with counseling and debriefing . Notify the Patient's Rights Advocate . Standards compliance responsibilities . all alleged violation involving abuse . which occurred in Skilled Nursing units shall be reported by SCD [Standards Compliance Department]/Designee to CDPH [California Department of Public Health] immediately but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse . SCD shall submit to CDPH within 5 working days of the incident the result of investigations and/or a follow up report . Prevention . Identify, correct, and intervene in situations in which abuse is more likely to occur. This includes an analysis of: The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors .

Based on observation, interview, and record review the facility failed to provide ongoing assessment, monitoring and implementation of interventions for one of 21 sampled residents (Resident 10) when on 10/23/2025, Resident 10 was diagnosed with a blood clot in his arteriovenous fistula (AV fistula- surgical connection of an artery and a vein that allows for blood to flow directly to provide a long-term access point for filtering blood in patients with kidney disease) and the physician had an order to check the AV fistula for bruit and thrill (bruit is a swooshing sound heard over a blood vessel, while a thrill is the vibrating or buzzing sensation felt over the same vessel, both indicate a strong blood flow of an AV fistula), on the left upper arm every shift, since 11/24/2025. In addition, the facility failed to provide training and ensure staff competency for caring for residents that were dependent on renal dialysis (life-sustaining treatment that filters waste, extra salt, and fluid from the blood when the kidneys fails and are unable to) when four of four licensed nursing staff did not know how to properly assess and monitor for AV fistula complications - including how to assess for bruits and thrills. This failure resulted in Resident 10 experiencing pain, significant swelling with decreased mobility to the left arm. This failure had the potential to result in fistula failure, severe pain, limb ischemia (restricted blood flow to the arm), infection, deep vein thrombosis (DVT- serious condition when a blood clot forms in a deep vein), pulmonary embolism (fatal blockage in a lung artery caused from a blood clot that traveled), heart failure and/or death.Findings:During a review of Resident 10's Face sheet (demographics), the Face sheet indicated Resident 10 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease (ESRD- a medical condition that occurs when the kidneys permanently fail and cannot clean the blood or manage fluids anymore), dependence on renal dialysis, type 2 diabetes mellitus (condition when the body cannot use insulin correctly and sugar builds up in the blood), hypertension (high blood pressure) and heart failure.During a concurrent observation and interview on 12/2/2025 at 10:28 a.m., in Resident 10's room with Resident 10, Resident 10 was sitting on the edge of his bed with a visibly swollen left hand. Resident 10 removed his jacket and showed surveyor his AV fistula to the left upper arm with significant swelling to the entire left arm. Resident 10 had facial grimacing when attempting to make a fist with the left hand. Resident 10 stated he was informed about a month ago that he had a blood clot in the left arm near his AV fistula. Resident 10 stated the AV fistula is not being used at dialysis due to the blood clot and he had to undergo a procedure to have a new access site to the right side of the chest. Resident 10 further stated the swelling has made it very difficult to move his wrist and hand, and experiences pain constantly. During an interview on 12/2/2025 at 12:05 p.m. with Licensed Psychiatric Technician (LPT) 1, LPT 1 stated he was unsure how to monitor an AV fistula site. LPT 1 further stated he has not received any training for caring for dialysis patients. During an interview on 12/3/2025 at 3:59 p.m. with Medical Doctor (MD) 1, MD 1 stated Resident 10 was admitted with swelling to the left arm in May 2025 but did not get evaluated by a vascular surgeon (doctor specialized in circulation and surgery) until 10/23/2025 due to MD 1 believing it was a Nephrologist's (doctor specialized in kidneys) concern and not a Primary Care Physician (PCP) concern. MD 1 was informed by facility management that it was the PCP's responsibility to oversee care of AV fistula complications. MD 1 stated he ordered a vein mapping ultrasound (a test completed by using high-frequency sound waves to view the inside of the veins to show sizes, depth, and blood flow and used to diagnose blood clots.) for the left arm and on 10/23/2025, the test found a blood clot to the left arm. MD 1 further stated there has been no new interventions or monitoring for Resident 10 since the diagnosis of a blood clot on 10/23/2025.During an interview on 12/5/2025 at 8:46 a.m. with Registered Nurse Shift Lead (RNSL) 2, RNSL 2 was involved in direct patient care for Resident 10 and stated she was informed of Resident 10's diagnosis of a blood clot in the left arm on 10/23/2025 and confirmed no interventions have been implemented. RNSL 2 stated she has not received any training for caring for a dialysis patient while being employed at the facility. RNSL 2 further stated, I don't know when asked how to assess for bruits and thrills with an AV fistula.During an interview on 12/5/2025 at 9:05 a.m. with Registered Nurse Unit Supervisor (RNUS) 1, RNUS 1 was involved in direct patient care for Resident 10 and stated she was unaware of Resident 10 having significant swelling to the left arm until 12/4/2025. RNUS 1 further stated she was not familiar with how to assess for bruits and thrills on an AV fistula, and the facility did not provide training for caring of dialysis patients.During an interview on 12/5/2025 at 9:45 a.m. with LPT 2, LPT 2 stated she did not know how to monitor an AV fistula. LPT 2 further stated she has not received any training on caring for dialysis patients.During an interview on 12/5/2025 at 10:32 a.m. with Standard and Compliance Director (SCD), SCD stated the facility does not provide specific training for caring for dialysis patients or how to assess AV fistulas.During a review of Resident 10's Physician's Orders, dated 11/24/2025, the Physician Orders indicated, AV shunt [fistula] on LUA [left upper arm], check for bruit and thrill every shift.During a review of Resident 10's ESRD Care Plan, dated 11/18/2025, the ESRD Care Plan indicated, Assess non-functional AV fistula on the left upper arm for bleeding (if any), thrombosis (thrill) [thrombosis is a formation of a blood clot that would be found by checking for thrills], and stenosis (bruit) [stenosis is abnormal narrowing of a vein that would be found by checking for bruits], q shift [every shift], Monitor for pain q shift, Monitor increased swelling to left upper extremity/arm, daily.During a review of the facility's policy and procedure (P&P), CARE OF THE VASCULAR ACCESS FOR HEMODIALYSIS [life-sustaining medical treatment that acts as an artificial kidney by using a machine and a special filter to clean the blood and remove excess fluids] ARTERIOVENOUS (AV) FISTULA, AV GRAFT [surgical connection between an artery and a vein, typically in the arm to provide access for hemodialysis] AND VENOUS CATHETHERS [a thin tube inserted into a large vein in the neck, chest or groin that leads to a major vein near the heart], dated April 2025, the P&P indicated, .RN's will be responsible for assessing the patient every shift, prior to and upon return from the dialysis center. Notify physician immediately of signs and symptoms of possible complications. The RN will: Assess the vascular access site every shift. Assess vascular access site for bleeding. Assess for signs/symptom's (s/s) of infection such as fever and/or appearance of small pustular lesions [small, inflamed bumps on the skin filled with pus] to the cannulation site [specific location on the body where there is access into a vein from a thin tube], swelling, erythema [redness of the skin], warmth, tenderness/soreness, pus/purulent [thick fluid that is made of dead cells, bacteria and dead tissue] drainage. Assess for vascular insufficiency, which may include delayed capillary refill (< 3 seconds) [test that assesses blood flow by pressing on the tip of a finger and noting the time it takes for the white to disappear]. assess for evidence of venous or arterial stenosis and thrombosis by assessing for pulse, thrill and bruit:. Thrill: A thrill is a palpable vibration of the patient's pulse over the AV graft/fistula. It is best evaluated using the palm of the hand. A thrill is soft and continuous. Any turbulent flow may indicate the presence of a stenotic lesion (thrombosis). REPORT IMMEDIATELY TO PHYSICIAN. Bruit: Using a stethoscope, you can hear blood flowing through the vascular access known as the bruit. If the sound gains in pitch and sounds like a whistle, the blood vessels could be tightening (stenosis). If the tightening becomes to severe, blood flow could be cut off completely. REPORT IMMEDIATELY TO PHYSICIAN. MONITORING 1. Licensed nursing staff will monitor and report signs/symptoms/complaints to the RN for assessment. Notify physician of findings. 2. Signs/symptoms/complaints may include: a. diminishing, absent or change in character of pulse, thrill, or bruit.On 12/5/2025 at 1:36 p.m., the survey team called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident), related to the lack of licensed nurse competency in assessing, monitoring and implementing physician's order for resident receiving dialysis treatment, at F 698 [CFR S 483.25(l)], in the presence of the Nurse Administrator.On 12/5/2025 at 7:50 p.m., the Standard and Compliance Director provided the survey team with a Plan of Action which included the following actions to be completed and/or started immediately:a.) Resident 10 was assessed at the time of the concern was identified by Unit Physician.b.) Unit Physician was notified, and new orders were received and implemented.c.) Pain was assessed and addressed per physician's orders.d.) Training was initiated with all licensed nursing staff on Nursing Policy and Procedure 408: Care of Vascular Access for Hemodialysis AV fistula, AV graft and Venous Catheter and were able to provide return demonstration on: how to assess for bruit and thrill, documentation and communication requirements.e.) Staff competency will be validated in assessment of AV fistula will be validated using the newly developed Vascular Access Assessment checklist.f.) Unit Supervisor/designee will review and verify the completion of 1147B form (Outside Facility Information form is to notify the facility of the treatment and recommendations provided by an outside facility) immediately following each patient dialysis appointment to ensure real time information and patient status. Medical Services Physician will maintain ongoing communication as need with the Dialysis center, including the Nephrologist as needed to ensure coordination of care and follow up. g.) Patients who could have been affected by this deficient practice who are receiving dialysis were assessed by nursing and physician for possible AV fistula/graft complications using checklist tool. On 12/8/2025 at 2:46 p.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the survey team accepted the Plan of Action and removed the immediacy in the presence of the Risk Management & Program Quality Assurance Coordinator, Standard and Compliance Director and Nurse Administrator.

Based on observation, interview, and record review, the facility failed to implement their policy to ensure the provision of pressure-injury (damage to skin from pressure) prevention, monitoring, and treatment were consistent with professional standards of practice for two of 21 sampled residents (Resident 30 and Resident 4). 1.Resident 30's buttocks were previously identified as areas of impaired skin integrity and were not monitored for two months. In addition, Resident 30's Low Air Loss mattress (LAL-pressure relieving air mattress) was not set to the accurate weight in accordance with the manufacturer's instructions. 2.Resident 4's ischial tuberosity (sit bone) was previously identified as an area of impaired skin integrity and was not monitored for three weeks. In addition, Resident 4's LAL mattress was not set to the accurate weight in accordance with the manufacturer's instructions. These failures resulted in Resident 30 developing three painful, unidentified wounds: Stage II pressure injury (open sore with a red or pink wound bed), on the left buttock, a Stage II pressure injury and a Deep Tissue Injury (DTI-dark purple spot showing underlying skin damage), on the right buttock and Resident 4 developing a Stage II pressure injury (open sore with a red or pink wound bed), to the ischial tuberosity. In addition, the failure of leadership oversight led to missed opportunities for timely identification and early interventions in wound care management for Resident 30 and Resident 4.Findings: 1. During a review of Resident 30's Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 9/3/2025, the MDS indicated Resident 30 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus (inability to monitor blood sugar). The MDS indicated Resident 30 required maximum assistance (needing extensive two-person physical help) for all mobility, was dependent on a wheelchair and at risk for developing pressure injuries. The MDS further indicated Resident 30's BIMS (Brief Interview for Mental Status) score was 9 (score of 9 indicated moderate difficulty with thinking). During a review of Resident 30's Height/Weight/BMI [body mass index] Record, [undated], the Height/Weight/BMI Record indicated Resident 30's weight in November 2025 was 167.8 lbs. (pounds).During an observation on 12/1/2025 at 2:14 p.m., in Resident 30's room, Resident 30 was lying flat on his back with an inflated LAL mattress programmed for 400 lbs. (despite Resident 30 not weighing 400 lbs). During a concurrent observation and interview on 12/2/2025 at 3:15 p.m. in Resident 30's room with Resident 30, Resident 30 was lying flat on his back in bed on an LAL mattress. Resident 30 reported having a painful wound on his bottom and stated he was not receiving wound care. During an interview on 12/2/2025 at 3:50 p.m. with Registered Nurse Shift Lead (RNSL) 2, RNSL 2 confirmed Resident 30 required an LAL mattress and that the device must be programmed based on the resident's actual weight to function correctly. During a concurrent interview and record review on 12/4/2025 at 11:52 a.m. with RNSL 1, the following documents were reviewed: 10/9/2025 Impaired Skin Integrity Risk Care Plan: Two boils on gluteal area are open. mild redness to surrounding area noted. Monitor the patient's skin both buttocks and abdomen area noting, color, moisture, texture and temperature, qshift [every shift]. 10/10/2025 Photographic Wound Documentation: photograph shown three open sores to the right buttocks that had deep red wound bed and two areas on the right buttocks that were intact and deep red, that were not included in the assessment, treatments, and interventions. October 2025 to December 2025 Medication and Treatment Records: no wound treatment entries or weekly wound assessments after 10/10/2025. Further review from the above documents indicated missed opportunities for early interventions.RNSL 1 stated he was unaware that Resident 30 had any pressure injuries to the buttock's area and confirmed that there were multiple wounds shown in the photograph on 10/10/25 without assessments, treatments and interventions. RNSL 1 further stated each wound should have an individual assessment, treatment and intervention.During a concurrent interview and record review on 12/4/2025 at 3:49 p.m. with Registered Nurse Unit Supervisor (RNUS 1), Resident 30's full health-record was reviewed. RNUS 1 confirmed there were multiple wounds identified on 10/10/25 that did not have wound care assessments and treatments. RNUS 1 stated she was unaware if Resident 30 had pressure injuries. RNUS 1 confirmed that daily RN assessments, weekly wound photographs, and treatment documentation should have been completed for each individual wound. During a concurrent observation and interview on 12/4/2025 at 3:53 p.m. in Resident 30's room with Resident 30 and RNSL 2, during a toileting observation with RNSL 2, Resident 30 was noted to have: Approximately 1 centimeter (cm- unit of measurement) open sore with a red wound bed with approximately 5 cm of redness to the area around the wound on the left buttock;Approximately 1.5 cm open sore with a red wound bed with approximately 10 cm of redness to the area around the wound on the right buttock; Approximately 1.5 cm deep purple discoloration that was non-blanchable on the right buttock; Resident 30 stated he developed the wounds from being stuck in the wheelchair for long periods. During the observation RNSL 2 stated the open sore with a red wound bed on the left buttock was a stage II pressure injury, the open sore with a red wound bed on the right buttock was a stage II pressure injury and the non-blanchable (skin discoloration that does not fade to white when pressed on) deep purple discoloration was a DTI. RNSL 2 also confirmed there was no previous wound documentation for the three newly identified, untreated pressure injuries.During an interview on 12/5/2025 at 9:24 a.m. with Medical Doctor (MD 1), MD 1 stated he was unaware of the status of Resident 30's wounds and he did not physically see Resident 30's wounds/pressure injuries until the untreated wounds/pressure injuries were discovered on 12/4/25. During an interview on 12/5/2025 at 4:56 p.m. with Program Director (PD), PD stated she was involved with record keeping of wound care and photographs. PD further stated program management did not have a tracking system for monitoring wounds. During a review of facility's policy and procedure (P&P) titled, Assessment, Prevention and Treatment of Pressure Injuries and Wounds, dated February 2024, the P&P indicated, All patients shall have an assessment of the condition and integrity of their skin. the assessment shall be conducted. as clinically indicated. the RN shall assess wound or pressure injury daily. The Physician/Nurse Practitioner shall assess the wound on a weekly basis and more often if clinically indicated. Measure wound weekly to track and measure the progression of healing. inspection and monitoring at least daily when patients are deemed at risk for pressure injury or have an existing impaired skin integrity.PRESSURE INJURY PREVENTION. Conduct a comprehensive skin inspection for those at risk as soon as possible . subsequent inspections and monitoring at least daily when patients are deemed at risk for pressure injury or have an existing impaired skin integrity.During a review of the Operational Manual for [low air loss mattress name], [undated], the manual indicated, System is designed for prevention, treatment and management of pressure ulcers. Press up or down buttons to select the correct patient weight.2. During a review of Resident 4's Minimum Data Set (MDS-federally required assessment tool used to guide resident care), dated 9/23/25, the MDS indicated an admission date on 6/17/24 with Non-Traumatic Brain Dysfunction (damage to the brain by internal factors). The MDS indicated Resident 4 required maximum assistance (needing extensive two-person physical help) for mobility, was dependent on a wheelchair, and at risk for developing pressure injuries. During a review of Resident 4's Height/Weight/BMI [body mass index] Record, [undated], the Height/Weight/BMI Record indicated Resident 4's weight in November 2025 was 163.0 lbs. (pounds).During an observation on 12/2/25 at 11:18 a.m. in Resident 4's room, Resident 4 was lying flat on his back in bed on an inflated LAL mattress (pressure relieving air mattress), programmed for 300 lbs. (despite Resident 4 not weighing 300 lbs). Resident 4 was non-interview able.During an interview on 12/2/25 at 3:50 p.m. with Registered Nurse Shift Lead (RNSL) 2, RNSL 2 stated Resident 4 did not have any wounds/pressure injuries. RNSL 2 confirmed Resident 30 required an LAL mattress and that the device must be programmed based on the resident's actual weight to function correctly. During an interview on 12/5/25 at 9:24 a.m. with Medical Doctor (MD 1), MD 1 stated Resident 4 previously had a wound/pressure injury that was treated, and he was not aware of any new or current wounds/pressure injuries.During a concurrent interview and record review on 12/8/25 at 2:22 p.m. with Supervising Registered Nurse (SRN 1), the following documents were reviewed:-11/13/25 Photographic Wound Documentation: Previous pressure injury to the left ischial tuberosity (sit bones- on the buttocks area) appeared closed. Intervention was to continue to monitor the skin for further skin break down and signs/symptoms of infection.-Medication and Treatment Record for November 2025 indicated no weekly assessment/monitoring to the left ischial tuberosity was completed after 11/13/25.-11/19/25 Altered Skin Integrity Care Plan: Assess the patient's skin, noting color, moisture, texture, and temperature. Also observe for erythema (reddening of skin), edema, and tenderness every shift. Observed wounds, noting characteristics of wound size, appearance, and drainage every shift.-12/8/25 Photograph of pressure injury: A new unidentified open sore with a red wound bed approximately 8 cm to the left buttocks was present.Further review from the above documents indicated missed opportunities for early interventions.SRN 1 stated, after the Photographic Wound Documentation on 11/13/25 there was no documentation of skin assessments or monitoring being completed of the left ischial tuberosity, that was previously identified as an area of skin impairment. SRN 1 confirmed the open sore with a red wound bed to the left buttock was a Stage II pressure injury and considered a new wound.During a review of facility's policy and procedure (P&P) titled, Assessment, Prevention and Treatment of Pressure Injuries and Wounds, dated February 2024, the P&P indicated, PRESSURE INJURY PREVENTION. Conduct a comprehensive skin inspection for those at risk as soon as possible . subsequent inspections and monitoring at least daily when patients are deemed at risk for pressure injury or have an existing impaired skin integrity.During a review of the Operational Manual for [low air loss mattress name], [undated], the manual indicated, System is designed for prevention, treatment and management of pressure ulcers. Press up or down buttons to select the correct patient weight.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when:1. Two cutting boards used for food preparation were found to have discolorations and deep gouges on the surface.2. Five resident food trays were dirty with built-up food debris and found stacked in the clean tray area.3. One open box of previously frozen french toast was found uncovered and labeled with a date of 3/25/25.These failures had the potential to place residents at risk for developing foodborne illness (any illness resulting from eating contaminated/spoiled foods) by exposing residents to contaminated food and unsanitary practices.Findings:1. During a concurrent observation and interview on 12/1/25 at 12:16 p.m. with the Food Service Supervisor (FSS) in the kitchen, two cutting boards used for preparation of resident meals were found to have areas of discoloration and deep gouges on the surface. The FSS stated the cutting boards were worn out and both needed to be thrown away.During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 4-501.12-Cutting Surfaces, the FDA Food Code indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.2. During a concurrent observation and interview on 12/1/25 at 12:20 p.m., with the Food Service Supervisor (FSS) in the kitchen, five resident food trays were dirty with areas of old, built-up chocolate pudding and rice, and had unknown black marks. The FSS confirmed the five trays were stored in the clean tray area and needed to be re-cleaned.During a review of the facility's policy and procedure (P&P) titled, Infection Control: Client, Staff, Equipment & Food Safety, dated July 2018, the P&P indicated, All kitchen and dining room utensils along with food contact surfaces used in preparation and/or serving of food and drink are cleaned and sanitized before use, after being used and after each meal.3. During a concurrent observation and interview on 12/1/25 at 12:46 p.m., with the Director of Dietetics (DD) in the kitchen, an opened box of previously frozen french toast was found in a refrigerator uncovered and labeled with a date of 3/25/25. The DD stated the food was previously in the freezer and was placed in the refrigerator to thaw (the process of bringing frozen food to an unfrozen state). The DD stated, the box should also be completely closed and covered. The DD further stated the food was expired and it was not known when the food was brought into the refrigerator to thaw.During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 3-501.18-Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, the FDA Food Code indicated, Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interview and record review, the facility failed to update its Facility Assessment (document that determines the necessary resources to care for residents competently during day-to-day operations and emergencies) annually. In addition the facility failed to include the specific competencies (measurable pattern of knowledge, skills and abilities to perform occupational functions successfully) of the licensed nursing staff and how often the competency evaluations needed to be done to properly care for the residents. This failure resulted in substandard quality of care related to treatment and services of dialysis AV fistulas (arteriovenous fistula - a surgically created connection between an artery and a vein for dialysis access) and an Immediate Jeopardy (a critical deficiency in healthcare facilities where non-compliance creates a high likelihood of serious harm or death) situation.Cross reference F698Findings:During a review of the facility assessment titled, Program 6: Skilled Nursing Facility Program Description, [undated], the facility assessment indicated, the required skills and competencies for licensed staff based on resident population and needs was not found.During an interview on 12/5/25 at 4:44 p.m. with the Program Director (PD), PD confirmed the facility assessment was last updated in 2021 and stated that it was completed by herself and one Supervising Registered Nurse. PD was unaware of how frequently the assessment was required to be updated. PD stated the facility assessment does not break down required skills and competencies required by licensed nursing staff and the skills and competencies were dependent upon staff license. PD confirmed the facility assessment does not contain the required education, training and staff competencies related to ongoing needs of residents.During an interview on 12/8/25 at 10:22 a.m., with the Standards Compliance Director (SCD), SCD stated the facility does not have a policy on the requirements of the facility assessment.Facility was unable to provide a policy and procedure (P&P) for Facility Assessment.

Based on interview and record review, the facility failed to ensure their Quality Assurance and Performance Improvement (QAPI- a program that enables a facility to evaluate and improve the quality of Resident care and services through data collection, staff input, and other information), did not implement their plan to identify areas for improvement for residents at risk for developing pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).This failure resulted in an ineffective QAPI program that did not identify systemic problems related to the monitoring of pressure ulcers.Cross Reference F686.Findings:During an interview on 12/8/25 at 2:53 p.m. with Nursing Coordinator (NC), NC stated performance improvement plans (PIP) were based on the previous year's survey results and included monitoring for resident call light accessibility, resident dignity while dining, and the use of enhanced barrier precautions (infection control guidelines) for identified residents. There were no PIPs that included monitoring of pressure ulcers and no PIPs for assessment of AV fistulas (Arteriovenous, an irregular connection between an artery and a vein), for those resident's requiring dialysis (treatment that filters waste from your blood). NC stated there was no formal mechanism for prioritizing issues.During an interview on 12/8/25 at 2:58 p.m., with the Program Director (PD), PD stated the QAPI team did not have any data to monitor and were not aware of any issues in the incidences (occurrence) of pressure ulcers or assessments of AV fistulas because there was not a baseline assessment for residents returning from outside facilities so a comparison of before and after could not be made.During a review of the facility's plan titled, Department State Hospital-Metropolitan Program VI Skilled Nursing QAPI Plan, dated December 2024, the plan indicated, Plan to Address Key Issues: . Identify and use data to monitor our performance; Establish goals and thresholds for our performance measurement; Utilize resident and staff input; Identify and prioritize problems and opportunities for improvement; Systematically analyze underlying causes of systemic problems and adverse events; Develop corrective action or performance improvement activities.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices that protect residents from the spread of communicative diseases and infections when:1.Unit 404's clean linen room had multiple pieces of laundry piled on a chair, in a corner on the floor, and on the floor in front of the storage shelving; there was also uncovered clean laundry storage and an opened water bottle on the floor mixed in with clean laundry.2.Resident 4's foley catheter (medical device- tube that drains urine from the bladder into a bag) collection bag was not below the waistline.3.Licensed Psychiatric Technician (LPT 1) did not wear Personal Protective Equipment (PPE, specialized clothing or equipment used to reduce exposure to hazards or infections), while performing a glucose (blood sugar) monitoring test on Resident 10.These failures had the potential to spread infection in a medically fragile population of 60 residents.Findings: 1. During an observation on 12/1/25 at 12:21 PM in Unit 404's clean laundry room, three linen covers were not covering clean laundry, multiple pieces of laundry was observed on the floor and on a chair. Observed an opened water bottle on the floor mixed in with laundry. During an interview on 12/1/25 at 12:24 PM with Unit Supervisor (US), in the clean linen room, US confirmed a mostly empty water bottle was found on the floor mixed in with laundry and stated staff should not be drinking in the clean laundry room. US stated the laundry on the floor and chair should have been picked up and did not belong there. US stated laundry should be covered to prevent dust and contamination. Review of facility's policy and procedures (P&P) titled, Transportation and Management of Clean Linen, dated May 2023, the P&P indicated, Purpose: To Maintain standard precautions by guarding and protecting against the possibility of transmission of infection and bacterial diseases. Clean linen should be handled,. stored by methods that will ensure its cleanliness to avoid the contamination. 5. Place clean linen on shelves with protective covering. DO NOT store . other equipment/items in the clean linen room. DO NOT store soiled linen/clothing with clean linen. 2. During a review of Resident 4's Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 9/23/25, the MDS indicated Resident 4 was admitted to the facility on [DATE], with diagnosis of urine retention (inability to completely empty the bladder of urine) and required an indwelling catheter (long term use of a foley catheter). During a concurrent observation and interview on 12/3/25 at 2:59 p.m., in Unit 404's Day Hall with the Registered Nurse (RN 10), Resident 4 was lying in a geriatric chair (large padded multi-position recliner designed for seniors and individuals with limited mobility) with a foley collection bag lying across Resident 4's lap. The foley tubing had cloudy yellow urine with a moderate amount of sediment (visible particles). RN 10 stated Resident 4's foley collection bag needed to be placed below the bladder to drain properly. During a review of Resident 4's Urinary Retention Care Plan, dated 10/8/25, the Urinary Retention Care Plan indicated, Perform catheter care every shift. keep the drainage bag below bladder. 3. During a review of Resident 10's Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 11/12/25, the MDS indicated Resident 10 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus (condition when the body cannot use insulin correctly and sugar builds up in the blood) and Human Immunodeficiency Virus (HIV- life long virus that attacks cells that help the body fight infection). During an observation on 12/2/25 at 11:44 a.m. in Unit 404's day hall, LPT 2 was not wearing gloves and poked Resident 10's right index finger with a lancet (tiny needle) then applied pressure to Resident 10's right index finger with his ungloved right hand to assist with blood flow. LPT 2 inserted a glucose test strip (disposable strip that reacts with drops of blood to measure blood sugar) into the glucometer (machine used to measure the concentration of sugar in the blood) and checked Resident 10's blood sugar. During an interview on 12/2/25 at 12:04 p.m. with LPT 2, LPT 2 confirmed he did not wear gloves while checking Resident 10's blood sugar. LPT 2 stated he should always wear PPE when checking blood sugar. During an interview on 12/2/25 at 3:54 p.m. with Registered Nurse Shift Lead (RNSL 2), RNSL 2 stated staff needed to always wear PPE, at minimum gloves, for checking a resident's blood sugar. During a review of Resident 10's Acquired Immunodeficiency Syndrome [AIDS-chronic condition caused by HIV] and Human Immunodeficiency Virus [HIV] Care Plan, dated 11/18/25, the AIDS and HIV Care Plan indicated, NSG [nursing] to wear PPE, including gloves, gowns, and eyewear, during invasive procedures involving blood or body fluids as clinically indicated. NSG to use appropriate barrier protection, safe injection practices, and meticulous hand hygiene, at all times.

Based on observation, interview, and record review, the facility failed to ensure four of five outside dumpsters were covered. This failure had the potential to attract pests and/or rodents that carried diseases and could result in food borne illness (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 60 residents.Findings:During a concurrent observation and interview on 12/1/25 at 12:53 p.m. with the Dietetics Director (DD) in the outside loading dock area of Program VI building, there were four dumpsters with overflowing garbage that were uncovered. There were many flies and a foul odor coming from the dumpsters. The DD stated the dumpsters should have been covered and the area should have been kept clean.During a review of the 2022 Food and Drug Administration's (FDA) Food Code-Section 5-501.15 Outside Receptacles, the FDA food code indicated, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview and record review the facility failed to ensure Licensed nurses were competent (having the necessary ability, knowledge, or skill to do something successfully), in assessing and monitoring dialysis residents when two licensed nurses, Registered Nurse Shift Lead [RNSL 2], and Registered Nurse Unit Supervisor [RNUS]), were unable to properly demonstrate how to assess and monitor for bruits and thrills (bruit is a swooshing sound heard over a blood vessel, while a thrill is the vibrating or buzzing sensation felt over the same vessel, both indicating a strong blood flow of an AV fistula- surgical connection of an artery and a vein that allows for blood to flow directly to provide a long-term access point for filtering blood in residents with kidney disease), for one of 21 sampled residents (Resident 10). In addition two licensed nursing staff (Licensed Psychiatric Technician [LPT 1]) and LPT 2, were unable monitor dialysis residents for bruits and thrills.This failure resulted in the inability of properly monitoring and assessing for dialysis complications in dialysis residents and the potential for harm.Cross Reference F698 Findings:During a review of Resident 10's Face sheet (demographics), the Face sheet indicated Resident 10 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease (ESRD- a medical condition that occurs when the kidneys permanently fail and cannot clean the blood or manage fluids anymore), dependence on renal dialysis, type 2 diabetes mellitus (condition when the body cannot use insulin correctly and sugar builds up in the blood), hypertension (high blood pressure) and heart failure.During a review of Resident 10's Physician's Orders, dated 11/24/25, the Physician Orders indicated, AV shunt [fistula] on LUA [left upper arm], check for bruit and thrill every shift.During a review of Resident 10's ESRD Care Plan, dated 11/18/25, the ESRD Care Plan indicated, Assess non-functional AV fistula on the left upper arm for bleeding (if any), thrombosis (thrill) [thrombosis is a formation of a blood clot that would be found by checking for thrills], and stenosis (bruit) [stenosis is abnormal narrowing of a vein that would be found by checking for bruits], q shift [every shift], Monitor for pain q shift, Monitor increased swelling to left upper extremity/arm, daily.During an interview on 12/2/25 at 12:05 p.m. with LPT 1, LPT 1 stated he was unsure how to monitor an AV fistula site. LPT 1 further stated he has not received any training for caring for dialysis residents.During an interview on 12/5/25 at 8:46 a.m. with RNSL 2, RNSL 2 stated, I don't know when asked how to assess for bruits and thrills with an AV fistula.During an interview on 12/5/25 at 9:05 a.m. with RNUS 1, RNUS 1 stated she was not familiar with how to assess bruits and thrills on an AV fistula, and the facility did not provide training for caring for dialysis residents.During an interview on 12/5/25 at 9:45 a.m. with LPT 2, LPT 2 stated she did not know how to monitor an AV fistula. LPT 2 further stated she has not received any training on caring for dialysis residents.During an interview on 12/5/25 at 10:32 a.m. with Standard and Compliance Director (SCD), SCD stated the facility does not provide specific training for caring for dialysis patients/residents or how to assess AV fistulas.During an interview on 12/5/25 at 4:56 p.m. with Program Director (PD), PD stated the facility does not provide training to staff for caring for residents that have dialysis and assessing AV fistulas.During an interview on 12/8/25 at 11:20 a.m. with Nurse Coordinator (NC), NC stated the facility does not provide training to staff or check staff competency with assessing AV fistulas. NC further stated the facility should have provided AV fistula training and check for staff competency.During an interview on 12/8/25 at 1:32 p.m. with the Director of Nursing Education (DNE), DNE confirmed the facility's training provided to staff did not cover caring for dialysis residents or assessing AV fistula.During a review of the facility's policy and procedure (P&P) titled, CARE OF THE VASCULAR ACCESS FOR HEMODIALYSIS [life-sustaining medical treatment that acts as an artificial kidney by using a machine and a special filter to clean the blood and remove excess fluids] ARTERIOVENOUS (AV) FISTULA, AV GRAFT [surgical connection between an artery and a vein, typically in the arm to provide access for hemodialysis] AND VENOUS CATHETHERS [a thin tube inserted into a large vein in the neck, chest or groin that leads to a major vein near the heart], dated April 2025, the P&P indicated, RN's (registered nurses) will be responsible for assessing the resident every shift. Notify physician immediately of signs and symptoms of possible complications. The RN will: Assess the vascular access site every shift. assess for evidence of venous or arterial stenosis and thrombosis by assessing for pulse, thrill and bruit:. Thrill: A thrill is a palpable vibration of the resident's pulse over the AV graft/fistula. It is best evaluated using the palm of the hand. A thrill is soft and continuous. Any turbulent flow may indicate the presence of a stenotic lesion (thrombosis). REPORT IMMEDIATELY TO PHYSICIAN. Bruit: Using a stethoscope, you can hear blood flowing through the vascular access known as the bruit. If the sound gains in pitch and sounds like a whistle, the blood vessels could be tightening (stenosis). If the tightening becomes to severe, blood flow could be cut off completely. REPORT IMMEDIATELY TO PHYSICIAN. MONITORING 1. Licensed nursing staff will monitor and report signs/symptoms/complaints to the RN for assessment. Notify physician of findings. 2. Signs/symptoms/complaints may include: a. diminishing, absent or change in character of pulse, thrill, or bruit.

Based on interview and record review, the facility failed to maintain an effective abuse and neglect training program for 13 of 116 skilled nursing employees (Licensed Psychiatric Technician [LPT] 1, LPT 2, LPT 3, LPT 4, LPT 5, LPT 6, LPT 7, LPT 8, LPT 9, Registered Nurse [RN] 4, RN 5, RN 6 and RN 7), when employee abuse and neglect training was not completed annually.This failure had the potential for abuse and neglect to go unnoticed and/or not reported by the staff.Findings:During a concurrent interview and record review on 12/8/25 at 10:10 a.m. with Supervising Registered Nurse (SRN 1), the employee Recognizing and Reporting Abuse Neglect training records were reviewed. The records indicated the following:1. LPT 1's annual abuse training last completed 5/21/24.2. LPT 2's annual abuse training last completed 10/12/21.3. LPT 3's annual abuse training last completed 9/28/24.4. LPT 4's annual abuse training last completed 10/24/24.5. LPT 5's annual abuse training last completed 9/29/24.6. LPT 6's annual abuse training last completed 11/15/24.7. LPT 7's annual abuse training last completed 11/25/24.8. LPT 8's annual abuse training last completed 11/26/24.9. LPT 9's annual abuse training last completed 5/23/24.10. RN 4's annual abuse training last completed 10/29/24.11. RN 5's annual abuse training last completed 7/16/24.12. RN 6's annual abuse training last completed 1/16/24.13. RN 7's annual abuse training last completed 10/28/24.SRN 1 confirmed the abuse training dates for the 13 licensed nursing staff and stated they were past due for their annual abuse training. SRN 1 confirmed the 13 staff were currently employed and assigned to the skilled nursing units and that they were not out on long-term leave.During an interview on 12/8/25 at 11:08 a.m., with the Nursing Coordinator (NC), NC stated Nursing Education provides a monthly list of staff who are due for training. NC stated when the list is received, she sends it to the Unit Supervisors so that staff can be signed up for the training. NC stated that staff are scheduled to complete annual training during their birth month and confirmed that since it is based off birth month and not month of last completion, staff could go longer than a year between trainings. NC stated that not receiving abuse training annually would cause staff to not receive the most current updates, and stated staff might miss information. NC confirmed abuse training should be completed annually.During a review of facility's policy and procedures(P&P) titled, Reporting Patient Abuse and Neglect, dated 5/7/25, the P&P indicated, 12.0 Employee Training. 12.2 Training All employees are required to complete annual patient abuse prevention training.

Based on observation, interview, and record review, the facility failed to honor a resident's expressed desire for privacy and dignity for one of 21 sampled residents (Resident 10) when Licensed Psychiatric Technician (LPT 2) denied Resident 10 privacy during medication administration.This failure resulted in Resident 10 being exposed in view of other residents.Findings:During a review of Resident 10's Face sheet (demographics), the Face sheet indicated Resident 10 was admitted to the facility on [DATE], with a diagnosis of type 2 diabetes mellitus (condition when the body cannot use insulin correctly and sugar builds up in the blood).During an observation on 12/2/25 at 11:51 a.m., in Unit 404's Day Hall, Resident 10 was sitting in a wheelchair at a table with a food tray in front of him and there was a total of six other residents in the Day Hall. LPT 2 wheeled the medication cart over to Resident 10 and informed Resident 10 that he needed insulin (crucial hormone produced by the pancreas that regulates blood sugar) due to elevated blood sugar level. LPT 2 uncovered Resident 10's abdomen by pulling up his shirt. Resident 10 pulled his shirt back down and informed LPT 2 he did not want to get undressed in the Day Hall while eating with other residents. LPT 2 informed Resident 10 it's okay and proceeded to lift Resident 10's shirt back up again and administered insulin to Resident 10 in lower quadrants of abdomen.During an interview on 12/2/25 at 12:04 p.m. with LPT 2, LPT 2 confirmed Resident 10 requested for privacy by stating he did not want to get undressed in the Day Hall. LPT 2 stated he should have taken Resident 10 to his room or the treatment room to administer insulin.During an interview on 12/2/25 at 3:55 p.m. with Registered Nurse Shift Lead (RNSL) 2, RNSL 2 stated staff should always provide privacy to residents during medication administration. RNSL 2 further stated LPT 2 should have brought Resident 10 to his room for administering insulin.During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect of Individuality, dated March 2025, the P&P indicated, Maintain resident's privacy of body including residents sufficiently covered.

Based on interview and record review, the facility failed to assess and submit accurate data for two of 21 sampled residents (Resident 1 and 21) when the Minimum Data Set (MDS- federally required assessment tool used to guide resident care) did not reflect Resident 1 and Resident 21's current status.This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS).Findings:During a concurrent interview and record review on 12/3/25 at 3:09 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 21's MDS 3.0 Section I- Active Diagnoses, dated 10/4/25, and Active Orders, dated 11/26/25, were reviewed. Resident 21's MDS 3.0 Section I- Active Diagnoses indicated under infections Resident 21 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 21's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 21 was diagnosed with hepatitis C in 2015 and has not received any treatment for hepatitis while residing at the facility. The MDSC confirmed Resident 21's MDS should not have indicated viral hepatitis was an active infection.During a concurrent interview and record review on 12/3/25 at 3:15 p.m. with MDSC, Resident 1's MDS 3.0 Section I- Active Diagnoses, dated 8/23/25, and Active Orders, dated 11/26/25, were reviewed. Resident 1's MDS 3.0 Section I- Active Diagnoses indicated under infections Resident 1 had an active diagnosis of viral hepatitis. Resident 1's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 1 was diagnosed with hepatitis C in 2022 and has not received any treatment for hepatitis while residing at the facility. The MDSC confirmed Resident 1's MDS should not have indicated viral hepatitis was an active infection.During a review of the CMS Long-Term Care Facility [LTCF] Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2024, the CMS LTCF RAI 3.0 User's Manual indicated, Code disease that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Example of inactive Diagnoses . the resident has recovered . with no residual effects and no continued treatment.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when:1.Three of three licensed nurses (Licensed Psychiatric Technician [LPT] 10, LPT 11, LPT 12) inaccurately completed skin assessments for Resident 30.This failure had the potential to result in delayed wound healing and unidentified new wounds.2.Licensed Vocational Nurse (LVN 1) administered Trazadone (a prescription antidepressant medication) to Resident 29 by mouth, instead of crushed via G-tube (surgically placed tube into the stomach for feeding, medication, or drainage) as ordered by the physician.This failure had the potential to result in Resident 29 aspirating (accidentally inhaling food, liquids, particulates into the lungs).Findings: 1.During a review of Resident 30's Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 9/3/25, the MDS indicated Resident 30 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes Mellitus (inability to monitor blood sugar). The MDS indicated Resident 30 required maximum assistance (needing extensive two-person physical help) for all mobility, was dependent on a wheelchair and at risk for developing pressure injuries (localized skin and tissue damage from sustained pressure). During a concurrent interview and record review on 12/4/25 at 3:35 p.m. with Registered Nurse Shift Lead (RNSL 2), Resident 30's documents were reviewed: -Impaired Skin Integrity Risk Care Plan, dated 10/9/25, indicated an active care plan for five boils (painful fluid filled skin infection) to the buttocks, one boil to the left abdomen and two boils on gluteal area (buttocks). -Photographic Wound Documentation, dated 9/19/25, 10/3/25 and 10/10/25 indicated on going wound care for a Stage III (deep full thickness skin wound where the skin is lost and revealing fat) pressure injury (localized skin and tissue damage from sustained pressure) to sacral (bony area between hip and pelvis) area. -Weekly Body Check, dated 10/1/25, signed by LPT 12 and LPT 11 indicated there was no skin impairment -Weekly Body Check, dated 10/8/25, signed by LPT 12 and LPT 10 indicated there was no skin impairment -Weekly Body Check, dated 11/12/25, signed by LPT 12 indicated there was no skin impairment -Weekly Body Check, dated 12/3/25, signed by LPT 11 indicated there was no skin impairment RNSL 2 stated LPT 10, LPT 11, and LPT 12 should have filled out the condition of the skin to include all of the on-going wounds that were being treated on Resident 30's Weekly Body Check Report. During an interview on 12/4/25 at 3:49 p.m. with Unit Supervisor (US), US stated she reviewed the Weekly Body Check reports, dated 10/1/25, 10/8/25, 11/12/25, 12/3/25, and confirmed LPT 10, LPT 11, and LPT 12 did not accurately document the current status of Resident 30's skin and stated staff expectation was to fill out the weekly body checks to accurately reflect Resident 30's skin. During a review of the facility's policy and procedure (P&P) titled, Assessment, Prevention and Treatment of Pressure Injuries and Wounds, dated February 2024, the P&P indicated, Pressure Injury Prevention . Conduct a comprehensive skin inspection for those at risk as soon as possible . subsequent inspections and monitoring at least daily when patients are deemed at risk for pressure injury or have an existing impair skin integrity. 2. During a review of Resident 29's Face Sheet (demographics), the face sheet indicated Resident 29 was re-admitted to the facility on [DATE] with a diagnoses that included: schizoaffective disorder-bipolar type (a serious mental illness blending symptoms of schizophrenia [hallucinations, delusions, disorganized thinking] with those of bipolar disorder [manic highs and depressive lows]), dysphagia (difficulty swallowing food or liquids) and gastrostomy status (having a surgically placed tube [G-tube] into the stomach for feeding, medication, or drainage). During an observation on 12/3/25 at 12:01 p.m. in Resident 29's room, LVN 1 was observed to prepare Resident 29's noon medication. LVN 1 was observed to prepare one 100 mg (milligrams), Trazadone HCL tablet, by crushing it and mixing it in pudding. LVN 1 identified resident as Resident 29 and then administered the medication to Resident 29 by mouth. During a review of Resident 29's Medication and Treatment Administration Record (MTAR), dated December 2025, the MTAR indicated Resident 29 was to receive Trazadone HCL 100 mg tablet, oral at noon (Crushed) give via g-tube. During an interview on 12/3/25 at 2:50 p.m., with LVN 1, LVN 1 confirmed Resident 29's noon medication order was to administer Trazadone crushed via G-tube. LVN 1 stated she saw Resident 29 eating by mouth so she just administered the medication by mouth. During an interview on 12/3/25 at 2:54 p.m. with the Registered Nurse (RN 1), RN 1 stated if a Resident was given a medication by mouth that was ordered to be given via G-tube, he would be concerned for risk of aspiration. RN 1 stated the expectation was that staff follow medication orders as written. During a concurrent interview and record review on 12/3/25 at 3:08 p.m. with RN 1, Resident 29's Physician's Orders, dated 11/25/25 at 2130 was reviewed. The physician orders indicated Resident 29 had Choking/Aspiration Precautions, and the physician ordered Trazadone HCL 100 mg tablet, oral daily at noon 1200 (crushed) give via g-tube. RN 1 confirmed the physician order indicated Resident 29 should have received 100 mg Trazadone, crushed via G-tube per physician orders. During a record review of Resident 29's Dysphagia/Choking Screen, dated 1/31/25 at 0830, the record indicated Resident 29's annual assessment indicated active dysphagia. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Protocol, dated November 2023, the P&P indicated, Prior to administering medication to a resident, Medication-Competent nursing staff will confirm the right: resident, medication, form, dose, route, date, time and the ordered indication. During a review of the facility's policy and procedure (P&P) titled, Medication Administration Guidelines, dated October 2025, the P&P indicated Medications and/or treatment shall be administered .as appropriately ordered via an authorized prescriber.

Based on interview and record review, the facility failed to ensure the environment remained free from accidents for one of 21 sampled residents (Resident 51), when the net zipper of Resident 51's enclosure bed (specialized bed with mesh walls that zip closed around a resident to prevent falls) malfunctioned and Resident 51 got up from bed and fell on the floor.This failure had the potential for serious injury.Findings:During a review of Resident 51's Face Sheet (demographics), dated 9/2/25, the face sheet indicated Resident 51 was admitted on [DATE] with diagnoses that included neurocognitive disorder (problems with thinking and memory caused by changes or damage in the brain), epileptic seizures (when the brain briefly loses control of normal activity, leading to sudden changes in movement, behavior, or awareness) and a history of traumatic brain injury.During a review of the facility's Interdisciplinary Note, documented by the Registered Nurse (RN 11), dated 11/26/25 at 9:07 a.m., the Interdisciplinary Note indicated, Resident 51 was a high risk for fall, and sleeps in a bed enclosure for safety. Review of the interdisciplinary note indicated, Resident 51 was found on the floor on 11/26/25 around 6:28 a.m. Further review of the interdisciplinary note indicated the net zipper malfunctioned and Resident 51 managed to manipulate the net zipper and open the bed.During an interview on 12/4/25 at 4:22 p.m. with the Psychiatric Technician Assistant (PTA 1), PTA 1 stated prior to Resident 51's unwitnessed fall on 11/26/25, staff observed Resident 51 inspecting the zipper while inside the enclosure bed. PTA 1 further stated Resident 51 had been observed by staff while inside the enclosure bed, attempting to maneuver the zipper to open the enclosure bed.During a concurrent interview and record review on 12/5/25 at 9:09 a.m. with RN 3, Resident 51's Observational Status (OS) Record, dated 11/25/25 and 11/26/25, was reviewed. RN 3 stated Resident 51's fall from the enclosure bed was likely the result of the zipper not being properly secured by staff. RN 3 stated it was possible that Resident 51 was able to manipulate the zipper or a malfunction of the zipper had occurred. Review of Resident 51's OS record indicated Resident 51 was on 15-minute supervision for safety at the time of the unwitnessed fall. RN 3 stated during resident rounds staff were expected to look at the position of the resident and their location while in the enclosure bed. RN 3 further stated staff were expected to ensure the enclosure bed was secured and in good working condition.During a review of the facility's policy and procedure (P&P) titled, Enclosure Bed, dated October 2024, the P&P indicated, During rounds, nursing staff will ensure all zippers are secure and clipped around the enclosure bed when the bed is occupied or unoccupied.

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice for two of 21 sampled residents (Resident 9 and Resident 10) when:1.Resident 9's oxygen order did not specify amount or frequency of oxygen to be administered.2.Resident 10's CPAP (Continuous Positive Airway Pressure- machine that delivers pressurized air through a mask to keep airways open during sleep, prevents breathing pauses and improves oxygen levels), machine was not cleaned or maintained for over six months.3.Resident 10's oxygen concentrator humidifier (small, water-filled bottle attached to an oxygen machine which adds moisture to oxygen therapy for comfort), was not changed in 4 days.These failures had the potential to result in respiratory complications, equipment malfunction, and reduced effectiveness of prescribed therapy for the residents.Findings: 1.During a record review of Resident 9's Face Sheet (demographics), the face sheet indicated Resident 9 was re-admitted to the facility on [DATE] with a diagnoses that included: major neurocognitive disorder (a significant decline in at least one cognitive area [memory, attention, language.] severe enough to interfere with independence in daily activities) and disorders of the diaphragm (issues with the main breathing muscle). During a concurrent observation and interview on 12/1/25 at 1:00 p.m. with the Registered Nurse (RN 8), in Resident 9's room, observed oxygen (O2) running at 2L (liters-unit of measurement) per minute, via nasal cannula (tubing that delivers oxygen via the nasal passages). Observed Resident 9's nasal cannula prongs (tube used to deliver oxygen directly into the nose), outside his nose. RN 8 confirmed the nasal cannula prongs should have been in Resident 9's nose, and stated Resident 9 is on 2L of oxygen continuously. During a concurrent interview and record review on 12/3/25 at 11:25 a.m. with the Health Service Specialist (HSS), Resident 9's Physician Orders, dated 11/26/25 at 2035, were reviewed. The physician orders indicated, Respiratory. May apply Oxygen to keep Oxygen Saturation 92% or above. HSS confirmed there was no amount to be administered and stated the order should specify the amount of oxygen. During an interview on 12/3/25 at 3:48 p.m. with the Medical Doctor (MD 2), MD 2 stated he did not put the specific liters of oxygen to be administered to Resident 9 and that 2 liters are administered instinctively. MD 2 further stated he could have put the liters of oxygen to be administered into the order. During an interview on 12/4/25 at 9:36 a.m. with the RN Shift Lead (RNSL 1), RNSL 1 stated oxygen is considered a medication. RNSL 1 further stated oxygen orders should have parameters for how much oxygen to deliver to Resident 9 as well as titration parameters (dose increase to achieve a therapeutic effect). During a review of Resident 9's Care plan for Activity Intolerance Risk, dated 12/10/25, related to COPD (Chronic Obstructive Pulmonary Disease - a condition involving constriction of the airways and difficulty or discomfort in breathing), indicated Resident 9 will not exhibit shortness of breath during activities of daily living or at rest. is on continuous nasal cannula O2 per order. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration and Storage, dated March 2025, the P&P indicated, Medication competent licensed nursing staff may administer oxygen per Physician's/Nurse Practitioner's order. 2.During a review of Resident 10's Minimum Data Set (MDS- federally required assessment tool used to guide resident care), dated 11/12/25, the MDS indicated Resident 10 was admitted to the facility on [DATE], with a diagnosis of Obstructive Sleep Apnea (sleep disorder where the throat muscles relax and block the airway while sleeping causing a pause in breathing). During a review of Resident 10's Physician Orders, dated 11/26/25, the physician orders indicated, CPAP- On at HS [night], Off when awake in AM (morning). During a concurrent observation and interview on 12/2/25 at 10:28 a.m. with Resident 10, in Resident 10's room, Resident 10 was sitting on the edge of his bed with a CPAP mask on. Resident 10 stated he cleaned his CPAP tubing and mask in the public bathroom sink, and he had never received training on cleaning the CPAP components. Resident 10 further stated staff have not cleaned or changed any of the CPAP components since admission in May 2025. During an interview on 12/3/25 at 12:32 p.m. with the Registered Nurse Shift Lead (RNSL) 1, RNSL 1 confirmed staff have not cleaned Resident 10's CPAP machine because there was no documentation on the form CPAP/BiPAP [Bilevel Positive Airway Pressure- a breathing therapy device that delivers two pressure levels of air through a mask] Parts Cleaning Log. During an interview on 12/5/25 at 8:40 a.m. with the Respiratory Therapist (RT), RT stated she was unaware of Resident 10 having a CPAP machine. RT further stated CPAP components- mask, tubing and water chamber needed to be dumped out and cleaned daily to prevent mold buildup. During a review of the facility's policy and procedure (P&P) titled, Nasal CPAP & BiPAP System, dated July 2023, the P&P indicated, When the treatment is over, follow these steps . Clean and disinfect the equipment using a facility-approved disinfectant, according to the manufacturer's instructions . Document cleaning of the CPAP/BiPAP parts on the CPAP/BiPAP Parts Cleaning Log. 3. During a concurrent observation and interview on 12/1/25 at 2:09 p.m., with the Registered Nurse (RN 9), in Resident 10's room, the humidifier on Resident 10's oxygen concentrator was labeled, change Thursday 11/28/25. RN 9 confirmed the date on the label and stated the humidifier should have been changed and it is supposed to be changed daily. During an interview on 12/3/25 at 12:32 p.m., with the Registered Nurse Shift Lead (RNSL 1), RNSL 1 stated staff were responsible for oxygen equipment and supplies and the humidifiers are changed every day. During an interview on 12/5/25 at 8:40 a.m., with the Respiratory Therapist (RT), RT stated the humidifiers on the residents' oxygen concentrators are changed daily and staff will label it with the date it needs to be changed on. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration and Storage, dated March 2025, the P&P indicated, Replace humidifier every 24 hours, labeling with expiration sticker.

Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 sampled residents (Resident 1) when Resident 2 assaulted Resident 1. This failure resulted in physical harm to Resident 1 when he sustained multiple facial lacerations, contusions, and a nasal bone fracture. Findings: During a review of Resident 1 (R1)'s Face sheet, (undated), the record indicated that R1 was admitted to the facility on [DATE], with a history of diagnoses that included: unspecified neurocognitive disorder (decreased mental function due to a medical disease other than psychiatric illness), unspecified displaced fracture of second cervical vertebra (break in the second bone of the neck) .with routine healing, aneurysm (a ballooning and weakened area in an artery) of vertebral artery, and tracheostomy (A hole made by surgeons into the throat to help with breathing) status. During a review of R1's Minimum Data Set (MDS - A standardized assessment tool that measures health status), dated [DATE], the MDS indicated that R1 was non-verbal, was rarely able to express ideas and wants, and rarely understood others. The record indicated staff assessed that R1 had short-term memory problems, long-term memory problems and severe cognitive impairment. Record further indicated that R1 had no identifiable behavioral issues. During a review of Treatment Plan, dated [DATE], showed R1 was non-verbal, medically compromised and bed ridden. During a review of Resident 2 (R2)'s Face sheet (undated), the record indicated that R2 was admitted to the facility on [DATE] with a history of diagnoses that included: major neurocognitive disorder due to probable frontotemporal degeneration (brain damage), with behavioral disturbance, hydrocephalus (a build-up of fluid in the cavities of the brain), and unsteadiness on feet. During a review of R2's MDS, dated [DATE], the MDS indicated that R2 had difficulty stating correct year, month, and day of week as well as difficulty with recall. Record further indicated that R2 exhibited physical behavioral symptoms directed towards others that occurred ,d+[DATE] days out of the seven day look back period. During an observation on [DATE] at 10:57 a.m. in R1's room, multiple facial discolorations were observed on R1. A green and yellow discoloration was observed next to R1's right eye and a reddish/purple discoloration underneath R1's right eye. A light reddish/purple discoloration was observed under R1's left eye. A slight greenish/yellow discoloration was observed around the bridge of R1's nose. During an interview on [DATE] at 12:31 p.m. with Clinical Social Worker (CSW), CSW stated that R2 was very impulsive and gets easily irritated. CSW stated that R2 has a history of low frustration, difficulty adjusting to changes and DTO (danger to others). CSW stated that R2 had recently moved rooms and was roomed with R1 due to a Covid quarantine on the unit. During an interview on [DATE] at 11:46 p.m. with RN2, RN2 stated that on [DATE] at approximately 4:00 am, he was doing every 30 minute safety checks and entered the room of R1 and R2. RN2 stated he observed blood all over R1's face and that R1 had multiple facial contusions and lacerations. RN2 further stated he observed R2's hands and blanket covered in blood. RN2 stated that the physician ordered R1 to be transferred to the hospital for evaluation. RN2 stated that R2 has an extensive history of DTO, especially with his peers. RN2 also stated that R2 was very strong, even though he needs a wheelchair for ambulation, he was still able to stand himself up and can shuffle a few steps. RN2 stated that R2's behaviors are unpredictable, he will be calm one moment and aggressive the next. RN2 stated that R1 is not capable of provoking or defending himself as he is non-verbal and non-ambulatory. RN2 stated he would consider this incident to be assault. During a review of Physician's Orders, dated [DATE] at 4:45 a.m., the Physician's Orders indicated, physician ordered R1 to be transferred to the ER via paramedics for evaluation post assault with facial injuries. During a review of Physician Note: Transfer to Outside Facility for Emergency or Other Services, dated [DATE], the record indicated that R1 was being transferred to higher level of care due to s/p (status post) assault c/o (complaint of) facial bleed and bleeding from tracheostomy. Record indicated that R1 was assaulted by other patient and sustained multiple facial injuries and had noticeable bleeding from nose, mouth, eye and tracheostomy site. During a review of Return from Outside hospitalization Note, dated [DATE], the record indicated that upon readmission to facility R1 had .multiple abrasions on face, with bilateral periorbital (surrounding the socket of the eye) edema (swelling) and purplish discoloration. Nasal abrasions noted. The record also indicated that R1 had a CT Maxillofacial (an imaging procedure that uses x-ray and computer to create cross-sectional images of the face, mouth and jaw) scan which showed R1 sustained a comminuted (bone broken in at least two places) nasal bone fracture. During a record review of Interdisciplinary Notes (IDN), dated [DATE] at 8:21 a.m., the IDN indicated that R1 was assaulted by R2 and that it was unwitnessed but R2 was observed to have bloodied hands and blanket. Record further indicated that R2 refused assessment by staff, no PRN (as needed medication) for DTO was given to R2 after the incident. During a review of Treatment Plan, dated [DATE], showed R2's violence risk factor was moderate, decreased from high on [DATE]. The record indicated that R2 had poor impulse control, low frustration tolerance and poor verbal communication resulting in violent behavior towards peers and staff. Record further indicated that R2 had .multiple allegations of threatening and assaulting other patients. During further review of Treatment Plan, dated [DATE], showed R2 had an active Focus #3.1 for Dangerousness and Impulsivity. The objective was that R2 will practice positive coping skills 2x a day as measured by staff observation and self-report to decrease violent behavior. There were no documented interventions in the treatment plan related to dangerousness and impulsivity for R2. During a review of Physician Progress Notes, dated [DATE] at 5:10 a.m., the record indicated that R2 had a previous incident that occurred the day prior. The record indicated . since unit population is vulnerable patient may harm himself indirectly or may cause further danger to others. During a review of Physician Progress Notes, dated [DATE] at 8:20 a.m., the record indicated that when R2 was asked about the incidents and motive, R2 was not able to recall or provide a motive and stated, I don't know. During a review of IDN, dated [DATE] at 2:54 p.m., it was discovered that R2 had a previous resident-to-resident altercation with another Resident (R3) at approximately 1:55 p.m. on [DATE]. The IDN indicated that R3 reported that she was hit by R2. During an interview on [DATE] at 3:20 p.m. with Unit Supervisor (US), US stated that on [DATE] R2 swung at R3 in the hallway. US stated that after that incident on [DATE] no interventions were ordered for R2. US stated that if a Resident's behaviors are escalating staff would get an order for an as needed (PRN) medication and that the psychiatrist may also order observation, either every 30-minute safety checks or 1-to-1 observation (close observation of resident by staff). During an interview on [DATE] at 10:54 a.m. with Registered Nurse (RN) 1, RN1 stated on the afternoon of [DATE] there was an incident with R2 that involved him hitting R3. RN1 stated that no interventions were implemented following the incident on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Reporting Patient Abuse and Neglect, dated [DATE], the P&P indicated, Abuse or neglect of patients is not condoned and shall not be tolerated . The P&P also indicated that .Physical Abuse: Any of the following: (a) Assault, as defined in Section 240 of the Penal Code. During a review of the facility's P&P titled, Treatment Plan, dated [DATE], the P&P indicated, .3.1 Treatment Plan (TxP) . is developed by an interdisciplinary team . It documents focus of treatment, an intervention plan . The P&P further indicated .5.1 The TxP is: . 5.1.5 Identifies foci of treatment, objectives, and interventions . 5.1.7. Ensures that there are interventions that relate to each objective .

Based on observation, interview, and record review, the facility failed to ensure a safe and accident free evironment by: 1. The facility failed to identify environmental hazards and implement interventions for residents' safety in one of two Skilled Nursing Facility (SNF) Units (Unit 417). There were 32 residents in Unit 417 on 1/5/16. The environmental hazards were as follows: a. Ceiling tiles sagging and falling due to water dropping through the roof in Day hall (Room 101), Nurses station (Room 104), and Staff restroom (Room 134); b. Puddles of water on facility floors from raining; c. Water leaking down the wall of electrical panel in janitor's closet (Room 132), creating puddles on floor. These failures had the potential harm to result in residents' fall and injuries, and electrical hazard being that an electrical panel was located inside the janitor's closet. 2. Failing to follow physicians' order and implement the plan of care, when they failed to ensure the one to one staff assigned to a resident to prevent falls and accidents was alert and awake, for one of 63 Residents of the facility, (Resident 5). This failure had the potential for Resident 5 to fall from his wheelchair and sustain serious injury. Findings: 1. On 1/5/16, at 9:15 a.m., one missing tile was observed in day hall (Room 101, size about 900 square feet), which provided activities, televisions, games, and socialization, for 32 residents. There were about three wheelchair bound residents watching TV and one resident ambulating around. Ten missing ceiling tiles (size, 12 by 12 inches) and leaking stains on 16 tiles were observed in Unit 417 Nurses station (Room 104). There were two lights (size, 48 inches in length) hanging on the damaged ceiling. The lights were mounted under the tiles. Staff restroom (Room 134) had several tiles with leaking stains. During an interview with the Nurse Coordinator (NC) on 1/5/16 at 9:30 a.m., she stated the ceiling damage was from water leaking through the roof when it rains. The Plant Operations came to check several times, but they could not fix it. The NC also stated that one staff slipped and was injured in December 2015 due to the leaking water from rain. During an interview with Chief Plant 1 and 3 on 1/5/2016, at 10:15 a.m., they stated they were aware of the leaking roof in Unit 417. The ceiling repair was still in the process because it was hard to identify location of the leaks. They stated the last repair to the ceiling was about two weeks ago. On 1/5/16, at 11:50 a.m. after heavy rain, one bucket and several wet towels on the floor for collecting the rain water in day hall (Room 101) were observed. One wheelchair bound resident and one ambulatory resident were observed close to the rain water, about one foot distance. There were several residents around different areas in the day hall at the same time. No caution sign for the wet floor was observed at that time. Also, there were two buckets and several large wet towels on floor for collecting rain water in Unit 417 Nurses station; and three collecting rain water buckets in staff restroom (Room 134). A review of the work orders for the SNF indicated the following: On 4/2/2014, room 134 ceiling is leaking from last night's rain; On 4/17/14, missing ceiling tile at Day hall (Room 101); On 4/28/14, room 134 ceiling leaking due to the rain. Room 104 ceiling panel fell -2 fell and 1 fell at 1700 On 1/5/16, Day hall roof leaking. On 1/5/2016, at 3:45 p.m., an observation was made in Unit 417. A standing puddle of water, approximately one to two inches deep was observed across the entire width of the hallway from the nurses' station to the janitor closet (Room 132). The width of the hallway was approximately six feet wide. This area was the access to resident rooms on one wing for rooms 107 to 118. One ambulatory and one wheelchair bound resident were observed approximately two feet from the puddle. A staff member that was assigned to the area was seated in a chair against the wall from the nurses' station, approximately six to eight feet from the puddle. There was no sign indicating the floor was wet. In a concurrent interview with Supervising Registered Nurse (SRN) 2, he acknowledged there was a large puddle of water as he took a blanket and wiped up the puddle of water. He stated, The water was coming from the janitor's closet (Room 132). SRN2 opened the door of the janitor's closet (Room 132) and water was observed leaking from the ceiling onto the walls, and coming under the door. The water was flowing from under the door. On the one wall, an electrical panel was observed. The SRN 2 acknowledged the presence of the electrical panel in the janitor's closet. Immediate Jeopardy was called on 1/5/16 at 5:08 p.m. with Executive Director, Hospital Administration, and Program Director. The survey team notified of an Immediate Jeopardy situation and the immediate threat of harm due to the falling tiles, the water dripping from the ceiling, puddles on the floor which could cause injury from falling, and the possibility of electrocution that could be caused from water dripping on the wall with the electrical panel in janitor's closet. On 1/8/2016 at 9:30 a.m., the surveyor met with the Executive Director, Hospital Administration, and Program Director, informed them the Immediate Jeopardy was abated after the plan of correction was submitted, accepted, implemented and verified. The facility planned to move 32 Residents from Unit 417 to the available Unit 418. Unit 418 was inspected and ready for 32 Residents in Unit 417. 2. During a review of the clinical record for Resident 5, the admission face sheet indicated the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. During an observation on 1/5/16, at 9:03 a.m., with the Nursing Coordinator present, Resident 5 was observed in Unit 417, up in his wheelchair, awake. During the observation, Psychiatric Technician (PT) 5 was sitting next to the resident, with her feet up in another chair, with her eyes closed. At the time of the observation, the Nursing Coordinator cleared her throat loudly several times in attempt to wake up PT 5. When PT 5 did not wake up, the Nursing Coordinator gently nudged her and asked if she needed to be relieved for a break. During an interview with PT 5, at the time of the observation on 1/5/16, at 9:03 a.m., she stated I just meant to close my eyes for a minute. During an interview with the Nursing Coordinator on 1/5/16, at 9:05 a.m., she stated, The staff should not be sleeping. She should be awake and observant. The resident needs the one to one supervision for safety purposes and to help prevent falls. A review of a physician's order dated 1/5/16, indicated the following order: Continue one to one supervision x 24 hours DTS (danger to self)/safety. A review of a document titled, Fall Risk Assessment dated 9/22/15 and 12/17/15, 2015, indicated Resident 5 scored a 19 on the assessment. Further review of the document titled Fall Risk Assessment indicated if the total score is 10 or above, a care plan or focus (medical conditions) 6 with interventions is indicated. During a review of a nursing care plan titled, Fall Risk, dated 12/12/15, indicated the following intervention: On one to one for safety. Provide surveillance continually as indicated by the patient's condition. A review of the facility policy and procedure titled Supervision for High Risk Patients, revised 9/15, indicated: To ensure optimal health and safety of patients under conditions that warrant special supervision. One to One supervision is the continuous observation with no barriers between the assigned staff and the patient. The assigned staff shall be within arms reach of the patient at all times, unless otherwise specified by the ordering physician/Nurse Practitioner/Psychologist. Section 1.5 The patient's condition will be re-evaluated daily by the prescriber and if the evaluation indicates that the level of observation is necessary, then a new order must be written.

Based on observation, interview, record review and review of the facility's policies, the facility failed to ensure that the dishes were properly sanitized prior to serving, failed to ensure the Central Kitchen Area was pest free, failed to date label food product and discard expired foods, failed to allow plate covers to air dry, failed to store non-food items separately, failed to ensure equipment was properly cleaned and failed to follow facility policies, which left the residents at risk due to unsanitary conditions. Findings: On 9/23/13 at 10:30 AM, an unannounced visit was made to the facility for an annual recertification survey. While inspecting the Central Kitchen on 9/25/13 at 12:20 PM, it was determined that the facility staff failed to use an alternate method for dish washing when staff had identified, on 9/24/13. that the dish washing machine had malfunctioned. After the equipment failure was determined, the dietary staff failed to inform the director of the problem and continued to use the malfunctioning dishwasher and continued to serve meals on contaminated dishes. This resulted in residents being served five meals under unsanitary conditions. This facility failure presented a situation of unsanitary conditions in the Central Kitchen with a potential for food borne illness that could cause significant harm to all residents. The survey team identified an immediate jeopardy situation on 9/25/13 and met with the Executive Director via phone, and with the Medical Director, the Director of Standards Compliance and the Director of Clinical Services on 9/25/13 at 3 PM and declared IMMEDIATE JEOPARDY (IJ). A preliminary plan of correction was delivered by the facility that same day that included immediate protection of the residents. The dishwasher will NOT be used until the machine meets the standards and is signed off by the Chief Plant Operations Engineer or his delegate. Staff will utilize the accepted three compartment sink sanitizing protocol to wash all dishes and to ensure that the risk for food borne illness is eliminated. The staff will continue to implement this practice until the dishwasher is repaired. A system to ensure that staff is able to account for the sanitizing of the dishes to be used by residents will be created immediately and will be available for review. On 9/27/13 at 1:10 PM, the survey team accepted the facilitiy's corrective action plan. After review of evidence of implementation of the corrective action plan, the survey team abated the IMMEDIATE JEOPARDY on 9/27/13 at 1:10 with the Executive Director and the Director of Standard Compliance. Findings: 1. On 9/25/13 at 12 PM, a visit was made to the Central Kitchen. The dish machine temperature log was reviewed at that time. The temperatures listed were logged three times a day and titled: breakfast, lunch and dinner. The last temperature documented for the dish machine was 9/24/13, at 7:15 AM, at the breakfast hour. The temperature logged at that time indicated that the wash temperature was 151 degrees and the rinse was documented at 190 degrees. Further review of the temperature log revealed a hand-written note, signed by the Food Service Supervisor II. The note read, "Plant OPS, (Operations) called at 7:15 AM wash temp low work order put in and dated 9/24/13." The dishwasher was inspected on 9/25/13 at 1210. The four temperature gauges that were located on the side of the machine were observed. Of the four gauges, three registered below the minimum water temperature range. The manufacturer recommendations were as follows: Gauge 1: Wash tank 1 should maintain a minimum water temperature of 150 degrees, however, the gauge registered at 138 degrees. Gauge 2: Wash tank 2 should maintain a minimum water temperature of 160 degrees, however, the gauge registered at 138 degrees. Gauge 3: Auxiliary rinse should maintain a minimum water temperature of 165 degrees, however, the gauge registered at 145 degrees. On 9/25/13 at 12:15 PM, a test strip "plate thermometer" was used to test the effectiveness of the dish machine. An adhesive strip was placed on a plastic tray and set on the dish machine conveyor belt. The test strip did not change colors which indicated that the dish machine was not sanitizing the dishes properly. Interviews were conducted that same day at 12:20 PM with the Director of Nutritional Services and the Food Service Supervisor II (FSSII). The FSSII stated she reported the low water temperatures to the Assistant Director of Nutritional Services on 9/24/13. In addition, she sent a work order to the Plant Operation Department 9/24/13, when the water temperature gauges registered as low, and the water was not hot enough to sanitize the dishes. When the surveyor asked if the FSSII followed up with the staff assigned to the dishwashing area, she stated, "No I rely on the staff to tell me if there's a problem." On 9/25/13 at 12:30 PM, an interview was conducted with the Assistant Director of Nutritional Services. She stated that she was informed by the FSSII that the dish machine water temperatures were low and not properly sanitizing the dishes. When she was asked why there was no follow up to ensure that an alternate method of washing was done to ensure the dishes were sanitized, the Assistant Director stated, "She (FSSII), did her job, she reported the dish machine to Plant Operations, she's a good employee." And when asked if the Director of Nutritional Services was notified, she said, "No," I only notify others if the problem is reported two times. Further observation of the dish washing machine equipment noted water draining from a valve (that was located on the underside of the washer), and was pouring onto the floor. At that time, at 12:35 PM, an interview was conducted with the Food Service I staff member. The staff member stated that he was assigned to the dish machine area and indicated that the valve under the dish machine had been draining for approximately 2-3 weeks. On 9/25/13 at 12:40 PM, the Director of Nutritional Services stated that she was unaware that the temperature was low and therefore, not sanitizing the dishes effectively. The Director further stated that the three compartment sink should have been utilized at the time the staff identified that dish machine temperatures did not meet their minimum range. She further stated that the dish machine had been in use for at least 5 meals, after the discovery of the low water temperatures on 9/24/13. Lastly, the Director confirmed that the meals had been served on the same plates that were not properly sanitized. Review of the facility Policy 3403, Sanitation and Safety, included "Utilize the alternate method for dish washing when temperatures on the dish machine are not reaching the correct temperature levels. The three compartment sink method is designed for manual washing, rinsing and sanitizing all utensils, tableware and pots and pans..." 2. On 9/23/13 at 11:30 AM, during the tour of the kitchen, rodent droppings were observed next to the three compartment sink area. Further observation noted a sticky pad labeled for the use capturing rodents located beneath the metal counter tops. Further observation noted a second sticky pad located under the food docking equipment. At that time, an interview was conducted with the Assistant Director of Dietetic Services and the Food Service Supervisor II. It was confirmed that there were rodent droppings and both stated that they were unaware that there was a problem with rodents and that sticky pads had been placed in the Central Kitchen. On 9/25/13 at 11:55 AM, an interview was conducted with the Director of Dietetic Services. The Director stated that she too was unaware that the Central Kitchen area had a rodent infestation. An interview was conducted with Standards Compliance Staff on 9/26/13. At that time a pest control log was requested. Standards Compliance Staff stated that there was no log or documented evidence to show that pest control had been done in the Central Kitchen. 3. On 9/23/13, during a tour of the kitchen area, there were 4 one gallon jars of condiments observed in a refrigerated room. All of which had expired August 2013. A stainless steel pan was observed placed next to the condiments and a plastic food tray was used as a cover for pan. Staff was observed as they uncovered the pan and identified the food item as dried prunes. The pan containing prunes was not date labeled or identified. An interview was conducted at that time the FSSII. The staff confirmed that the jars of condiments were expired and would be disposed of and that the prunes needed to be labeled. Review of the facility policy 3403 Sanitation/Safety indicated that "All food products should be dated or identified to indicate an expiration date..." 4. On 9/23/13 during a tour of the kitchen, the pot washing area was observed with an excessive amount of water that had pooled on the floor. On 9/25/13 at 11 AM, an interview was conducted with Administrative Staff who indicated that floor mats should be used to prevent a potential for hazards. 5. On 9/23/13, during the tour of the kitchen, there was a tall, free standing working fan observed facing an open food cart. The food cart contained several shelves of uncovered food. A closer look at the fan observed blades that were coated with dust and grime. An interview was conducted at that time with dietary staff that confirmed that the fan was dirty and required cleaning. 6. During the tour on 9/23/13, there were several stacked of plastic dish covers. Further observation noted that the dish covers were wet. At that time, the Food Service II confirmed that the dishes were stacked wet and should have been left to air dry. On 9/27/13, the facility's "SOP's, (Standard Operating Procedures)," cleaning and sanitizing food contact surfaces was reviewed. The purpose, " to prevent food borne illness..." The instructions included #5. Wash, rinse, and sanitize...Place wet items in a manner to allow air drying."