Every finding on record at Diablo Valley Post Acute

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Dry food items were stored less than six inches from the floor.A resident's ice pack was stored in the resident refrigerator.A resident's drink was not labelled with use by or opened date in the Resident Refrigerator.Cook (CK) 1 did not wear a beard restraint when they prepared resident food.There was hair on the inside part of the ice machine. During an observation on 8/10/26, at 9:44 a.m., in the dry storage, food thickener, flour, oatmeal and rice were stored approximately 5.5 inches from the floor. During a concurrent observation and interview on 8/13/26, at 10:40 a.m., with Kitchen Manager (KM), in the dry storage, the food thickener, flour, oatmeal and rice were stored above six inches from the floor. KM stated they raised the food and food should have been stored at least six inches above the floor to prevent pests. During an observation on 8/10/26, at 9:49 a.m. the resident refrigerator and freezer were observed with one resident reusable cold compress stored with resident food and one opened bottle of prune juice without an opened or use by date. During an interview on 8/13/26, at 10:46 a.m. with Registered Dietician (RD), RD stated cold compresses should not have been stored in the resident refrigerator and freezer because it was a risk for contamination. RD stated food in the resident refrigerator and freezer should have been labeled with an open date so they could have known if it was expired. During a concurrent observation and interview on 8/12/26, at 9:45 a.m., in the kitchen, CK 1 was observed with exposed facial hair while they prepared rice and cooked marinara sauce for resident lunch. CK 1 stated their beard should have been fully covered when they prepared resident food. During an interview on 8/12/26, at 9:52 a.m., with RD, RD stated kitchen staff should not have had exposed facial hair and should have worn a beard restraint when they prepared resident food. RD stated it was important to cover facial hair and wear a beard restraint to prevent hair from falling on the food. During a concurrent observation and interview on 8/13/26, at 10:42 a.m., with KM, the ice machine was observed with hair on the inside parts. KM stated the hair should not be in the ice machine and the ice machine should have been cleaned because the hair had the potential to get on the ice. During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/ Visitors, dated 5/28/2025, the P&P indicated, Containers are labeled with the resident's name, the item and the use by date. The nursing staff will discard perishable foods on or before the use by date. During a review of the facility's P&P titled, Food Receiving and Storage, dated 2001, the P&P indicated, Food in designated dry storage areas are kept at least six (6) inches off the floor. During a review of the facility's P&P titled, Hairnet Use, dated 2001, the P&P indicated, All staff. entering the kitchen or food preparation areas must wear an approved hairnet that fully covers the hair. Hairnets must be worn at all times while in these areas. Do not adjust, remove or expose hair while in the food preparation or storage areas. During a review of the facility's P&P titled, Ice Machine and Ice Storage Chests, dated 2001, the P&P indicated, Ice machines. will be used and maintained to assure a safe and sanitary supply of ice.

Based on observation, interview, and record review, the facility failed to ensure the disposal of discontinued controlled medications (a prescription medication tightly regulated by the government due to its potential for misuse of can lead to physical or psychological dependence) within the timeframe specified by facility policy for four of seven residents (Resident 21, Resident 61, Resident 193, and Resident 205). This failure resulted in discontinued controlled medications being retained in the Director of Nursing (DON)'s office beyond the required disposal timeframe thereby increasing the potential for medication diversion or misuse.During a concurrent observation and interview on 8/13/26 at 2:30 p.m. with Director of Nursing (DON) in the DON's office, discontinued medications were observed in their original bubble packaging in a basket inside a double-locked cabinet. An Rx Destroyer container (a medication disposal system used to make unwanted medications unusable and prevent them from being taken or reused) was also observed inside the double-locked cabinet. The Rx Destroyer container contained multiple initial storage date labels. None of the initial storage date labels contained a date. DON stated that discontinued medications are collected on Mondays and Fridays and placed in the double-locked cabinet pending disposal with the Omnicare pharmacy consultant. DON stated, Pharmacy comes once a month and the last medication disposal occurred on 7/30/26. DON further stated that the Omnicare pharmacy consultant opens the medication packaging and places the medications into the Rx Destroyer container during the pharmacy's monthly visit.During a phone interview on 8/13/26, at 2:37 p.m. with the Pharmacy Consultant (PC), PC stated that discontinued medications are held at the facility until she comes in. PC stated that she and the DON review the medications, after which the medications are placed in the Rx Destroyer container and securely sealed. PC stated that the facility then contacts pharmacy waste services to arrange for pickup. PC stated there was no regulation specifying a disposal date for the Rx Destroyer container.During a review of Resident 21's admission Record (AR) dated 07/01/26, the record indicated Resident 21 had a diagnosis of lumbago (low back pain) with left sided and right sided sciatica (nerve pain traveling to left and right side of legs) and opioid (a strong pain medication) dependence.During a review of Resident 21's Controlled Drug Record (CDR) dated 7/18/26, CDR indicated Oxycontin (a strong prescription pain medication that is used to relieve severe pain) 15mg Tab ER (extended release), with 25 tablets received on 7/18/26. On 07/30/26, the amount remaining was documented as one tablet.During a review of Resident 21's Progress Notes (PN) dated 07/30/26, the discharge summary indicated Resident 21 was discharged from the facility on 7/30/26.During a review of Resident 61's AR dated 7/20/26, AR indicated Resident 61 had a diagnosis of cellulitis (bacterial infection of skin) of left and right lower limb.During a review of Resident 61's CDR dated 7/21/26, CDR indicated Hydrocodone-Acet (a combination prescription pain medication used to relieve moderate to severe pain) 5mg-325mg tablet, with 24 tablets received on 7/21/26. No entry was documented indicating that any tablets were administered.During a review of Resident 61's Order Listing Report (OLR) dated 8/13/26, OLR indicated Hydrocodone-Acetaminophen 5-325mg Tablet was discontinued on 7/21/26.During a review of Resident 61's PN dated 7/31/26, PN indicated discharge date of 7/31/26.During a record review of Resident 193's AR dated 08/02/26, AR indicated Resident 193 had a diagnosis of displaced mid-cervical fracture of left femur (a broken left thigh bone near the hip that shifted out of place), subsequent encounter for closed fracture with routine healing (a follow-up for a fracture that is healing normally).During a review of Resident 193's CDR dated 8/3/26, CDR indicated Oxycodone-Acet (a combination prescription pain medication used to relieve moderate to severe pain) 5/325mg tablet, with six tablets received. On 8/13/26, the amount remaining was documented as five tablets.During a review of Resident 193's OLR dated 8/13/26, OLR indicated Oxycodone-Acetaminophen 5-325mg Tab was discontinued on 8/3/26.During a review of Resident 205's AR dated 5/02/26, AR indicated Resident 205 had a diagnosis of unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing (a broken right upper-arm bone, with the exact type of break not specified, being seen for follow-up care while the bone is healing normally).During a review of Resident 205's CDR dated 5/3/26, CDR indicated Oxycodone (a strong prescription pain medication used to relieve moderate to severe pain) Immediate 5mg Tab, with 15 tablets received. On 5/25/26, the remaining amount was documented 14 tablets.During a review of Resident 205's SNF/NF to Hospital Transfer Form (Skilled Nursing Facility/Nursing Facility) dated 6/21/26, the record indicated date transferred to hospital on 6/21/26. During a concurrent interview and record review on 8/13/26 at 2:53 p.m. with DON, the facility's policy and procedure (P&P) titled Discarding and Destroying Medications, undated, was reviewed. The P&P indicated, Disposal of controlled substances must take places immediately (no longer than three days) after discontinuation of use by the resident. DON confirmed that the facility's policy requires discontinued controlled medications to be disposed of within three days of discontinuation.

Based on observation, interview, and record review, the facility failed to follow the physician's orders for wound care for one of three sampled residents (Resident 74). Resident 74's low air-loss mattress was found unplugged and deflated. Staff also failed to follow the physician's ordered instructions regarding the use of offloading boots for pressure relief for an existing wound.This failure had the potential to delay wound healing and increase the risk for further skin breakdown for Resident 74.During a review of Resident 74's admission Record (AR), dated 8/12/26, the record indicated Resident 74 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus with diabetic neuropathy (a disorder that can cause numbness in the feet and hands, increasing risk for unnoticed injuries or sores).During a review of Resident 74's Quarterly Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status), dated 7/20/26, the MDS indicated Resident 74 is as able to understand others and make self-understood.During a review of Resident 74's Quarterly Brief Interview for Mental Status (BIMS, an assessment for mental status), dated 7/20/26, the BIMS indicated a score of six out of 15, which indicated severe cognitive impairment.During a concurrent observation and interview on 8/13/26, at 10:20 a.m., with Assistant Director of Nursing 1 (ADON 1), in Resident 74's room, Resident 74's low air loss (LAL) mattress (a specialized mattress that uses air to reduce and redistribute pressure on the skin and help prevent pressure injuries) was turned off and deflated. ADON 1 stated the LAL mattress is for Resident 74's wounds. ADON 1 stated the plug can get tugged during resident care and needs to be checked before leaving the room.During a concurrent observation and interview on 8/13/26 at 10:20 a.m., with ADON 1 in Resident 74's room, ADON 1 stated that new provider orders are communicated directly to staff through room-to-room reporting, wound rounds, and weekly team meetings. ADON 1 stated treatment nurses review orders at the beginning of their shifts and staff are trained to apply the Prevalon heel offloading boots. ADON 1 stated, If I'm following doctor's order and it says to take it off, we'll take it off. ADON 1 further stated, The order will probably specify a specific part of the boots, otherwise it defeats the purpose of having the boots. During a concurrent observation and interview on 8/13/26, at 9:50 a.m., with Certified Nursing Assistant 2 (CNA 2), in Resident 74's room, Resident 74's left heel offloading boot was observed with the black forefoot strap fastened. CNA 2 stated she works with Resident 74 regularly and was familiar with her care. CNA 2 stated Resident 74's LAL mattress is for Resident 74's wounds. CNA 2 stated Resident 74 has a wound located on the left inner forefoot (the inside part of the front of the left foot near the big toe). CNA 2 stated she ensures the placement of the boots is aligned and ensures the black straps is on but not too tight. CNA 2 stated the wounds won't heal if the straps are on and touching the area of the wound.During a record review of Resident 74's July Treatment Administration Record (TAR) dated 7/1/2026 to 7/31/2026, the TAR indicated LAL mattress for pressure redistribution, License Nurse (LN)'s to check for machine malfunction. The TAR also indicated, Continue green prevalon heel offloading boots at all times while in bed. Do not fasten the black forefoot strap - leave this area open as to not apply pressure to the wound / bony prominences of the forefoot. Only secure the black strap that crosses over the lower leg.During a record review of Resident 74's August Treatment Administration Record (TAR) dated 8/1/2026 to 8/31/2026, the TAR indicated LAL mattress for pressure redistribution, LN's to check for machine malfunction. The TAR also indicated, Continue green prevalon heel offloading boots at all times while in bed. Do not fasten the black forefoot strap - leave this area open as to not apply pressure to the wound / bony prominences of the forefoot. Only secure the black strap that crosses over the lower leg.During a record review of Resident 74's Foot & Ankle Consult Note dated 6/18/2026 recommendations indicated, Do not fasten the black forefoot strap - leave this area open as to not apply pressure to the wound / bony prominences of the forefoot. It also indicated, Only secure the black strap that crosses over the lower leg.During review of Resident 74's After Visit Summary dated 6/18/26, podiatry discharge instructions indicated, Do not fasten the black forefoot strap - leave this area open as to not apply pressure to the wound / bony prominences of the forefoot. It also indicated, Only secure the black strap that crosses over the lower leg.During a record review of the facility's Policy and Procedure (P&P) titled, Wound care revised on April 2026, the P&P indicated, Review the care plan to understand any special needs of the resident. The policy further indicated, Use supportive device as instructed.

Based on interview and record review, the facility failed to ensure Medicare beneficiary notices (notices informing Medicare beneficiaries of changes or termination of Medicare coverage and potential financial liability) were issued for two of three sampled residents (Resident 1 and Resident 8) including the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), CMS-10055 (a notice informing the beneficiary of potential financial liability for services that Medicare may not cover).This failure resulted in Resident 1 and Resident 8 not being informed of their potential financial liability for services following the termination of Medicare Part A coverage (stays in hospitals and skilled nursing facilities).During a review of Resident 1's SNF Beneficiary Protection Notification Review, dated 6/10/2026, the document indicated Resident 1's Medicare Part A Skilled Services began on 5/5/2026 with the last day of covered Part A services on 6/10/2026. Resident 1 remained in the facility and transitioned from skilled services to custodial care. Resident 1's Notice of Medicare Non-Coverage (NOMNC), CMS-10123 (a notice informing the beneficiary that Medicare coverage for covered services is ending and the right to expedited appeal), was issued. However, because Resident 1 remained in the facility following the termination of Medicare Part A coverage and continued to receive services that were not covered by Medicare, the SNF ABN, CMS-10055, was required to inform Resident 1 of potential financial liability. The SNF ABN, CMS-10055, was not found in the Resident 1's record.An attempt was made to interview Resident 1 on 8/10/2026 at 3:34p.m Resident 1 declined the interview and stated No, I don't want to talk.During an interview on 8/11/2026 at 1:52 p.m. with Social Services Director (SSD), SSD stated Resident 1 transitioned from skilled services to custodial care and continued to reside in the facility. The SSD stated he did not know whether Resident 1 received CMS-10055 and was unable to provide a copy or other documentation showing CMS-10055 had been issued.During a review of Resident 8's SNF Beneficiary Protection Notification Review, dated 4/15/2026, the SNF Beneficiary Protection Notification Review indicated, Resident 8's Medicare Part A skilled services began on 3/11/2026, with the last day of covered Part A services on 4/17/2026. Resident 8 remained in the facility following the termination of Medicare Part A coverage. Resident received NOMNC, CMS-10123; however, the required SNF ABN, CMS-10055, was not found in Resident 8's record.During an Interview on 8/11/2026 at 1:52p.m. with SSD, SSD stated CMS-10055 was not issued to Resident 8.

Based on observation, interview and record review, the facility failed to treat one of three sampled residents (Resident 75) with dignity when Certified Nursing Assistant (CNA) 1 did not empty Resident 75's urinal (a plastic container used by men who cannot easily get out of bed to use the bathroom) and left the urinal hanging on the bedrail near Resident 75's face.These failures resulted in not ensuring Resident 75's rights to be treated with dignity and respect.During a review of Resident 75's admission Record, dated 8/11/26, indicated Resident 75 was admitted to the facility in 2020.During a review of Resident 75's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/1/26, indicated Resident 75 had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident)) score of 5 out of 15. Meaning, Resident 75 had severe cognitive impairment. MDS further indicated Resident 75 had multiple diagnoses that included stroke, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), aphasia (brain-related condition that makes it difficult to speak/understand words), dysarthria (speech disorder caused by brain or nerve damage that weakens or impairs control over the muscles used for speaking), and Benign Prostatic Hyperplasia (BPH - enlarged prostate). MDS also indicated Resident 75 was dependent (helper does ALL of the effort to complete the activity) on staff with toileting.During an observation on 8/10/26, at 10:33 a.m., in Resident 75's room, a urinal contained with highly foul/malodorous dark liquid was hanging on Resident 75's left upper bedrails near Resident 75's face. During a concurrent observation and interview on 8/10/26, at 11:43 a.m., in Resident 75's room with Certified Nursing Assistant (CNA) 1, CNA 1 acknowledged there was urine in Resident 75's urinal. CNA 1 stated, it was not appropriate that she did not empty Resident 75's urinal and leaving the urine filled container hanging on Resident 75's bedrail.During a review of Resident 75's care plan (personalized roadmap that details healthcare needs), dated 3/6/26, indicated Resident 75 had bladder incontinence (cannot control bladder). Care plan also indicated, Resident 75 had left side hemiplegia, hemiparesis, communication barriers and incontinence. One of the interventions for Resident 75 was, anticipate and meet the resident's needs and provide toileting assistance/urinal.During a review of facility's policy and procedure (P&P) titled, Dignity dated 2/2021, under Policy Interpretation and Implementation, indicated 1. Residents are treated with dignity and respect at all times.12. Staff are expected to promote dignity and assist residents; for example: .b. promptly responding to a resident's request for toileting assistance;During a review of facility's P&P titled, Resident Rights, dated 2/2021, Policy Interpretation and Implementation, indicated 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence; b. be treated with respect, kindness, and dignity;

Based on interviews and record reviews, the facility failed to ensure three out of 175 residents (Resident 8, Resident 57, and Resident 150's representative) understood the Binding Arbitration Agreement that they signed. (Binding Arbitration Agreement - a binding agreement by the parties to submit to arbitration [mediation] disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not.) This failure resulted in Resident 8, Resident 57 and Resident 150 of potentially not using this option to resolve any disputes they may have with the facility. During a review of Resident 57's admission record, dated 7/13/26, the record indicated Resident 57 was admitted to the facility on [DATE].During a record review of Resident 57's Annual Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional abilities, health needs, and clinical status) assessment dated [DATE], the assessment showed Resident 57 was able to understand others and make herself understood. Resident 57 was assessed with an Annual Brief Interview for Mental Status (BIMS, an assessment used to evaluate cognitive status) score of 15 out of 15, indicating no impaired cognition.During a review of Resident 57's Arbitration Agreement, dated 7/14/26, the record revealed the arbitration agreement was signed by Resident 57.During a review of Resident 8's admission record, dated 3/10/26, the record indicated Resident 8 was originally admitted to the facility on [DATE] and was re-admitted on [DATE].During a record review of Resident 8's Annual Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional abilities, health needs, and clinical status) assessment dated [DATE], the assessment showed Resident 8 was able to understand others and make himself understood. Resident 8 was assessed with an Annual Brief Interview for Mental Status (BIMS, an assessment used to evaluate cognitive status) score of 11 out of 15, indicating moderately impaired cognition.During a review of Resident 8's Arbitration Agreement, dated 3/10/26, the record revealed the arbitration agreement was signed by Resident 8.During a review of Resident 150's admission record, dated 8/13/26, the record indicated Resident 150 was admitted to the facility on [DATE] with a diagnosis of dementia (a condition that affects memory, thinking, and the ability to perform daily activities).During a record review of Resident 150's Annual Minimum Data Set (MDS, an assessment tool used to evaluate a resident's functional abilities, health needs, and clinical status) assessment dated [DATE], the assessment showed Resident 150 was able to understand others and make himself understood. Resident 150 was assessed with an Annual Brief Interview for Mental Status (BIMS, an assessment used to evaluate cognitive status) score of six (6) out of 15, indicating severely impaired cognition.During a review of Resident 150's Arbitration Agreement, dated 7/7/26, the record revealed the arbitration agreement was signed by Resident 150's representative.During an interview on 8/12/26, at 1:05 p.m., with Resident 57, in Resident's room, Resident 57 stated she was not aware she had signed a binding arbitration agreement. Resident 57 also stated the facility did not explain what binding arbitration was and that, if it had been explained to her, she would not have signed it. Resident 57 stated she thought she was going to get in trouble if she did not sign it.During a phone interview on 8/12/26, at 1:15 p.m., with Resident 57's daughter using Resident 57's phone, Resident 57's daughter stated she was not aware Resident 57 had signed the binding arbitration agreement. Resident 57's daughter stated the agreement was not explained to her, and Resident 57 should not have signed it.During a phone interview on 8/11/26 at 12:02 p.m. with Resident 150's representative, the representative stated he did not remember signing a binding arbitration agreement and did not know what a binding arbitration agreement was. He stated the facility did not explain binding arbitration to him. He also stated he did not recall the facility informing him that he had 30 days to rescind (cancel) his signature.During an interview on 8/13/26 at 9:40 a.m. in Resident 8's room, Resident 8 stated he was not familiar with the binding arbitration agreement but remembered signing it. He reported the facility did not explain what binding arbitration was but stated he did recall the facility informing him he could rescind his signature within 30 days.During a review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, dated November 2017, the policy indicated under Policy Interpretation and Implementation, The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (i.e., litigation).

Based on observation, interview and record review, Registered Nurse (RN)1 failed to observe infection control measures for one of three sampled residents (Resident 106) when RN1 was observed wearing clean gloves before administration of medication via gastrostomy tube (G-tube, a flexible medical tube placed through a small opening in the belly directly into the stomach) to Resident 106. RN 1 did not remove their gloves after medication administration and then proceeded to initiate tube feeding without performing hand hygiene.These failures had the potential to transmit infectious microorganisms and increase the risk of infection to Resident 106.During a review of Resident 106's admission record, dated 8/13/26, indicated Resident 106 was admitted to the facility in 2024 with multiple diagnoses that included, persistent vegetative state (a condition where a person with severe brain damage seems awake and has sleep-wake cycle but has no mental awareness), dysphagia (trouble swallowing), and encounter for attention to gastrostomy (routine care, cleaning, or checking of a feeding tube (G-tube).During medication administration observation on 8/12/26, at 1:00 p.m., in Resident 106's room, Registered Nurse (RN) 1, RN 1 drew Resident 106's privacy curtain closed with gloved hands. RN 1 then administered Resident 106's medication through syringe attached to the opening port of the G-tube. RN 1 completed medication administration by flushing the syringe with water. RN 1 then proceeded to prepare Resident 106's enteral nutrition bag without removing gloves and/or performing hand hygiene. During an interview on 8/12/26, at 1:09 p.m., in Resident 106's room, RN 1 stated, the gloves she was wearing was considered dirty after touching Resident 106's privacy curtain. RN 1 added, she should have changed to clean gloves before proceeding to perform medication administration via G-tube. RN 1 further added, there was risk for infection to Resident 106 when she administered medication wearing dirty gloves.During an interview on 8/13/26, at 3:21 p.m., with the Infection Preventionist (IP), IP stated, RN 1's glove was considered dirty when she touched the privacy curtain. IP added, RN 1 should have removed dirty gloves, perform hand hygiene and don on new pair of clean gloves before proceeding to administer Resident 106's medication via G-tube. IP added, there was high risk to introduce bacteria through opening or port when RN 1 touched privacy curtain then administering medication through G-tube port. Furthermore, IP stated the standard practice when starting enteral feeding (delivering food) straight into the stomach through a small hole in the belly) was to perform hand hygiene and don on new pair of clean gloves. IP added, it was not acceptable practice that RN 1 started Resident 106's enteral feeding immediately after medication administration via G-tube because RN 1's hand was already exposed to bodily fluids and can contaminate the feeding formula.During a review of Resident 106's Order Summary, dated6/23/26, indicated Resident 106 had Enteral Feed Order two times a day Isosource (medical liquid meal) 1.5 (amount of calorie) at 60 ml/hr (milliliter fluid per hour) for 20 hours. On at 1PM.During a review of Resident 106's August 2026 Medication Administration Record (MAR), indicated, on 8/13/26 at 1 p.m., Resident 106 received Isosource 1.5 at 60 ml/hr.During a review of facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, dated 11/2018, indicated under Steps in the Procedure .20. Wash your handsDuring a review of facility's P&P titled, Infection Prevention and Control Program, dated 12/2023, under Elements of the IPCP (Infection Prevention and Control Program) 7. Prevention of Infection a. Important facets of infection prevention include: .(2) instituting measures to avoid complications or dissemination; (3) educating staff and ensuring that they adhere to proper techniques and procedures;.(7) implementing appropriate enhanced barrier and transmission-based precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).9.c. Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment.

Based on observation, interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 used a facility approved blood pressure monitoring device on one of 27 sampled Residents during medication administration observation.This failure had the potential to have inaccurate blood pressure reading and can negatively affect clinical treatments.During medication administration observation on 8/12/26 at 8:17 a.m. with LVN 1, LVN 1 used a compact wristband digital device (Choice MMed) to take blood pressure prior to administering blood pressure medication.During an interview on 8/12/26 at 9:01 a.m. with LVN 1, LVN 1 stated, he brought the wristband digital blood pressure device from home. LNV 1 added, he did not consult with nursing management prior to using his own supply for residents.During a concurrent interview and record review on 8/12/26 at 3:56 p.m., with the Assistant Director of Nursing (ADON) 1, the facility's policy and procedure (P&P) titled, Blood Pressure, Measuring, dated, April 2026, under General Guidelines indicated .4. Obtain accurate blood pressure measurement. Ensure the following conditions for accuracy: .c. the blood pressure device has been validated for accuracy by the facility (validatebp.org); ADON 1 stated, LVN 1 brought and used a blood pressure device brought from home that was not validated in validatebp.org according to facility's policy and procedure.During an interview on 8/12/26 at 4:06 p.m. with the Director of Nursing (DON), DON stated, staff are expected to check with nursing management when bringing equipment for resident use. DON added, wristband digital blood pressure device may not be accurate and can potentially affect treatment given to residents.

Based on observation, interview and record review facility did not monitor the hemodialysis (artificial kidney machine treatment, that pumps the blood outside the body, cleans out extra waste and water through a special filter, and sends the clean blood back) access site for one of three sampled residents (Resident 183).This failure to monitor the hemodialysis access site may lead to delayed identification of adverse conditions, placing the resident at risk for preventable harm such as infection. Findings: During a record review of Resident 183's admission record indicated Resident 183 was admitted to the facility on [DATE] and had a diagnosis of End Stage Renal Disease (permanent kidney failure, where the kidneys can no longer clean your blood or remove extra water).During a record review of Resident 183's Minimum Date Set (MDS, a resident assessment tool used in identifying problems to be addressed in plan of care) dated 8/13/26, indicated Resident 183's Brief Interview for Mental Status (BIMS, short-term memory screening tool) score was 13 out of 15, indicating intact memory and thinking.During an observation and interview on 8/13/26 at 11:15a.m, Resident 183 stated they have a regularly scheduled hemodialysis and the access site used was a permanent catheter (perma cath, a flexible plastic tube placed in a large vein in the neck or chest and threaded down near the heart). Resident 183 pointed to their perma cath and showed a tube, covered with white dressing, that was inserted in their right chest.During an interview on 8/13/26 at 11:34 a.m., Registered Nurse (RN 2) stated that doctor's orders for monitoring a hemodialysis access site are in the Treatment Orders, and they can document their assessment in the Treatment Administration Record (TAR). RN 2 stated there was no order for monitoring of the perma cath and no documentation, so they cannot be sure that it was being monitored. RN 2 stated monitoring should include checking for redness, bleeding, intact dressing, any soaking, and signs and symptoms of infection (harmful germs like bacteria or viruses that enter the body, multiply, and make a person sick). RN 2 stated it is very important to monitor the perma cath because the risk is great since the perma cath is directly connected to the heart, and an infection at the access site can lead to sepsis (an extreme and dangerous reaction to an infection).During an interview on 8/13/26 at 2:05p.m. Director of Nursing (DON) stated it is important to monitor perma cath or hemodialysis access site for proper placement, watch out for infection, bleeding, integrity of the port site since the risk of missing these signs may lead to sepsis or worse, death. During a record review of Facility's Policy and procedure (P&P) titled Hemodialysis Catheters - Access and Care of dated June 2025, indicated Central catheters for hemodialysis are generally inserted in the neck or chest area. There is more risk of clotting and infection that with either fistulas (access is created surgically connecting an artery and a vein) or grafts (access using a plastic tubing to connect the artery and vein).

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and comfortable environment when:-Bugs, flies, and spiders were observed in/or near resident rooms.-Garbage leakage in the garbage compactor area was noted, creating odors.-Unused/out-of-service equipment were stored outdoors in an area where the ground was muddy.These failures potentially increase the risk of pest infestation and posed avoidable health and safety risks to residents.Findings:During an interview on [DATE] at 9:35 a.m. with Resident 4, Resident 4 stated she observed a spider on her curtain and informed staff, asking them not to sit near it; staff acknowledged and agreed. Resident 4 also stated she saw a fly in her room.During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with cellulitis (common bacterial infection of the skin and underlying soft tissues) of the lower limb.During a review of Resident 4's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to evaluate a resident's memory, orientation and short-term recall) score of 15. A BIMS score of 13-15 is an indication of intact cognitive (mental) status.During an interview on [DATE] at 9:43 a.m. with Housekeeping Staff (HS) 1, HS stated she occasionally noticed dead fruit flies on the windowsill and sometimes found spiders, which she simply picked up removed from the residents' rooms.During an interview on [DATE] at 10:18 a.m. with Resident 5, Resident 5 stated she occasionally saw flies inside the room during lunch and dinner.During a review of Resident 5's MDS dated [DATE], the MDS indicated a BIMS score of 14.During a telephone interview on [DATE] at 10:39 a.m. with Family Member (FM) 1, FM 1 stated upon arrival at the facility on [DATE], there were roaches in the hallway, moldy walls and chipped paint inside the resident room.During a concurrent observation and interview on [DATE] at 11:48 a.m. with HS 1, in the hallway by the exit next to the kitchen, a deceased roach-like insect was noted near the exit door leading to the garbage area. HS 1 stated she was not sure of the insect's species; however, two similar dead insects were also observed outside the exit door. Adjacent to the area was a garbage compactor, with liquid waste leaking toward the drain. Medical equipment such as old manual lifts were stored nearby, and the ground was wet and muddy. Additionally, two dumpsters containing empty boxes were present, both lacking covers.During a concurrent observation and joint interview on [DATE] at 12:11 p.m. with Residents 6 and 7, Resident 6 stated she noticed flies in the room during mealtimes, which is why she kept a fly swatter because she did not like seeing flies while eating. Resident 6 stated she also gave a swatter to her roommate, Resident 7. Resident 7 also stated seeing roaches running around their room at night. During the interview, a fly was observed moving across rooms. Upon leaving the residents' room, there was a spider near the doorway.During a review of Resident 6's AR, the AR: indicated Resident 6 was admitted to the facility in [DATE].During a review of Resident 6's MDS dated [DATE], the MDS indicated a BIMS score of 14.

Based on interview and record review, for two of two (Resident 2 and 3) sampled residents reviewed for Restorative Nursing Program (RNP, a structured nursing-driven program designed to maintain or improve a resident's functional abilities, prevent decline and support independence with daily mobility, self care, and other ADLs), the facility failed to provide Restorative Nursing Assistant services (RNA, also referred to as RNP) as required in the resident's comprehensive care plans nor did it maintain restorative program to prevent further functional decline when:-Resident 2's RNA program was not initiated timely after skilled therapy ended.-Resident 3's repeated refusals to RNA services for ambulation were not addressed for three months from May 2026 to July 2026.This failure had the potential to result in decreased range of motion and overall functional decline.Findings:During a review of Resident 2's admission Record (AR) dated 7/30/26, the AR indicated Resident 2 was admitted to the facility in June 2025 with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting left dominant side, muscle weakness, and need for assistance with personal care.During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/11/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to evaluate a resident's memory, orientation and short-term recall) score of 14. A BIMS score of 13-15 is an indication of intact cognitive (mental) status.During an interview on 7/29/26 at 10:05 a.m. with Resident 2, Resident 2 stated that the last time she received RNA services was approximately two weeks ago. Resident 2 stated that staff told her that RNA would follow up on Monday; however, no one came. Resident 2 further stated that after her skilled therapy (rehabilitation) ended, RNA services were not initiated or continued.During a review of Resident 2's Activities of Daily Living (ADL, such as bathing, personal hygiene, getting in and out of bed, eating) care plan last revised 3/19/26, the interventions included Physical Therapy (PT), Occupational Therapy (OT) evaluation and treatment as ordered.During a review of Resident 2's Physical Therapy PT Discharge Summary (PTDS) for dates of service 3/18/26-5/21/26, the PTDS indicated, at the start of therapy on 3/18/26, Resident 2 was totally dependent on staff for movement (turning and repositioning in bed, walking) and transfers (transferring in and out of chair, and bed). Upon discharge, Resident 2 required maximum assistance for turning, repositioning, walking, and transferring between bed and chair. Resident 2 was discharged from skilled therapy with recommendation for RNP.During a review of the Restorative Nursing Program (RNP) Referral dated 5/13/26, the RNP Referral indicated for Resident 2's active Range of Motion (ROM, how far a joint or body part can move in each direction, active ROM is movement of a joint performed by the resident herself using their own muscle without any assistance from another person or device) program three times weekly for both upper and both lower extremities using a bicycle.During a review of Resident 2's physician order dated 6/25/26 (42 days after referral), the physician order indicated RNA program to both upper and lower extremities three times weekly using omni cycle (motor assist therapeutic exercise system designed for patients with limited strength, coordination, endurance, or neurological/orthopedic limitations) for 15 minutes every dayshift on Monday, Wednesday and Friday for 90 days.During a review of Resident 2's Documentation Survey Report (DSR) for June 2026, the DSR indicated Resident 2 received RNA program two times, on 6/26/26 and 6/29/26. DSR for July 2026 indicated Resident 2 did not receive RNA services from 7/15/26 to 7/24/26.During a telephone interview on 7/29/26 at 2:21 p.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Rehab therapy services resumed after Resident 2 returned from the hospital on 7/12/26. After completing skilled therapy, Resident 2 was transitioned back to the RNA program this Monday 7/27/26. RNA 1 also stated Resident 2 experienced multiple hospitalizations, and each time she returned to the facility, Resident 2 was reassessed by the rehabilitation (rehab) team before being referred to the RNA program. RNA 1 stated prior to Resident 2's recent hospitalization, Resident 2 consistently participated in the RNA program.During a concurrent interview and record review on 7/29/26 at 2:28 p.m. with Assistant Director of Nursing (ADON), ADON stated Resident 2 was hospitalized on [DATE] and returned on 7/12/26. RNA services were provided on 7/13/26, but Resident 2 was picked up by therapy on 7/15/26, 7/17/26 and 7/22/26. ADON stated, on 7/27/26, Resident 2 was advised by the gastroenterologist to go to the Emergency Department (ED) but returned to the facility same day.During an interview on 7/30/26 at 10:47 a.m. with Infection Preventionist/Licensed Vocational Nurse (IP/LVN), IP/LVN stated there was a lapse between the time rehab department generated the referral and when it was picked up by the RNA staff that resulted in the delay in initiating restorative services. IP/LVN stated, ideally, when rehab discharges a resident from skilled therapy, the referral should be received and acted upon within 1-2 days so the resident can begin the RNA program without interruption.During a follow-up interview on 7/30/26 at 11:19 a.m. with IP/LVN, IP/LVN stated there was a lapse in communication regarding RNA referrals. IP/LVN stated referrals were not consistently routed to a single point of contact, at times the referral was given directly to the RNA staff, other times to her, and on other occasions Director of Rehabilitation (DOR) or the Physical Therapist/Physical Therapy Aide would provide the referral to nursing. IP/LVN stated there should be a more appropriate and efficient referral process that ensures all RNA referrals are received, tracked, and acted upon promptly. During an interview on 7/30/26 at 11:42 a.m. with DOR, DOR stated Resident 2 was not in therapy in June 2026, her last skilled therapy date was 5/21/26. DOR stated, at discharge from therapy on 5/21/26, the plan was for Resident 2 to return to custodial care, and a referral for RNA was completed at that time and given to nursing. DOR also stated Resident 2 did not receive skilled therapy upon her return from the hospital on 7/12/26, or anytime in July 2026. DOR stated that the referral process from rehab to nursing could be more efficient as there was no formal protocol for referral routing.During a review of Resident 3's ADL care plan last revised 3/24/26, the care plan indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, osteoporosis of the right knee and left shoulder and difficulty walking. The Restorative Nursing care plan last revised 4/23/26 indicated Resident 3 was at risk for decline in ambulation and required RNP. Resident 3 needed RNA program for ambulation and mobility.During a review of Resident 3's DSRs from May 2026 to July 2026 indicated the following for Resident 3's RNA program for ambulation/mobility program three times weekly using front-wheeled walker (assistive device featuring two wheels in the front and non wheeled rear legs) with supervision or touching assistance for 50 feet as tolerated.-In May 2026, the DSR indicated nine refusals and three episodes of missed RNA services, Resident 3 participated with RNA services only once on 6/12/26.-In June 2026, DSR indicated seven refusals and two episodes of missed RNA services. Resident 3 participated with RNA services four times during this period.-In July 2026, DSR indicated five refusals and five episodes that were marked NA.During review of Resident 3's RNA Weekly Summary (RNAWS) dated 6/4/26, 6/10/26, 6/17/26, 6/24/26/ 7/5/26 and 7/16/26, the RNAWS indicated resident refuses to do any of her RNA most of the time, nurse in [charge] aware.During an interview on 7/30/26 at 10:47 a.m. with IP/LVN, IP/LVN stated when a resident declines RNA, it is important to ascertain the reasons for their refusal; consider whether timing or medication may be influencing their decision. IP/LVN stated refusals should not be accepted without exploring the underlying cause and determining whether adjustments can be made.

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food safety when a can of [NAME] pears with a dented rim and a package of pasta was open to the air were found on the shelves in the dry storage area of the facility kitchen, and when ceiling tiles throughout the facility kitchen were found to be stained, separating, peeling and had significant gaps between tiles.This failure could have resulted in resident's being served contaminated food causing potentially serious illness.FindingsDuring a concurrent observation and interview on 5/26/26 at 12:10 p.m. with Dietary Supervisor 1(DS1) in the dry storage area of the facility kitchen , a can of [NAME] pears with a dented rim and a package of pasta open to the air, were found on the shelf in the dry storage area of the facility. DS1 stated dented cans and unsealed packages of pasta are at risk for contamination and should not be used.During a concurrent observation and interview on 5/26/26 at 1:10 p.m. with Director of Maintenance 1(DM1) in the facility kitchen, ceiling tiles throughout the facility kitchen were observed. Ceiling tiles above the dishwashing area were observed to be peeling, there were gaps between tiles throughout the kitchen and on the ceiling by the coffee maker and a preparation counter, there was a separated ceiling tile exposing the area above the tile. Along the back wall of the kitchen by a fire sprinkler, ceiling tiles were observed to be heavily stained and one tile next to the stained tiles was missing. DM1 stated there should be no gaps, loose tiles, missing tiles, stained tile or peeling tile in the kitchen to keep debris and pests from falling into the food.

Based on interview and record review, the facility failed to notify the California Department of Public Health(CDPH) of a cockroach infestation in the facility kitchen resulting in a 24-hour facility kitchen closure by local public health. This failure had the potential to put the facility at risk for providing meals which would have threatened the well-being of medically fragile residents.During an interview on 5/22/26 at 12:30 p.m. with Registered Dietician (RD1), RD1 stated the facility did not report the kitchen closure to the California Department of Public Health (CDPH), because RD1 thought local public health would notify CDPH.During a concurrent interview and record review on 5/26/26 at 4:00 p.m. with the Administrator (ADM) in the ADM's office, files of incidents reported to CDPH were reviewed. The ADM stated he could not locate verification that the kitchen closure was reported to CDPH. The ADM stated the last facility reported incident to CDPH was on 3/19/26, and the kitchen closure qualified as an unusual occurrence which had the potential to harm residents. The ADM stated the facility did not report the kitchen closure to CDPH as required.A review of the facility's policy and procedure titled Unusual Occurrences dated 12/2007 indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Our facility will report the following events to appropriate agencies: .Other occurrences that interfere with facility operations and affect the welfare, safety or health of residents, employees and visitors. Unusual occurrences shall be reported via telephone to appropriate agencies and required by current law and/or regulations within 24 hours of such incident or as otherwise required by federal and state regulations. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulation.

Based on interviews and record reviews, the facility failed to maintain an effective pest control program.This failure resulted in the presence of live cockroaches and cockroach remains in the facility kitchen. The presence of pests had the potential to contaminate food and cause disease.During an interview on 5/22/26 at 12:30 p.m. with Registered Dietician(RD1), RD1 stated on 5/20/26 the local health department found roach remains inside the panel located below the hot food service area. RD1 stated the kitchen was closed by local public health until pest control was completed and the kitchen was deep cleaned.During an interview on 5/22/26 at 3:30 p.m. with the Director of Maintenance(DM1), DM1 stated the facility kitchen had not been inspected for pests from 12/1/25 until 5/20/26. During an interview on 5/26/26 at 1:30 p.m. with Cook(CK1), CK1 stated he had seen an occasional live roach prior to the 5/20/26 pest control visit.During an interview on 5/26/26 at 1:55 p.m. with Cook(CK2), CK2 stated prior to 5/20/26 he did see live roaches in the kitchen. CK2 stated he had not seen any new traps or pest control going through the kitchen for several months until the pest control visit on 5/20/26.During a telephone interview on 6/2/26 at 11:34 a.m. with Registered Environmental Health Specialist (REHS1), REHS1 stated she observed live cockroaches and cockroach remains under the steam table, (area of the kitchen used to keep food warm while serving), and issued a red tag closure, (an emergency shut down of a kitchen by a public health department for serious safety concerns), of the facility kitchen. REHS1 stated the kitchen will remain closed until pest control provider services the kitchen and the kitchen is deep cleaned. The REHS1 stated cockroaches spread disease and are unacceptable in a commercial kitchen due to food safety risk. During a review of Food Facility Routine Inspection Report dated 5/20/26, the report indicated there were two live cockroaches observed under the active steam table in the cooks line (area in a commercial kitchen where all the cooking and plating takes place during meal service). The report stated there were three live cockroaches under the dirty side counter of the dish machine (commercial dishwasher), and there were two dying cockroaches (one under the steam table and one on the pre-wash ware-wash sink [the first basin in a multi-basin commercial sink used to manually clean, rinse and sanitize dishware, utensils and cookware]), and there were four dead cockroaches (three under the steam table and one under the pre-rinse ware-wash sink). The report indicated there were five to eight dead/dying cockroaches inside monitor traps (a device used to detect, trap, track, and identify insect populations). Three traps were located under back preparation area, (food preparation area). During a review of Eco-Guard Pest Management invoice, dated 5/20/26, the invoice stated .upon arrival I did a full inspection around the affected areas. Found multiple old insect monitors, around the kitchen. got all the old monitors out and place new ones around the kitchen. I also added gel bait around the cracks and crevices for the perimeter I spray all around the baseboard around the kitchen and under appliances and cabinets.service was completed and everything was properly treated. During a review of the facility's policy and procedure titled Pest Control, dated 5/2028, indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on interviews and a review of facility records, the facility failed to ensure a safe environment and adequate supervision for one of five sampled residents (Resident 1) when Resident 1 first eloped from the facility and later, while back in the facility, Resident 1 fell and sustained a fracture.This deficient practice resulted in serious and preventable harm to Resident 1, including injury and fracture.A review of Resident 1's admission RECORD indicated Resident 1 was admitted to the facility with multiple diagnosis including bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between high-energy mania (or milder hypomania) and low-energy depression) and Alcohol abuse.A review of Resident 1's progress noted, IDT (Interdisciplinary Team) dated 3/17/26 indicated .On 03/15/2026 at approximately 2030, the resident was heard calling for help from her room. When the nurse entered, the resident was found sitting on the floor next to her bed. She complained of pain in her right shoulder and head. The physician was notified, and orders were received to transfer to ER (Emergency Room) for a CT scan (Computed tomography) of the brain and X ray (radiology picture) of the right shoulder. Resident refused to be transferred despite teaching on importance of further evaluation. Although the resident initially refused transfer to the ER despite education on risks, she later agreed to transfer due to uncontrolled pain.She admitted to consuming an entire bottle of vodka and stated, to be honest I drank a bottle of vodka (alcohol), and I don't know how I ended up on the floor. She reported that she left the facility earlier in the day with another resident, taking County Link transportation to CVS (pharmacy and store) where they both purchased vodka. She confirmed she did not inform nursing staff of her intent to leave and did not have physician approval for an outside pass.The resident returned from the hospital on [DATE] with x-ray result indicating a mildly displaced comminuted fracture of the distal right clavicle (part of shoulder bone).A review of Resident 1's Order Summary Report dated 3/1/26 indicated Resident 1 had no approval order from the physician to leave the facility.A review of the hospital ED (Emergency Department) AFTER VISIT SUMMARY dated 3/16/26, for Resident 1, indicated .Diagnosis: Closed displaced fracture of right clavicle (part of shoulder bone), unspecified part of clavicle, initial encounter.A review of Resident 1's X-ray chest AP (Anteroposterior) portable dated 3/16/26 indicated .Impression 1. Mildly displaced comminuted fracture of distal right clavicle.A review of Resident 1's Care Plan indicated Resident 1 had a history of fall . Falls (name of Resident1) is at risk for fall or injury due to generalized weakness, diabetes, anemia (is a common blood condition characterized by a low number of healthy red blood cells or insufficient hemoglobin, resulting in decreased oxygen delivery to body tissues), hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormones ), pain, HX (History) of convulsions (seizure), HX of lumbar FX (fracture) s/p(Status Post ), kyphoplasty (a minimally invasive surgical procedure used to treat painful vertebral compression fractures, often caused by osteoporosis [bones lose density], tumors, or trauma ) in 2023, medication side effects, Date Initiated: 10/02/2025 Goal: Will be free from fall or injury.A review of Resident 1's FALL RISK OBSERVATION/ASSESSMENT dated 12/11/2025, indicated Resident 1's fall score was . Score: 20, .C. HIGH RISK 16-42. During an interview on 4/23/26, at 3:35 p.m. with the Director of Nursing (DON), DON stated that Resident 1 told her that she left the facility with another resident with paratransit (transportation) in daytime (not sure what time) to the store and did not inform anyone at the facility. DON stated staff have responsibility to supervise the residents, however they did not know Resident 1 was not in the facility at that time.During an interview on 4/23/26 at 3:25 p.m. with the Administrator (ADM), ADM stated residents are supposed to sign out when they leave the facility if they have a physician permission and staff need to ask the resident where they are going and questioning their representative or transportation agency about the plan and make sure resident stay safe and free of any incidents.During an interview on 4/23/26 at 2:50 p.m. with Resident 1, Resident 1 stated on the date of incident (3/15/26), she called the paratransit and left the facility with her friend and both went to the CVS (Pharmacy) and bought bottle of Vodka and couple of hours later went back to the facility, drank the [NAME] of Vodka at night time and went to bed and slept, then in a middle of night she woke up on the floor with pain on her shoulder and did not remember anything how it that happened. Resident 1 stated she did not inform anybody nor sign any paper.During an interview on 4/23/26 at 3:15 p.m., with the Registered Nurse (RN)1, RN 1 stated nobody told her about Resident 1 in day shift left the facility and RN 1 did not know anything about Patient 1 being out of the facility.A review of the facility's policy and procedures Safety and Supervision of Residents Revised July 2017, indicated .Our facility-oriented approach to safety addresses risks for groups of residents.Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.A review of the facility's policy and procedures Resident Freedom of Movement revised July 2025 indicated .C. Leaving the Facility - NOT ON PASS (Unplanned / AMA) If Resident is Alert & Oriented: Staff will: Assess decision-making capacity Educate resident on risks (falls, meds, treatment interruption) Attempt to notify responsible party. Resident must not be physically prevented from leaving. All exits (planned or unplanned) must be documented. Patterns of frequent unplanned exits should trigger: Care plan review, Social services involvement, Facility will monitor for: Elopement risk Unsafe behaviors.A review of the facility's policy and procedure Wandering and Elopements revised March 2019, indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to notify Resident 1's Attending Physician and Resident 1's Representative (RR) 1 following Resident 1's multiple falls.This failure violated Resident 1's right to have the physician and RR 1 promptly informed of an accident that may result in injury and had the potential to delay necessary medical assessment and involvement in care decisions.During a review of Resident 1's admission Record (AR) dated [DATE], the AR indicated Resident was initially admitted to the facility in February 2005 with diagnoses that included morbid obesity, open angle glaucoma (an eye disease that causes slow, symptomless vision loss), history of falling, and heart failure.During a review of Resident 1's Progress Notes (PN) from [DATE] to [DATE], the PN indicated an eInteract SBAR Summary for Providers (system-generated clinical summary that auto compiled for practitioners when a resident has a change in condition) dated [DATE], when Resident 1 was exposed to the flu virus. A Nurse's Note dated [DATE] indicated, Resident 1 was found unresponsive on [DATE] at 4:45 a.m., with no pulse or spontaneous breathing; code blue was initiated and 911 was called. Paramedics arrived and Resident 1 was pronounced deceased at 5:29 a.m. The PN did not indicate documentation between [DATE] and [DATE].During a telephone interview on [DATE] at 3:06 p.m. with Family Member (FM) 1, FM 1 stated, after Resident 1 passed away, an anonymous caller informed FM 1 that Resident 1 had fallen twice, on [DATE] and [DATE], before being found unresponsive on the early morning of [DATE]. FM 1 stated Resident 1 was not taken to the hospital and no one from the facility told the family about the falls. FM 1 also stated Resident 1 had stayed in bed all day Sunday, [DATE], which seemed unusual since Resident 1 loved getting out of bed, suggesting something serious had happened. FM 1 stated the family was devastated by the treatment Resident 1 received after a 21-year stay at the facility.During a telephone interview on [DATE] at 3:25 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on the early morning of [DATE], a Certified Nursing Assistant (CNA) requested assistance after Resident 1 was found sitting on the floor next to the bed. LVN 1 stated, when she entered the room, two CNAs were already in Resident 1's room. LVN 1 stated Resident 1 could not go back to bed as the other side of the bed was tilted up. LVN 1 stated, due to Resident 1's weight, and the tilted bed, multiple staff helped move Resident 1 to a wheelchair instead of back to bed. LVN 1 stated she left for the day after the incident without documenting what had happened. LVN 1 also stated she was unaware documentation was required since similar incidents had occurred before.During an interview on [DATE] at 7 a.m. with Certified Nursing assistant (CNA) 4, CNA 4 stated Resident 1 had multiple falls that he knew of. The first occurred months ago, after breakfast between 8-10 a.m. CNA 4 stated Resident 1's CNA from a registry had to transfer Resident 1 using the standing lift (a mobility device designed to assist individuals with limited leg strength in transitioning from a seated to a standing position), during the transfer, Resident 1's knees buckled and Resident 1 slipped to the floor. CNA 4 stated about six staff members were needed to help Resident 1 with a Hoyer lift (a mechanical device used to safely transfer patients with limited mobility between beds, wheelchairs, and commodes). The second fall happened on the early morning of [DATE], when CNA 4 found Resident 1 sitting on the floor. The third fall took place the next day, [DATE], after breakfast when CNA 4 transferred Resident 1 from the bed to the wheelchair using a standing lift. During the transfer, Resident 1's knees buckled again, so Resident 1 was lowered to the floor. CNA 4 stated LVN 3 instructed that Resident 1 remain in bed all day on [DATE] after the fall.During a concurrent interview and record review on [DATE] at 1:10 p.m. with ADON, a Nurse's Note dated [DATE] indicated Resident 1 was lowered down to the floor after a CNA transferred Resident 1 from the bed to the wheelchair using a standing lift but the lift was not properly used. Resident 1 was assisted back to bed using a Hoyer lift. ADON stated, Resident 1's fall on [DATE] was documented in the record as CoC but there were no follow-through progress notes from nursing staff, which should have been completed. ADON stated licensed nurses must adhere strictly to the established fall protocol. ADON stated, whenever a resident experiences a fall, whether witnessed or assisted, an immediate assessment is required, followed by notification of both the attending physician and family members. In accidents involving unwitnessed falls, prompt neurological checks after the fall are necessary, along with completion of a fall risk assessment, eInteract charting, and documentation through 72-hour progress notes. An IDT conference should be conducted for risk management purposes on the subsequent workday. ADON also stated, for any change of condition, such as a fall, 72-hour monitoring is mandated and critical, as the resident's status may deteriorate rapidly. It is also essential to inform both the family and the attending physician. However, in these incidents, on 2/14 and [DATE], neither the physician nor the family was notified due to incomplete CoC documentation. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition/Status last revised [DATE], the P&P indicated the licensed staff will notify the resident's Attending Physician or On-Call Physician following any accident or incident involving the resident, if the resident is involved in any accident or incident that results in an injury including injuries of an unknown origin, the resident's.

Based on observation, interview and record review, the facility failed to maintain a safe, comfortable and homelike environment for residents when:1. a. Resident 2's closet door was not repaired timely, despite staff awareness of the defect. The closet door subsequently detached and fell on Resident 2's ankle, causing pain, bruising and swelling. b. Staff repaired Resident 2's closet door using hinges that were not the correct size for the door. This resulted in a large gap on one side and the opposite side overlapping with another door. As a result, Resident 2's closet door must be left open so the other door can be accessed. Additionally, Resident 2's bottom drawer could not be accessed unless the top drawer was open.These failures resulted in Resident 2's avoidable injury to the left ankle, and negatively affected Resident 2's sense of safety and did not support a homelike environment.2. Room temperature in multiple resident rooms were uncomfortably cold, outside the required range of 71-81 degrees Fahrenheit (deg F). This failure had the potential to result in adverse health effects related to temperature extremes.1.During a review of Resident 2's admission Record (AR) dated 4/22/26, the AR indicated Resident 2 was admitted to the facility in February 2021 with diagnoses that included left hemiplegia and hemiparesis.During a review of Resident 2's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/21/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 13. A BIMS score of 13-15 is an indication of intact cognitive status.During a concurrent observation and interview on 4/22/26 at 10:57 a.m. with Resident 2, inside Resident 2's room, Resident 2 stated repeatedly requesting repairs for the closet door, which was not fixed properly. The closet door had a visible gap at the hinges, and overlapped with the adjacent closet door, misaligned, making it impossible to open drawers correctly. Resident 2 stated when she attempted to open the closet door, it fell onto Resident 2's head and left foot, resulting in a severely swollen and bruised left ankle that required ice packs.During a review of Resident 2's Progress Notes (PN), eInteract Summary for Providers (system-generated clinical summary that auto compiled for practitioners when a resident has a change in condition) dated 10/16/25 indicated, Resident 2 reported that a closet door fell on her head, impacting the left side of her head, arm, and ankle. Resident 2 stated using her hands to deflect the door. Resident 2 had pain upon palpation and redness on the left hand and left ankle. During a concurrent observation and interview on 4/22/26 at 11:28 a.m. with Maintenance Director (MD), inside Resident 2's room, MD stated the hinges to the closet door were the wrong size, resulting in a large gap on the right and overlap on the left. MD stated he will order proper hinges and fix the door properly.2. During an interview on 4/21/26 at 6:45 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated when the weather outside was cold, residents reported feeling chilly. LVN 5 stated providing extra blankets and heat packs.During a concurrent interview on 4/22/26 at 10:22 a.m. with Activities Director (AD), resident council meeting minutes were reviewed. There were issues raised regarding room temperatures, the Management's response was for staff to do daily temperature checks for both buildings starting 4/1/26.During a concurrent observation and interview on 4/22/26 at 11:11 a.m. with MD, MD stated a temperature gun was used to check room temperatures during maintenance, with thermostats set between 74-76 deg F for comfort but must read between 71-81 deg F per regulation. MD stated if the temperatures are outside this range, the facility contacts the contractor, who provides 24-hour service. The facility's HVAC units were checked weekly and as needed. MD stated the daytime range was 72-75 deg F, nighttime is 73-76 deg F. Temperatures for several rooms were checked:a. room [ROOM NUMBER]= 68 deg Fb. room [ROOM NUMBER]= 67 deg Fc. room [ROOM NUMBER]= 60 deg Fd. room [ROOM NUMBER]= 67 deg Fe. room [ROOM NUMBER]= 68 deg Ff. room [ROOM NUMBER]= 67 deg F.During interviews on 4/22/26 at 2:38 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated some residents would sometimes complain of their rooms being cold. Resident 3 and Resident 4 both stated their room was cold, and that the facility did not seem to have working heaters.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to identify and assess a change in condition for Resident 1 who experienced multiple falls when facility did not complete a timely evaluation of Resident 1's post-fall status, including neurological checks (neuro checks, relating to the brain, spinal cord and the nerves, checks for alertness, language, level of consciousness, muscle strength and coordination, sensation), pain assessment, and monitoring for injury according to professional standards of care.This failure resulted in a delay in identifying Resident 1's change of condition and in implementing necessary interventions.During a review of Resident 1's admission Record (AR) dated [DATE], the AR indicated Resident was initially admitted to the facility in February 2005 with diagnoses that included morbid obesity, open angle glaucoma (an eye disease that causes slow, symptomless vision loss), history of falling, and heart failure.During a review of Resident 1's Minimum Data Set assessment (MDS, an assessment tool used to direct resident care) dated [DATE], the MDS indicated Resident 1 needed two or more helpers during transfers from bed to chair (helper does all of the effort), and maximum assistance (the helper lifts or holds the trunk or limbs and provides more than half the effort) with bed mobility (rolling from lying to left and right side, sitting on the side of the bed to lying flat, move from lying on the back to sitting on the side of the bed and to come to a standing position from sitting in a chair, wheelchair or on the side of the bed).During a review of Resident 1's Fall Risk Observation/Assessment dated [DATE], the Fall Risk Assessment indicated a Fall Risk Score of 16 (a score of 16-42 indicates high risk of falling).During a review of Resident 1's Progress Notes (PN) from [DATE] to [DATE], the PN indicated an eInteract SBAR Summary for Providers (system-generated clinical summary that auto compiled for practitioners when a resident has a change in condition) dated [DATE], when Resident 1 was exposed to the flu virus. A Nurse's Note dated [DATE] indicated, Resident 1 was found unresponsive on [DATE] at 4:45 a.m., with no pulse or spontaneous breathing; code blue was initiated and 911 was called. Paramedics arrived and Resident 1 was pronounced deceased at 5:29 a.m. The PN did not indicate documentation between [DATE] and [DATE].During a telephone interview on [DATE] at 3:06 p.m. with Family Member (FM) 1, FM 1 stated, after Resident 1 passed away, an anonymous caller informed FM 1 that Resident 1 had fallen twice, on [DATE] and [DATE], before being found unresponsive on the early morning of [DATE]. FM 1 stated Resident 1 was not taken to the hospital and no one from the facility told the family about the falls. FM 1 also stated Resident 1 had stayed in bed all day Sunday, [DATE], which seemed unusual since Resident 1 loved getting out of bed, suggesting something serious had happened. FM 1 stated the family was devastated by the treatment Resident 1 received after a 21-year stay at the facility.During a telephone interview on [DATE] at 3:25 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on the early morning of [DATE], a Certified Nursing Assistant (CNA) requested assistance after Resident 1 was found sitting on the floor next to the bed. LVN 1 stated, when she entered the room, two CNAs were already in Resident 1's room. LVN 1 stated Resident 1 could not go back to bed as the other side of the bed was tilted up. LVN 1 stated, due to Resident 1's weight, and the tilted bed, multiple staff helped move Resident 1 to a wheelchair instead of back to bed. LVN 1 stated she left for the day after the incident without documenting what had happened. LVN 1 also stated she was unaware documentation was required since similar incidents had occurred before.During a concurrent interview and review of the medical records on [DATE] at 3:38 p.m. with Director of Nursing (DON), Resident 1's fall care plans, progress notes and evaluations were reviewed. DON stated, after learning about Resident 1's passing on [DATE], DON first spoke with LVN 1 to ask if Resident 1 fell. DON stated, on [DATE], Resident 1 slid down the bed rather than fell, with half his body still on the bed and only needing assistance from staff due to his weight. DON stated no fall was documented for that day, no progress notes or investigation notes by the Interdisciplinary Team (IDT, a group composed of individuals representing different departments of the facility) were entered. DON stated the medical record had already been closed, and the DON could not reopen it to add documentation. DON stated the incident was not considered a fall since Resident 1 had part of his body on the bed and tried to prevent himself from falling, though Resident needed help from staff to be safely lowered to the floor due to his weight. However, DON stated LVN 1 should have documented the event with a progress note. DON also stated Resident 1 likely did not sustain an injury, as the bed was set to its lowest height. When asked whether any diagnostic test or imaging was performed after the incident to confirm there were no injuries, DON stated that none were conducted, and nothing was noted in the medical record. DON also stated there was no documentation of any assessment or intervention following the incident.During a follow-up telephone interview on [DATE] at 3:55 p.m. with LVN 1, LVN 1 stated, when she entered Resident 1's room on [DATE], Resident 1 was already sitting on the floor, his back leaned against the bed, and two CNAs were already at the bedside. LVN 1 stated she did not see how Resident 1 ended up on the floor (unwitnessed).During interviews on [DATE] to [DATE], multiple staff stated the following:a. [DATE] at 11:28 a.m. with CNA 1, CNA 1 stated, sometime in February 2026, in the early morning after she clocked in for the morning shift, there was a commotion from Resident 1's room. CNA 1 stated she was told Resident 1 needed help; CNA 1 entered the room and found Resident 1 sitting on the floor with his back against the bed. CNA 1 stated there were four CNAs in the room that included CNA 2, CNA 3, CNA 4 and LVN 2.b. On [DATE] at 11:50 a.m. with CNA 2, CNA 2 stated on [DATE], upon arriving for the day shift, entered Resident 1's room and found Resident 1 lying flat on the floor. CNA 2 stated several staff were already in the room that included Infection Preventionist (IP), CNA 3, and CNA 4. CNA 2 stated she assisted by holding the wheelchair so Resident 1 could be seated. A sling was placed under Resident 1, and he was lifted into the wheelchair. CNA 2 stated this was not Resident 1's first fall incident as Resident 1 had fallen before.c. On [DATE] at 11:58 a.m. with LVN 2, LVN 2 stated he was in the hallway about to start medication pass when one of the CNAs came to ask for help. LVN 2 stated going to Resident 1's room and found Resident 1 already sitting on the floor, back against the bed. d. On [DATE] at 12:54 p.m. with CNA 3, CNA 3 stated helping other staff to get Resident 1 up in the wheelchair using a sling.e. On [DATE] at 1:06 p.m. with LVN 3, LVN 3 stated being told by LVN 1 about Resident 1's fall on [DATE], no 24-hour report was completed, only verbal communication. LVN 3 stated all incidents should be documented in progress notes, after a fall, residents must be assessed, vital signs and neuro checks done as indicated, and any abnormal findings reported to the physician. LVN 3 stated falls are considered a Change of Condition (CoC, any significant alteration in a resident's physical, mental, or functional baseline, demanding prompt assessment and intervention). Progress notes should be completed every shift for 72 hours following a fall.f. On [DATE] at 1:46 p.m. with IP, IP stated, on the morning of [DATE], a CNA requested assistance after finding Resident 1 on the floor. IP stated she entered the room and found staff helping Resident 1 into the wheelchair as the bed was not functioning properly. IP stated she communicated with IP to follow appropriate fall procedures, including completing the CoC documentation, notifying the physician and informing Resident 1's family. IP stated, the next day, LVN 4 reported the incident to Director of Staff Development (DSD) stating IP sustained an injury during the transfer. IP stated she provided a detailed account of the incident to the facility leadership and subsequently took leave due to the injury.g. On [DATE] at 7 a.m., CNA 4 stated Resident 1 had multiple falls that he knew of. The first occurred months ago, after breakfast between 8-10 a.m. CNA 4 stated Resident 1's CNA from a registry had to transfer Resident 1 using the standing lift (a mobility device designed to assist individuals with limited leg strength in transitioning from a seated to a standing position), during the transfer, Resident 1's knees buckled and Resident 1 slipped to the floor. CNA 4 stated about six staff members were needed to help Resident 1 with a Hoyer lift (a mechanical device used to safely transfer patients with limited mobility between beds, wheelchairs, and commodes). The second fall happened on the early morning of [DATE], when CNA 4 found Resident 1 sitting on the floor. The third fall took place the next day, [DATE], after breakfast when CNA 4 transferred Resident 1 from the bed to the wheelchair using a standing lift. During the transfer, Resident 1's knees buckled again, so Resident 1 was lowered to the floor. CNA 4 stated LVN 3 instructed that Resident 1 remain in bed all day on [DATE] after the fall.h. On [DATE] at 7:53 a.m. with CNA 6, CNA 6 stated on [DATE], after breakfast, another CNA requested assistance, upon entering the room, Resident 1 was sitting on the floor waiting to be helped up. CNA 6 stated he was one of the last CNAs to arrive at Resident 1's room and Resident 1 was helped back to bed.i. On [DATE] at 7:49 a.m. with CNA 5, CNA 5 stated, on [DATE], CNA 4 had asked for assistance with Resident 1. CNA 5 stated when he entered the room, several people were present and Resident 1 was already sitting at the edge of the bed after being helped up. CNA 5 stated he assisted in moving Resident 1 back onto the bed.During an interview on [DATE] at 7:29 a.m. with LVN 3, LVN 3 stated she was not aware of Resident 1's fall on [DATE]. LVN 3 also stated she would have notified Assistant Director of Nursing (ADON) about it. LVN 3 further stated the Hoyer lift was more appropriate due to Resident 1's weight and advised against the standing lift. When asked about Resident 1's fall care plan, LVN 3 stated she could not access Resident 1's medical record.During a concurrent interview and record review on [DATE] at 1:10 p.m. with ADON, a Nurse's Note dated [DATE] indicated Resident 1 was lowered down to the floor after a CNA transferred Resident 1 from the bed to the wheelchair using a standing lift but the lift was not properly used. Resident 1 was assisted back to bed using a Hoyer lift. ADON stated, Resident 1's fall on [DATE] was documented in the record as CoC but there were no follow-through progress notes from nursing staff, which should have been completed. ADON stated licensed nurses must adhere strictly to the established fall protocol. ADON stated, whenever a resident experiences a fall, whether witnessed or assisted, an immediate assessment is required, followed by notification of both the attending physician and family members. In accidents involving unwitnessed falls, prompt neurological checks after the fall are necessary, along with completion of a fall risk assessment, eInteract charting, and documentation through 72-hour progress notes. An IDT conference should be conducted for risk management purposes on the subsequent workday. ADON also stated, for any change of condition, such as a fall, 72-hour monitoring is mandated and critical, as the resident's status may deteriorate rapidly. It is also essential to inform both the family and the attending physician. However, in these incidents, on 2/14 and [DATE], neither the physician nor the family was notified due to incomplete CoC documentation. During a review of Resident 1's fall care plan, undated, the care plan indicated interventions that included following facility fall protocol and notifying the physician and family in the event of a fall. Another fall care plan last revised [DATE], the care plan indicated interventions that included educating staff on how to operate a standing lift.During a concurrent interview and record review on [DATE] at 2:10 p.m. with ADON, the In-Service Training Attendance Sign-in Sheet for the course title Using Hoyer lift and Standing Lift dated [DATE] was reviewed. CNA 4 and CNA 7's names were missing from the in-service attendance sheet; both CNAs were assigned to Resident 1.During an interview on [DATE] at 3:39 p.m. with Physical Therapist (PT) 1, PT 1 stated the last evaluation of Resident 1 by the Rehabilitation Department (Rehab) was some time ago when Resident 1 was stronger. PT 1 stated Rehab did not receive a nursing referral to assess if a standing lift was still appropriate. PT 1 stated that nurses were trained to do Hoyer and standing lift transfer whichever was more appropriate for a resident.During a review of the facility's policy and procedure (P&P) titled Falls-Clinical Protocol last revised [DATE], the P&P indicated staff will evaluate and document falls that occur while the resident is in the facility, when and where they happen and any observations of the events, etc. Falls are categorized by whether they occur while trying to rise from a sitting or lying to an upright position and slide out of a chair or rolling from a low bed to the floor. Within 24 hours after the fall, staff must identify possible causes, with ongoing evaluation by staff and physician until a cause is found or deemed uncorrectable. Complications like fractures, bruising, or intracranial (inside the brain) bleeding can appear hours to weeks after a fall.

Based on observation, interview and record review, the facility failed to follow infection control practices to prevent cross-contamination during resident care when Certified Nursing Assistant (CNA) 8 was placed dirty linens directly on the floor without bagging them and touched multiple items at the bedside, including personal care supplies and environmental surfaces, without removing and changing gloves between tasks.These failures created a risk for the spread of infectious organisms.During a concurrent observation and interview on 4/21/26 at 6:19 a.m. with CNA 8, inside Resident 5's room, CNA 8 placed a soiled linen on the floor near the trash can without bagging it. CNA 8, wearing gloves, repositioned Resident 8, adjusted the curtain and bed remote without changing gloves. CNA 8 then picked up the linen and trash, bagged them and exited the room. CNA 8 acknowledged placing the linen on the floor without bagging and apologized for her actions.During an interview on 4/22/26 at 1:46 p.m. with Infection Preventionist (IP), IP stated used linen must be bagged and not placed on the floor. Unrolled bags are kept at the foot of the bed so staff can easily bag linen or garments removed from residents. Used linen is not placed on the floor because it may contain microorganisms, which could be spread by staff stepping on them, as shoes can transfer bacteria throughout the facility.During a review of the facility's policy and procedure (P&P) titled, Laundry and Bedding, Soiled last reviewed January 2026, the P&P indicated all used laundry is treated as contaminated and bagged at the collection point with standard precautions.

Based on observations, interviews, and record reviews, the facility failed to identify and ensure that two out of three sampled residents (Resident 1 and Resident 2), were protected from sexual abuse (non-consensual sexual contact of any type with a resident). Resident 1 reported to staff members being sexually abused during care provided by Certified Nurse Assistant (CNA) 1. CNA 1 was not removed from the staffing schedule and was allowed to continue to care for other residents in the facility. These failures in a delay in implementing protective and preventative action resulted in Resident 2 experiencing sexual abuse. Cross Reference to F600Findings: During a review of facility's admission Record (AR) printed on 03/10/2026, the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included fracture of left lower leg and generalized muscle weakness. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 01/28/2026 indicated a Brief Interview for Mental Status (BIMS - a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 15, (BIMS score of 13 - 15, cognitively intact).During a review of facility's AR printed on 03/16/2026, the AR indicated Resident 2 was admitted on [DATE], with diagnoses that included hemiplegia (paralysis) and hemiparesis (partial weakness) following bleeding within the brain not caused by head trauma affecting the left side of the body. Resident 2's MDS, dated [DATE], indicated a BIMS score of 14.During a concurrent observation, interview, and record review on 03/16/2026 at 12:59 p.m., with Resident 1 in her room, Resident 1 was sitting up on her bed. Resident 1 stated she was bothered by her experience during a diaper change, that she immediately wrote detailed personal notes. Resident 1 showed four pages of personal notes of the events that started on 02/24/25. Resident 1 stated it was past 7 p.m., CNA 1 assisted her when she needed her diaper changed. Resident 1 stated her diaper was only soiled with urine. Resident 1 stated this was her first encounter with CNA 1. Resident 1 stated that during the diaper change, CNA 1 was on the left side of her bed. CNA 1 used wet wipes and wiped her vaginal area multiple times. Resident 1 stated CNA 1 asked her if it hurts, because she flinched when CNA 1 wiped her vaginal area. Resident 1 stated CNA 1 wiped her again, but this time, CNA 1 went deeper in between her lips[labia] and rubbed his finger within her clitoris. Resident 1 stated I told him he needed to stop, and it's not okay. Resident 1 stated she usually needed a barrier cream applied, but she asked CNA 1 not apply the barrier cream, and she just wanted it done. Resident 1 stated later in the evening, her roommate's CNA, CNA 2, came into the room to check on her roommates. Resident 1 stated she was familiar with CNA 2, and she asked CNA 2 on who could she tell what happened to her during diaper change. Resident 1 stated CNA 2 stated he would let the nurse know. Resident 1 stated she spoke to Registered Nurse (RN)1. Resident 1 stated she told RN 1 that she was inappropriately touched by CNA 1, and that she never wanted him to change her again. Resident 1 stated the following day, she saw CNA 1 in the hallway. Resident 1 stated she felt like she was being gaslighted (a term used to describe that could someone to question the validity of their own thoughts, perception of reality, or memories), after she reported her experience during her diaper change, and that there was no consequence. Resident 1 wrote on her personal notes indicated 2/25/[2025] - [CNA 1] worked day shift! I guess no problem to be inappropriate with pts[patients]? Resident 1 stated that she reported her experience with CNA 1 to Licensed Vocational Nurse (LVN) 1 in the early morning hours of 02/26/2025. Resident 1 stated LVN 1 stated she would report this to her nurse supervisor. Resident 1 stated RN 2 visited her, and she reported her experience during diaper change that happened on 2/24/2025 with CNA 1. Furthermore, Resident 2 wrote on her personal notes that 02/26/2025 at around 09 a.m., Assistant Director of Nursing (ADON) 1 heard the prob [problem] said he'll handle it from here. Remove him from schedule until investigate. During an interview on 03/17/26 at 09:06 a.m., with RN 1, RN 1 stated it was about 10 p.m., on 2/24/25, when RN 1 administered Resident 1's medication. RN 1 stated that Resident 1 don't like that guy, pointing to the direction of CNA 1. RN 1 stated Resident 1 did not want CNA 1 to change her diaper again. RN 1 stated she did not ask additional questions, because she was busy with medication pass. RN 1 stated that her main concern was that the incoming shift would know about Resident 1's request to have another CNA to change her diaper.During a review of facility's Nursing Staffing Assignment and Sign-In Sheet for 02/24/2025, CNA: 2:45 PM - 11:15 PM, indicated CNA 1 was on the schedule and signed for his assignment. The facility's Nursing Staffing Assignment and Sign-In Sheet for 02/25/2025, for CNA: 6:30 AM - 3:00 PM, indicated CNA 1 was on the schedule and signed for his assignment. The facility's Nursing Staffing Assignment and Sign-In Sheet for 02/25/2025, CNA: 2:45 PM - 11:15 PM indicated CNA 1 was on schedule and signed for his assignment. During an interview on 03/16/2026 at 05:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she worked the night shift on 02/25/2025 - 02/26/2025, from 11:30 p.m. to 7:30 a.m. LVN 1 stated on 02/26/25 at around 04:30 a.m., she was in Resident 1's room for medication pass. LVN 1 stated Resident 1 seemed emotional to her, and Resident 1 wanted to tell her something that happened on 02/24/2025 afternoon shift. LVN 1 stated Resident 1 told her that on 02/24/2025, Resident 1stated she reported the abuse to two staff, and Resident 1 felt that nothing happened. LVN 1 stated Resident 1 reported to her that during diaper change, LVN 1 stated Resident 1 was very clear that the diaper only had urine, CNA 1 wiped Resident 1 repeatedly, and one of this time CNA 1 touched and wiggled his finger in her vagina. LVN 1 stated after the medication pass, she immediately reported to the nurse supervisor (RN 2) on her shift. During an interview on 03/21/2025 at 07:44 a.m., with RN 2, RN 2 stated he worked on 02/25/2025 - 02/26/2025, from 11:30 p.m. to 7:30 a.m. RN 2 stated LVN 1 reported that Resident 1 made a report of sexual abuse allegations. RN 2 stated on 02/26/2025 at around 07:30 a.m., he visited Resident 1 in her room. RN 2 stated Resident 1 seemed distressed and tense. RN 2 stated Resident 1 recounted to him that during diaper change, CNA 1 wiped her repeatedly and seemed excessive. RN 2 stated that Resident 1 reported when CNA 1 wiped Resident 1's vaginal area, CNA 1 penetrated her with his finger. RN 2 stated after she spoke to Resident 1, RN 2 reported this to the supervisor in the building. RN 2 stated he reported this information to the Director of Staff Development (DSD). RN 2 stated he would also call the Administrator (ADM) 1 to report. RN 2 stated DSD stated that he would report Resident 1's allegations to the ADM 1. RN 2 stated DSD stepped out of the office and called ADM 1.During an interview on 03/20/2025 at 12:21 p.m., with ADON 1, ADON 1 stated that Resident 1's complaint was costumer care complaint. ADON 1 stated that Resident 1 requested not to have CNA 1 assigned to care for her. ADON 1 stated that he called RN 1 to ask about Resident 1's concern that CNA 1 was rough during incontinence care. RN 1 confirmed that Resident 1 reported a concern during incontinence care and requested that CNA 1 would not be assigned to care for Resident 1.During a concurrent observation and interview on 03/16/2026 at 01:26 p.m., with Resident 2, Resident 2 was sitting on her motorized wheelchair in the facility's smoking area. Resident 2 started recounting the event that she experienced on 02/25/2025, when CNA 1 helped her in the shower. Resident 2's face was getting flushed, her eyes were teary, and she started shaking her hand. Resident 2 stated she was scheduled to have a shower in the afternoon. Resident 2 was on the patio, and CNA 1 took her back to her room to get ready for her shower. Resident 2 stated she was wearing a sweater because it was cold, and when CNA 1 removed her sweater, CNA 1 rubbed her breast. Resident 2 stated she swiped CNA 1's hand away and told CNA 1 to stop it. Resident 2 stated she was seated on a shower chair, and CNA 1 took her to shower room A. Resident 2 stated during shower CNA 1 tried to use the washcloth to wipe her breast area again. Resident 2 stated she asked CNA 1 to give her the washcloth, and she would clean her breast area. Resident 2 stated she could not reach her buttocks area. Resident 2 stated that CNA 1 cleaned her buttocks, CNA 1 was behind her in shower chair. Resident 2 demonstrated by lifting her arm and with her index finger extended, Resident 2 stated while CNA 1 was cleaning her buttocks, CNA 1 inserted his finger in her anus. Resident 2 stated she was shocked, and all she could tell CNA 1 was that she was done, and to bring her back to her room. Resident 2 stated when she was brought to her room, CNA 1 used a towel to dry her chest area, and CNA 1 squeezed her nipples. Resident 2 stated she felt nervous during and after the event. Resident 2 stated she reported to Restorative Nurse Assistant (RNA) 1 the following day.During a review of Resident 2's Progress Notes printed on 03/16/2026, indicated On 2/26/25 at around 1130H [11:30 a.m.], resident informed staff that the previous day that there's a male CNA, who assisted her with her shower, and she was touched inappropriately. Resident alert and oriented. Resident claims that she feels safe in the facility. The CNA she alleged to be inappropriate with her was advised to stop working in the facility.During a review of facility's undated policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation, the P&P indicated Policy Statement. All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigation are documented and reported. Policy Interpretation and Implementation. Reporting Allegations to the Administrator and Authorities. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspension must be reported immediately to the administrator and other officials according to state law. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations. 5. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on observations, interviews, and record reviews, the facility failed to ensure that two out of three sampled residents (Resident 1 and Resident 2), were protected from sexual abuse (non-consensual sexual contact of any type with a resident). Resident 1 and Resident 2 were sexually abused during care provided by Certified Nurse Assistant (CNA) 1. This failure resulted in Resident 1 and Resident 2 experiencing sexual abuse and emotional distress. Cross Reference to F610Findings:During a review of facility's admission Record (AR) printed on 03/10/2026, the AR indicated Resident 1 was admitted on [DATE], with diagnoses that included fracture of left lower leg and generalized muscle weakness. Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 01/28/2026 indicated a Brief Interview for Mental Status (BIMS - a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score of 15 (BIMS score of 13 - 15, cognitively intact).During a concurrent observation, interview, and record review on 03/16/2026 at 12:59 p.m., with Resident 1 in her room, Resident 1 was sitting up in the middle on her bed. Resident 1 stated she was bothered by her experience during a diaper change, that she immediately wrote detailed personal notes. Resident 1 showed four pages of personal notes of the events that started on 02/24/2025, that she kept on the over bed table. Resident 1 stated it was past 7 p.m., CNA 1 assisted her when she needed diaper changed. Resident 1 stated her diaper was only soiled with urine. Resident 1 stated this was her first encounter with CNA 1. Resident 1 stated that during the diaper change, CNA 1 was on the left side of her bed. CNA 1 used wet wipes and wiped her vaginal area multiple times. Resident 1 stated CNA 1 asked her if it hurts, because she flinched when CNA 1 wiped her vaginal area. Resident 1 stated CNA 1 wiped her again, but this time, CNA 1 went deeper in between her lips[labia] and rubbed his finger within her clitoris. Resident 1 stated I told him he needed to stop, and it's not okay. Resident 1 stated she usually needed a skin barrier cream applied, but she asked CNA 1 not to apply the barrier cream, and she just wanted it done. Resident 1 stated later in the evening, her roommate's CNA, CNA 2, came to room to check on her roommates. Resident 1 stated she was familiar with CNA 2, and she asked CNA 2 on who could she tell what happened to her during diaper change. Resident 1 stated CNA 2 stated he would let the charge nurse know. Resident 1 stated she spoke to Registered Nurse (RN)1. Resident 1 stated she told RN 1 that she was inappropriately touched by CNA 1, and that she never wanted him to change her again.During an interview on 03/20/2025 at 05:23 p.m., CNA 2, CNA 2 stated he worked 02/24/2025 the afternoon shift (02:45 p.m. - 11:15 p.m.). CNA 2 stated he spoke to Resident 1, and Resident 1 seemed uncomfortable during their conversation about her diaper change. CNA 2 stated Resident 1 stated that she was not comfortable with CNA 1 during diaper change, and Resident 1 did not want CNA 1 to come back and change her again. CNA 2 stated he offered Resident 1's diaper change later in the evening, and Resident 1 agreed to have CNA 2 do the next diaper change. CNA 2 stated he told Resident 1 that he would report this to charge nurse. During an interview on 03/17/2026 at 09:06 a.m., with RN 1, RN 1 stated on 02/24/2025 at around 10 p.m., RN 1 administered Resident 1's medication. RN 1 stated that Resident 1 don't like that guy, pointing to the direction of CNA 1. RN 1 stated Resident 1 did not want CNA 1 to change her diaper again.During an interview on 03/16/2026 at 05:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she worked the night shift on 02/25/2025 - 02/26/2025, from 11:30 p.m. to 7:30 a.m. LVN 1 stated on 02/26/25 at around 4:30 a.m., she was in Resident 1's room for medication pass. LVN 1 stated Resident 1 seemed emotional to her, and Resident 1 wanted to tell her something that happened on 02/24/2025 afternoon shift. LVN 1 stated Resident 1 told her that on 02/24/2025, Resident 1 stated she reported the sexual abuse to two staff, and Resident 1 felt that nothing happened. LVN 1 stated Resident 1 reported to her that during diaper change, LVN 1 stated Resident 1 was very clear that the diaper only had urine. CNA 1 wiped Resident 1 repeatedly, and one of these times CNA 1 touched and wiggled his finger in her vagina. LVN 1 stated after the medication pass, she immediately reported to the nurse supervisor (RN 2) on her shift.During an interview on 03/21/2025 at 07:44 a.m., with RN 2, RN 2 stated he worked on 02/25/2025 - 02/26/2025, from 11:30 p.m. to 07:30 a.m. RN 2 stated LVN 1 reported that Resident 1 reported a sexual abuse allegation. RN 2 stated on 02/26/2025 at around 07:30 a.m., he visited Resident 1 in her room, and Resident 1 seemed distressed and tense. RN 2 stated Resident 1 recounted to him that during diaper change, CNA 1 wiped her repeatedly and seemed excessive. RN 2 stated that Resident 1 reported when CNA 1 wiped Resident 1's vaginal area, CNA 1 penetrated her with his finger.During a review of Resident 2's Progress Notes dated 03/04/2025, and printed on 03/16/2026, indicated At around 1600 [04:00 p.m.], while doing rounds, [Resident 1] reported about being uncomfortable with one of the CNA. This nurse allowed resident to verbalize feelings and concerns. Per [Resident 1], she was thinking and she felt that during her continent care CNA wiped her twice and the third time there's more pressure and she felt it was excessive and she felt something is off with the way she was cleansed by this specific CNA.2. During a review of facility's AR printed on 03/16/2026, the AR indicated Resident 2 was admitted on [DATE], with diagnoses that included hemiplegia (paralysis) and hemiparesis (partial weakness) following bleeding within the brain not caused by head trauma affecting the left side of the body. Resident 2's MDS, dated [DATE], indicated a BIMS score of 14.During a concurrent observation and interview on 03/16/2026 at 01:26 p.m., with Resident 2, Resident 2 was sitting on her motorized wheelchair in the smoking area. Resident 2 recounted the event that she experienced on 02/25/2025, when CNA 1 helped her in the shower. Resident 2's face was flushed, and her eyes were teary, and she started shaking her hand. Resident 2 stated she was scheduled to have a shower in the afternoon. Resident 2 was on the patio, and CNA 1 took her back to her room to get ready for her shower. Resident 2 stated she was wearing a sweater because it was cold, and when CNA 1 removed her sweater, CNA 1 rubbed her breast. Resident 2 stated she swiped CNA 1's hand away and told CNA 1 to stop it. Resident 2 stated she was seated on a shower chair, and CNA 1 took her to shower room A. Resident 2 stated during shower CNA 1 tried to use the washcloth to wipe her breast area again. Resident 2 stated she asked CNA 1 to give her the washcloth, and she would clean her breast area. Resident 2 stated she could not reach her buttocks area. Resident 2 stated that CNA 1 cleaned her buttocks, CNA 1 was behind her in shower chair. Resident 2 demonstrated by lifting her arm and with her index finger extended. Resident 2 stated that while CNA 1 was cleaning her buttocks, CNA 1 inserted his finger in her anus. Resident 2 stated she was shocked, and all she could tell CNA 1 was that she was done, and to bring her back to her room. Resident 2 stated when she was brought to her room, CNA 1 used a towel to dry her breast area, and CNA 1 squeezed her nipples. Resident 2 stated she felt nervous during and after the event. Resident 2 stated she reported the event to Restorative Nurse Assistant (RNA) 1 on 02/26/2025.During an interview on 03/17/2026 at 02:07 p.m., with RNA 1, RNA 1 stated she worked on 02/26/2025 from 07:00 a.m. - 03:30 p.m. RNA 1 stated she was helping Resident 2 with combing her hair, and Resident 2 seemed emotional and was about to cry. RNA 1 stated Resident 2 started telling her experience during shower the day before (02/25/2025). RNA 1 stated Resident 2's shower schedule was during the afternoon shift. RNA 1 stated she checked the staffing schedule for 02/25/2025, and RNA 1 confirmed that CNA 1 was the staff who helped Resident 2 with her shower.During a review of Resident 2's Progress Notes printed on 03/16/2026, indicated On 2/26/25 at around 1130H [11:30 a.m.], resident informed staff that the previous day that there's a male CNA, who assisted her with her shower, and she was touched inappropriately. Resident alert and oriented.During an interview on 04/16/2025 at 12:10 p.m., with Ombudsman Representative (OR), OR stated she visited the facility on 03/07/2025. OR stated she spoke with Resident 2 in an office to give her privacy. OR stated during the interview, Resident 2 seemed fine until she recounted the events on 02/25/2025. OR stated that Resident 2 was distraught and cried.During a review of facility's policy and procedure (P&P) last Reviewed 1/2026 titled Abuse, Neglect, Exploitation or Misappropriation Prevention Program, the P&P indicated Policy Statement. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect the residents for abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff.

Based on interviews and record reviews, the facility failed to provide timely and appropriate nursing assessment, monitoring, and interventions to one sampled resident (Resident 1) under the care of a previously employed nursing staff member who was unlicensed and was using another individual's Registered Nurse (RN) license, when Resident 1 did not receive a physician ordered medication, nitroglycerin (medication used to treat chest pain by relaxing and widening blood vessels, which helps more blood and oxygen reach the heart) and emergency services were not initiated in a timely manner despite Resident 1 experiencing ongoing chest and abdominal pain lasting for approximately nine hours on [DATE].These failures resulted in actual harm to Resident 1, who experienced prolonged, untreated chest pain due to delayed nursing interventions, medication administration, and initiation of emergency medical services by an unlicensed nurse. Resident 1 was subsequently transferred from the facility to the hospital and expired approximately two hours after arrival at the emergency department (ED) due to a heart attack, following complaints of chest and abdominal pain. During a record review of Unlicensed Nurse (UN) 1's record, titled, Background Report (BR), dated [DATE], the professional license verification portion reflected inconsistencies between UN 1's identity and the name listed on the nursing license. The BR report showed the license belonged to a different RN with a similar name; however, the first name was spelled differently, and the individual had a different middle name. During a record review of UN 1's most recent publicly available nursing license verification record, dated [DATE], the record indicated UN 1's Licensed Vocational Nurse (LVN) license had been revoked (officially canceled) on [DATE], and UN 1's right to practice nursing was removed.During an interview on [DATE] at 12:42 p.m. with the Director of Nursing (DON), DON stated she was unaware that UN 1 was unlicensed during UN 1's employment at the facility until an investigation was initiated related to a drug diversion (when prescription medicine is taken or given to someone for a purpose other than what it was meant for) incident involving another resident. DON stated it was subsequently identified that the name listed on UN 1's submitted RN nursing license did not match the name on UN 1's driver's license or Social Security card, and that UN 1's LVN license had been revoked in 2020 due to drug diversion.During a record review of Resident 1's record titled, Physician History and Physical (H&P), dated on [DATE], documented by Medical Doctor (MD) 1, the H&P indicated Resident 1 was admitted to the facility on [DATE] with past medical history of hypertension, gastric outlet obstruction (the passage between the stomach and the small intestine becomes blocked), and history of stroke (when blood can't get to part of the brain). The H&P further indicated Resident 1 had a ventral hernial repair on 11/14 (fixing a hole or weak spot in the abdominal wall) .Afterward, Resident 1's recovery was complicated by a NSTEMI (Non-ST Elevated Myocardial Infarction, a type of heart attack when blood flow to part of the heart is blocked). Cardiology (branch of medicine that deals with the heart) was consulted and recommended medical management.had episode of chest pain 11/17. indicating Resident 1 had a history of heart attack. During a record review of Resident 1's record titled, Change in Condition Evaluation (CCE) record with effective date on [DATE] at 11:05 p.m., the CCE indicated, resident noted to have pain unrelieved by pain medication and complaining of abdominal and upper chest area pain, resident noted with increase respiration. The CCE record also showed Resident 1 had uncontrolled pain that started on [DATE], with no specific time documented other than afternoon. The CCE record further indicated that Resident 1 had occasional moaning and groaning, facial grimacing, rigid, fists clenched, and knees pulled up during the assessment.During a record review of Resident 1's Medication Administration Report (MAR), dated from [DATE] through [DATE], the MAR indicated the physician order for Nitroglycerin Sublingual (placed under the tongue) Tablet 0.4 milligrams (mg).Give 0.4 mg sublingually every 5 minutes as needed for chest pain.May repeat x2 (twice) every 5 minutes. Call 911 if the pain persists longer than 5 minutes after the first dose.Continue to take the 2nd and 3rd dose if pain persists. was not given at any time on [DATE], despite Resident 1's complaints of chest pain. The physician's order did not include any blood pressure (bp) parameters restricting administration of nitroglycerin.During a record review of Resident 1's record, titled, SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form, dated [DATE], the SNF/NF to Hospital Transfer Form indicated Resident 1 was transferred to the hospital on [DATE] at 11:00 p.m.During a record review of Resident 1's emergency medical services (EMS) record, titled, Patient Care Report (PCR), dated [DATE], the PCR showed EMS assumed Resident 1's care at 10:53 p.m. The PCR indicated, Complaints: (Chief) chest pain as of 9 hours ago. The record also indicated, RP (Responsible Party) stated that starting at 1500 (3:00 p.m.) hours pt. (patient) began to complain of abdominal pain that radiated up to her chest. pt. was in obvious discomfort and stated the pain was sharp.pt. had previous MI (myocardial infarction or heart attack) on Saturday.pt recent surgery for hernia repair. The PCR also indicated that the EMS administered the nitroglycerin 0.4 mg sublingually to Resident 1 at 11:23 p.m.During record review of Resident 1's Progress Notes, dated [DATE], the Progress Notes did not show any documentation of nursing assessment, monitoring, and interventions in response to Resident 1's complaints of chest and abdominal pain that began approximately at 3:00 p.m.During a record review of Resident 1's record from the hospital, titled, ED Provider Note, dated [DATE], the ED Provider Note indicated Resident 1 had an acute ST elevation MI (a severe heart attack from complete blockage of a coronary artery), inferior wall (lower portion of the heart) and cardiac arrest (heart suddenly stops beating). The ED Provider Note further indicated, Pt (patient) was having chest pain and upper abdominal pain earlier today.Pt was having agonal (gasping, irregular, or labored breath) respirations on arrival and not too responsive .Pt lost her pulses and CPR (cardiopulmonary resuscitation) started. The ED Provider Note further indicated Resident 1 was pronounced deceased at 1:39 a.m. on [DATE].During an interview and record review on [DATE] at 1:10 p.m. with the Assistant Director of Nursing (ADON) 1, Resident 1's medical records including Progress Notes and MAR, dated [DATE], were reviewed. ADON 1 stated on [DATE], Resident 1 received PRN (as needed) pain medications, including two tablets of acetaminophen (over-the-counter pain reliever) 500 mg for moderate pain at 4:08 p.m. and one tablet of Norco 5-325 mg (controlled substance used for severe pain) PRN for pain at 8:05 p.m.; however, ADON 1 stated there was no documented evidence of a comprehensive pain assessment, including location and type of pain, nor documentation of any nursing interventions implemented beyond administration of pain medication. ADON 1 stated she was unable to determine whether the pain medication was administered in response to chest or abdominal pain due to lack of documentation. ADON 1 further stated accurate pain assessment and nursing interventions were essential, as pain was considered as the fifth vital sign (basic measurement that shows how well your the body is working), and failure to perform such placed Resident 1 at risk for worsening conditions.During a follow up interview and record review on [DATE] at 1:47 p.m. with ADON 1, Resident 1's MAR, CCE and SNF/NF to Hospital Transfer Form dated [DATE] were reviewed. ADON 1 stated on [DATE], Resident 1 was transferred to ED after exhibiting symptoms consistent of a heart attack, including chest pain, abdominal pain, and increased respirations. ADON 1 stated there was no documentation indicating UN 1 initiated the timely administration of nitroglycerin in response to Resident 1's unresolved chest pain, despite the physician's order indicated nitroglycerin should have been given as an intervention prior to calling 911 if chest pain was unrelieved. ADON 1 stated in the event of a heart attack, failure to administer nitroglycerin in a timely manner could place an individual at risk for death. During an interview and record review on [DATE] at 3:11 p.m. with Nurse Supervisor (NS) 1, SNF/NF to Hospital Transfer Form, dated [DATE], was reviewed. NS 1 stated she documented SNF/NF to Hospital Transfer Form because she was the nursing supervisor during Resident 1's transfer to ED. NS 1 stated she also documented that the physician was notified through the hospital's advice line on [DATE] at 10:00 p.m. based on the information UN 1 gave her. NS 1 stated there was no documentation made by UN 1 regarding the call with the hospital advice line. NS 1 stated if UN 1 had contacted the advice line, UN 1 should have documented the information such as the nurse UN 1 spoke with, any new orders or instructions regarding Resident 1's change in condition, and who the ordering physician was. NS 1 stated UN 1 told her that Resident 1 was having an uncontrolled pain, but UN 1 did not notify her about the chest pain. NS 1 stated that if UN 1 had informed her of Resident 1's symptoms, she would have assisted with the assessment and interventions, as Resident 1 could have been experiencing a heart attack. NS 1 further stated that emergency services or calling 911 should have been initiated instead of contacting the hospital advice line if Resident 1 was having chest pain.During a record review of a copy of an email dated [DATE] from the hospital's Accreditation, Regulation, and Licensing Specialist (ARLS), ARLS indicated in the email that there was no record found to confirm the facility contacted the physician through the hospital's advice line on [DATE].During a record review of the facility's record, titled, Controlled Subs (Substance) (CS), dated [DATE] through [DATE], the CS indicated one tablet of hydrocodone (Norco) 5/325 mg was issued from the emergency kit to UN 1 for Resident 1 on [DATE] at 11:03 p.m., indicating a discrepancy between the issuance and the documented administration to Resident 1.During an interview on [DATE] at 2:18 p.m. with DON, DON stated she was unable to explain why the CS record reflected the issuance of the Norco 5/325 mg occurred after Resident 1's transfer to ED, or why the timing of the documented issuance did not align with UN 1's MAR entry dated [DATE] at 8:05 p.m. DON stated when pain medication was not administered, a resident's pain would remain unresolved, and the resident would continue to experience pain. DON stated the timely administration of nitroglycerin, when clinically indicated, was essential to increase blood flow to the heart for a resident experiencing chest pain but stated she believed Resident 1 would have died in the facility if the nitroglycerin had been administered, due to the documented low diastolic (heart relaxes) bp of 108/51 mmHg (millimeters of mercury, a way to measure pressure), despite the absence of physician-ordered bp parameters restricting administration. DON stated nursing assessment and judgment were required prior to administration of nitroglycerin. DON stated she was not defending UN 1's choice of action when UN 1 did not administer the nitroglycerin and acknowledged there was no excuse for employing UN 1 without an active nursing license. DON further stated, UN 1 lost her LVN nursing license not because she killed a patient, but due to drug diversion. When DON was asked whether working without an active nursing license was acceptable, DON stated UN 1 somehow still had the knowledge and nursing skills despite not holding a valid license. DON stated she could not deny the fact that UN 1 had previously been a licensed nurse. During an interview on [DATE] at 11:47 a.m. with the Medical Director (Med Dir), Med Dir 1 stated when a resident experienced a significant change in condition, such as severe chest pain, particularly for a resident with a history of a recent heart attack, the expectation was to administer the prescribed nitroglycerin and immediately activate emergency medical services by calling 911. Med Dir stated nitroglycerin administration may be held if the resident's bp was below 90/50 mmHg. Med Dir further stated delayed interventions for a resident experiencing chest pain could result in cardiac arrest and prolonged, unrelieved pain.During a record review of the facility's undated policy and procedure (P&P), titled, Pain Assessment and Management, the P&P indicated, The purposes of this procedure are to help staff identify pain in resident, and to develop interventions that are consistent with the resident's goals an needs and that address the underlying causes of pain.2. Monitor the resident for presence of pain and the need for further assessment when there is a change of condition.5. During the pain assessment gather the following information as indicated from the resident (or legal representative) .c. Characteristics of pain.(1) Location of pain. (2) Intensity of pain.(3) Characteristics of pain (e.g., aching, crushing, numbness, burning, etc.).(4) Pattern of pain (e.g., constant or intermittent).and (5) Frequency, timing, duration of pain.d. Impact of pain on quality of life.i. Current medical conditions and medications.Identifying causes of pain.3. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including.d. circulatory/heart . (1) angina (chest pain) .During a record review of the facility's P&P, titled, Administering Medications, revised in [DATE], the P&P indicated Medications are administered in accordance with prescriber orders, including any required timeframe.During a record review of the facility's P&P, titled, Change in a Resident's Condition or Status, revised in February 2021, the P&P indicated, 2. A 'significant change' in condition is a major decline or improvement in the resident's status that.a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.9. If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of resident's condition will be conducted.During a record review of the facility's record, titled, Job Description: Registered Nurse (RN), prepared by Human Resources in February 2024, the RN job description indicated, The primary responsibility of your job is to supervise day-to-day nursing activities of the facility.Such supervision must be accordance with current and federal, state, and local standards, guidelines and regulations that govern the facility.to ensure that highest degree of quality of care is maintained at all times.Must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of resident served.Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.Must possess a current, unencumbered, active license to practice as an RN in this state.Must remain in good standing State Board of Nursing at all times.

Based on interviews and record review, the facility failed to re-admit one (Resident 1) of three sampled residents when she was ready to return to the facility after hospitalization . Resident 1 was sent to the hospital on [DATE] with a bed-hold of seven days and was ready to return to the facility, the day after her bedhold expired on [DATE]. The facility refused to re-admit her to one of their vacant beds and had no policy and procedure to direct staff to re-admit after the bed hold expires. As a result of this failure, Resident 1 has continued to remain in the hospital, although she does not require hospital care and the facility continues to refuse to admit the resident, denying her access to the home she had lived for over a year. Findings: According to the medical record, Resident 1 was admitted to the facility on [DATE]. The face sheet showed admission [DIAGNOSES REDACTED]. Review of the complete resident assessment, dated [DATE], showed that Resident 1 had long and short term memory problems, was moderately impaired for daily decision making, required cues and supervision. Resident 1 required extensive assistance of two staff for transfers and moving about on the unit in a wheelchair, extensive assistance of one staff for eating, and was totally dependent in personal hygiene, toilet use, and bathing. Resident 1 was always incontinent (lack of control) of bowel and bladder. Review of nurses' notes, dated [DATE] at 5:13 a.m., showed "Resident noted at 3:20 a.m. to have difficulty breathing...was diaphoretic (perspiring) and less responsive." Resident 1 was sent to hospital emergently at 4:00 a.m. Review of Social Service (SS) Progress Notes, dated [DATE] at 4:35 p.m., showed, "Noted from admission that resident's seven day bed hold...has expired. Admission staff called family and left a message and given an option to pay private pay if desired. Made ombudsman aware and spoke of option to put resident on waiting list if resident wants to return to this facility." During an interview on [DATE] at 8:30 a.m., the Administrator (ADM) stated, "Yes, we denied her re-admission. There was a seven day bed- hold. On the eight day, she was said to be ready to return to this facility. The Director of Nurses (DON) reviewed the referral and determined that she had become too medically complex. We continue to refuse her as needing more resources than we have available." During an interview on [DATE] at 10:00a.m., the Acting DON stated, "She always required a lot of care. The previous DON refused her re-admission. I don't know the details." During an interview on [DATE] at 10:50 a.m., the Admissions Coordinator stated, "I called Resident 1's family on the eight day, [DATE], to tell them that the bed hold was up and they would have to pay privately to hold a bed." During phone interview on [DATE] at 8:20 a.m., the hospital discharge planner stated, "She was ready to transfer back to the facility on [DATE]. Our department has been looking for placement. Resident 1 is doing really well. She's alert and up in a wheelchair." During phone interview on [DATE] at 11:30 a.m., the admission staff (AD) was asked how many vacancies were there on [DATE]. AD stated, "On [DATE], we had 21 vacant beds. In the long term unit, we had two female vacancies." During phone interview on [DATE] at 11:50 a.m., the Acting DON stated, "We are still refusing her re-admission. We are working on a policy and procedure about what to do when the bed hold expires." Review of the facility's policy and procedure titled "Admission of Residents," revised ,[DATE], showed, "Policy: It is the policy of (this facility) to admit residents using a safe and orderly process, which minimizes stress and obtains baseline data for initial care planning and medical management." The procedure gives instructions on the general admission procedure and the procedure when a resident was readmitted within seven days of transfer to hospital. The final portion of this procedure, titled "Readmission eight to thirty days since discharge/ transfer" showed instructions regarding the clinical record forms and complete resident assessment.

Based on record review and staff interview, the facility failed to ensure that one of six sampled residents (Resident 2) was free of accident hazards and received adequate supervision during a shower. CNA 1 (certified nurses aide) left Resident 2 alone and unsupervised in the shower chair and when she returned she found the resident on the floor with a laceration on right forehead. Findings: On 8/29/13, record review showed that Resident 2 was a Spanish speaking [AGE] year old admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The care plan dated 1/20/13 showed that the resident was at risk for falls related to unstable balance and gait. The care plan interventions included to "anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and the resident needs prompt response to all requests for assistance." The care plan further stated that the resident needs a safe environment. The MDS (Minimum Data Set), dated 7/6/13, showed that the resident had no long/short term memory problems and no cognitive impairment. The MDS continued to show that the resident required extensive assistance with her needs and she could feed herself with limited assistance. The MDS further showed that the resident was totally dependent on staff for her bathing and was not steady without staff assistance when moving from a seated to standing position. The nurses notes dated 8/9/13 showed that the resident had an unwitnessed fall while in the shower room, she was found by a CNA (Certified Nurses Assistant) lying on the floor, and fell from the shower chair sustained a laceration on the right forehead with bleeding. The nurses notes indicated that the resident was sent out to the acute hospital by ambulance at 10:45 AM. The nurses notes further stated that the resident was alert and verbally responsive, the physician was faxed and a message was left for the family. The fall risk assessment done on 8/9/13 showed that the resident was high risk for falls and unsteady. The care plan was updated on 8/12/13 regarding the fall with bump, and hematoma on the right forehead near the eyebrow. The care plan did not mention that the resident should not be left alone without staff supervision when on a shower chair. The emergency room (ER) report from the acute hospital dated 8/9/13 showed that the resident had an unwitnessed fall in the shower. The resident was able to state, using a translator and her daughter, that she slipped on a wet floor, striking her head. The ER report continued to show there was no/loss of consciousness and the resident complained primary of constant aching, throbbing pain over the right forehead where she has a laceration. The ER report further stated that the resident was complaining of some mild neck, right hip and right knee pain. The ER report showed that the final [DIAGNOSES REDACTED]. X-Ray reports on 8/9/13 of the neck, right hip and skull showed no fracture. During an interview on 8/29/13 at 10:50 AM, CNA 1 (Certified Nurse Assistant) stated that she left the resident unattended on the shower chair in the shower and she went out of that shower into another shower room to get soap. CNA 1 stated that when she came back into the shower the resident was on the floor. CNA 1 stated she called the charge nurse immediately and the resident had to go to the hospital. CNA 1 further stated that she was not suppose to leave a resident unattended on a shower chair. During an interview on 8/29/13 at 1:40 PM the DSD (Director of Staff Development) stated that she talked to CNA 1 and other CNAs after the incident about getting supplies together before giving a shower and never leaving a resident alone in the shower. On 8/29/13 at 1:55 PM, during an interview with Resident 2 in, her daughter, and translator came to office for the interview. The resident was observed sitting in wheelchair. The resident was neatly dressed and groomed. The resident had a purple yellow fading bruise on her right knee, a bruise on the back of her head that she stated was painful, a bruise on the right forehead with scar from laceration on forehead, and bruise on her ears. During the interview the resident stated that she fell trying to take her sock off because it was wet. Resident 2 further stated that she was on the shower chair in the shower and no one was with her. Resident 2's daughter stated that her mother should never be left alone on a shower chair in the shower. On 12/4/13 at 1:23 p.m. LVN 1 stated that CNA 1 left Resident 2 alone in the shower room, did not tell anyone to watch the resident and when she went back to the shower she found the resident on the floor. LVN 1 Further stated that Resident 2 should not have been left alone in the shower and that the resident cannot walk or transfer herself. The facility's policy, Fall Management stated, "It is the policy of the SNF (Skilled nursing Facility) that our physical environment remains as free of accidents hazards as possible. Residents will be assessed for fall risk and interventions will be implemented to reduce the risk of falls. The policy further stated, residents will be assessed for injuries, nursing or medical interventions will be provided to maintain the well-being of the resident, and required notification will be made when a fall related injury occurs."

Based on observation, interview and record review, the facility failed to protect one of two sampled residents (1) from physical and mental abuse by CNA 1 and failed to do a thorough investigation into the alleged abuse and mental abuse. Resident 2 saw the reflection of CNA 1 poking his roommate Resident (Resident 1) and yelling at him resulting in Resident 2 being upset and afraid of CNA 1 who was assigned to his care. When Resident 2 reported the incident to the DON (Director of Nurses) he was told the allegation could not be substantiated and the facility allowed CNA 1 to remain on the facility's on-call list. Findings: The facility reported to the Department on 10/12/11, that Resident 2 claimed he saw CNA 1 hit Resident 1 with a closed fist during care on 10/10/12. The facility placed CNA 1 on administrative leave pending further investigation. During an on-site visit on 10/25/12 at 9:15 a.m., Resident 2 was lying in bed watching his computer that was on his overbed table. When asked about the incident10/10/12, Resident 2 stated that on the evening shift CNA 1 was assigned to him and his roommate, (Resident 1). He stated he had never seen CNA 1 in the facility before. Resident 2 then instructed the surveyor to turn off the overhead light above his area of the room, and stand next to the head of his bed and then look to the left at his poster which was in a frame. Resident 1 who was lying on his back in his bed in the same room in the opposite corner of their four bed room, was clearly visible. The poster in the frame with the light off reflected the image as if it were a mirror. Resident 1, his bed, the window and the entire area around his bed was plainly visible. Resident 2 then continued his recollection that Resident 1, who was turned over on his left side with his back to the room was being changed by CNA 1. Resident 2 first heard CNA 1 yell "Stop it" in an "angry" voice. Resident 2 looked in the poster and saw CNA 1 poke Resident 1 on his right cheek with his finger. Resident2 said Resident 1 was moving his arm up and down and his legs were moving a little bit, which he said was "normal" for Resident 1. Then he saw CNA 1 "punch" Resident 1's right forearm with a closed fist. Resident 2 stated that he was "upset and scared" so he called his sister. He said that she told him to report it to the Administration in the morning. He said that he just laid in his bed, he didn't tell the night supervisor because she wouldn't do anything about it. When he woke up in the morning he called the front desk and they sent a social worker to come and take his statement. He said the Director of Nurses (DON) came and said he would take care of it. He said that he had been a resident at the facility for over [AGE] years and had never witnessed anything like that before. Later the DON told him that he could not substantiate the allegation of abuse because he said, "Your poster's not a mirror." Resident 2 felt like his "word was not good enough." He said he could not sleep for a couple of nights after that happened. Then he asked the surveyor to open his drawer and pull out a piece of paper and read it. Resident 2 said it was a staffing sheet that somebody gave him, and it had CNA 1's name and phone number listed as an "On Call CNA (AM) (PM) Bldg. 200 only per DON." A review of Resident 1's medical record revealed that he was [AGE] year old male with [DIAGNOSES REDACTED]. According to his care plan dated 8/25/12 , "The resident has self care deficit with ADL (activities of daily living) functions...personal hygiene, dressing, groom, toileting..." with a goal of "The resident will maintain dignity and self-esteem...", and the approaches were, "Do not rush resident, explain all procedures before starting, promote dignity by ensuring privacy conversing with resident while providing care..." According to Resident 2's medical record he was a [AGE] year male who was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to his most recent minimum data set assessment ((MDS) dated [DATE]) he had no problems with his cognition and his memory was intact. He had no mood or behavior problems identified. In a telephone interview on 10/30/12 at 11:40 a.m. CNA 1 stated that he was a new CNA and this was his first CNA job. He had been on the job for about a month. He stated that a charge nurse told him to be careful with Resident 1 because he "can kick." He said that he went to Resident 1 three times that evening and was doing incontinent care around the end of his shift at 10:30 p.m. He stated that Resident 1 tried to kick him twice so he calmed him down by talking to him and telling him, "calm down it's going to be quick." In an interview with the Director of Staff Development (DSD) on 10/25/12 at 1 p.m. she stated that she interviewed Resident 2 after the allegation was made against CNA 1 and she could see that Resident 2 would be able to see in the "picture everything the CNA was doing with (Resident 1)," and she wrote it down. She gave her report to the DON. The DSD's written investigation dated 10/11/12 revealed that Resident 2 stated, "What I say I don't feel I'm safe. He abused my roommate. He went to (Resident 1) said I need to change you. He removed his gown and (Resident 1) moved his hand. CNA got mad and started poking his finger in his face. CNA told patient to stop and shoved patient in the face. He was man handling (Resident 1). He hit (Resident 1) on the forearm with his fist, while he was turned on his side. He didn't ask me if I needed changing and I'm glad I didn't want him to change me. I ack (act) like I didn't see nothing. I was afraid if I told him I saw him. I don't want him taking care of me."

Based on record review and staff interview, the facility failed to ensure that one of three residents (Resident 1) received the correct medications. The facility sent the wrong medication order sheet to the pharmacy resulting in Resident 1 not receiving her blood pressure medication ([MEDICATION NAME]) and being given two diabetic medications ([MEDICATION NAME] and [MEDICATION NAME]) although she was not a diabetic. This resulted in Resident 1 having a very low blood sugar of 39 (normal range is 82-110 mg/dl) and a high blood pressure of 218/88 (normal adult blood pressure ranges from 120/80 to 139/85) requiring hospitalization . Findings: On 8/7/12, review of Resident 1's record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nurses notes dated 7/21/12 at 3:44 p.m. showed that Resident 1 was not feeling well. and had a medication reaction. She was sweating, skin cold to touch, blood sugar checked and it was 46 mg/dl (normal blood sugar range is 82-110 mg/dl), orange juice was given and glucose given. Blood sugar was rechecked after 15 minutes and the reading was 76 and the physician visited the resident. The nurses notes further indicated that at 4:30 p.m. the resident's blood sugar dropped to 39 mg/dl and she was sweating. Orange juice was given, 911 called and the patient was transported to the acute hospital. The history and physical (H&P) from the acute hospital dated 7/21/12 showed that Resident 1 was having an altered level of consciousness with profound sweating and dizziness, nausea, and shakiness and was found to have a blood sugar in the 39-40 range which turned out to be due to her being given another resident's (4) medications. Resident 1 received some oral antidiabetic medications although the resident was not a diabetic. The history and physical continued to state that at some point in the transfer from the acute hospital to the nursing facility the patient received a medication list from a different resident and ended up getting that other resident's medications. Record review showed that Resident 1's medication list from the acute hospital had another resident's name. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 1 did not recieve her blood pressure medicaton [MEDICATION NAME]. When the resident was admitted to the hospital her blood pressure was 218/88. The H&P further showed that the resident stated that she had two episodes yesterday (7/20/12) where she felt dizzy, nausea, had a little bit of sweating, felt shaky and lightheaded, but she did not pass out or lose consciousness. Today she had an episode around noon and again around 5 pm where again she felt lightheaded, dizzy, shaky and nausea then she had profound sweating they checked her blood sugar when the daughters at the bedside, daughter said the resident was not a diabetic. Her blood sugar was 40 or 39 at the time. The nursing home staff realized she had been getting diabetic medication ( [MEDICATION NAME] and [MEDICATION NAME]). She was given orange juice, the paramedic ambulance was called and patient was transferred to the emergency room of the acute hospital. The Discharge Summary dated 7/21/12 from the acute hospital showed that the resident was admitted with [DIAGNOSES REDACTED] (low blood sugar) secondary to administration of [MEDICATION NAME] and [MEDICATION NAME]( drugs used to treat diabetes) . The patient was noted to have isolated hypertension with blood pressure at 218/88 on admission. . During an interview on 8/7/12 at 12:45 pm, RN 1 stated that she was the nurse who admitted Resident 1 to the facility. RN 1 stated, we had an error with this resident, she came from the acute hospital with the wrong orders. RN 1 stated that when she went through the orders from the hospital the pages in front had the resident's name. She went through the papers and did not see another resident name on the medication sheets. She faxed the copies over to the pharmacy and they sent the medications. The pharmacy did not pick up that the medication was for another resident. The next day she checked and had entered the wrong medication that belonged to another resident whose medication sheets were sent with the resident when she was admitted . RN1 stated, we monitored the resident. She was having [DIAGNOSES REDACTED] (low blood sugar). She was not a diabetic. We sent her out to the hospital. On 8/17/12 at 10 am Physician 1 stated that the nurse and the pharmacy made a mistake and it was not picked up that the medication sheet for the Resident 1 belonged to another resident (4). Physician 1 stated that Resident 1 was sent out to the hospital with low blood sugar. The facility's policy, "Physician orders, Accepting, Transcribing and Implementing " dated July 2008 indicated that all physician orders [REDACTED]. Under 2. Implementation of Orders ("Noting): d. Transcribe orders onto the appropriate forms (medication, administrator record, treatment administration record, etc.) and date, and to fax new medication orders and changes/discontinuations to the pharmacy. The facility's policy, "Medication Related Errors," showed that if a medication reaches a resident in error the facility should notify the pharmacy, notify the physician and staff should monitor the resident.

Based on record review and staff interview, the facility failed to provide pharmaceutical services for one of three sampled residents (1) that assured the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident. The pharmacy dispensed drugs to Resident 1 that were ordered for another resident. This failure resulted with Resident 1 receiving two medications for diabetes and she was not a diabetic. Resident 1 had high blood pressure and did not receive medications for her high blood pressure. Resident 1 was transported to the acute hospital with low blood sugar of 39 (normal range is 82-110 mg/dl) and a high blood pressure of 218/88 (normal adult blood pressure ranges from 120/80 to 139/85) . Findings: Record review on 8/7/12 at 9: 50 showed that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 8/7/12 at 12:45 pm, RN 1 stated that she was the nurse who admitted Resident 1 to the facility. RN (registered nurse) 1 stated "We had an error with this resident, she came from the acute hospital with the wrong orders. When I went through the orders from the hospital the pages in front had the resident's name. I went through the papers and I did not see another resident name on the medication sheets. I faxed the copies over to the pharmacy and they sent the medications. The pharmacy did not pick up that the medication was for another resident. The next day I checked and I had entered the wrong medication that belonged to another resident whose medication sheets were sent with the resident we admitted . We monitored the resident. She was having [DIAGNOSES REDACTED] (low blood sugar). She was not a diabetic. We sent her out to the hospital." On 8/7/12 at 1:30 p.m. the Director of Nurses (DON) stated that Resident 1 medication list had another resident's name. The DON continue to state that the nurse usually transcribe the orders, put the information into the computer, call the physician to verify the medications and fax the original to the pharmacy. The DON further stated that the pharmacy did not see that the orders belonged to another resident. On 8/17/12 at 10 a.m. Physician 1 stated that the nurse and the pharmacy made a mistake and they did not notice that medication sheet fr the Resident 1 belonged to another resident (4). Physician 1 stated that the resident was sent out to the hospital with low blood sugar. Resident 1 medication list from the acute hospital had another resident name. The nurse putting the medication information into the computer to produce a Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 1 received two medications for diabetes ( glipizide and metformin) and she was not as diabetic. In addition, to Resident 1 receiving the wrong medications and did not receive the medications the physician ordered for her. Resident 1 was on medication for her blood pressure (Felodipine) that she did not get. Resident 1 was admitted to the hospital with [REDACTED]. The facility's policy, "Medication Related Errors," showed that if a medication reaches a resident in error the facility should notify the pharmacy, notify the physician and staff should monitor the resident. The policy continues to show that dispensing errors include unauthorized medication error: dispensing to resident a dose of medication not authorized by physician/prescriber for the resident, dispensing to resident a dose that is greater than or less than the amount ordered, dispensing to the resident a medication other than that ordered by physician/prescriber, transcription error-entire order or part of order incorrectly transcribed from the original order. Administration Errors: Facility incorrectly transcribes to Pharmacy an entire order or part of order, facility administers a medication dose not authorized for resident and omission errors: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication.