Every finding on record at Edgemoor Hospital

Based on interview and record review, the facility failed to ensure Resident 1 (who resided on Unit C) was protected from mental abuse and intimidation and 63 other residents on two units (Unit A and Unit B) were protected from potential abuse when: 1. Certified nursing assistant (CNA) 1 responded to Resident 1's request for assistance with a raised voice, angry demeanor, and threatening and aggressive posturing on 1/6/26.2. Charge Nurse (CN) 1 and CNA 2 failed to report the incident between CNA 1 and Resident 1 as an allegation of abuse to the facility's administrator.4. The facility did not investigate and report the allegation of abuse to the state agency (California Department of Public Health, CDPH) for three days.5. The facility continued to assign CNA 1, with known behavioral issues, to provide care to 63 residents on Unit A and Unit B on 1/7/26 and 1/8/26 prior to beginning their investigation into the allegation of abuse on 1/9/26. As a result of these failures, Resident 1 expressed feeling scared, worried, and withdrawn from socialization due to her emotional distress. Furthermore, this failure to identify Resident 1's allegation as abuse posed an immediate jeopardy to the safety and well-being of the 63 other residents on Unit A and Unit B where CNA 1 had been assigned during the facility's three-day investigation and reporting delay.Findings: On 1/9/26, CDPH received a faxed SOC 341 (standardized abuse reporting form) from the facility dated 1/9/26. The SOC 341 indicated the facility was reporting an incident of psychological/mental abuse and verbal aggression that allegedly occurred between CNA 1 and Resident 1 on 1/8/26 7:00 PM. The SOC 341 further indicated, .On 10/6/26 [sic] resident reported to the charge nurse that [CNA 1] was aggressive to her because she did not say Hi to him when she asked him to get something from the fridge. She said that she felt defenseless because her wheelchair is slow and did not know what to do. On 2/3/26 at 2:55 P.M., an onsite visit was conducted to investigate a Facility Reported Incident (FRI) alleging CNA 1 was aggressive to Resident 1 because she did not say Hi to him when she asked CNA 1 to get something from the refrigerator for her. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia (a form of paralysis that causes the loss of movement and feeling in all four limbs and the torso) due to motor vehicle accident. A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/30/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On 2/3/26 at 3:19 P.M., an interview was conducted with Resident 1while in the dining hall.Resident 2, who was a witness to the incident on 1/6/26, was also present. Resident 1 was asked about the incident that involved CNA 1 on 1/6/26. Resident 1 stated she asked CNA 1 to get a food item out of the fridge, but CNA 1 told her, Are you gonna say hi to me if you want something from me? Resident 1 stated it was her first encounter with CNA 1. Resident 1 stated she was confused by his reply. CNA 1 then repeated in an angry manner, Are you gonna say hi to me if you want something from me? Resident 1 stated she was still confused but also thought that maybe he was joking. Resident 1 then told CNA 1, I don't have to say hi to you if I don't want to. Resident 1 stated CNA 1 was coming out of the nurse's station walking toward the refrigerator at which point he turned around and yelled, If you don't say hi to me, you're not getting anything from me! Now you have to call your [assigned] CNA! Resident 1 stated CNA 1 charged toward her with his chest out and aggressive arm movements. Resident 1 stated CNA 1 charged toward her in a manner that looked like he wanted to physically fight her. Resident 1 stated she was scared when CNA 1 was verbally and physically aggressive and charging toward her with his threatening posture because her electric wheelchair moved slowly. Resident 1 stated she was worried she could not get away from him fast enough. CNA 1 then walked back into the nurse's station without getting what she requested out of the refrigerator. Resident 1 called for help and told CNA 2 and CN 1 what had happened. Resident 1 stated that she told CNA 2 and CN 1 that she was scared and did not feel safe with the way CNA 1 behaved toward her. Resident 2 stated that she witnessed the incident on 1/6/26 and that was what happened. A review of Resident 1's Interdisciplinary Progress Notes after the incident on 1/6/26 indicated:1/6/26 at 11:15 P.M., .Resident appeared to be in emotional distress at the time of incident.1/7/26 at 10:03 P.M., .Resident just verbalized that she still couldn't believe the incident from yesterday occurred. 1/8/26 at 1:45 P.M., Therapist made two attempts before lunch and after lunch to speak with resident and assess psychosocial wellbeing, however both times resident was sleeping and did not respond to knock at door or calling out of name. 1/8/26 at 7 P.M., .Resident was upset regarding the [facility's] action and verbalized that she will be reporting to Police and Ombudsman tomorrow. Resident stated that she's not safe with alleged PM CNA staff [CNA1]. 1/8/26 at 11:03 P.M., Resident still verbalized feeling upset r/t incident with staff. 1/9/26 at 1:33 P.M. Resident refused to get OOB [out of bed]. Resident told CNA that she doesn't want to talk to anyone today. 1/9/26 at 1:38 P.M. Attempted multiple times to talk with resident regarding grievances reported on PM shift, she declines to talk. 1/9/26 at 10:40 P.M. Tried to talk to resident to follow up on alleged abuse but resident declined. 1/9/26 at 11:05 P.M.resident declined to talk about it anymore when asked. 1/10/26 at 10:27 P.M.Resident stayed in her room all shift and did not get up. A review of Social Work Progress Note dated 1/12/26, indicated, .The resident states she does not feel safe with the staff [CNA 1] from the SOC 341 being around her. The resident states she feels unsafe as she feel[sic] the alleged individual could lose their temper at any time not only with herself but other residents. A review of Resident 1's psychotherapy note dated 1/14/26, indicated, .The resident appeared disheveled. reported a recent interaction with a male CNA that elicited feelings of unsafety and a sense of being frozen during the incident. Subsequently, the resident endorsed spending three consecutive days in bed, primarily sleeping, citing significant fatigue.stating avoidance of social interaction to prevent retraumatization.The resident.agreed to continue working on reducing immobilization responses associated with fear. A review of facility's staff assignment for 1/6/26 through 1/13/26, indicated CNA 1 provided resident care on 1/7/26 on Unit A and on 1/8/26 on Unit B during the PM shift (3 P.M. to 11:30 P.M.). A review of facility's census for Unit A and B combined on 1/7/26 and 1/8/26 indicated a total census of 63 residents. On 2/3/26 at 3:42 P.M., an interview with CNA 2 was conducted. CNA 2 stated she had witnessed CNA 1 being rude and sarcastic with other staff. CNA 2 stated she responded to Resident 1's call for help after the incident on 1/6/26. CNA 2 stated Resident 1 looked scared and Resident 2 was sitting nearby having witnessed the incident. On 2/3/26 at 3:55 P.M., an interview was conducted with CNA 4. CNA 4 stated she was familiar with Resident 1. CNA 4 stated she noticed Resident 1 was emotionally distressed for a few days after the incident on 1/6/26. On 2/4/26 at 2:15 P.M., an interview and record review was conducted with the Director of Staff Development (DSD) 1 and DSD 2. The DSDs stated they had already identified red flags at the beginning of CNA 1's onboarding orientation (on 10/31/25) at the facility. The DSDs described CNA 1's behavior as arrogant and he would give them lots of push backs against their instructions. DSD 1 and DSD 2 both stated CNA 1 often would not follow directions. The DSDs stated CNA 1 would make statements such as, I know that; I've been a CNA for nine years. The DSDs stated CNA 1 was late on the first day of orientation and had a bad attitude about it. The DSDs stated CNA 1 violated facility policy by taking food from residents' finished trays and stealing other staff's food and eating it. The DSDs stated they could totally' imagine CNA 1 acting aggressively toward Resident 1. The DSDs stated CNA 1 should not have acted aggressively toward any residents regardless of the reason. DSD 1 reviewed CNA 1's employment record on her computer and stated CNA 1 was dismissed from his position on 1/13/26 during his probational period. DSD 1 stated at approximately 3:00 P.M. on 1/13/26, CNA 1 burst into their office yelling, They're trying to let me go they can't do this! DSD 1 stated Assistant Director of Nursing (ADON) 1 escorted CNA 1 out of the building. DSD 1 stated when she left work that day, CNA 1 ran after her in the parking lot and chased her car as she drove away. DSD 1 further stated that Resident 1 was not the type of resident who would report abuse allegations indiscriminately. DSD 1 stated, I can see it's pretty serious if she reports abuse. DSD 1 stated CNA 1's behavioral concerns were reported to the leadership. A review of Dismissal During Probation letter dated 1/13/26 indicated that CNA 1 was dismissed from his position as a CNA at the facility because he was found unsatisfactory in fulfilling the duties required for the position. On 2/4/26 at 3:09 P.M., an interview was conducted with Nursing Supervisor (NS) 2. NS 2 was the day shift supervisor. NS 2 stated Resident 1 was given the choice to report the incident that occurred on 1/6/26 as a facility internal complaint/grievance or report to CDPH as a formal complaint. NS 2 stated when Resident 1 told another staff on 1/9/26 that she was scared of CNA 1 that was when the facility reported the incident as an allegation of abuse to CDPH on 1/9/26. NS 2 was asked about CNA 1's job performance and behavior toward residents and she refused to answer. On 2/4/26 at 3:41 P.M., an interview with Charge Nurse (CN) 1 was conducted. CN 1 stated CNA 1 would interrupt staff conversation and say, You need to tell me what you guys are talking about. Are you talking about me? CN 1 stated other staff members would report to her that they had concerns about CNA 1's behaviors which included false accusations. CN 1 stated CNA 1 was floated to Resident 1's unit around 7:30 P.M. on the day the incident happened (1/6/26). CN 1 stated CNA 1 was assigned to answer call lights while other CNAs and staff were making rounds. CN 1 stated this resulted in no other staff being present in the dining hall and nurse's station at the time of the incident which happened around 8:20 P.M. When the incident happened, CN 1 stated, she was called to the dining room where she saw Resident 1 and Resident 2 sitting close to each other. CN 1 stated Resident 1 was, very shaken about it, shaking and visibly in distress. CN 1 stated Resident 1 told her she was scared. CN 1 stated Resident 1 told her, Don't leave me here with him [CNA 1], he's there. On 2/4/26 at 4:20 P.M., a follow up interview was conducted with Resident 1 while inside the resident's room. Resident 1 stated a few minutes after the incident on 1/6/26, three nursing supervisors approached her and asked her if she would be willing to meet with CNA 1 to discuss the incident. Resident 1 stated she refused and told the nursing supervisors that she was too scared of CNA 1 to meet and talk with him. Resident 1 further stated she was worried about other residents, especially the more vulnerable ones, those who could not speak for themselves, and those who could become agitated through interactions with CNA 1 because of their psychiatric conditions. Resident 1 stated she stayed in bed for the next few days after the incident because she felt closed off and put shells around herself due to the incident. Resident 1 stated she refused to keep talking about the incident with staff because she did not want to be re-traumatized by thinking of or talking about it. On 2/10/26 at 12:14 P.M., a follow up interview was conducted with DSD 1 and DSD 2 regarding CNA1's misconduct and behavior during his new hire orientation. The DSDs stated they informed ADON 1 and possibly ADON 2 within the first seven to 10 days of noticing his behavior. The conversation included reporting CNA 1's tardiness on the first day of orientation, multiple instances of resistance, and his unprofessional attitude. DSD 1 and DSD 2 stated the incident between Resident 1 and CNA 1 on 1/6/26 was emotional abuse and should have been addressed immediately. DSD 1 stated when Resident 1 told CNA 2 and CN 1 about the incident with CNA 1 on 1/6/26, they should have filled out the SOC 341 immediately and reported this incident to CDPH. DSD 1 stated the facility's investigation should have started immediately and should not have been delayed. On 2/10/26 at 1 P.M., an interview was conducted with ADON 1. ADON 1 stated CNA1's behavior and misconduct was not documented in an employee file because he was aprobationary employee. ADON 1 was asked if there were more issues with CNA 1'sbehavior toward residents or allegations of abuse made against him. ADON 1 stated theissues with CNA 1's behavior was discussed with leadership in an email thread. ADON 1stated he would not elaborate on CNA 1's behavioral issues and he would not disclose anyinformation related to any of CNA 1's disciplinary action. On 2/10/26 at 3:59 P.M., an interview was conducted with CNA 5. CNA 5 stated working with CNA 1 was very difficult because CNA 1 was rude and would give him push backs when anything was explained to him. CNA 5 stated he worked with CNA 1 and witnessed CNA 1 raising his voice and shouting to redirect residents. CNA 5 stated this behavior put the unit's residents at risk for escalation. On 2/10/26 at 4:23 P.M., a follow-up interview was conducted with CN 1. CN 1 stated what Resident 1 reported to her on 1/6/26 was verbal abuse. CN 1 stated she should have reported this immediately to the administrator, CDPH, and the police. On 2/19/26 at 9:57 A.M., and 10:15 A.M., two phone calls were made to CNA 1. CNA 1's phone was disconnected. On 2/24/26 at 1:39 P.M., an interview was conducted with the ADM who was also the abuse coordinator. The ADM stated according to the nursing supervisors, Resident 1 did not mention that the incident was abuse. The ADM stated she only interviewed CNA 1 regarding the incident that occurred on 1/6/26. The ADM stated she did not interview Resident 1. The ADM stated she spoke to nurse supervisors about the incident on 1/6/26 and they did not tell her that this was an abuse allegation. The ADM stated she would not consider this incident abuse. The ADM stated Resident 1 chose to file an internal complaint/grievance over asking the facility to report the incident to CDPH. The ADM stated she was not told by the nurse supervisors that Resident 1 was scared of CNA 1. The ADM stated no one reported to her that Resident 1 had experienced emotional distress. On 2/24/26 at 3:40 P.M., a follow up interview with CNA 2 was conducted. CNA 2 was asked how she became aware Resident 1 needed help on 1/6/26. CNA 2 stated she heard Resident 1 screaming her name, which prompted her to run out of a resident's room. CNA 2 stated Resident 1 then told her [CNA 2], stay here, stay here, don't leave, and observed the resident's body was tense and shaking. CNA 2 explained that Resident 1 reported asking CNA 1 for food from the refrigerator. CNA 2 stated Resident 1 told her that CNA 1 said, Are you gonna say hi to me if you want something from me? while raising his voice. CNA 2 stated Resident 1 told her that when she did not say hi to CNA 1, his demeaner quickly changed. CNA 2 stated Resident 1 told her CNA 1's body language was intimidating and threatening. CNA 2 stated Resident 1 told her she felt fatigued, had refused to get up, and did not socialize after the incident. CNA 2 stated what happened to Resident 1 on 1/6/26 was abuse. CNA 2 stated she thought the nurse supervisors and the CN 1 who responded to the incident on 1/6/26 had appropriately reported the abuse allegation to the ADM. CNA 2 stated if she had known that the facility was not treating the incident as an abuse allegation, she would have said something about it sooner. On 2/25/26 at 8:06 A.M., an interview with NS 1 was conducted. NS 1 stated she reported the incident that occurred between CNA 1 and Resident 1 to the ADM on speaker phone in the unit's medication room. NS 1 stated NS 4 and CN 1 were also present during the call. NS 1 stated she reported to the ADM what CNA 1 told her had happened. NS 1 stated CNA 1 went to get food for the resident and asked the resident her name. NS 1 stated CNA 1 told her Resident 1 replied to him that she did not have to tell him her name. NS 1 stated she reported to the ADM that CNA 1 did not engage in physical contact or raise his voice at Resident 1. NS 1 stated she did not tell the ADM Resident 1's statement of the incident. NS 1 stated she could not remember what Resident 1 told her. On 2/25/26 at 4:08 P.M., an interview was conducted with Social Worker (SW) 1. SW 1 stated what Resident 1 experienced with CNA 1 on 1/6/26 caused emotional and psychosocial distress.A review of the State Operations Manual revised 7/23/25, indicated, .Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.Examples of mental and verbal abuse include, but are not limited to.Yelling or hovering over a resident with the intent to intimidate; Threatening residents.depriving a resident of care. A review of facility policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, indicated, I. POLICY.All [Facility] employees, contracted workers and volunteers are mandated reporters.It is the Policy of [Facility] to: Assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42CFR 483.12(c), .and other relevant laws, of known or suspected abuse and/or criminal activity directed against [Facility] residents. Provide assistance to [Facility] staff in carrying out this responsibility. The facility will facilitate the making of group reports, but will in no way impede an individual from making an individual report in compliance with the law. Respond to concerns about abuse and investigate them thoroughly with a resident-centered approach that includes assessment.III PROCEDURES.A. endure that effective measures are put in place to ensure that further potential abuse.does not occur while the investigation is in process.C. External Reporting.c. Time Frames Required: ii. For all abuse.report to law enforcement ([local] Sheriff) by phone immediately.Then fax the SOC341 form to the Ombudsman and to CDPH.This shall be accomplished within 2 hours of the observation or report of the act.reporting withing a 24-hour window may be permitted.D. Internal Reporting.a. Evidence of, suspicion of, or witnessed or suspected abuse or criminal activity must be reported to the Administrator.supervisory Nurse.e.ii. When staff are accused.the employee may be moved to another assignment or department if it is determined that there is risk to residents. The staff member.generally should not have contact with the resident during the period in which the alleged abuse is being investigated.F. Documentation a. The employee who witnesses or hears about the abuse completes the Abuse Report of Suspected Dependent Adult Elder Abuse Form SOC341/SOC-341/SOC 341 with as much information as possible.J. Prevention and Identification.c. Identification, Tracking, & Trending: . staff are educated on how to identify .behavior which may indicate potential abuse.K. Training All [Facility].staff are educated annually of their reporting obligations and the names and phone numbers of where to make a report. On 2/24/26 at 12:32 P.M., a meeting was conducted with the Administrator (ADM), the Director of Nursing (DON), and ADON 1. Two of the facility counsels joined the meeting via speaker phone. The facility was informed of Immediate Jeopardy (IJ) related to the facility's failure to protect residents from abuse and failure to identify CNA 1's mistreatment of Resident 1 as verbal abuse and intimidation. This resulted in Resident 1 experiencing psychosocial harm: Feeling scared and unsafe, withdrawn from socialization, and ongoing worry. In addition, the facility failed to keep residents in two other units safe and protected from CNA 1 after the incident. The IJ Template was provided to the ADM. The facility began to develop a plan to remove the IJ. On 2/24/26 at 1:08 P.M., a plan of action (POA)/removal plan was provided by the facility. The POA was reviewed and was not acceptable. On 2/24/26 at 5:11 P.M., a plan of action (POA)/removal plan was re-submitted by the facility. The POA was reviewed and was not acceptable. On 2/25/26 at 2:27 P.M., a plan of action (POA)/removal plan was re-submitted by the facility. The POA was reviewed and was not acceptable. On 2/25/26 at 4:28 P.M., and 2/26/26 at 8:44 A.M., a plan of action (POA)/removal plan was re-submitted by the facility. Both POAs were reviewed and were not acceptable. On 2/26/26 at 3:56 P.M., the facility re-submitted a revised POA. It was reviewed and accepted. On 2/27/26 at 1:20 P.M., the facility's POA/removal plan was reviewed with the ADM and the DON. The removal plan included: 1. Immediate Protective ActionsAny staff member identified as the subject of an allegation involving intimidation, fear, or potential abuse is immediately removed from direct resident care pending investigation.Facility leadership confirmed that no residents are currently exposed to staff under investigation. 2. Corrective Measure for the Affected ResidentResident was observed by nursing staff on 1/6/26 approximately one hour after the verbal exchange and appeared more calm. Resident was placed on monitoring for emotional distress every shift. Behavioral Health Program Coordinator (BHPC- organize, plan, and manage care programs, connecting patients with therapists and resources) attempted to see resident twice on 1/8/26; however, resident was presumably sleeping as she did not respond to the knock at door or calling out name. BHPC attempted to see the resident on 1/12/26 at 10:50 am, but resident was out of the facility. Resident was seen by the Social Worker on 1/12/26 at 11:25 am. Facility psychologist (a licensed mental health expert who works inside specific institutions such as hospitals, prisons, rehabilitation centers, or nursing homes, rather than private offices) and social workers are available to all residents as needed. 3. Facility-Wide Systemic ChangesEffective 2/24/26, regardless of the type of investigation (complaint versus abuse), if staff is alleged perpetrator, staff will be removed from direct patient care pending the abuse investigation results or determination that staff identified in the complaint may return to direct care as the complaint does not involve abuse. Staff reporting incidents to the Abuse Coordinator shall report thorough and accurate statements based upon the knowledge they have gathered, observations, preliminary interviews of parties involved in the situation, and the psychosocial disposition of the residents. Allegations or suspicions of abuse will continue to be reported promptly, according to the required regulatory timeline, and Form SOC 341will be submitted. Staff are educated that they are mandated reporters and they have the right and obligation to report abuse or suspicion of abuse, regardless of the opinions of others. Staff are educated and have access to the SOC 341 form and abuse policies and procedures for guidance. Staff in all departments will receive in-service education F600 Staff Training: Abuse, Neglect, and Exploitation Prevention on 2/25/26 and 2/26/26. Staff on scheduled days off, leave, or paid time off will complete the education on the date of their return and prior to providing patient care. This in-service describes the different types of abuse or neglect, risk factors, signs of abuse, protecting residents during an investigation, reporting requirements, and prevention practices. A thorough investigation of the allegations will continue to be conducted, including resident interviews, staff interviews, other witness interviews, employee personnel file review, resident record review, and other items as deemed necessary or that arise during the course of the investigation. All results of the investigation will be submitted to CDPH within 5 days. The ADM/Abuse Coordinator will review the abuse investigation protocols using the Abuse Investigation Checklist on 2/26/26 with the Assistant Administrator, DON, and ADON, and QA nurse, and, upon return from leave, the other ADON and the BHPC, before assuming direct patient care. On 2/27/26 at 3:48 P.M., the IJ was removed, and the ADM, DON, and Quality Assurance Nurse were notified after verifying the IJ removal plan while on-site.

Based on interview and record review, the facility failed to implement its written abuse policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, in accordance with required procedures when:1. The facility did not identify, report, or investigate an allegation of abuse in a timely manner.2. The facility did not thoroughly investigate the allegation at the time of its report. 3. The facility did not assess the risk to other residents when CNA 1 was assigned to provide resident care for two days after an abuse allegation was made.4. The facility did not identify Resident 1's increased fearfulness as a behavior which may indicate potential abuse.As a result, this failure placed Resident 1 and 63 other residents at risk for potential abuse.Cross reference F600, F609, and F610.Findings:On 1/9/26, CDPH received a faxed SOC 341 (standardized abuse reporting form) from the facility dated 1/9/26. The SOC 341 indicated the facility was reporting an incident of psychological/mental abuse and verbal aggression that allegedly occurred between CNA 1 and Resident 1 on 1/8/26 7:00 PM. The SOC 341 further indicated, .On 10/6/26 [sic] resident reported to the charge nurse that [CNA 1] was aggressive to her because she did not say Hi to him when she asked him to get something from the fridge. She said that she felt defenseless because her wheelchair is slow and did not know what to do.On 2/3/26 at 2:55 P.M., an onsite visit was conducted to investigate a Facility Reported Incident (FRI) alleging CNA 1 was aggressive to Resident 1 because she did not say Hi to him when she asked CNA 1 to get something from the refrigerator for her.A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia (a form of paralysis that causes the loss of movement and feeling in all four limbs and the torso) due to motor vehicle accident.A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/30/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On 2/3/26 at 3:19 P.M., an interview was conducted with Resident 1while in the dining hall. Resident 2, who was a witness to the incident on 1/6/26, was also present. Resident 1 was asked about the incident that involved CNA 1 on 1/6/26. Resident 1 stated she asked CNA 1 to get a food item out of the fridge, but CNA 1 told her, Are you gonna say hi to me if you want something from me? Resident 1 stated it was her first encounter with CNA 1. Resident 1 stated she was confused by his reply. CNA 1 then repeated in an angry manner, Are you gonna say hi to me if you want something from me? Resident 1 stated she was still confused but also thought that maybe he was joking. Resident 1 then told CNA 1, I don't have to say hi to you if I don't want to. Resident 1 stated CNA 1 was coming out of the nurse's station walking toward the refrigerator at which point he turned around and yelled, If you don't say hi to me, you're not getting anything from me! Now you have to call your [assigned] CNA! Resident 1 stated CNA 1 charged toward her with his chest out and aggressive arm movements. Resident 1 stated CNA 1 charged toward her in a manner that looked like he wanted to physically fight her. Resident 1 stated she was scared when CNA 1 was verbally and physically aggressive and charging toward her with his threatening posture because her electric wheelchair moved slowly. Resident 1 stated she was worried she could not get away from him fast enough. CNA 1 then walked back into the nurse's station without getting what she requested out of the refrigerator. Resident 1 called for help and told CNA 2 and CN 1 what had happened. Resident 1 stated that she told CNA 2 and CN 1 that she was scared and did not feel safe with the way CNA 1 behaved toward her. Resident 2 stated that she witnessed the incident on 1/6/26 and that was what happened.A review of Resident 1's Interdisciplinary Progress Notes after the incident on 1/6/26 indicated:1/6/26 at 11:15 P.M., .Resident appeared to be in emotional distress at the time of incident.1/7/26 at 10:03 P.M., .Resident just verbalized that she still couldn't believe the incident from yesterday occurred.1/8/26 at 1:45 P.M., Therapist made two attempts before lunch and after lunch to speak with resident and assess psychosocial wellbeing, however both times resident was sleeping and did not respond to knock at door or calling out of name.1/8/26 at 7 P.M., .Resident was upset regarding the [facility's] action and verbalized that she will be reporting to Police and Ombudsman tomorrow. Resident stated that she's not safe with alleged PM CNA staff [CNA1]. 1/8/26 at 11:03 P.M., Resident still verbalized feeling upset r/t incident with staff.1/9/26 at 1:33 P.M. Resident refused to get OOB [out of bed]. Resident told CNA that she doesn't want to talk to anyone today.1/9/26 at 1:38 P.M. Attempted multiple times to talk with resident regarding grievances reported on PM shift, she declines to talk.1/9/26 at 10:40 P.M. Tried to talk to resident to follow up on alleged abuse but resident declined.1/9/26 at 11:05 P.M.resident declined to talk about it anymore when asked.1/10/26 at 10:27 P.M.Resident stayed in her room all shift and did not get up.A review of Social Work Progress Note dated 1/12/26, indicated, .The resident states she does not feel safe with the staff [CNA 1] from the SOC 341 being around her. The resident states she feels unsafe as she feel[sic] the alleged individual could lose their temper at any time not only with herself but other residents.A review of Resident 1's psychotherapy note dated 1/14/26, indicated, .The resident appeared disheveled. reported a recent interaction with a male CNA that elicited feelings of unsafety and a sense of being frozen during the incident. Subsequently, the resident endorsed spending three consecutive days in bed, primarily sleeping, citing significant fatigue.stating avoidance of social interaction to prevent retraumatization.The resident.agreed to continue working on reducing immobilization responses associated with fear.A review of facility's staff assignment for 1/6/26 through 1/13/26, indicated CNA 1 provided resident care on 1/7/26 on Unit A and on 1/8/26 on Unit B during the PM shift (3 P.M. to 11:30 P.M.).A review of facility's census for Unit A and B combined on 1/7/26 and 1/8/26 indicated a total census of 63 residents.On 2/4/26 at 4:20 P.M., a follow up interview was conducted with Resident 1 while inside the resident's room. Resident 1 stated a few minutes after the incident on 1/6/26, three nursing supervisors approached her and asked her if she would be willing to meet with CNA 1 to discuss the incident. Resident 1 stated she refused and told the nursing supervisors that she was too scared of CNA 1 to meet and talk with him. Resident 1 further stated she was worried about other residents, especially the more vulnerable ones, those who could not speak for themselves, and those who could become agitated through interactions with CNA 1 because of their psychiatric conditions. Resident 1 stated she stayed in bed for the next few days after the incident because she felt closed off and put shells around herself due to the incident. Resident 1 stated she refused to keep talking about the incident with staff because she did not want to be re-traumatized by thinking of or talking about it.On 2/10/26 at 12:14 P.M., an interview was conducted with DSD 1 and DSD 2. DSD 1 and DSD 2 stated the incident between Resident 1 and CNA 1 on 1/6/26 was emotional abuse and should have been addressed immediately. DSD 1 stated when Resident 1 told CNA 2 and CN 1 about the incident with CNA 1 on 1/6/26, they should have filled out the SOC 341 immediately and reported this incident to CDPH. DSD 1 stated the facility's investigation should have started immediately and should not have been delayed.On 2/10/26 at 4:23 P.M., a follow-up interview was conducted with CN 1. CN 1 stated what Resident 1 reported to her on 1/6/26 was verbal abuse. CN 1 stated she should have reported this immediately to the administrator, CDPH, and the police.On 2/24/26 at 1:39 P.M., an interview was conducted with the ADM who was also the abuse coordinator. The ADM stated according to the nursing supervisors, Resident 1 did not mention that the incident was abuse. The ADM stated she only interviewed CNA 1 regarding the incident that occurred on 1/6/26. The ADM stated she did not interview Resident 1. The ADM stated she spoke to nurse supervisors about the incident on 1/6/26 and they did not tell her that this was an abuse allegation. The ADM stated she would not consider this incident abuse. The ADM stated Resident 1 chose to file an internal complaint/grievance over asking the facility to report the incident to CDPH. The ADM stated she was not told by the nurse supervisors that Resident 1 was scared of CNA 1. The ADM stated no one reported to her that Resident 1 had experienced emotional distress.On 2/24/26 at 3:40 P.M., an interview with CNA 2 was conducted. CNA 2 was asked how she became aware Resident 1 needed help on 1/6/26. CNA 2 stated she heard Resident 1 screaming her name, which prompted her to run out of a resident's room. CNA 2 stated Resident 1 then told her [CNA 2], stay here, stay here, don't leave, and observed the resident's body was tense and shaking. CNA 2 explained that Resident 1 reported asking CNA 1 for food from the refrigerator. CNA 2 stated Resident 1 told her that CNA 1 said, Are you gonna say hi to me if you want something from me? while raising his voice. CNA 2 stated Resident 1 told her that when she did not say hi to CNA 1, his demeaner quickly changed. CNA 2 stated Resident 1 told her CNA 1's body language was intimidating and threatening. CNA 2 stated Resident 1 told her she felt fatigued, had refused to get up, and did not socialize after the incident. CNA 2 stated what happened to Resident 1 on 1/6/26 was abuse. CNA 2 stated she thought the nurse supervisors and the CN 1 who responded to the incident on 1/6/26 had appropriately reported the abuse allegation to the ADM. CNA 2 stated if she had known that the facility was not treating the incident as an abuse allegation, she would have said something about it sooner.On 2/25/26 at 8:06 A.M., an interview with NS 1 was conducted. NS 1 stated she reported the incident that occurred between CNA 1 and Resident 1 to the ADM on speaker phone in the unit's medication room. NS 1 stated NS 4 and CN 1 were also present during the call. NS 1 stated she reported to the ADM what CNA 1 told her had happened. NS 1 stated CNA 1 went to get food for the resident and asked the resident her name. NS 1 stated CNA 1 told her Resident 1 replied to him that she did not have to tell him her name. NS 1 stated she reported to the ADM that CNA 1 did not engage in physical contact or raise his voice at Resident 1. NS 1 stated she did not tell the ADM Resident 1's statement of the incident. NS 1 stated she could not remember what Resident 1 told her. On 2/25/26 at 4:08 P.M., an interview was conducted with Social Worker (SW) 1. SW 1 stated what Resident 1 experienced with CNA 1 on 1/6/26 caused emotional and psychosocial distress.A review of facility policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, indicated, I. POLICY.All [Facility] employees, contracted workers and volunteers are mandated reporters.It is the Policy of [Facility] to: Assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42CFR 483.12(c), .and other relevant laws, of known or suspected abuse and/or criminal activity directed against [Facility] residents. Provide assistance to [Facility] staff in carrying out this responsibility. The facility will facilitate the making of group reports, but will in no way impede an individual from making an individual report in compliance with the law. Respond to concerns about abuse and investigate them thoroughly with a resident-centered approach that includes assessment.III PROCEDURES.A. ensure that effective measures are put in place to ensure that further potential abuse.does not occur while the investigation is in process.C. External Reporting.c. Time Frames Required: ii. For all abuse.report to law enforcement ([local] Sheriff) by phone immediately.Then fax the SOC341 form to the Ombudsman and to CDPH.This shall be accomplished within 2 hours of the observation or report of the act.reporting withing a 24-hour window may be permitted.D. Internal Reporting.a. Evidence of, suspicion of, or witnessed or suspected abuse or criminal activity must be reported to the Administrator.supervisory Nurse.e.ii. When staff are accused.the employee may be moved to another assignment or department if it is determined that there is risk to residents. The staff member.generally should not have contact with the resident during the period in which the alleged abuse is being investigated.F. Documentation a. The employee who witnesses or hears about the abuse completes the Abuse Report of Suspected Dependent Adult Elder Abuse Form SOC341/SOC-341/SOC 341 with as much information as possible.J. Prevention and Identification.c. Identification, Tracking, & Trending: . staff are educated on how to identify .behavior which may indicate potential abuse.(i.e. increased fearfulness.).This policy was not implemented.

Findings:On 1/9/26, the state agency (California Department of Public Health, CDPH) received a faxed SOC 341 (standardized abuse reporting form) from the facility dated 1/9/26. The SOC 341 indicated the facility was reporting an incident of psychological/mental abuse and verbal aggression that allegedly occurred between CNA 1 and Resident 1 on 1/8/26 7:00 PM. The SOC 341 further indicated, .On 10/6/26 [sic] resident reported to the charge nurse that [CNA 1] was aggressive to her because she did not say Hi to him when she asked him to get something from the fridge. She said that she felt defenseless because her wheelchair is slow and did not know what to do.On 2/3/26 at 2:55 P.M., an onsite visit was conducted to investigate a Facility Reported Incident (FRI) alleging CNA 1 was aggressive to Resident 1 because she did not say Hi to him when she asked CNA 1 to get something from the refrigerator for her.A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia (a form of paralysis that causes the loss of movement and feeling in all four limbs and the torso) due to motor vehicle accident.A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/30/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On 2/3/26 at 3:19 P.M., an interview was conducted with Resident 1while in the dining hall. Resident 2, who was a witness to the incident on 1/6/26, was also present. Resident 1 was asked about the incident that involved CNA 1 on 1/6/26. Resident 1 stated she asked CNA 1 to get a food item out of the fridge, but CNA 1 told her, Are you gonna say hi to me if you want something from me? Resident 1 stated it was her first encounter with CNA 1. Resident 1 stated she was confused by his reply. CNA 1 then repeated in an angry manner, Are you gonna say hi to me if you want something from me? Resident 1 stated she was still confused but also thought that maybe he was joking. Resident 1 then told CNA 1, I don't have to say hi to you if I don't want to. Resident 1 stated CNA 1 was coming out of the nurse's station walking toward the refrigerator at which point he turned around and yelled, If you don't say hi to me, you're not getting anything from me! Now you have to call your [assigned] CNA! Resident 1 stated CNA 1 charged toward her with his chest out and aggressive arm movements. Resident 1 stated CNA 1 charged toward her in a manner that looked like he wanted to physically fight her. Resident 1 stated she was scared when CNA 1 was verbally and physically aggressive and charging toward her with his threatening posture because her electric wheelchair moved slowly. Resident 1 stated she was worried she could not get away from him fast enough. CNA 1 then walked back into the nurse's station without getting what she requested out of the refrigerator. Resident 1 called for help and told CNA 2 and CN 1 what had happened. Resident 1 stated that she told CNA 2 and CN 1 that she was scared and did not feel safe with the way CNA 1 behaved toward her. Resident 2 stated that she witnessed the incident on 1/6/26 and that was what happened.On 2/4/26 at 3:41 P.M., an interview with CN 1 was conducted. CN 1 stated CNA 1 was floated to Resident 1's unit around 7:30 P.M. on the day the incident happened (1/6/26). CN 1 stated CNA 1 was assigned to answer call lights while other CNAs and staff were making rounds. CN 1 stated this resulted in no other staff being present in the dining hall and nurse's station at the time of the incident which happened around 8:20 P.M. When the incident happened, CN 1 stated, she was called to the dining room where she saw Resident 1 and Resident 2 sitting close to each other. CN 1 stated Resident 1 was, very shaken about it, shaking and visibly in distress. CN 1 stated Resident 1 told her she was scared. CN 1 stated Resident 1 told her, Don't leave me here with him [CNA 1], he's there.On 2/10/26 at 4:23 P.M., a follow-up interview was conducted with CN 1. CN 1 stated what Resident 1 reported to her on 1/6/26 was verbal abuse. CN 1 stated she should have reported this immediately to the administrator, CDPH, and the police.On 2/24/26 at 1:39 P.M., an interview was conducted with the ADM who was also the abuse coordinator. The ADM stated according to the nursing supervisors, Resident 1 did not mention that the incident was abuse. The ADM stated she only interviewed CNA 1 regarding the incident that occurred on 1/6/26. The ADM stated she did not interview Resident 1. The ADM stated she spoke to nurse supervisors about the incident on 1/6/26 and they did not tell her that this was an abuse allegation. The ADM stated she would not consider this incident abuse. The ADM stated Resident 1 chose to file an internal complaint/grievance over asking the facility to report the incident to CDPH. The ADM stated she was not told by the nurse supervisors that Resident 1 was scared of CNA 1.On 2/24/26 at 3:40 P.M., a follow up interview with CNA 2 was conducted. CNA 2 stated she heard Resident 1 screaming her name, which prompted her to run out of a resident's room. CNA 2 stated Resident 1 then told her [CNA 2], stay here, stay here, don't leave, and observed the resident's body was tense and shaking. CNA 2 explained that Resident 1 reported asking CNA 1 for food from the refrigerator. CNA 2 stated Resident 1 told her that CNA 1 said, Are you gonna say hi to me if you want something from me? while raising his voice. CNA 2 stated Resident 1 told her that when she did not say hi to CNA 1, his demeaner quickly changed. CNA 2 stated Resident 1 told her CNA 1's body language was intimidating and threatening. CNA 2 stated Resident 1 told her she felt fatigued, had refused to get up, and did not socialize after the incident. CNA 2 stated what happened to Resident 1 on 1/6/26 was abuse. CNA 2 stated she thought the nurse supervisors and the CN 1 who responded to the incident on 1/6/26 had appropriately reported the abuse allegation to the ADM. CNA 2 stated if she had known that the facility was not treating the incident as an abuse allegation, she would have said something about it sooner.On 2/25/26 at 8:06 A.M., an interview with Nursing Supervisor (NS) 1 was conducted. NS 1 stated she reported the incident that occurred between CNA 1 and Resident 1 to the ADM on speaker phone in the unit's medication room. NS 1 stated NS 4 and CN 1 were also present during the call. NS 1 stated she reported to the ADM what CNA 1 told her had happened. NS 1 stated CNA 1 went to get food for the resident and asked the resident her name. NS 1 stated CNA 1 told her Resident 1 replied to him that she did not have to tell him her name. NS 1 stated she reported to the ADM that CNA 1 did not engage in physical contact or raise his voice at Resident 1. NS 1 stated she did not tell the ADM Resident 1's statement of the incident. NS 1 stated she could not remember what Resident 1 told her. A review of facility's staff assignment for 1/6/26 through 1/13/26, indicated CNA 1 provided resident care on 1/7/26 on Unit A and on 1/8/26 on Unit B during the PM shift (3 P.M. to 11:30 P.M.).A review of facility's census for Unit A and B combined on 1/7/26 and 1/8/26 indicated a total census of 63 residents.A review of the State Operations Manual revised 7/23/25, indicated, .In response to allegation of abuse.the facility must.Prevent further potential abuse.during the investigation.thoroughly collect evidence to allow the Administrator determine what actions are necessary .for the protection of residents.A review of facility policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, indicated, I. POLICY.Respond to concerns about abuse and investigate them thoroughly with a resident-centered approach that includes assessment.III PROCEDURES.A. ensure that effective measures are put in place to ensure that further potential abuse.does not occur while the investigation is in process.D. Internal Reporting.a. Evidence of, suspicion of, or witnessed or suspected abuse or criminal activity must be reported to the Administrator.supervisory Nurse.e.ii. When staff are accused.the employee may be moved to another assignment or department if it is determined that there is risk to residents.F. Documentation a. The employee who witnesses or hears about the abuse completes the Abuse Report of Suspected Dependent Adult Elder Abuse Form SOC341/SOC-341/SOC 341 with as much information as possible.J. Prevention and Identification.c. Identification, Tracking, & Trending: . staff are educated on how to identify .behavior which may indicate potential abuse.

Based on interview and record review, the facility failed to implement its written abuse policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, in accordance with required procedures and ensure that all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation was made when:1. Charge Nurse (CN) 1 and Certified Nursing Assistant (CNA) 2 failed to report the incident between CNA 1 and Resident 1 as an allegation of abuse to the facility's administrator.2. The facility did not thoroughly investigate the allegation of abuse at the time of its report.As a result, this failure caused a delay in reporting the abuse allegation to the state agency (California Department of Public Health, CDPH) for three days.Cross reference F600, F609, and F610.Findings:On 1/9/26, CDPH received a faxed SOC 341 (standardized abuse reporting form) from the facility dated 1/9/26. The SOC 341 indicated the facility was reporting an incident of psychological/mental abuse and verbal aggression that allegedly occurred between CNA 1 and Resident 1 on 1/8/26 7:00 PM. The SOC 341 further indicated, .On 10/6/26 [sic] resident reported to the charge nurse that [CNA 1] was aggressive to her because she did not say Hi to him when she asked him to get something from the fridge. She said that she felt defenseless because her wheelchair is slow and did not know what to do.On 2/3/26 at 2:55 P.M., an onsite visit was conducted to investigate a Facility Reported Incident (FRI) alleging CNA 1 was aggressive to Resident 1 because she did not say Hi to him when she asked CNA 1 to get something from the refrigerator for her.A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia (a form of paralysis that causes the loss of movement and feeling in all four limbs and the torso) due to motor vehicle accident.A review of Resident 1's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) dated 12/30/25, indicated the resident's BIMS (Brief Interview for Mental Status) was 15 out of 15, indicating the resident was cognitively intact (no memory, focus, or judgment issues).On 2/3/26 at 3:19 P.M., an interview was conducted with Resident 1while in the dining hall. Resident 2, who was a witness to the incident on 1/6/26, was also present. Resident 1 was asked about the incident that involved CNA 1 on 1/6/26. Resident 1 stated she asked CNA 1 to get a food item out of the fridge, but CNA 1 told her, Are you gonna say hi to me if you want something from me? Resident 1 stated it was her first encounter with CNA 1. Resident 1 stated she was confused by his reply. CNA 1 then repeated in an angry manner, Are you gonna say hi to me if you want something from me? Resident 1 stated she was still confused but also thought that maybe he was joking. Resident 1 then told CNA 1, I don't have to say hi to you if I don't want to. Resident 1 stated CNA 1 was coming out of the nurse's station walking toward the refrigerator at which point he turned around and yelled, If you don't say hi to me, you're not getting anything from me! Now you have to call your [assigned] CNA! Resident 1 stated CNA 1 charged toward her with his chest out and aggressive arm movements. Resident 1 stated CNA 1 charged toward her in a manner that looked like he wanted to physically fight her. Resident 1 stated she was scared when CNA 1 was verbally and physically aggressive and charging toward her with his threatening posture because her electric wheelchair moved slowly. Resident 1 stated she was worried she could not get away from him fast enough. CNA 1 then walked back into the nurse's station without getting what she requested out of the refrigerator. Resident 1 called for help and told CNA 2 and CN 1 what had happened. Resident 1 stated that she told CNA 2 and CN 1 that she was scared and did not feel safe with the way CNA 1 behaved toward her. Resident 2 stated that she witnessed the incident on 1/6/26 and that was what happened.On 2/4/26 at 3:41 P.M., an interview with CN 1 was conducted. CN 1 stated CNA 1 was floated to Resident 1's unit around 7:30 P.M. on the day the incident happened (1/6/26). CN 1 stated CNA 1 was assigned to answer call lights while other CNAs and staff were making rounds. CN 1 stated this resulted in no other staff being present in the dining hall and nurse's station at the time of the incident which happened around 8:20 P.M. When the incident happened, CN 1 stated, she was called to the dining room where she saw Resident 1 and Resident 2 sitting close to each other. CN 1 stated Resident 1 was, very shaken about it, shaking and visibly in distress. CN 1 stated Resident 1 told her she was scared. CN 1 stated Resident 1 told her, Don't leave me here with him [CNA 1], he's there.On 2/10/26 at 12:14 P.M., an interview was conducted with Director of Staff Development (DSD) 1 and DSD 2. DSD 1 and DSD 2 stated the incident between Resident 1 and CNA 1 on 1/6/26 was emotional abuse and should have been addressed immediately. DSD 1 stated when Resident 1 told CNA 2 and CN 1 about the incident with CNA 1 on 1/6/26, they should have filled out the SOC 341 immediately and reported this incident to CDPH. DSD 1 stated the facility's investigation should have started immediately and should not have been delayed.On 2/10/26 at 4:23 P.M., a follow-up interview was conducted with CN 1. CN 1 stated what Resident 1 reported to her on 1/6/26 was verbal abuse. CN 1 stated she should have reported this immediately to the administrator, CDPH, and the police.On 2/24/26 at 3:40 P.M., an interview with CNA 2 was conducted. CNA 2 stated she heard Resident 1 screaming her name, which prompted her to run out of a resident's room. CNA 2 stated Resident 1 then told her [CNA 2], stay here, stay here, don't leave, and observed the resident's body was tense and shaking. CNA 2 explained that Resident 1 reported asking CNA 1 for food from the refrigerator. CNA 2 stated Resident 1 told her that CNA 1 said, Are you gonna say hi to me if you want something from me? while raising his voice. CNA 2 stated Resident 1 told her that when she did not say hi to CNA 1, his demeaner quickly changed. CNA 2 stated Resident 1 told her CNA 1's body language was intimidating and threatening. CNA 2 stated Resident 1 told her she felt fatigued, had refused to get up, and did not socialize after the incident. CNA 2 stated what happened to Resident 1 on 1/6/26 was abuse. CNA 2 stated she thought the nurse supervisors and the CN 1 who responded to the incident on 1/6/26 had appropriately reported the abuse allegation to the ADM. CNA 2 stated if she had known that the facility was not treating the incident as an abuse allegation, she would have said something about it sooner.On 2/25/26 at 8:06 A.M., an interview with NS 1 was conducted. NS 1 stated she reported the incident that occurred between CNA 1 and Resident 1 to the ADM on speaker phone in the unit's medication room. NS 1 stated NS 4 and CN 1 were also present during the call. NS 1 stated she reported to the ADM what CNA 1 told her had happened. NS 1 stated CNA 1 went to get food for the resident and asked the resident her name. NS 1 stated CNA 1 told her Resident 1 replied to him that she did not have to tell him her name. NS 1 stated she reported to the ADM that CNA 1 did not engage in physical contact or raise his voice at Resident 1. NS 1 stated she did not tell the ADM Resident 1's statement of the incident. NS 1 stated she could not remember what Resident 1 told her. A review of facility policy titled Abuse and Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigation 300R, dated 1/30/2025, indicated, I. POLICY.All [Facility] employees, contracted workers and volunteers are mandated reporters.It is the Policy of [Facility] to: Assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42CFR 483.12(c), .and other relevant laws, of known or suspected abuse and/or criminal activity directed against [Facility] residents. Provide assistance to [Facility] staff in carrying out this responsibility. The facility will facilitate the making of group reports, but will in no way impede an individual from making an individual report in compliance with the law. Respond to concerns about abuse and investigate them thoroughly with a resident-centered approach that includes assessment.C. External Reporting.c. Time Frames Required: ii. For all abuse.report to law enforcement ([local] Sheriff) by phone immediately.Then fax the SOC341 form to the Ombudsman and to CDPH.This shall be accomplished within 2 hours of the observation or report of the act.reporting withing a 24-hour window may be permitted.D. Internal Reporting.a. Evidence of, suspicion of, or witnessed or suspected abuse or criminal activity must be reported to the Administrator.supervisory Nurse.F. Documentation a. The employee who witnesses or hears about the abuse completes the Abuse Report of Suspected Dependent Adult Elder Abuse Form SOC341/SOC-341/SOC 341 with as much information as possible.K. Training All [Facility].staff are educated annually of their reporting obligations and the names and phone numbers of where to make a report.

Based on observation, interview, and record review, the kitchen failed to ensure safe food handling practices during tray line, of pureed diets (when food has been ground, and strained to a soft, smooth consistency, like a pudding), served to 16 of 157 residents. This failure had the potential for residents on pureed diets to experience foodborne illnesses. Findings: An observation of lunch puree diet preparation was conducted with [NAME] 1 (CK 1) on 12/3/25 at 8:30 A.M. CK 1 stated they had 16 residents receiving puree diets, but they prepare 18 servings for request of extra-large potions. The main entree for the day was pizza.An observation was conducted of Food Service Worker 2 (FSW 2) during lunch tray line on 12/3/25 at 12:05 P.M The pureed diet consisted of layered pureed crust, topped with pureed sausage and pepperoni, topped with a red sauce, and finished with white cheese sauce. FSW 2 was observed dipping a blue handle scoop into a red buck (a designated bucket which contains water and disinfectant solution), located on a shelve below the tray line table. FSW 2 then placed the wet blue handle scoop within the white cheese sauce and continued service for pureed diets. At the time of this observation, the tray line was filling the first of five food carts, starting with Santa [NAME].An interview was conducted with the Chief of Nutritional Services (CNS) and Registered Dietitian 1 (RD 1) on 12/3/25 at 3:25 P.M. The CNS and RD 1 were informed of the observations conducted during tray line. The CNS stated the scoop should have been allowed to dry before placing in the chess sauce to avoid contamination. The CNS left the room to ask FSW 2 if the scoop was placed in the red bucket and then placed in the chesses sauce. The CNS returned stating FSW 2 admitted to dipping the scoop in the red buck after rinsing it in water, because it dirty from food by the handle. FSW 2 stated she should have allowed the scoop to dry first and she did not. The CNS stated because the scoop was placed in the while cheese sauce after the red bucket, it had the potential for the white sauce to be contaminated, which could have made resident's receiving pureed diets ill from cross contamination. An interview was conducted with the Director of Nursing (DON) on 12/4/25 at 9:50 A.M. The DON stated she expected all food service workers to perform safe food handling practices, so resident did not become ill.Per the facility's Policy titled, Nutrition Services Infection Control, dated August 2024, .R. Service Standards: .i. During service and handling, employees shall avoid touching the food contact surfaces of dishes and serving utensils.w. Use convenient and suitable utensils such as forks, knives, spoons, scoops to handle food during preparation and service.

Based on observation, interview and record review, the facility failed to properly store and label Resident 54's pain medication. As a result, the facility could not ensure medications were safely stored.Findings:On 9/28/20 Resident 54 was admitted to the facility per the facility Records of Admission.On 5/8/25 Resident 54 had a physician order for Diclofenac gel to apply topically to both knees every shift routinely for pain.On 12/1/25 at 1:06 P.M., concurrent observation and interview were conducted with Resident 54, Resident 54 was in bed. There was an unlabeled, undated and unpackaged topical gel medication on top of Resident 54's bedside drawer. Resident 54 stated this was his topical pain medication for his shoulder and knee joints. Resident 54 stated he was supposed to administer the unlabeled, undated and unpackaged topical gel medication this morning after shower but he was in a hurry because his family was already here to pick him up. Resident 54 stated he just came back from an out on pass with his relative today and will administer the unlabeled, undated and unpackaged topical gel medication by himself now. Resident 54 stated either Resident 54 or a Licensed Nurse (LN) administer his medication.On 12/1/25 1:10 P.M., at a concurrent observation and interview were conducted with LN 8 and Resident 54. LN 8 stated she did not leave the unlabeled, undated and unpackage medication at Resident 54's bedside.On 12/1/25 at 1:17 P.M., an concurrent observation and interview were conducted with LN 9 and Resident 54. LN 9 stated she was supposed to administer the unlabeled, undated and unpackaged topical gel medication after Resident 54's shower this morning. LN 9 stated she should not leave the unlabeled, undated and unpackaged topical gel medication at Resident 54's bedside. LN 9 stated the unlabeled, undated and unpackaged topical gel medication was Resident 54's diclofenac topical gel.On 12/3/25 at 10: 56 A.M., an interview was conducted with LN 10. LN 10 stated LN s should not leave medications at bedside for safety and another resident might take it.ON 12/4/25 at 2:26 P.M., an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) was conducted. The DON stated LNs should not leave medications at bedside for safety. The ADON stated LNs should not leave medications at bedside because it could pick up by another resident. According to the facility policy entitled Self-Administered Medications, dated 5/22/2024, indicated .No medications is to be stored at resident's bedside, without a physician 's order.

Based on observation, interview, and record review, the facility failed to prevent possible cross contamination (where microorganisms are unintentionslly transferred from one object to another) when a urinary catheter (a bag that contained urine which is draining from the bladder via a tube) was in contact with the floor for one of seven residents (Resident 159), reviewed for urinary catheter care.This failure had the potential for Resident 159 to obtain a transmitted urinary infection from the dirty floor.Findings:An observation was conducted during initial tour of Resident 159, asleep in his room on 12/1/2025 at 9:50 A.M. Resident 159 had a urinary collection bag, clipped to the left side of the bed, with a blue/black dignity bag covering the collection bag. The dignity bag was in contact with the floor. An observation and interview was conducted with Licensed Nurse 3 (LN 3), of Resident 159 on 12/1/25 at 9:51 A.M. LN 3 observed the urinary collection bag and stated the bag should not be on the floor, because the floor was dirty and bacteria could travel up to the catheter, causing an infection. Resident 159'2 clinical record was reviewed on 12/1/25. Resident 159 was admitted on [DATE] with a urinary catheter, due to malignant neoplasm of the bladder (cancer of the bladder), per the facility's Record of Admission. An observation was conducted of Resident 159 in bed on 12/2/25 at 2:59 P.M. Resident 159 was awake sitting up in bed with the bed in a low position and a wheelchair next to the bed. The urine collection bag and the dignity bag was on the left side of the bed. The dignity bag was in contact with the floor, leaning sideways.An observation and interview of Resident 159's urinary collection bag was conducted with certified nursing assistant (CNA 1) on 12/2/25 at 3:01 A.M. CNA 1 stated Resident 159's urinary collection bag should not be on the floor, because the floor was dirty and could cause an infection to the resident. An interview was conducted with Infection Control Preventionist (ICP) on 12/3/25 at 4:18 P.M. The ICP stated urinary collection bags should never touch the floor, because the floors were dirty and it could cause cross contamination. An interview was conducted with the Director of Nursing (DON) on 12/4/25 at 9:50 A.M. The DON stated urinary collection bags and the tubing should never be in contact with the floor.According to the facility's policy, titled Catheter Indwelling Care, dated November 2024, .D. Licensed nurses utilize best practices as outlined in the CDC references including: .h. Keeping bags below the level of the bladder, but not on the floor.

Based on observation, interview, and record review, the facility failed to ensure food brought in from the outside and stored in the designated resident refrigerator was discarded in a timely manner, for two of five resident refrigerators (Santa [NAME] and [NAME]), when reviewed for safe food storage,This failure had the potential for resident's personal food to be unsafe if consumed after the expiration date.Findings:1. An observation was conducted of the resident refrigerator in Sanat [NAME] on 12/4/5 at 9:02 A.M. Inside the refrigerator on the bottom shelf was a white plastic grocery bag which was labeled with Resident 114's name. Inside the grocery bag, was a store-bought container of sour cream and shredded cheese. Also inside the grocery bag was an opened, but sealed clear plastic bag of flour tortillas.All the products were labeled with Resident 114's name and each had a different discard date. The package of flour tortillas contained a sticker with a discard date of 12/3/25.An observation, interview, and record review was conducted with Licensed Nurse 1 (LN 1), of the resident refrigerator on 12/4/25 at 9:07 A.M. LN 1 stated the nurses on the day shift (7 A.M. through 3:30 P.M.) were responsible for checking and documenting the temperature within the refrigerators. LN 1 stated the nurses on the previous night shift (11 P.M. through 7:30 A.M.) were responsible for inspecting and discarding foods labeled with discard dates and documenting the inspection was completed. LN 1 reviewed the refrigerator log and confirmed it was checked and signed off last night, and all the old food had been discarded. LN 1 viewed the package of tortillas with the discard date of 12/3/25, and stated, those should have been thrown away. LN 1 stated if the resident ingested the tortillas, they could get sick because the tortillas were old. 2. An observation was conducted of the resident refrigerator in [NAME] on 12/4/25 at 9:30 A.M. The temperature log clipped to the outside refrigerator was reviewed. The temperature had not yet been documented for the morning of 12/4/25, and the food checked for discarding had been initialed by the night staff for 12/3/25 through 12/4/25. The refrigerator section was unlocked. Inside the door was a clear plastic cup with a clear plastic straw, which appeared half consumed of a dark brown substance. The cup was labeled as Vietnamese coffee with a preparation date of 11/29/25. The cup was inside a clear sealed plastic zip lock bag, labeled with Resident 24's name and a discard date of 12/2/25. An observation, interview, and record review of the resident refrigerator was conducted with LN 2 on 12/4/25 at 9:38 A.M. LN 2 stated all refrigerators should be locked when not in use, to prevent other residents from accessing. LN 2 reviewed the temperature log and stated the temperature on the refrigerator had not been checked yet, but the food had been inspected last night by the night shift and signed off. LN 2 review the clear plastic bag that contained the 1/2 consumed Vietnamese coffee. LN 2 stated the coffee should have been discarded on 12/2/25, since the discard label indicated 12/2/25. LN 2 stated resident food was only stored for 48 hours and then thrown away, in order to prevent residents from becoming ill.An interview was conducted with the Director of Nursing (DON) on 12/4/25 at 9:50 A.M. The DON stated all resident food brought in from the outside needed to be discarded after 48 hours, in order to prevent residents from getting a foodborne illness.An interview was conducted with Chief Nutritional Services (CNS) regarding the resident refrigerators on 12/4/25 at 10:30 A.M. The CNS stated resident refrigerators should always be locked when not in use, to prevent unauthorized personas from accessing. The CNS stated it was important for staff to check the refrigerator temperature to ensure the food was safe to consume and stored properly. The CNS stated resident food brought in from the outside should always be discarded after 48 hours, in order to ensure the food was safe and did not contain any bacteria that could make the resident's sick.According to facility's policy, titled Outside Personal Food Storage-Reheating, dated August 2024, .Procedures:.D. After inspection, the nursing staff will label food items with the resident's name, date and time stored and expiration date.G. Personal food is visually inspected for any signs of spoilage, infestation, and expired or best buy dates.Food maybe discarded without notice to resdietn if it is past the expiration date, best buy date, or if there are signed of spoilage.

Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) reviewed for feeding assistance and weight loss was supervised during meals. This failure placed Resident 1 at risk for aspiration (inhaling food particles into the lungs), choking, and weight loss. Findings: During a record review on 1/16/25, Resident 1 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) following cerebral infarction (stroke). During a record review on 1/16/25,the Minimum Data Set (MDS, an assessment tool) dated 11/20/24 indicated, Resident 1 had a BIMS (a tool to measure cognition) of 13, which indicated intact cognition. A review of the Interdisciplinary Progress Notes indicated on 11/20/24, At 8:30Am [sic], staff witnessed resident is coughing and started turning red. One staff went to notify the RN and another help [sic] resident with back thrust and encouraged him to cough, resident cleared his throat with cough and little tap on his back. Nothing had visibly come out but looked like resident chew [sic] food and swallow it again . A review of the In-House Referral dated 11/20/24 indicated, CONSULTANT'S COMMENTS: 11/20/24 Resident seen during skilled ST [Speech Therapy] session to discuss this episode of choking. Resident reported that he was eating quickly [and] taking larger bites of his eggs and a piece of egg went towards airway, causing expressive coughing . on 1/16/24 a review of the Interdisciplinary Progress Notes (IPN) was conducted. The IPN dated 12/18/24 at 2:26 P.M. indicated, Resident noted to have episode of choking during lunch time with [NAME] [sic] pasta and ground meat, noted with coughing and turning so red. Heimlich maneuver done and got relief . A review of Resident 1's Plan of Care effective 12/18/24 indicated At risk for choking/aspiration .with re-current choking episode during lunch time . The interventions indication, Follow Eating safe strategy at [facility's name] per facility policy .Do 1:1 supervision (one staff member dedicated to sit with/supervise the resident) during meals. On 1/16/25 at 12:54 P.M., an interview was conducted with Restorative Nursing Assistant (RNA) 1. RNA 1 stated Resident 1 is able to feed himself, and staff does not sit with Resident 1 during meals. RNA 1 stated, .we just watch him sometimes. He eats fast, he needs to slow down. Sometimes he coughs, but nobody sits with him. As far as I know nobody watches him during meals . On 1/16/25 at 1:08 P.M , an observation was conducted in the dining room during lunch. Resident 1 was sitting at a table with his lunch, by himself. Resident 1 picked up a spoon and took a bite of food. During an observation in the dining room on 1/16/25 at 1:23 P.M., Licensed Nurse (LN) 1 sat next to Resident 1, picked up a spoon and fed Resident 1 a bite of food. On 1/17/25 at 10:06 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 2. LN 2 stated .there's always a licensed nurse present during meals. Someone watches [Resident 1] but doesn't sit with him. We just do spot checks because he has episodes of choking. He tends to eat fast and cough . LN 2 stated she was unaware of Resident 1's care plan to have 1:1 supervision during meals. On 1/21/25 at 9:38 A.M., a telephone interview was conducted with the Speech Language Pathologist (SLP). The SLP stated Resident 1 required 1:1 supervision during meals, due to dysphagia and a history of choking while eating without assistance. The SLP stated, .he tends to eat fast. He has limited upper extremity movements and does require feeding assistance . The SLP stated Resident 1 was at risk for further choking because, .he doesn't want to comply with the diet orders [for mince and moist diet with mildly thickened liquids] .he enjoys .cookies, but doesn't have the lingual coordination or oral coordination to swallow it safely. The SLP stated Resident 1 required 1:1 supervision so staff could watch him eat, and to provide verbal cues when necessary. The SLP stated, From what I see with him I agree, someone should sit with him [during meals]. On 2/3/25 at 5:09 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation for Resident 84 to receive 1:1 supervision if it was indicated in the care plan. The DON stated, .We have to be compliant on what the resident needs. Safety is our priority, so if the resident is 1:1 [supervision] he should be 1:1 [supervision] . A review of the facility's policy titled Assisting Residents With Eating/Dining/Feeding Techniques dated 10/19/23 indicated, .h. Trays are not placed in front of a resident who requires feeding help until help is available .l. Watch swallowing to determine if one bite is swallowed prior to offering another .m. Stop/slow down feeding if resident is having difficulty swallowing/coughing .

Based on observation, interviews, and record review, the facility failed to identify an injury of unknown origin as possible abuse for one resident (Resident 1), and failed to report the allegation of abuse to the California Department of Public Health. As a result, the facility failed to initiate their abuse policy and procedure related to an injury of unknown origin and placed Resident 1 at risk for further abuse. This failure also placed other residents at risk for abuse and delayed the abuse investigation proces. Findings: Resident 1's record was reviewed. The Record of Admission indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer ' s disease (a disease which destroys memory and other important mental functions), vascular dementia with behavioral disturbance (a disorder that causes problems with personality and behavior), and hearing loss. According to Resident 1 ' s MDS (an assessment tool), her BIMS (used to assess cognition) indicated Resident 1 was rarely or never understood. On 8/15/24 at 10:32 A.M., a joint observation and interview was conducted in Resident 1 ' s bedroom. Resident 1 was observed laying on her back in bed. Resident 1 had dark purple discoloration surrounding her right eye. Certified Nursing Assistant (CNA) 1 stated staff thinks Resident 1 had a fall, which created the facial bruise, but nobody witnessed it. CNA 1 stated Resident 1 always wore her hair down and a large hat which covered her face. Resident 1 was wearing a black baseball cap, and her hair was down and there was bruising on her face visible from the doorway. CNA 1 was sitting in a chair at Resident 1 ' s bedside. CNA 1 stated she was assigned to stay with Resident 1 and was doing supervision with assistance . which meant always being with Resident 1. CNA 1 stated she is unsure how Resident 1 sustained the injury. CNA 1 stated .it ' s hard to take care of her . and Resident 1 is hard of hearing. CNA 1 stated Resident 1 had aggressive behaviors. She doesn ' t understand that we are only trying to help .[Resident 1] she walks facing down and won ' t let you touch her (Resident 1) and will push you or punch you . On 8/15/24 at 10:56 A.M., Resident 1 was observed waking up. Resident 1 was awake and stated, done here we are eating. Resident 1 said other words that were unintelligible. On 8/15/24 at 11 A.M., an interview was conducted with Licensed Nurse (LN). LN 1 stated on 8/3/24 around 8:30 A.M., Resident 1 was eating breakfast in the dining room. LN 1 stated CNA 2 noticed the bruise on Resident 1 ' s face, then informed LN 1. LN 1 stated staff was not certain when Resident 1 was injured because it was often difficult to see her face. LN 1 stated Resident 1 always wore her hair down and a large hat which covered her face. LN 1 stated Resident 1 had dementia and was unable to tell staff how she got the bruise. LN 1 stated when staff attempts to remove her hat to provide care, Resident 1 .gets aggressive and tries to hit staff . and .she screams and yells . LN 1 stated staff also found two dime sized bruises on Resident 1 ' s left forearm. LN 1 stated the cause of the bruises was unknown and stated .we have possible conclusions, but we really don ' t know how it happened .it was probably a fall, but we don ' t know for sure . LN 1 stated if a resident has an injury with an undetermined cause we would tell the administrator because it could be abuse. On 8/15/24 at 12:36 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated an in-service titled Abuse Reporting and Falls was given to staff after [Resident 1] had the bruise . The DSD stated the QA nurse reviewed the incident report and asked the DSD to provide the abuse in-service training based on the incident report. The DSD stated she considered the bruise to be possible abuse because they could not determine how Resident 1 acquired the bruise. The DSD further stated if you see an injury of unknown origin, it needs to be reported. The DSD stated if an injury of unknown origin is not reported their safety gets compromised .it ' s a serious offense . We are supposed to keep them (residents) safe. The DSD stated the facility did not report the injury and we did not keep them safe. The DSD stated the Administrator (Admin) was the facility ' s abuse coordinator. On 8/15/24 at 2:08 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the Interdisciplinary Team (IDT- team consisting of members from different disciplines) concluded, based on Resident 1 ' s history, that the resident had a .possible fall . The DON stated Resident 1 is a vulnerable resident with dementia. The DON stated, .people with dementia are more prone to be victimized .they cannot talk . The DON stated the possible fall was unwitnessed and the resident was not seen on the ground or assisted up from the ground by staff. On 8/15/24 at 2:32 P.M., an interview was conducted with the Administrator (ADM) via telephone. The ADM stated on 8/3/24, Resident 1 was sent to the Emergency Department for evaluation of the bruise. The ADM stated the ombudsman informed the facility that the hospital reported the bruise to the state agency. The ADM stated Resident 1 ' s bruise was not reported to the state agency by the facility. The ADM stated, police were not notified because it was reported by the hospital and .We did not deem it suspicious in nature for abuse reporting . A review of the Facility ' s undated reference document titled Injuries of Unknown Origin indicated, Bruises were more likely to indicate abuse when found in the following areas: Head/neck .Abusive bruising was often found on more than one plane of the body .both the inner and outer sides of the arm . Policy & Procedure titled Abuse & Criminal Activity Identification, Screening, Prevention, Response, Reporting and Investigating, dated 3/15/24, indicated, all (facility) employees and other workers will comply with mandated reporting requirements . and .it is the policy of (the facility) to assure that every staff member and contractor fully understands their responsibility, as mandated reporters under California law, 42 CFR 483.12

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. The ice machine had black debris inside the ice making parts of the tray and curtain. 2. Two (2) large onions in the refrigerator had mold on them. 3. Three (3) floor sinks had piping without an air gap of at least 1 (inch) between the pipe and drain. 4. Two (2) green cutting boards with deep cuts and food stains were stored in the clean area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Cross reference F802 Findings: 1. During the initial kitchen tour on 7/22/24 at 8:26 A.M. an observation and interview with the Chief of Nutrition Services (CNS) and the Plant Operations Director (POD) was conducted. A Surveyor wiped the inside of the ice machine bin walls with a white paper towel and there was black debris on the paper towel. The POD opened the ice machine cover and there was tannish pinkish colored debris inside the area of the ice machine water pan and curtain. The CNS acknowledged the discolored debris and stated the kitchen staff was responsible for cleaning the storage bin and the maintenance plant operations department was responsible for cleaning/sanitizing the ice-machine's ice making parts. The POD stated the maintenance/plant operations department staff clean and sanitize the ice machine quarterly but they do not remove the baffle or the ice machine water tray underneath the ice making grid during the cleaning procedure. The manufacturer's cleaning/sanitizing instructions indicated, .1. Turn off the electrical and water supply to the ice machine. 2. Remove all ice from the bin. 3. Remove the water curtain and the components you want to clean or sanitize. 4. Soak the removed part(s) in a properly mixed solution. 5. Use a soft-bristle brush or sponge (NOT a wire brush) to carefully clean the parts .6. Use the sanitizing solution and a sponge or cloth to sanitize (wipe) the interior of the ice machine and the entire inside of the bin/dispenser. 7. Thoroughly rinse all of the parts and surfaces with clear water. 8. Install the removed parts According to the 2022 Federal FDA Food Code section 4-602.11, Equipment Food-Contact Surfaces and Utensils. Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold .Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . A review of the facility's undated policy and procedure titled Ice Machine Maintenance indicated, .cleaning and sanitizing of all internal water contact areas of all ice machines which shall be performed in accordance with manufacturer's recommendation . 2. During the initial kitchen tour conducted on 7/22/24 at 9:40 A.M., two floor sink drains next to reach-in refrigerators were observed with the PVC (polyvinyl chloride) white pipes extending into the floor drains. Also, a copper pipe that extended from a walk-in refrigerator was observed directly into a floor sink drain. The CNS acknowledged the three pipes going into the floor sinks and stated they should not extend into the floor drain without an appropriate air gap. According to the 2022 Federal FDA Food Code, section 5-402.11(A), .A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment .are placed . A review of the facility policy titled Nutrition Services: Food Storage indicated, .Food storage areas will not be subject to sewage or wastewater backflow . 3. During the initial kitchen tour on 7/22/24 at 8:40 AM, an observation and interview was conducted with the CNS. A walk-in refrigerator containing produce was observed with an opened case of onions. One large onion was observed with a large moldy blackish-graying color on it. Another onion was observed with blackish grayish color on it. The CNS stated the staff usually checks the food deliveries received by the case. The CNS stated staff were assigned to check the produce every morning. The CNS stated, That one should've been pulled . and the onions were no longer good for consumption. According to the 2022 Federal Food Code, Annex 4 Table 2a, .Check condition at receiving; do not use moldy or decomposed food . A review of the facility's policy and procedure titled Nutrition Services: Food Procurement indicated, All fresh fruits and vegetables will be of good quality and freshness . 4. During a kitchen observation and interview on 7/22/24 at 2:55 P.M., a blue rubber cutting board was observed on the kitchen counter near the cold food prep area. The cutting board had multiple deep knife cuts and scratches. There were green colored stains visible inside the scratches and on the surface of the cutting board. The cutting board appeared to be in use by kitchen staff. There was a knife laying on the cutting board, with bits of food visible on the knife. On 7/23/24 at 9:30 A.M., an observation and interview was conducted with the Nutrition Services Supervisor (NSS) in the back of the kitchen. Two cutting boards, a blue and a green one, were observed on the clean storage shelf. The cutting boards had a large white discolored stain in the middle and several deep scratches on the surface, with green stains embedded in the scratches. The NSS stated the cutting boards were checked daily for wear, but the NSS stated the cutting board should be replaced. On 7/23/24 at 9:35 A.M., an interview was conducted with the CNS. The CNS stated his expectations were for the kitchen areas to be in compliance with standards of practice and the regulations. According to the 2022 Federal FDA Food Code, section 4-501.12, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . A review of the facility's policy titled Nutrition Service Infection Control dated 3/30/23 indicated, .Cutting boards are inspected for stains, excessive wear, and deep cuts. Cutting boards that are deemed a safety concern are discarded .

Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one of 32 residents (Resident 136) reviewed for call light accessibility. As a result, Resident 136 was not able to reach the call light to call for assistance in order for staff to address the resident's needs in a timely manner. Findings: Resident 136 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body), per a Record of Admission. During an interview with Resident 136 conducted on 7/23/24 at 8:36 A.M. inside the resident's room, Resident 136 stated he sometimes received help when he needed it, and sometimes he did not. Resident 136 stated he used the call light to ask for help. Resident 136 stated he needed assistance to set up meals, get cleaned, or get in the wheelchair. A concurrent observation and interview on 7/23/24 at 4:20 P.M. was conducted with Resident 136. Resident 136 was seen in his room sitting on a Broda chair (a specialized wheelchair) in front of the television out of reach from the call light. Resident 136 stated, They left the call light so far away that I can't call to ask for a drink. Resident 136 stated he also needed to be cleaned. Resident 136 stated he had been sitting in his current position for about 20 minutes. Inside Resident 136's room, a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 41 on 7/23/24 at 4:25 P.M. CNA 41 stated Resident 136's call light was on the bed, and the resident could not reach the call light. CNA 41 stated the call light should be within the resident's reach so the resident could call for help. On 7/24/24, a record review was conducted. Per a Minimum Data Set (MDS - a patient/resident assessment tool), dated 5/15/24, Resident 136 had a Brief Interview for Mental Status (BIMS, an assessment tool) score of 13, which indicated intact cognition. The MDS indicated Resident 136 was dependent on staff assistance for transfers into and out of bed, to use the bathroom, and for personal hygiene care. Resident 136's care plan, dated 3/20/23 indicated Resident 136 was total care (needed assistance with all care) and dependent in all tasks. The care plan indicated an intervention including, Be sure call light is within reach and respond promptly to all requests for assistance. During an interview with Licensed Nurse (LN) 43 on 7/24/24 at 3:15 P.M., LN 43 stated the importance of the call light was for the resident to be able to ask for help and for staff to provide the assistance needed. During an interview with the Assistant Director of Nursing (ADON) on 7/25/24 at 2:18 P.M., the ADON acknowledged the call light should be within the resident's reach in order for the resident to call for help and get assistance from staff. A review of the facility's policy titled, Call Lights and Ascom Nursing Call light and Mobile Device System, dated 2/8/24, indicated .e. CNA staff and other staff interacting with residents will check to assure the call lights are placed within easy reach of the resident in bed or a nearby chair

Based on observation, interview and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the Food and Nutrition Services department when: 1. A food services worker could not correctly operate the dishwashing machine. 2. A food services worker could not properly demonstrate how to calibrate a food thermometer. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen. Cross reference F812 Findings: 1. During the initial kitchen tour on 7/22/24 at 9:10 A.M., an observation and interview was conducted in the dishwashing room. Food Service Worker (FSW) 1 was at the dish machine station. FSW 1 stated the dish machine.Sanitizes the dishes and utensils. Surveyor asked FSW 1 to demonstrate how the kitchen staff ensures that the temperatures are accurate. The FSW 1 stated they use the, .Blue Screen on the wall- mounted digital controller on the wall to the left of the dish machine to verify accurate temperatures. FSW 1 proceeded to touch the screen, but the display did not read any change in temperatures. The buttons on the screen observed below and to the right of the screen indicated it was not a touch screen. During an observation and interview on 7/22/24 at 11:15 A.M. with the Chief of Nutrition Services (CNS), the CNS stated the dish machine sanitizer is tested using a test strip attached to a dish that goes through the machine. The CNS stated the test strip changes colors from light gray to dark gray to indicate it reached the correct sanitizer temperature of 160-165 (degrees) Fahrenheit (F) at the manifold. A review of the facility Job Description for Food Services Worker indicated the skills and abilities to include .Operate and maintain kitchen equipment in a safe and efficient manner According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: .(2) .180 F. A review of the facility policy titled Nutrition Services Infection Control indicated, .The dish machine is to be checked regularly throughout the day to ensure that the proper wash cycle temperature (150 F) and the proper rinse cycle temperature (180 F) are continuously maintained . 2. During a joint observation and interview on 7/22/24 at 12:35 P.M. with Food Services Worker (FSW) 2 and the Chief of Nutrition Services (CNS), the FSW 2 stated he used his own personal food thermometer to take food temperatures during food preparation. FSW 2 stated he does not use the facility's thermometer because he did not like the way it reads. The FSW 2 stated he did not know how to fully operate his thermometer but he has calibrated it before. FSW 2 further stated the battery in his thermometer was dead and therefore he was unable to demonstrate thermometer calibration. The FSW 2 stated he made the tuna salad earlier in the morning and used his own thermometer to take the temperature of the tuna salad. The CNS continued, stating the food thermometers provided to the kitchen staff several months ago were approved by the food and nutrition services department management for use in the kitchen. The CNS stated it was his expectation kitchen staff utilize the food thermometers provided by management and not their personal food thermometers. The CNS acknowledged it was important for staff to be trained on how to use the facility provided thermometers. The CNS further stated the kitchen staff were to avoid using personal food thermometers because they may not take accurate temperatures. A review of the Food Services Worker job description indicated Food Service Workers were expected to have, .Knowledge of: Safety practices as applied to food preparation and use of kitchen and cleaning equipment . According to the 2022 Federal FDA Food Code Annex 7-42, .Thermometers provide a means for assessing active managerial control of .food temperatures .Food thermometers must be calibrated at a frequency to ensure accuracy .

Based on observation, interview, and record review, the facility failed to ensure: 1. The Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBPs, an infection control intervention using protective gowns and gloves) were implemented for 26 of 29 residents, and, 2. A Licensed Nurse (LN 1) used appropriate Personal Protective Equipment (PPE - gloves, gown, masks and other equipment used to control the spread of infection) when administering tube feeding (a replacement food source, administered through a tube directly into the stomach or intestines) to Resident 88, whose room was posted as requiring EBP. These failures had the potential to result in the spread of Multiple Drug Resistant Organisms (MDROs, microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) throughout the facility. FINDINGS: 1. On 7/22/24 beginning at 8 A.M. observations were conducted of all nursing units. Of 156 residents, 29 residents were identified with indwelling medical devices, such as feeding tubes and urinary catheters (a tube used to empty the bladder and collect urine in a drainage bag). Of the 29 residents identified, 26 were not on EBP. During an interview on 7/22/24 at 1:45 P.M. with Supervisor Nurse (SN) 41, SN 41 stated not all residents met the EBP criteria. SN 41 stated the physician and the Infection Preventionist (IP) determined who will be placed on EBP. During an interview on 7/23/24 at 11 A.M. with Certified Nursing Assistant (CNA) 22, CNA 22 stated EBP meant a cabinet containing extra gowns and gloves would be placed outside of the resident room for staff to wear, but EBP was only for residents with COVID (a contagious disease). On 7/23/24 at 4:13 P.M., an interview with Licensed Nurse (LN) 11 was conducted outside Resident 106's room. LN 11 stated Resident 106 was not on EBP. Per LN 11, Resident 106 had recently been hospitalized , had an infection related to the feeding tube, and was on antibiotics (anti-infective medications). On 7/24/24 at 9 A.M., an interview with CNA 13 was conducted. CNA 13 stated the IP or charge nurse would place a sign by the resident's door if staff had to use PPE when providing resident care. On 7/24/24 at 11:08 A.M., an interview was conducted with LN 12. LN 12 stated the facility had a process using an assessment tool. Per LN 12, the assessment criteria for a resident to be placed in EBP included: returned from the hospital, had history of candida auris (fungal organism) or carbapenem resistant organism (an antibiotic-resistant infection), were hospitalized for a significant MDRO exposure and had a medical device. Per LN 12, the residents would have to meet the criteria before they were placed on EBP. During an interview on 7/24/24 at 2:47 P.M. with LN 43, LN 43 stated there were criteria that had to be met to place a resident on EBP. LN 43 stated the criteria included whether the resident came from a hospital or if the resident had any tubes. LN 43 stated a team, including the doctor, would decide if a resident should be on EBP. LN 43 stated the staff were in-serviced by the IP regarding EBP. On 7/24/24 at 3:17 P.M., an interview with IP was conducted. The IP stated the facility followed the CDC Guidelines on EBP. The IP stated she got information from the CDC, the California Department of Public Health (CDPH) and presented to the facility's leadership. The IP stated the leadership together with the primary physicians developed an assessment tool. The IP stated the facility was different from other facilities because residents were not as high risk as compared to the typical residents in other facilities. The IP stated the residents had no history of MDRO. The IP stated they placed the residents on EBP only when they came back from the hospital. The IP also stated 80 percent of their population had tubes and staff were PPE burned out (exhausted from excessive use of PPE) after COVID. The IP stated they, .May be incorrect . with their interpretation of the CDC guidelines. On 7/25/24 at 1:13 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated there was an assessment tool the facility used, and the residents had to meet the criteria before they were placed on EBP. Per ADON, the facility had to follow their policy. Per ADON, the IP was responsible for infection control concerns. During an interview on 7/25/24 at 2:18 P.M. with ADON, the ADON stated, the EBP criteria form was completed for new admission and when a resident came from the hospital. The ADON stated the criteria for EBP was taken from an AFL (All Facilities Letter, issued by CDPH). The ADON stated, What we are doing is CDC guidelines .it is subject to interpretation .it is controversial . During an interview on 7/25/24 at 5:59 P.M. with the Medical Director (MD), the MD stated the criteria was based on, .Our interpretation of the CDC guidelines. The MD stated they looked at the facility's infection rates, how much time it took for staff to use the PPE, and the federal regulation. The MD stated the facility has a modified assessment tool. The MD stated the facility was doing something different than other facilities. Per the facility's policy titled, Infection Prevention Program Plan, dated 4/24/23, .Procedures .c. Maintain compliance with regulatory and governmental regulations and standards . During a review of the facility's policy and procedure titled Enhanced Standard Precautions (ESP)/Enhanced Barrier Precautions (EBP) Quick Reference, dated 4/12/24, indicated, .(name of facility) implements enhanced standard precautions (ESP)/enhanced barrier precautions (EBP) through an individualized assessment of resident characteristics and risk in combination with risk assessment based on our unique facility characteristics, namely single rooms, high staffing, high air exchange, low admissions, almost no resident to resident transmission of infection, and with NO CDC-targeted Multidrug-resistant organisms (MDROs) in the history of the building operation . During a review of the CDC's guidelines, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, indicated, .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include .device care or use .Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of the resident's stay in the facility or until .discontinuation of the indwelling medical device that placed them at higher risk .Enhanced Barrier Precautions applies to all residents with any of the following: .indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy .) regardless of MDRO colonization status Per the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group publication QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes., dated March 20, 2024, with an effective date of April 1, 2024, .EBP recommendations now include use of EBP for residents with chronic wounds or indwelling devices during high-contact resident care activities regardless of their multidrug-resistant organism status . 2. Resident 88 was admitted to the facility on [DATE] with diagnoses to include pneumonitis (a lung infection), per a Record of Admission. On 7/23/24 at 9:30 A.M., an observation of Resident 88 was conducted in his room. Resident 88 was lying in bed, and did not respond to questions asked. A sign outside of Resident 88's door indicated he was on Enhanced Standard Precautions (also known as EBP). The sign indicated, Anyone participating in any of these six moments must also: [NAME] (put on) gown and gloves .Caring for devices & giving medical treatments . A plastic bin outside of the room contained isolation gowns, gloves, and other PPE. On 7/23/24 at 4:23 P.M., an observation of LN 1 was conducted in Resident 88's room. LN 1 connected a syringe to Resident 88's feeding tube, a medical device located on his abdomen. LN 1 was wearing gloves when touching the resident, and when connecting the syringe to the feeding tube. LN 1 was not wearing a gown. On 7/23/24 at 4:22 P.M., an interview was conducted with LN 1 as she exited Resident 88's room. LN 1 stated she should have been wearing a gown and gloves when using the feeding tube as she had been providing care through a medical device. LN 1 stated the use of the correct PPE was important to prevent the spread of infection to the resident. On 7/23/24 at 4:30 P.M., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated LN 1 should have put on gloves and a gown when providing care for Resident 88. CN 1 stated all staff should review the signs prior to entering the room, and use the appropriate PPE to prevent the spread of infection. CN 1 stated more education may be necessary on the process. On 7/24/24 at 3:10 P.M., an interview was conducted with the ADON. Per the ADON, the nurse should have followed the instructions posted on the sign. The ADON stated this deficient practice had the potential to spread infection to other residents or staff. Per a facility policy, reviewed 4/12/24 and titled Enhanced Standard Precautions (ESP)/Enhanced Barrier Precautions (EBP), .A. Who receives Enhanced Standard Precautions .a .high risk residents, particularly those with wounds or tubes .B. What are Enhanced Standard Precautions/Enhanced Barrier Precautions? a. The use of a Gown and gloves .b. 6 moments: .caring for medical devices .E. How do we communicate about enhanced standard precautions? a. Each patient will have a sign placed outside their door .over a little drawer set of PPE .

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment was in safe operating condition according to standards of practice when: 1. A dishwashing machine had temperatures below the sanitation level. 2. A reach-in refrigerator and a reach-in freezer had condensation. This failure had the potential to place residents at risk of developing foodborne illness. Cross reference F812 Findings: 1. During a kitchen observation and interview on 7/22/24 at 9:22 A.M. with the food services worker/dishwasher (DSW), the DSW stated dishes, utensils, and trays are placed in the dish machine to wash and sanitize. The DSW stated the machine sanitizes dishes when the on button on the wall mounted digital control pad is pressed. The Surveyor asked how the staff ensures the dish machine is sanitizing and the DSW stated, We run it (the machine), and we check the gauges . The DSW stated the dinnerware first goes through the power scraper and power wash cycles, then through the power rinse tank and final rinse. The DSW stated the dish machine wash goes up to 145 (degrees) but mostly stays between 140 and 145 Fahrenheit. The gauges on the dish machine read: Power scrapper= 109 Fahrenheit Power wash= 140 Fahrenheit Power rinse tank= 156 Fahrenheit Final rinse= 168 Fahrenheit During an observation and interview on 7/22/24 at 11:15 A.M. with the CNS, the CNS acknowledged the wash temperature on the dish machine was not reaching the appropriate temperature. The CNS stated the dish machine needed to be repaired to ensure the wash and sanitizing steps were operating correctly. According to the 2022 Federal FDA Food Code, section 4-501.110, .The wash solution temperature in mechanical warewashing equipment is critical to proper operation . A review of the facility policy titled Nutrition Services Infection Control indicated, .The dish machine is to be checked regularly throughout the day to ensure that the proper wash cycle temperature (150 degrees Fahrenheit) and the proper rinse cycle temperature (180 degrees Fahrenheit) are continuously maintained . A review of the facility policy titled Nutrition Services: Essential and Important Use Equipment indicated the dishwasher was, .Equipment identified as ESSENTIAL USE .Essential Use Equipment is essential .a non-working condition may necessitate notification to the CDPH due to, risk of detrimental impact on resident health and or safety . 2. During the initial kitchen tour on 7/22/24 at 9:10 A.M., a reach-in freezer was observed with condensation build-up inside. There was frozen liquid observed on the bottom shelf of the freezer. There was frozen condensation observed on the racks. A reach-in refrigerator in the cold food nourishments prep area was also observed with ice condensation build-up on the bottom shelf and on the inside of the door. According to the 2022 Federal FDA Food Code, section 4-204.11 .The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms . A review of the facility's policy and procedure titled Nutrition Services: Essential and Important Use Equipment, dated 3/27/24 indicated it was the facility's policy to, .To establish repair categories for Nutrition Services equipment that is considered essential and important to the function of the Nutrition Services Department .

Based on interview and record review, the facility failed to ensure three of 62 residents reviewed for Choices received: 1. Foods purchased from outside of the facility, stored and reheated when requested (Residents 119, 131), and, 2. Items requested were purchased in the brands or type requested (Resident 126). As a result, the resident's preferences and choices were not honored and respected, placing them at risk for psychosocial harm. Findings: 1a. Resident 119 was admitted to the facility on [DATE] with diagnoses to include weakness, and an amputation of the leg, per a Record of Admission. On 7/22/24 at 2:23 P.M., an interview was conducted with Resident 119. Resident 119 complained about the facility meals, stating she preferred to order foods from outside of the facility. Resident 119 stated she was not allowed to store any foods purchased outside of the facility in the unit refrigerator, and there was no microwave available for her to reheat the foods anyway. Per Resident 119, she used a microwave when she lived independently, and she felt it was her right to have access to a refrigerator and a microwave. On 7/23/24, a record review was conducted. Resident 119s Brief Interview of Mental Status (BIMS, an assessment tool) indicated Resident 119 had intact cognition. On 7/25/24 at 11:07 A.M., a follow up interview was conducted with Resident 119. Resident 119 stated she had again asked for food from outside to be saved in the refrigerator. Resident 119 stated the assigned Certified Nursing Assistant (CNA) had asked the charge nurse, who said no to the request. Resident 119 stated she was aware there was a microwave for staff use on the unit, and she did not understand why she was unable to use it. Resident 119 stated she would also like to buy frozen food, like ice cream, but had been told residents cannot use the freezer. 1b. Resident 131 was admitted to the facility on [DATE] with diagnoses to include injury to the spine, per a Record of Admission. On 7/22/24 at 3:40 P.M., an interview was conducted with Resident 131. Resident 131 stated he enjoyed buying food from the gas station or getting food delivery from restaurants. Resident 131 stated he did not always like the food served by the facility. Resident 131 stated he had asked his CNA to place the leftover food in the unit refrigerator, and she had said no, and said the food had to be sealed, or new from the store. Resident 131 stated he asked to have restaurant food reheated, and was told there was no microwave for residents to use. Per Resident 131, he had asked for a refrigerator and microwave for his room, to save and reheat food from outside the facility, but he was told no. Resident 131 stated he had been told he could never go to the kitchen to reheat food. Resident 131 stated, They are supposed to be here for us, I have been to many other nursing homes that allow us to save and reheat food, but not here. On 7/23/24, a record review was conducted. Resident 131's BIMS indicated intact cognition. On 7/24/24 at 9:45 A.M., an interview was conducted with CNA 1. CNA 1 stated the only foods she could put in the unit refrigerator was pre-packaged, sealed food containers. CNA 1 stated there was no microwave where residents could use it. CNA 1 stated at the end of a shift, the CNAs would check on resident rooms and remove and dispose any opened food per policy. On 7/24/24 at 10:26 A.M., a concurrent interview and record review of the unit refrigerator Personal Food Storage Guidelines was conducted with Nursing Supervisor (NS) 1. NS 1 stated the facility did not allow residents to store food in the unit refrigerator because of the risk of contamination. NS 1 stated if residents wanted to put food in the refrigerator, it could stay for 24 hours. NS 1 reviewed the Personal Food Storage Guidelines, and stated the Guidelines gave an expiration date of 48 hours, not 24 hours. Per NS 1, the Guidelines say no frozen food items could be stored but she was not aware of the reasons. NS 1 stated there was no microwave available for safety reasons. NS 1 stated, We do not reheat food. The unit microwave is for staff use only. On 7/24/24 at 3:30 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). Per the ADON, We are supposed to accommodate preferences. Regarding leftover food, we should be able to label and date it, and store it safely, per policy. Per a facility document, reviewed 9/9/21 and titled Personal Food Storage Guidelines, .No frozen food items will be stored .Item: Pre-packaged, prepared food from outside the facility (un-opened) requiring refrigeration .Expiration date 48 hours from time accepted by staff . Per a facility policy, dated 10/19/20 and titled Outside Personal Food Storage-Reheating, .(Name of facility) provides residents a wide variety of food at mealtimes and between meals in an attempt to meet their food requirements in a healthy manner and accommodate some preferences and discourage the consumption of outside food within the facility .cannot guarantee the safety of food prepared outside the facility. 'Outside food' consumed .is done 'at your own risk' .staff will not assist in feeding or preparing outside food .staff do not reheat food for residents in facility microwaves .Residents who wish for special foods served or personal food items to be re-heated, can contact the Dietitian and/or the Nutrition Services Supervisor to consider storage, preparation and re-heating of food items . 40610 2. Resident 126 was admitted to the facility on [DATE] with diagnoses which included weakness, per a Record of Admission. Findings: On 7/22/24 at 10:46 A.M., an interview was conducted with Resident 126 in her room. Resident 126 stated she had money but needed the facility to go purchase items for her. Resident 126 stated she did not get what she requested. Resident 126 stated she preferred a certain brand of shampoo and brand of sweatshirt but never got them. Resident 126 stated she requested pistachio nuts since October, and she did not get them. Resident 126 stated the facility had a checklist of items to purchase but it did not specify brands. Resident 126 stated she wrote in the specific brand she preferred, but she did not get the desired brand. Resident 126 stated she had hoped the staff would work with her regarding her preferences. Resident 126 stated, That is my right, right? On 7/23/24 at 4:24 P.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 126 was alert, oriented and was able to express her needs. On 7/24/24 at 9:28 A.M., an interview with Social Services Aide (SSA) 11 was conducted. SSA 11 stated the facility had a process related to resident's request for purchase. SSA 11 stated there was an order form the residents would list their requests for purchase. SSA 11 stated that this was the residents' rights, but, We were told that we have to tell them (the residents) this is the policy and that those are wants, not needs. On 7/25/24 at 1:13 P.M., an interview with ADON was conducted. The ADON stated the staff would ask Resident 126's family if they could get Resident 126's preferred choice of supplies. The ADON stated, It is not a big deal. Per the facility's policy titled Resident Rights, dated 4/29/24, .Staff protect and promote resident rights as outlined in state and federal regulations .Staff recognize situations where it may be necessary to limit a right .Overview To ensure resident rights are not violated in this facility .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool used to guide resident care) was accurately coded for one of 31 sampled residents (Resident 134) when the resident's diagnosis was not reflected on the initial MDS assessment and three consecutive MDS assessments. This failure had the potential for Resident 134's needs to be unmet. Findings: Resident 134 was admitted to the facility on [DATE], with diagnoses including long-standing schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), per the History and Physical (H&P), dated 8/31/23. A record review was conducted on 7/24/24. Resident 134's physician's orders, dated 8/31/23, indicated olanzapine (an antipsychotic medication) to be given every night at bedtime for schizophrenia. The resident's current medication orders for July 2024 included olanzapine every night at bedtime for schizophrenia. Resident 134's MDS assessment for cognitive pattern, dated 5/16/24, indicated a Brief Interview for Mental Status (BIMS, an assessment tool) score of 3 (severely impaired cognition). Resident 134's initial MDS, dated [DATE], under section I for active diagnoses, schizophrenia was not marked as an active diagnosis. Resident 134's MDS, dated [DATE], under section I for active diagnoses, schizophrenia was not marked as an active diagnosis. Resident 134's MDS, dated [DATE], under section I for active diagnoses, schizophrenia was not marked as an active diagnosis. Resident 134's MDS, dated [DATE], under section I for active diagnoses, schizophrenia was marked as an active diagnosis. During an interview with MDS Coordinator (MDS) 1 and MDS Coordinator (MDS) 2 on 7/25/24 at 1:35 P.M., MDS 1 stated the MDS was completed based on how the physician coded a diagnosis on the diagnosis list. MDS 1 stated if the doctor did not list the diagnosis for schizophrenia, it would not be included on the MDS. MDS 1 stated he did not recall if he questioned the doctor regarding schizophrenia not being listed on Resident 134's diagnosis list, despite an order for medication specifically for schizophrenia, and the resident's past psychiatric history of long standing schizophrenia on the H&P. During an interview with the Medical Director (MD), MDS 1 and MDS 2, on 7/25/24 at 1:56 P.M., the MD stated, the admitting physician probably coded psychosis instead of schizophrenia. The MD stated H&P on admission indicated Resident 134 had schizophrenia. The MD stated the initial MDS should have indicated schizophrenia as an active diagnosis. During an interview with the Assistant Director of Nursing (ADON) on 7/25/24 at 2:18 P.M., the ADON acknowledged the MDS needed to be coded accurately to drive the plan of care for the resident. During a review of the facility's policy and procedure titled MDS Assessments, dated 10/18/23, .It is the policy of (name of facility) to ensure that MDS assessments are completed and transmitted .according to the guidelines and requirements set .

Based on observation, interview and record review, the facility failed to develop and/or implement: 1. An activities care plan for one resident (31), and 2. A call light care plan for one resident (136). This failure had the potential for the resident's needs to not be met. Findings: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage (bleeding in the brain) according to the facility's Record of Admission. A concurrent observation and interview with Resident 31 was conducted on 7/22/24 at 2:23 P.M. Resident 31 was walking in the hallway with his walker. Resident 31 stated that he was a former furrier (fur coat stylist) and tailor (a person who made clothing). Resident 31 stated he missed those activities and he would like to still be doing those things. Resident 31 further stated he was not able to do these things in the facility. On 7/23/24, a record review was conducted. Resident 31's care plan for activities, dated September 2023, indicated, . assist resident to activities of potential interest such as games, outdoor strolls and fresh air fit; introduce to Spanish speaking residents and staff; seat next to other Spanish speaking residents . There was no care plan for any other activities. An interview was conducted on 7/24/24 at 11:37 A.M. with the Director of Activities (DA). The DA stated, This resident (31) has mentioned his career was a furrier but we have not provided any activities related to sewing or design. His care plan does not reflect his interests. An interview was conducted on 7/25/24 at 2:51 P.M. with the Assistant Director of Nursing (ADON). The ADON stated, It is important to have a comprehensive care plan for staff to provide the best care for the residents. A review of the facility's policy, dated 7/11/23 and titled Care Plan Resident, indicated, I: Policy: All residents at (Name of facility) will have a care plan developed .based on the interdisciplinary assessments of team members which will include a list of problems, preferences, goals and interventions specific to the individual needs of that resident .C. a. Therapeutic Recreation .does their own care plans .G. Generally, care plan goals and interventions should be .specific and should reflect the goals/preferences of the resident . 50175 2. Resident 136 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) per a Record of Admission. Inside Resident 136's room an interview with Resident 136 was conducted on 7/23/24 at 8:36 A.M. Resident 136 stated he sometimes received help when he needed it, and sometimes he did not. Resident 136 stated, he uses the call light to ask for help. Resident 136 stated, he needed assistance to set up meals, get changed, or get on the wheelchair. During a concurrent observation and interview on 7/23/24 at 4:20 P.M. with Resident 136, Resident 136 was seen in his room. Resident 136's call light was placed beyond his reach. Resident 136 stated, They left the call light so far away that I can't call to ask for a drink. Resident 136 stated, he also needed to be cleaned. During an interview with Certified Nursing Assistant (CNA) 41 on 7/23/24 at 4:25 P.M., in Resident 136's room, CNA 41 acknowledged the call light was on the bed, and the resident could not reach the call light. CNA 41 acknowledged the call light should be within the resident's reach so the resident could call for help. On 7/24/24 a record review was conducted. Resident 136's care plan, dated 3/20/23, indicated Resident 136 was total care (needed assistance with all care), The care plan indicated an intervention including Be sure call light is within reach and respond promptly to all requests for assistance. During an interview with the Assistant Director of Nursing (ADON) on 7/25/24 at 2:18 P.M., the ADON acknowledged Resident 136's care plan related to call light should have been implemented to address the resident's needs. A review of the facility's policy and procedure titled, Care Plan Resident, dated 5/10/23, indicated .All residents at (Name of facility) will have a care plan developed .which will include a list of problems .and interventions specific to the individual needs of that resident .

Based on observation, interview and record review, the facility failed to provide an activity program to meet a resident's (31) preferences for one of one residents reviewed for activities. This failure had the potential to not support Resident 31's psychosocial well-being. Findings: Resident 31 was admitted to the facility on [DATE] according to the facility's Record of Admission. A concurrent observation and interview with Resident 31 was conducted on 7/22/24 at 2:23 P.M. Resident 31 was walking in the hallway with his walker. Resident 31 stated he was a former furrier (fur coat stylist) and tailor (a person who makes clothing). Resident 31 stated he missed those activities and he would like to still be doing those things. Resident 31 further stated he was not able to do those things in the facility. An interview was conducted on 7/24/24 at 11:37 A.M. with the Director of Activities (DA). The DA stated an activities assessment for residents was conducted on admission but it was not useful as it was mostly nursing based. The DA further stated, This resident has mentioned his career was a furrier but we have not provided any activities related to sewing or design. An interview was conducted on 7/24/24 at 11:39 A.M. with the Assistant Director of Activities (ADA). The ADA stated, He (Resident 31) has mentioned his career but we are not providing activities related to that. A review of the facility's Therapeutic Recreation Assessment for Resident 31, dated, 9/24/23 indicated, .individual interventions/recommendations: games, outdoor strolls, fresh air fit, introduce to Spanish speaking residents, praise and thank for participation efforts during groups . There was no reference to any other activities. An interview was conducted on 7/25/24 at 2:48 P.M. with the Assistant Director of Nursing (ADON). The ADON stated, It is important to provide meaningful activities to residents. A review of the facility's policy, dated 5/31/24, titled, Therapeutic Recreation Services, indicated, I. Policy: Therapeutic Recreation (TR) staff will complete a comprehensive assessment, and provide an ongoing program of activities in a therapeutic environment that promotes the resident's highest practicable degree of physical, cognitive, social and emotional well-being and functioning .III. Procedures .B. Activity Program-Requirements: a. the activity program consists of individual, small and large group activities which are designed to meet the needs and interests of each resident and which include but are not limited to .iii. creative activities .

Based on observations, interviews, and record reviews the facility failed to ensure one of 31 sampled residents, (Resident 18), received the prescribed tube feeding volume according to facility policy. This failure had the potential to result in further functional and physical decline and increase the risk of infections, pressure sore, and death. Cross reference F692 Findings: During an observation on 7/22/24 at 9:22 AM of Resident 18, the resident was lying in bed, in a low position, with head of bed (HOB) elevated to 45 degrees, with some drooping in his left face, as well as drooling from mouth. There was an oxygen pump with humidifier, and gastric tubing from stomach established for tube feeding (TF). The TF pole and kangaroo pump machine had no bag or bottles hanging. The resident's eyes were half open and did not respond to questions and appeared non-verbal. During an observation of Resident 18 on 7/23/24 at 2:55 PM in Resident 18's room, the resident was lying in asleep in bed with the head of the bed elevated at a 45-degree angle. The Resident's left and right arms were bent and contractures on both hands. A kangaroo pump was on the left side of the bed, turned off, without formula or water hanging on it. During a review of Resident 18's Physician's Diet Orders dated 3/14/24 indicated Texture: NPO, Liquid: NPO, Enteric feeding: Jevity 1.5 (1.5 CAL/ML) VIA GT (gastric or stomach tube) FOR NUTRITION 24 HOUR TOTAL OF ENTERIC FEEDING 701 ML/1052 CALS. CONTINUOUS MAX RATE IS 100 ML/HOUR, WATER/HYDRATION: 1050 ML/24 HRS PER GT. During a review of Resident 18's Quarterly Nutrition assessment dated [DATE] completed by the Registered Dietitian (RD), the assessment indicated, .Wt. 169.5, IBW (ideal body weight): 160# (pounds) .Weight variance: .-4.9% x 6 months, 13.8# (pounds) x 1 year .Diet order: (9/7/22) NPO. On 3/23/23, Jevity 1.5 via GT 701 ml/1052 calories. Maximum rate 100 ml/hour. On 1/18/22, water/hydration 1050 ml/24 hrs per GT. On 12/30/22, Pro T Gold 30 ml via GT QD supplement .Labs reviewed: 10/3/23: Gluc 63 (Low), Creatinine (a waste product that comes from the digestion of protein in your food and the normal breakdown of muscle tissue)- 0.29 (Low), Albumin (the most abundant circulating protein in blood plasma)- 3.1 (Low) .Abnormal labs expected due to multiple medical diagnoses .Medications: .Remeron (appetite stimulant) .Nutrient Requirements using IBW .160# (pounds): Kcals (calories) .1241-1679 kcal/day, Protein 73-88 g/d (grams/day), Fluid (30 cc/167.6 pounds): 2190 cc/day .Assessment summary .1122 kcal, 62 grams protein, 2258 cc total approximate water per day .Pertinent information: hospitalization ,d+[DATE]-[DATE] due to foley catheter complications. emergency room visit for shortness of breath likely due to 'acute episode of aspiration (difficulty breathing into lungs) per MD on 5/3/23' .Plan: Continue TF (tube feed) and water flush . Continue to update TF tolerance .and labs . During a review of Resident 18's Quarterly Nutrition assessment dated [DATE] completed by the RD, the assessment indicated .Wt. 166, IBW: 160 pounds .Nutrient requirements using IBW 160 pounds: KCALS 1241-1679 kcal/day, Protein .73-88 grams/day . During an observation and interview on 7/23/24 at 4:51 P.M. with Licensed Nurse (LN) 52 and LN 53, LN 52 stated she believed the kangaroo pump machine could store tube feed volume data for about 24 hours. LN 52 pressed the back button to review the previous tube feed amount received but the machine did not display the last formula volume from Resident 18's tube feeding. LN 53 also tried to turn on the kangaroo pump to check the last tube feed amount. LN 53 stated the kangaroo pump could store up to 72 hours of formula volume. LN 53 stated the nurses only run the daily volume from 4pm for 10 hours until the 701 mls are pumped. LN 53 stated the nurses do not document the daily intake amounts because they rely on the 72-hour kangaroo pump machine. LN 53 stated there could be potential concerns in the future if asked to provide formula intake amounts from months ago. During an interview on 7/23/24 at 4:38 P.M. with Licensed Nurse (LN) 51, LN 51 stated she typically starts the kangaroo pump machine for Resident 18's tube feeding at around 4 PM. LN 51 stated that she would press the on/off button to turn the machine 'on', then pressed 'start' to get the pump going. LN 51 then stated she makes sure the display reads 0 before she hangs a full bottle of the Jevity 1.5 formula. LN 51 stated she does not know how to fully check the kangaroo pump machine to determine how much formula Resident 18 had previously received because the machine is always off when she gets to work. LN 51 further stated she was a new employee that worked at the facility less than three months and had not received training on how to use the kangaroo pump. During a review of the facility's undated document titled Nutrition Service Tube Feeding and Supplement List indicated .[Resident 18] GT .cc's (cubic centimeters for liquid volume)/day- 701, Cals(calories)/day - 1052 . During a review Resident 18's G-Tube Feeding, Flushing, and Position Verification Record Form 334B, dated 2/1/23, for April-August 2024, indicated the nursing staff initials on each day for shifts 11-7 AM, 7-3 PM, and 3-11 PM by licensed nurses but does not include input or output fluid volume amounts. During an interview with LN 54 on 7/25/24 at 1:54 P.M., LN 54 stated when she does rounds on the residents, she checks all GT feedings and the history in the kangaroo pump for the last 24 hours. LN 54 also stated she checks to see if the total volume given was infused, and if not, then she will find the outgoing nurse to report it in the Medication Activity Record (MAR). LN 54 stated she initials the resident's tube feed report record each day. She said the intake/output record document is used if the resident is on antibiotics or fluid restricted. LN 54 further stated she doesn't think the machine can provide a history of infused volume for more than 72 hours. During an interview on 7/25/24 at 2:55 P.M. with the Assistant Director of Nursing (ADON), the ADON stated residents are weighed initially on admission, and monthly. Weight variances are referred to the RD so they could adjust the food, formula, calories, CC's, etc. The ADON stated GT kangaroo pumps have a total volume infused record, even for the water. The ADON stated if something is wrong with the machine or feeding, nurses will inform the MD. The ADON further stated The machine is not perfect, but it is important for the nurses to know how to operate the machine and to track the tube feeding formula volume. The ADON the nurses should be using the I&O (Input and Output) form to track the volume because the kangaroo pump only stores limited data up to a few days. Once they decide the appropriate weight for the resident, it is the duty of nurses to make sure the residents are getting the calories and volume they need. A review of the tube feed formula [Manufacturer's name] nutrient profile for Jevity 1.5 indicated a 1000 mL bottle provided 1500 calories, 63.8 grams of protein, and # 760 cc's of water. https://static.abbottnutrition.com/cms-prod/abbottnutrition-2016.com/img/Jevity%201.5%20Cal%20EN_tcm1310-73172.pdf A review of the facility's policy titled Intake and Output Measurement I-006, dated 3/2/2018, indicated .C. Measuring Enteral Feedings Intake- Licensed staff shall administer enteral food and fluids per Physician order and document volumes in the Intake and Output Record E-323 .E. Documentation- a. The Licensed Nurse will total the intake and output at the end of each shift and record on Intake and Output Record E323 .H. Resident Care Plans- Residents' Care Plans will be updated as necessary . A review of the facility's policy titled Enteral Tube Feeding for Gastrostomy (G-Tube or GT) ., dated 2/28/2022, indicated .Registered Dietitian will assess nutritional status and .makes recommendations for the diet order of formula and total volume/calories based upon the resident's: caloric requirements .current weight .overall nutrition status .Recommends hydration .Requests for laboratory data to aid in the assessment and monitoring of the resident .Monitors .resident progress .recommends changes in formula, nutritional adequacy of the formula .