Every finding on record at Fireside Health Care Center

Based on interviews and record review, the facility failed to readmit and allow one of the three sampled residents (Resident 1) who was admitted to General Acute Care Hospital (GACH) and while an appeal (a formal request to stop a discharge or transfer you do not want with the state of California) to remain in the facility was pending. This deficient practice resulted in Resident 1 being left unhoused after being discharged from GACH.During a review of Resident 1's admission record indicated that Resident 1 was initially admitted on [DATE] with diagnoses Including short bowel syndrome (a rare condition where the body cannot absorb enough water, vitamins, and nutrients from food) with colon (large intestines) in continuity, housing instability (not having a safe, permanent, or reliable place to live), chronic kidney disease stage three (your kidneys have moderate damage and work at 30% to 59% of their normal capacity). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 7/3/2026, the MDS indicated Resident 1 cognitively intact (can think, learn, remember, and make good choices without any problems). The MDS indicated Resident 1 was mostly independent for Activities of Daily Living (ADLs such as toileting hygiene, shower/bathe self, upper body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, sit to stand, chair/bed to chair transfer, toilet transfer, car transfer, walk 150 feet). The same MDS indicated Resident 1 had an ostomy (a surgically created opening in your abdomen that allows bodily waste such as urine or stool to leave the body).During a review of Resident 1's physician's orders dated 7/9/2026 indicated, Transfer resident to [GACH] via non-emergent transportation for further eval [evaluation] of AKI [Acute kidney Injury - a sudden drop in how well your kidneys work), hyponatremia (decreased levels of sodium in the blood) and unexplained fluid/weight loss. On bed hold (keeping a resident's spot open in a care facility while they are temporarily away) x 7 days. During a review of Resident 1's physician's orders dated 7/10/2026 at 2:06 pm indicated, Transfer resident to [GACH] via non-emergent transportation for further eval of AKI, hyponatremia and unexplained fluid/weight loss. During a review of Resident 1's physician's orders dated 7/10/2026 at 4:14 pm indicated, discharged AGAINST MEDICAL ADVICE (AMA) [ a term used when a patient chooses to leave a hospital or stop treatment before their doctor says it is safe]. During an interview with the admission's coordinator (AC) on 8/11/2026 at 10:37 am, the AC stated that one of his (AC) included reviewing and approving potential resident admissions from GACH and providing clinical records to the Director of Nursing (DON) for final approval. The AC stated that on 7/14/2026, a Case Manager (CM) from GACH had reached out to inquire about Resident 1's return to the facility and after consulting with the DON, AC informed the GACH CM that there was no bed for Resident 1 because he had left AMA. The AC defined AMA as, when a resident goes against what the facility's recommendations regarding his care and voluntarily signs himself out the facility. During an interview with the DON on 8/11/2026 at 10:46 am, the DON stated that on 7/9/2026, the facility noted that Resident 1 had lost six pounds (measure of weight) over a two day period. The DON stated that the physician ordered for Resident 1 to be transferred to GACH for further evaluation by ambulance, but that Resident 1 declined to be transferred by ambulance. The DON stated that she encouraged Resident 1 to be transferred to GACH and educated him about the risks and benefits of not following through with the physician's order. The DON stated that on 7/10/2026, Resident 1 verbalized that he (Resident 1) was going to drive himself to run some errands then go to GACH after. The DON stated that the facility decided to discharge Resident 1 because even though he stated that he was going to go to GACH after he ran his personal errands, there was no way of telling that he was going to make it there and that the facility would constantly worry if he had made it there. The DON admitted that there was an appeal with the state of California which was pending an outcome. During a review of the facility's policy and procedures titled, Discharging a Resident without a Physician's Approval, reviewed 1/29/2026, indicated, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. The same P&P indicated, If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will: discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings.

Based on interview, and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS-a resident assessment tool) Assessment timely for five of five sampled residents (Resident 23, 33, 39, 41 and 43) reviewed under the Resident Assessment task. This deficient practice had the potential to negatively affect the provision of necessary care and services needed Resident 23, 33, 39, 41 and 43.Findings: During a concurrent interview and record review with Minimum Data Set Coordinator (MDSC) on 12/15/2022 at 1:22 PM Residents 23, 33, 39, 41 and 43's most recent quarterly MDS assessments were reviewed. MDSC stated that every three months a quarterly MDS must be completed. MDSC stated that residents' MDS assessments were due to the workload. MDSC further stated the following: Resident 23's last quarterly MDS was submitted on 1/19/2025. The quarterly assessment was started on 12/12/2025 and should have been submitted by 12/26/2025.Resident 33's quarterly MDS was submitted on 1/19/2025 and should have been completed and submitted by 12/30/2025.Resident 39's quarterly MDS was submitted on 1/19/2025 and should have been completed and submitted by 12/30/2025.Resident 41's quarterly assessment was started on 12/22/2025 and was not completed. Resident 41's quarterly assessment should have been completed and submitted by 1/5/2026.Resident 43's quarterly assessment was started on 12/19/2025 and has not been completed. During an interview on 1/23/2026 at 11:58 AM, the Director of Nursing (DON) stated the MDS tells the complete story of the resident and should be submitted within CMS timeframes. The DON stated also stated It is so important for the quarterly MDS be done because it identifies the information that is needed to care for the resident. A review of the facility's policy and procedures (P&P) titled, Resident Assessments, revised 8/2025, indicated: The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conductstimely and appropriate resident assessments and reviews according to the following requirements:a. OBRA required assessments - conducted for all residents in the facility:1. Initial Assessment (Comprehensive) - Conducted within fourteen (14) days of the resident's admission to the facility;2. Quarterly Assessment- Conducted not less frequently than three (3) months following the most recent OBRA assessment of any type;3. Significant Change in Status Assessment (Comprehensive)-Conducted when there has been a significant change in the resident's condition;4. Annual Assessment (Comprehensive)- Conducted not less than once every twelve (12) months; and5. Discharge Assessment- Conducted when a resident is discharged from the facility.

Based on observation, interview, and record review, the facility failed to ensure that food was stored under sanitary condition and that food preparation equipment was clean when:An open whole egg mayonnaise and butter milk ranch dressing did not have the use by date on them.Ice scoop did not have a cleaned date on it and ice scoop cleaning logs for the month of 1/2026 had dates Saturday and Sunday blocked, blackened out and no initials noted. These failures had the potential to result in harmful bacteria growth and cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 59 of 60 medically compromised residents who received food and ice from the kitchen.Findings: During a concurrent observation and interview on 1/20/2026 at 8:10 A.M., with Dietary Supervisor (DS), the DS stated the whole egg mayonnaise and butter milk ranch were opened 12/1/2025 however, there was no use by date noted on the containers. The DS stated open items in the refrigerator need to have a delivery date, open date and use by date. The DS stated that the use by date is for knowing the storage time and to make sure that the food item is not used beyond the use by date. The DS stated if the food items are used beyond the use by date, it may lead to residents being sick.During a concurrent observation and interview on 1/20/2026 at 8:23 A.M., with Dietary Supervisor (DS), the DS stated ice scoops are cleansed, washed through the machine every day and staff cleaning the scoop put a date on the ice scoop when it was cleaned and staff initials on the dietary department cleaning and sanitization schedule once it is done. The DS stated that on 1/1/2026 to 1/20/2026 the log had no initials on Saturdays and Sundays, the spot for putting initial was blocked, with no initials meaning it was not done. The DS stated ice scoops are cleaned every day to prevent bacteria for the safety of the residents. The DS stated if the ice scoop is not cleaned, it can lead to spread of infection causing the residents to have stomach aches and diarrhea. During an interview, on 1/23/2026, at 12:17 P.M., with the Director of Nursing (DON), the DON stated that ice scoops need to be cleaned daily to prevent infection control that may lead to symptoms such as diarrhea and documentation should be done with the date, initials of the staff performing the task. The DON stated if there is no documentation of ice scoop cleaning, then it was not done. The DON stated that open items in the refrigerator should be have a used by date which alerts staff that after that date, items need to be discarded and not be used to prevent food borne illnesses. A review of the facility's Policy and Procedures (P&P), titled Recommended Food Storage Practices with review date of 1/29/2025 indicatedRefrigerated: Label all cooked and opened items with open and use by dates (00/00/00) . A review of the facility's P&P, titled Scoops with review date of 1/29/2025 indicated: Procedure: .2. The scoop will be washed and sanitized on daily basis. Staff will initial the cleaning log schedule as the task is completed. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred;(2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles;(3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and(4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment:(a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold.

Based on observation, interview, and record review, the facility failed to ensure that 28 out of 32 rooms met the 80 square feet (sq. ft.) per resident in multiple resident rooms. These 28 rooms consisted of twenty-five 2-bed rooms, two 3-bed rooms and one 4-bed room.This deficient practice had the potential to result In inadequate space to provide safe nursing care and privacy for the residents.On 1/21/2026, the Administrator provided a copy of the Client Accommodation Analysis, dated 1/20/2026 and the facility letter requesting for continuation of room waiver. A review of the Client Accommodation Analysis indicated that 28 of 32 rooms did not have at least 80 square feet per resident. The room waiver request and Client Accommodation Analysis showed the following:Rm# # of Beds Sq. Ft. Sq.Ft/Res1 2 140 702 2 140 703 2 140 704 2 140 705 2 140 706 2 140 707 2 140 708 2 140 709 2 140 7010 2 140 7011 2 140 7012 2 140 7013 2 140 7014 2 140 7015 2 140 7017 2 133 66.518 4 294.5 73.621 2 140 66.523 3 196 65.324 2 140 7025 2 140 7026 2 140 7027 2 140 7028 2 140 7029 2 140 7030 2 140 7031 2 140 7032 3 217 72.3The minimum requirement for a 2 bed-room should be at least 160 sq. ftThe minimum requirement for a 3 bed-room should be at least 240 sq. ft The minimum requirement for a 4 bed-room should be at least 320 sq. ftDuring the initial tour on 1/20/2026, at 8:30 AM, the evaluators inspected the aforementioned rooms and observed that nursing staff had enough space to provide care to the residents; there were curtains to provide privacy for each resident and the rooms had direct access to the corridors. During the group Interview with the residents on 1/22/2026 at 10:33 AM, Resident 21 stated the equipment in her room included a BiPAP (bilevel Positive Airway Pressure - an non-invasive breathing device that delivers two different levels of air pressure through a mask to help one breathe), oxygen concentrator and wheelchair and the room was a bit cramped. Resident 21 further stated she believed the room size was adequate she just had a lot of equipment. During this group interview, Resident 59 stated when he stayed in room [ROOM NUMBER], the Hoyer lift (a mechanical device used to lift and/or transfer a person), which he required to move from the bed to a wheelchair would not fit, so the resident was moved to a different room. The resident's did not have any complaints regarding the room sizes.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 5) who received dialysis (process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, by failing to:1. Administer Epogen per physician order2. Clarify with the physician if the facility or dialysis center was to administer Epogen (is an injectable prescription medicine that stimulates the bone marrow to produce red blood cell) to Resident 53. Communicate with the resident's dialysis center about Epogen being administered during dialysis treatment for Resident 5.A review of Resident 5's admission record indicated the facility re-admitted the resident on 12/15/2025 with diagnoses that included end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs) and dependence on renal dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) and diabetes (high blood sugar). A review of Resident 5's Order Summary Report, dated 1/22/2026, indicated the physician ordered the following:- On 12/15/2025, the dressing of the dialysis catheter was to be changed only by dialysis unit. Check site every shift and reinforce site with dressing as needed.- On 1/14/2026, the physician ordered for the resident to receive dialysis every Monday, Wednesday and Friday. A review of Resident 5's Physician's Order, dated 12/15/2025, indicated the resident to receive Epogen 1ml subcutaneously (under the skin) one time every Monday, Wednesday and Friday for ESRD. A review of the Minimum Data Set (MDS - a resident assessment tool), dated 12/22/2025, indicated Resident 5's cognition was intact. The MDS indicated Resident 5 required substantial assistance oral hygiene, toileting hygiene, bathing and dressing. The MDS also indicated Resident 5 was receiving dialysis treatment. A review of Resident 5's dialysis care plan, initiated 12/16/2025, indicated the resident was receiving dialysis for ESRD. at risk for fluid overload related to the kidney's inability to regulate fluid balance and the resident was at risk for hemodialysis (HD) access site infections and bleeding. The care plan goal was for Resident 5 to have no complications from dialysis. The interventions included to monitor/document/report signs of bleeding, hemorrhage, bacteremia and septic shock and staff were to work with the resident to relieve discomfort for side effects of the disease and treatment which included, fatigue, anemia, cramping and headaches. A review of Resident 5's Orders - Administration Notes for the month of January 2026 indicated Epogen was not given on 1/16/2026, 1/14/2026, 1/12/2026, 1/19/2026, 1/7/2026 and 1/5/2026 because the medication was unavailable. A further review of the notes did not indicate that the medication was given in the dialysis center and did not indicate that nursing staff contacted the pharmacy to request the medication. A review of Resident 5's Pre and Post Dialysis Assessments for the month of January 2026 indicated on the following dates: 1/2/2026, 1/5/2026, 1/7/2026, 1/9/2026, 1/13/2026, 1/16/2026, 1/19/2026, 1/21/2026 in the section where the dialysis staff were to write any medications given at the dialysis center were blank indicating no medications were given. On 1/14/2026, the Assessments form indicated Venofer (Iron), protein drink and heparin (a medication that delays blood clotting). A further review of the forms further indicated that Epogen was never given at the dialysis center. During an interview on 1/20/2026 at 8:45 AM, Resident 5 stated she was going to require dialysis for the rest of her life. Resident 5 stated that she had not missed any dialysis appointments since being admitted to the facility. During a concurrent interview and record review on 1/22/2026 at 9:24 AM, Resident 5's electronic medical chart was reviewed with Registered Nurse Supervisor (RNS) 1. RNS 1 stated Resident 5 received dialysis on Mondays, Wednesday, and Friday. During a concurrent review of Resident 5's physician orders, RNS 1 stated the physician ordered the facility to administer Epogen to Resident 5 on dialysis days. Upon a review of Resident 5's January 2026 MAR and order administration notes, RNS 1 stated Resident 5 did not receive Epogen on the following days in January 2006 1/2, 1/5, 1/7, 1/9, 1/12, 1/14 and 1/16. RNS 1 stated the resident not receiving Epogen could lead to anemia. During an interview on 1/23/2026 at 12:08 PM, the Director of Nursing (DON) stated Resident 5's physician order for Epogen indicated the medication would be given in the facility. The DON stated DON called the pharmacy to check what occurred with the Epogen order. The DON stated the pharmacy never sent the Epogen because the pharmacy knew the medication would be given in the dialysis center. When asked if the pharmacy confirmed this with the dialysis center, the DON didn't answer. The DON stated nursing staff should have clarified the order with the physician and pharmacy and confirmed with the dialysis center that the medication would be given there. The DON further stated she checked with the dialysis center and the dialysis center stated the resident wasn't receiving Epogen and instead was receiving Mircera (a long-acting medication used to treated anemia in people with kidney disease, similar to Epogen) because it only needed to be administered every two weeks. A review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with, revised 9/2025, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The P&P also indicated: 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.2. Education and training of staff includes, specifically:a. the nature and clinical management of ESRD (including infection prevention and nutritional needs);b. the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis;c. signs and symptoms of worsening condition and/or complications of ESRD;d. how to recognize and intervene in medical emergencies such as hemorrhages and septic infections;e. how to recognize and manage equipment failure or complications (according to the type of equipment used in the facility);f. timing and administration of medications, particularly those before and after dialysis;g. the care of grafts and fistulas; andh. the handling of waste. A review of the facility's P&P titled, Unavailable Medications, reviewed 6/2025, indicated Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This situation may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, manufacturer's shortage of an ingredient, or the situation may be permanent because the drug is no longer being made. The facility must make, every effort to ensure that medications are available to meet the needs of each resident. The P&P also indicated: B. Nursing staff shall:l) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available.a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and/or direction.2) Obtain ll new order and cancel/discontinue the order for the non-available medication.3) Notify the pharmacy of the replacement order.

Based on interview and record review, the facility failed to provide the correct liters of oxygen per physician order according to the physician order for one out of three sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 experiencing respiratory complications.Findings: A review of Resident 2's admission Record indicated the facility admitted the resident on 4/13/2024 with diagnoses including but not limited to, respiratory failure (condition in which there's not enough oxygen in one's body) with hypoxia (low levels of oxygen in the body tissues), kidney failure and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's Physician Order, dated 8/9/2024, indicated the physician ordered the resident to receive oxygen at two liter per minute (lpm - a measurement of how fast a gas flows) via nasal cannula (NC - a flexible plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously. A review of Resident 2's Oxygen Therapy care plan, initiated 3/3/2025, indicated the resident received oxygen related to respiratory failure with hypoxia. The care plan interventions included to stay with the resident during episodes of respiratory distress. A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/30/2025, indicated the resident's cognitive skills for daily decision making was severely impaired (never /rarely made decisions). The MDS also indicated Resident 2 was dependent upon staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During an observation on 1/20/2026 at 10:14 AM, at Resident 2's bedside, Resident 2 was observed laying in bed with the head of bed elevated. Resident 2's oxygen concentrator was running and connected to a nasal cannula that was on Resident 2's face but not in Resident 2's nose. Resident 2's oxygen concentrator flow rate was set to one liter per minute (1 lpm-unit of measurement/oxygen flow) During a concurrent observation and interview at Resident 2's bedside on 1/20/2026 at 10:43 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 2's oxygen concentrator was set a one lpm. LVN 1 then went to check the physician order, returned and stated that Resident 2's physician order required Resident 2 to receive two lpm. LVN 1 stated a potential outcome from not receiving the prescribed dosage of oxygen could lead to Resident 2's oxygen level dropping. During an interview on 1/23/2026 at 12:04 PM, the Director of Nursing (DON) stated nurses must follow the doctor's order when administering oxygen to residents. The DON further stated the resident could experience respiratory issues if the order is not followed. A review of the facility's policy and procedures titled, Oxygen Administration, revised 10/2025, indicated the purpose of this procedure was to provide guidelines for safe oxygen administration. The P&P also indicated staff must verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration and turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute.

Based on interview and record review, the facility failed to effectively manage a resident's pain for one of one (1) sample resident, Resident 74, as evidenced by failing to:Re-assess Resident 74's pain level after administering Tylenol (Acetaminophen- a common over-the-counter analgesic [pain reliever]) used to treat mild-to-moderate pain) according to facility's policy and procedures (P&P) titled Pain Assessment and Management dated 08/2025.Administer Oxycodone HCI (a powerful opioid controlled pain reliever used for moderate to severe pain) Oral (by mouth) Tablet 5mg give 0.5 tablet by mouth every 6 hours as needed for moderate pain 4-7/10 Hold for sedation or RR<12 as ordered on 1/16/2026 when Resident 74 complained of eight out of 10 pain level (8/10-a numerical pain assessment where zero is no pain and 10 is severe pain).These deficient failures resulted in Resident 74 getting angry and complained of inability to get a good night sleep for three nights. Findings: A review of Resident 74's admission information indicated Resident 74 was admitted to the facility on [DATE], with diagnoses that included osteoarthritis of the left knee (artificial knee joint (degenerative joint disease characterized by the progressive breakdown of articular cartilage, the protective tissue cushioning bone ends), atrial fibrillation(rapid, chaotic, and irregular electrical rhythm in the heart's upper chambers (atria), causing them to quiver (fibrillate) rather than contract effectively), protein calorie nutrition (severe nutritional deficiency caused by inadequate intake of protein and calories to meet metabolic needs), and hypothyroidism (underactive thyroid gland [located in the lower front of the neck] producing inadequate hormone levels, resulting in a slowed metabolic rate.) A review of Resident 74's Minimum Data Set (MDS, a resident assessment tool) dated 1/21/2026, indicated Resident 74's mental cognition (skills for daily decision-making) was intact. During an interview during a facility tour on 1/19/2025 at 9:37 a.m., Resident 74 stated she (Resident 74) was admitted to the facility on [DATE] and was not provided with adequate relief pain medication until 1/19/2026 at 0215 on Monday morning, Resident 74 stated for 3 days the medication nurses (unable to recall names) told Resident 74 she was not registered in the computer as an admission, Resident 74 stated her pain level of 8/10 the medication nurse (unable to recall the name) gave her Tylenol which did not provide much relief. Resident 74 stated she was unable to get a good night sleep for three nights and was angry. Resident 74 stated she received her 1st (first) dose of pain-relieving medication on Monday morning, 1/19/2026 at 2:15 a.m. A review of Resident 74's Order Summary Report indicated the following physician orders: 1. Acetaminophen tablet 500 mg (milligrams -unit dose measurement) give two (2) tablets by mouth every 8 hours for pain management for 5 Days, Max (maximum) daily dose 3g (grams - unit of measurement) from all Acetaminophen sources. ordered 1/16/2026. 2. Oxycodone HCI Oral Tablet 5mg give 0.5 tablet by mouth every 6 hours as needed for moderate pain 4-7/10 Hold for sedation or RR<12. ordered 1/16/2026.3. Oxycodone HCI oral give one (1) tablet by mouth every 6 hours as needed for severe pain of 8-10/10 Hold for sedation or RR<12., ordered 1/16/2026. A review of Resident 74's Electronic Medication Administration record (EMAR) for the month of 1/2026, indicated Resident 74 received Acetaminophen 500mg x 2 tablets for pain on 1/16/2026 at 10 p.m. to 1/19/2026 at 10 p.m. However, the same EMAR indicated that Resident 74 was never offered and/or administered Oxycodone as an alternative pain medications on 1/16/2026, 1/17/2026, and 1/18/2026. The same EMAR indicated that on 1/19/2026 at 2:15 a.m., Resident 74 received the 1st dose 5 mg of Oxycodone HCI 1 tablet oral give one (1) tablet by mouth every 6 hours as needed for severe pain of 8-10/10 and subsequently thereafter as needed. The same EMAR did not indicate any documented evidence that Resident 74 was reassessed for the effectiveness after Acetaminophen 500mg for pain. A review of Resident 74's Controlled Medication Count sheet indicated that Oxycodone HCI 5mg twenty-six (26) was delivered to the facility on 1/19/2026 at 10:15a.m. to give Resident 74 one (1) tablet oral give one (1) tablet by mouth every 6 hours as needed for severe pain of 8-10/10 and subsequently thereafter as needed. A review of Resident 74's Controlled Medication Count sheet indicated that Oxycodone HCI 5mg twenty-six (26) was delivered to the facility on 1/19/2026 at 10:15a.m. to give Resident 74 one (1) tablet oral give half (1/2) tablet by mouth every 6 hours as needed for severe pain of 8-10/10 and subsequently thereafter as needed. A review of the nurses Progress Notes from 1/16/2026 to 1/18/2026, did not indicated any documented evidence of a follow-up pain evaluation after Acetaminophen 500mg was administered to Resident 74. During an interview on 1/22/2026 at 3:02 p.m. Licensed Vocational Nurse (LVN) 3 stated during her (LVN3) shift she administered Acetaminophen 500mg as scheduled, LVN3 stated Resident 74 said her (resident) pain level was 3/10. LVN 3 did not re-assess Resident 74's pain after administering Acetaminophen 500mg. During an interview on 1/22/2026 at 3:09 p.m. LVN1 stated during her (LVN1) shift she administered Acetaminophen 500mg as scheduled to Resident 74 and she did not reassess Resident 74's pain after administering Acetaminophen 500mg. During an interview on 1/23/2026 at 1:23 p.m., the Director of Nursing (DON) stated licensed nurses are expected to follow physician's medications orders, offer pain medications as ordered and re-assess the residents pain level after administering pain medication/s to ensure that the resident's pain is relieved. The DON stated that poor pain management can lead to severe consequences, including increased patient morbidity delayed recovery, and the development of chronic, persistent pain and increased falls. A review of the facility's policy and procedures (P&P) titled Pain Assessment and Management dated 08/2025 indicated, Pain management is a multidisciplinary care process that includes monitoring for the effectiveness of interventions. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and re-assessed . until relief is obtained.

Based on observations, interviews and record review, facility failed to ensure infection control practices were adhered to in accordance with professional standards of practice when:The facility failed to isolate(to separate individuals with a known or suspected contagious disease from those who are not infected to prevent the spread of illness) Resident 60 after the resident's urine tested positive (presence of) for Extended spectrum beta lactamase (ESBL - bacteria that produce enzymes making them resistant to many common antibiotics, such as penicillin's and cephalosporins, making infections harder to treat).Resident 60 was on the patio with other residents while she was positive for ESBL. These deficient practices placed the residents and staff at increased risk to contract ESBL, and/or hospitalization.Findings: A review of Resident 60's admission Record indicated Resident 60 was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (any condition that causes the brain to function abnormally, leading to mental changes like confusion, memory loss, personality shifts, or drowsiness, resulting from injury, infection, toxins, or other illnesses that disrupt brain activity), hyperlipidemia (high fat levels in the blood), and chronic kidney disease (CKD - when kidneys are permanently damaged and cannot filter waste, toxins, and excess fluid from the blood as well as they should). A review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2025, indicated Resident 60 had impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), and required substantial/maximal assistance from staff with activities of daily living (ADL - activities such as bathing, dressing and toileting a person performs daily). A review of Resident 60's laboratory results with collection date of 1/13/2026 at 3:30 P.M., and reported on 1/16/2026 at 9:08 P.M., indicated that culture ESBL. A review of Resident 60's order summary report with order date of 1/16/2025 indicated contact isolation precaution for ESBL . During an initial tour of the facility on 1/20/2026, at 11:25 A.M., Resident 60 was not in her room and was sharing the room with three other residents. During an interview on 1/20/2026, at 12:30 P.M., with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated that Resident 60 was on the patio for activities. During an interview on 1/21/2026, at 8:47 A.M., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that Resident 60 is on contact isolation since 1/16/2026 due to ESBL of the urine. LVN 2 stated that Resident 60 is now in a single room and has been in that room since 1/20/2026 afternoon. LVN 2 stated Resident 60 was transferred to the single room after she left the patio for activities. LVN 2 states Resident 60 needs to be on should not be with the other residents because if she is not doing proper disinfection, she can be in contact with other resident which can lead to them being contaminated and getting infected as well. During an interview on 1/21/2026, at 9:50 A.M., with Infection Preventionist (IP), the IP nurse stated that Resident 60 is currently in a single room and is on contact isolation for ESBL of the urine. IP nurse stated that Resident 60 has been on contact isolation since 1/16/2026 when the urine results came back positive for ESBL of the urine that was collected and provided to the laboratory on 1/13/2026. IP nurse stated that ESBL is a urinary tract infection (UTI) that requires that the resident is isolated, it is not like an ordinary UTI, it can be transmitted if proper standards, precautions are not observed, the resident needs to be in a room by themselves. IP nurse states Resident 60 has been in the single room since 1/21/2026. IP nurse stated that on 1/20/2026 Resident 60 was assigned to a four bedroom however, Resident 60 was on the patio with the other resident all throughout the morning and afternoon. IP nurse stated that a resident with ESBL of the urine should not be around the other residents because ESBL of the urine requires contact isolation because there is a possibility for contamination and if the other resident may come in contact with it they may get infected which may lead to the spread of the infection. During an interview on 1/23/2026, at 12:42 P.M., with the Director of Nursing (DON), the DON stated that ESBL is an infection of the urine and requires resident to be placed on isolation. The DON stated that resident with ESBL of the urine should not be with other residents to prevent the spread of the infection which could potentially lead to the spread of the infection maybe hospitalization A review of the facility's Policy and Procedures (P&P), titled, Isolation -Initiating Transmission -Based Precautions, revised 8/2025, indicated Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents.Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions.Policy interpretation and implementation2. Transmission-based precautions are utilized when a resident meets the criteria for a transmissible infection AND the resident has risk factors that increase the likelihood of transmission. These may include (but are not limited to):a. Uncontained excretions/secretions;b. Non-compliance with standard precautions; orc. Cognitive deficits that restrict or interfere with the resident's ability to maintain precautions.

Based on observation and interview, the facility failed to ensure that dignity of the resident was maintained for one of seven sampled residents (Resident 3) in accordance with the facility's policy and procedures (P&P) titled Quality of Life -Dignity, revised 2/2025, by failing to maintain and protect residents privacy, including bodily privacy during assistance with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. This deficient practice violated the rights for privacy for Resident 3.Findings: A review of Resident 3's admission Record indicated the facility admitted Resident 3 on 7/22/2025 and the facility readmitted Resident 3 on 8/18/2025 with diagnoses including atrial fibrillation (a heart condition where the upper chambers of the heart beat irregularly and rapid causing racing sensation), diabetes mellites (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). A review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 10/29/2025, indicated Resident 3 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 3 required partial/moderate to dependency on staff with activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily). During an initial tour of the facility on 1/20/2026, at 9:23 A.M., Resident 3 was observed in bed and Certified Nursing Assistant (CNA) 3 was in the room assisting the resident with ADL care, while the privacy curtain was partially closed. CNA 3 then fully closed the curtain after seeing the surveyor. During an interview on 1/20/2026, at 9:23 A.M., with CNA 3, CNA 3 stated that she did not fully/completely close the privacy curtains when providing ADL care to Resident 3 and closed the privacy curtain when surveyor was in the room. CNA 3 stated that privacy curtains need to be fully closed all the way for privacy and dignity of the residents. During an interview on 1/23/2026, at 12:34 P.M., with the Director of Nursing (DON), the DON stated that facility staff need to pull the privacy curtain/s all the way when providing ADL care to the residents so that no other people can see the resident during care. The DON stated leaving the dignity curtain partially open may make the residents feel that their privacy has been invaded/violated. A review of the facility's P&P, titled, Quality of Life -Dignity, revised 2/2025, indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.Policy interpretation and implementation1. Residents are treated with dignity and respect at all times.4. Residents' private space and property are respected at all times.10. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview and record review, the facility failed to obtain physician's orders to treat and provide treatment to one of one sampled resident's (Resident 73) right and left buttock pressure ulcers from 1/9/2026 to 1/13/2026. This deficient practice placed Resident 73 at risk for worsening of the pressure injury and infection.Findings: A review of the Resident 73's admission Record indicated the facility admitted the resident on 1/9/2026, with diagnoses that included left femur fracture (broken thigh bone), pressure-induced tissue damage of left and right buttock and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) . A review of Resident 73's Admission/readmission Screener, dated 1/9/2026, indicated Resident 73 had pressure ulcer present and the screener indicated there was open areas on the resident's left and right buttocks. A review of Resident 73's pressure injuries care plan, created on 1/14/2026, indicated the resident had pressure injuries on the left and right buttock. The goal was for Resident 73's pressure ulcers will show signs of healing and remain free from infection. The interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) included to Administer treatments as ordered and monitor for effectiveness, monitor dressing every shift to ensure it is intact and adhering and follow facility policies/protocols for the prevention/treatment of skin breakdown. A review of Resident 73's Minimum Data Set (MDS - a resident assessment tool), dated 1/16/2026 indicated the resident's cognition was intact. The MDS indicated the resident required substantial assistance with showering, dressing and personal hygiene. The MDS indicated the resident was at risk to develop pressure injuries, had two unstageable pressure injuries. A review of Resident 73's Physician's Orders dated 1/13/2026, indicated the resident was to receive the following treatments:For the right buttock deep tissue injury (DTI) - cleanse area with normal saline (NS - is a mixture of salt and water), pat dry, apply Medihoney (medical-grade honey used to treat wounds) to open areas then follow with zinc barrier cream to surrounding areas then cover with dry clean dressing daily for 30 days and as needed for soiled or dislodged bandageFor the left buttock DTI - cleanse with NS, pat dry apply zinc barrier cream to wound bed then cover with dry clean dressing daily for 30 days every day shift for wound care During an interview and concurrent record review on 1/23/2026 at 8:06 AM, Resident 73's January 2026 Treatment admission Record (TAR - a log used by healthcare staff to track every treatment provided to a resident) was reviewed. Licensed Vocational Nurse (LVN) 5 stated Resident 73's right and left buttock pressure ulcers were present at admission on [DATE]. LVN 5 stated the nursing staff did not obtain treatment orders for the resident's wound at admission. LVN 5 stated physician orders were not obtained for Resident 73's pressure ulcers until LVN 5 returned to work. LVN 5 stated there was no documentation of Resident 73's wounds until 1/14/2026. LVN 5 stated the admitting nurse should have obtained orders for Resident 73's wounds when Resident 73 was admitted . LVN 5 also stated not providing wound care to Resident 73's pressures ulcers had the potential to lead to an infection of the wounds or the wounds becoming worse. During an interview on 1/23/2026 at 12:05 PM, the Director of Nursing (DON) stated Resident 73's right and left buttock pressure ulcers treatment orders should have been obtained upon Resident 73's admission. The DON stated not receiving orders meant the resident's wounds were not addressed and could lead to increased skin breakdown. A review of the facility's policy and procedures titled Pressure Ulcers/Skin Breakdown Clinical Protocol, revised 4/2025, indicated: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s).2. In addition, the nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width and depth, presenceof exudates or necrotic tissue;b. Pain assessment;c. Resident's mobility status;d. Current treatments, including support surfaces; ande. All active diagnoses.

Based on interview and record review, the facility failed to develop a comprehensive care plan for one of seven sampled residents (Resident 7) in accordance with the facility's policy and procedures (P&P) titled Care Plans, Comprehensive Person-Centered with revised date of 8/2025, by failing to have a care plan for Resident 7's apixaban (a medication that prevents dangerous blood clots from forming or getting bigger). This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 7. Findings: A review of Resident 7's admission Record indicated the facility admitted Resident7 on 6/2/2025 and readmitted Resident 7 on 10/28/2025 with diagnoses including paroxysmal atrial fibrillation (A-fib -irregular heartbeat where episodes start and stop suddenly), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and atherosclerosis of coronary (buildup of fats, cholesterol and other substances on the artery wall) artery bypass graft (surgery that restores blood flow to the heart by creating a detour around the blocked arteries). A review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 12/10/2025, indicated Resident 7 is cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 7 required supervisory/touch to setup/clean up assistance from staff with activities of daily living (ADL -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 7's order summary report with order date of 10/7/2025 and start date of 10/8/2025 indicated Apixaban oral tablet 5 milligrams (mg -unit of measure), give 1 tablet by mouth two times a day for A-fib. During a concurrent interview and record review, on 1/22/2026, at 2:22 P.M., with Registered Nurse Supervisor (RNS) 1, Resident 7's medical chart was reviewed. RNS 1 stated that Resident 7 did not have a care plan for the apixaban anticoagulant (blood thinner). RNS 1 stated that Resident 7 should have a care plan because the apixaban is an anticoagulant which places the residents at high risk for bleeding and if there are any sign and symptoms of bleeding they need to be reported to the doctor. RNS 1 stated the care plan is important because it allows the interdisciplinary team to know how to care for the resident, including their needs and preferences. RNS 1 stated she I will add the care plan now. During an interview, on 1/23/2026, at 12:38 P.M., with the Director of Nursing (DON), the DON stated that a care plan is a plan of care for the resident care in the facility. The DON stated that a care plan should be initiated upon admission, as needed, quarterly and annually. A care blood for the blood thinner is a guide on how the facility should care for the residents which includes monitoring and care approach. The DON stated that potential adverse effects of not having a care plan for a blood thinner is that care for a resident may not be coordinated and there is no guidance on the resident's care and Resident 7 should have a blood thinner care plan. A review of the facility's P&P, titled Care Plans, Comprehensive Person-Centered with review date of 8/2025 indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview and record review, the facility failed to provide one of three sampled residents (Resident 77) the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN - provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility). This deficient practice had the potential to result in the facility not giving Resident 77 the information needed to decide if he or she would like to continue or refuse receiving the specific skilled services and have those options honored. Findings: A review of the admission Record indicated the facility re-admitted Resident 77 on 5/13/2025 with diagnoses including difficulty walking, high blood pressure and lack of coordination. A review of Resident 77's SNF Beneficiary Protection Notification Review Form indicated the resident's last covered Medicare Part A Skilled Services was 8/12/2025. The form also indicated SNFABN form was not provided to the resident. A review of Resident 77's Transfer/Discharge Report indicated the facility discharged the resident on 9/26/2025. During an interview and record review on 1/23/2026 at 10:09 AM, the Social Services Director (SSD) stated Resident 77 was not given the SNF ABN. The SSD stated Resident 77's last covered day was 8/12/2025. The SSD further stated the facility discharged Resident 77 on 9/26/2025. During an interview on 1/23/2026 at 10:17 AM, the Minimum Data Set Coordinator (MDSC) stated Resident 77 was not given a SNF ABN form. The MDSC also stated Resident 77 should have received a SNF ABN form. The MDSC stated not receiving the SNF ABN may result in the resident not knowing about their right to appeal. During an interview on 1/23/2026 at 12:02 PM Director of Nursing (DON) stated beneficiary notices should be given when required. The DON further stated beneficiary notices tell residents of their right to appeal if not given, the may not know they have the right to appeal. A review of facility's policy and procedures (P&P) titled, Advance Beneficiary Notice, revised 5/13/2025, indicated advanced beneficiary notice of non coverage will be completed and delivered to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. The P&P also indicated Original Medicare Part A eligible residents will receive a SNF Advance Beneficiary Notice(SNF ABN) on the basis of the following exclusions:a. Not reasonable and necessary (medical necessity) for the diagnosis or treatment ofillness, injury, or to improve the functioning of a malformed body member;b. Custodial care (not a covered level of care);c. Services/items that may not be covered.

Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to report an allegation of suspected abuse to the correct agencies within the time frame specified by the facility policy.This deficient practice had the potential to leave Resident 1 at risk of further suspected alleged abuse.A review of Resident 1's admission Record indicated the facility admitted this [AGE] year old female on 12/1/2025 with diagnoses including spinal stenosis (narrowing of the spinal cavity), hyponatremia (low sodium in the blood), hydronephrosis with urethral stricture(condition causing urine to back up into the kidneys), venous insufficiency(damaged valves in veins cause blood to back up), adult failure to thrive (syndrome identified by decreased appetite, weight loss, physical inactivity and impaired physical function), chronic lymphocytic leukemia of b cell in remission (cancer of the blood that is not active), chronic kidney disease (irreversible kidney damage) and glaucoma (eye disease).A review of Resident 1's History and Physical (H&P- the physician assessment and plan of care) dated 12/4/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was intact.A review of Resident 1's Interdisciplinary Team Conference (IDT- meeting conducted with resident, family, nursing staff, rehabilitation and dietary staff to discuss the Resident 1's plan of care) note dated 12/3/2025, indicated Resident 1's family member (FM) was adamant about performing perineal care (the cleaning of the genital area) for Resident 1 when Resident 1 needed a diaper change. Both the Resident and the FM were informed that perineal care would be performed by trained staff members, and the FM could standby assist. The note indicated Resident 1 was agreeable to this plan.A review of Resident 1'a Minimum Data Set (MDS- a resident assessment tool) dated 12/4/2025 indicated Resident 1 was dependent (helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. In addition, Resident 1 was always incontinent (having no control) of bowel and bladder).On 12/8/2025 The California Department of Public Health (CDPH) received a report from the Adult Protective Services (APS) indicated the facility reported allegations of abuse to their department against the FM.During an interview on 12/9/2025 at 11:11am with the Registered Nurse (RN 1), RN 1stated on 12/6/2025 during the 3:00pm to 11:00pm shift was RN 1's first encounter with Resident 1 and the FM. RN 1 stated, I went to see Resident 1 when I got there, and Resident 1 seemed to be at Resident 1's baseline level of functioning that was reported to me during shift change. RN 1 stated at around 9:00 pm the FM requested to transfer Resident 1 to the general acute care hospital (GACH) alleging Resident 1 seemed lethargic and began to request them to give Resident 1 specific antibiotics (medications used to treat infection). RN 1 started at around 11:00pm, Resident 1 was assessed, and Resident 1 seemed lethargic, however it was late, and Resident 1 had been up all day and Resident 1's vital signs were normal. RN 1 called the attending physician and received an order to transfer Resident 1 to GACH; then arranged transportation. Transportation arrived and loaded Resident 1 onto the gurney (transport bed with wheels). At this time the Certified Nursing Assistant (CNA 1) informed RN 1 that earlier before CNA 1 went to change Resident 1's diaper, Resident 1 told CNA 1 that Resident 1 did not want the FM to perform perineal care during Resident 1's diaper change. CNA 1 went on to tell RN 1 during the diaper change; the FM was insistent, put on gloves and performed perineal care for Resident 1. CNA 1 stated the FM seemed to be wiping aggressively for a longer period than was necessary. RN 1 stated CNA 1 seemed very concerned. After which RN 1 went to the room where Resident 1 was on the gurney ready to go and the FM was at the bedside. RN 1 stated the FM would not step out for RN 1 to speak with Resident 1, so RN 1 was unable to interview Resident 1 nor assess Resident 1's perineal area. After Resident 1 left the facility at 11:30 pm RN 1 assured CNA 1 the incident would be reported. RN 1 then called APS and waited on hold for an hour and a half before no one answered. Then RN 1 called the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and no one answered. RN 1 came back to work the next day and called APS again and verbally reported then completed abuse report and faxed to their office. RN 1 stated the incident was reported to the Director of Nursing (DON) on the same day the verbal report was made to APS followed by the written report. RN 1 stated on the following Monday RN 1 was informed of a different reporting process; RN 1 was not sure how to report or to whom to report as RN 1 had never done the report before. RN 1 was told they usually go through the abuse coordinator, which RN 1 was not aware of who the abuse coordinator was.During an interview on 12/9/2025 at 12:30pm with CNA 1. CNA 1 started on 12/6/2025 before dinner CNA 1 asked Resident 1 if Resident 1 was wet and needed to be changed and Resident 1 said no. The FM arrived during dinner, then after dinner, CNA 1 asked Resident 1 if Resident 1 needed to be changed and the FM said yes and stepped out of the room to speak with the unnamed charge nurse. While the FM was out of the room CNA 1 asked Resident 1 if Resident 1 was okay with FM being present during the diaper change and Resident 1 stated no. CNA 1 then asked the FM to stay out of the room until the change was done, and the FM questioned why. CNA 1 did not feel comfortable telling the FM that Resident 1 did not want the FM there; so, CNA 1 stated, I can do it faster. The FM stated, no I don't let anyone do it alone I'm going to help you. Then the FM put on gloves and started to perform perineal care for Resident 1. CNA 1 stated that during the cleaning Resident 1 was having diarrhea and Resident 1 stated, no please stop you are hurting me to which the FM replied, no, I'm not going to stop because you are not clean, and you will get a urinary tract infection. CNA 1 stated that Resident 1 then became quiet and stopped talking. CNA 1 stated Resident 1's perineal area appeared very red and irritated possibly from a history of the aggressive wiping. CNA 1 stated, I did tell the RN that I suspected abuse because the resident (Resident 1) did not want [the FM] to do the perineal care, then once the FM was doing the perineal care Resident 1 asked the FM to stop wiping because it was hurting and the FM would not stop.During a concurrent interview and record review on 12/10/2025 at 2:03pm with the Director of Social Services (DSS), Resident 1's Report of Suspected Dependent Elder Abuse dated 12/7/2025 was reviewed. The Report of Suspected Elder Abuse from indicated physical abuse was reported with the alleged suspected listed as the FM. A telephone report was made to APS and the local Ombudsman as well as faxed. The DSS stated on the following Monday the DON informed the DSS that this report was made and sent out over the weekend. The DSS stated, I called APS to let them know there was a misunderstanding of the situation. The DSS went on to say during Resident 1's IDT meeting, the FM informed staff that the FM would do the perineal care for Resident 1 to ensure Resident 1 does not get an infection. The DSS stated, I was told the report was filed because [the FM] was performing the perineal care for Resident 1. The DSS stated, the form said physical abuse to assume that is what it was for. The DSS went on to say, I was not aware of [the FM] performing the perineal care roughly and the Resident asked [the FM] to stop, and [the FM] did not stop; that is a different situation, and I would have reported that as well. The DSS stated, That should have been reported to the DON and the Administrator (Adm) immediately as well as the Ombudsman and the police should have been called.During an interview on 12/10/2025 at 2:28pm with the Adm. The Adm stated, The nurse thought it was an act of abuse when [the FM] performed perineal care for Resident 1 and that is why the Elder abuse form was competed.During an interview on 12/10/2025 at 2:30pm with the DON. The DON stated, I spoke to the CNA yesterday and asked if [the FM] did anything unusual and that was when the CNA told me that [Resident 1] did not want [the FM] to do the perineal care but [the FM] did it anyway, and then the FM would not stop when Resident 1 asked because it was causing Resident 1 pain. The DON stated allegations of abuse should be reported right away to the abuse coordinator who is the administrator and the DON. The DON stated then the incident needed to be investigated, and the police should have been notified according to their policy.A review of the facility policy and procedure titled, Abuse Prevention and Prohibition Program, adopted 10/2022, indicatedIX Reporting/ResponseA. Facility Staff are Mandatory Reportersi. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and the California Elder Abuse and Dependent Adult Civil Protection Act to report known or suspected instances of abuse of elder or dependent adults.ii. The Facility will not impede or inhibit a Facility Staff member's reporting duties, nor will Facility Staff be reprimanded or disciplined for reporting abuse.iii. The Facility has a strict non-retaliation policy for good faith reporting in compliance with the Elder Justice Act and the Elder Abuse and Dependent Adult Civil Protection Act.iv. Failure to report suspected or known abuse may result in legal action against theindividual(s) withholding such information.B. Administrator, or his/her designee, as Abuse CoordinatorIn order to facilitate reporting, ensure confidentiality, and promote order at the facility, the Administrator, or his/her designees, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities.Facility staff will report known or suspected instances of abuse to the Administrator. Or his/her designee.Facility staff members shall be notified that the Administrator, or his/her designee, has the responsibility and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee.All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering.The Facility will report allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown sources, misappropriation of resident property, or other incidents that qualify as a crime.Immediately, but no later than 2 hours after forming the suspicion - if the allegedviolation involves abuse or results in serious bodily injury to the state surveyagency, adult protective services, law enforcement, and the Ombudsman. See AN- 01- Form G -Crosswalk of Abuse Reporting Requirements.ii. No later than 24 hours - if the alleged violation (e.g., misappropriation ofproperty, neglect) does not involve abuse and does not result in serious bodilyinjury to the state survey agency, adult protective services, law enforcement, andthe Ombudsman. See AN-01- Form G -Crosswalk of Abuse ReportingRequirements.i. Reporting requirements are based on real (clock) time, not business hours.ii. The administrator will provide the state survey agency, law enforcement and theOmbudsman with a copy of the investigative report within 5 days of the incident.i. If a resident experienced or alleges an instance of abuse at a location other than the Facility, the Administrator, or his/her designee, shall report the instance of abuse to Adult Protective Services agency and the local law enforcement agency.ii. The resident's attending physician and responsible party, if applicable, will also be notified of the of the allegation and outcome of the investigation.iii. Failure to file a report within the required time frames may result in disciplinary action, up to and including termination.i. A telephone or internet report of known or suspected instance of elder or dependent adult abuse shall include the following information, if known:I. The name of the person making the report;II. The name and age of the resident;III. The present location of the resident; members, or any other adult responsible for the resident's care;V. The nature and extent of the resident's condition;The date of the incident.

Based on observation, interview, and record review, the facility failed to display and provide a copy of the current Administrators license as per regulation. This failure had the potential for residents, families, and Department of Public Health to be provided the wrong information regarding the current Administrator. Findings: During an unannounced visit tour and observation of the facility on 3/18/2025 at 11:20 a.m., the facility posted the license of a former Administrator and did not the license of the current Administrator. During an interview on 3/19/2025 at 10:57 a.m., Administrator stated he did not have a current copy of his Administrators License because the license was mailed to the wrong address and had no way of printing another copy. Administrator stated he has only been employed with the facility for 1 month. Administrator stated he is aware that his Administrators license is supposed to be posted on the first day of employment. Administrator stated if the current Administrator ' s License is not posted the staff, residents ' family, or Department of Public Health will not know who the current Administrator is. During a record review of a letter that was sent to the Department of Public Health dated 2/19/2025, indicated, effective 1/29/2025 Administrator was the Administrator of the facility. During an interview on 3/18/2025 at 5:11 p.m., Director of Medical records stated the facility does not have a policy for Administrator.

The facility failed to take the appropriate corrective action to address grievances for two of two sampled residents (Residents 1 and 2) when: 1. Resident 1 complained about a missing cellphone and clothing 2. Resident 2 complained about missing clothing. 3. Facility failed to complete inventory list for Resident 1 upon admission to the facility. 4. The facility failed to investigate reports of missing property for Residents 1 and 2. As a result: 1. Resident 1 was angry about missing clothing and cellphone, and felt disconnected from the outside world 2. Resident 2 was angry about missing clothing. Findings: 1. During a record review, Resident 1's Admission Record indicated Resident 1 (Resident 2's roommate) was readmitted to the facility on [DATE], with the diagnoses of cognitive communication deficit (difficulties in communication arising from impairments in cognitive process like attention, memory, and executive functions), and generalized muscle weakness (lack of physical or muscle strength throughout the body). During a record review, Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/8/2025, indicated Resident 1s [cognitive skills- the core skills your brain uses to think, read, learn, remember, reason, and pay attention] for daily decision making was intact. The MDS further indicated Resident 1 needed moderate to substantial/maximal assistance with ADL's (bathing, showering, toileting, and mobility). During an observation, interview, and concurrent record on 3/18/2025 from 12:52 p.m., Resident 1 in his room sitting in a wheelchair. Resident 1 stated approximately a week ago a certified nursing assistant (CNA-unable to recall the mane) was his bed linen, and the CNA rolled his personal cell phone up in the linen and took the linen and the cellphone to the laundry. Resident 1 stated the cell phone got damaged and was no longer working. Resident 1 stated he has been requesting to speak to the social worker for about 6 or 7 days, but the social worker will not come and talk with the resident about replacing the cellphone and multiple missing clothing. Resident 1 stated his 2 pairs of blue jean pants, 1 pair of beige casual pants, 4 sets of sweat suits black, blue, burgundy, and brown, 1 pair of special white tennis shoes, 4 pair of underwear (stated he can't remember the color), 6 pairs of white diabetic socks, and 1 pair of metal frame glasses were missing. During a record review, Resident 1's medical chart indicated there was no inventory list developed/created for Resident 1. During an interview on 3/18/2025 at 1:35 p.m., certified nursing assistant (CNA) 2 stated a resident inventory list is supposed to be completed by a CNA or a License Nurse on the date of admission. CNA 2 Stated if a resident reports missing clothing, CNA 2 she checks with the laundry first and then reports about missing clothing to the LVN Charge Nurse if unable to find the resident's missing clothing. During an interview on 3/18/2025 at 3 p.m., Director of Social Service (DSS) stated Resident 1 reported to more than one facility staff that a CNA rolled the resident's cellphone up in bedsheets and that the cellphone got washed in the laundry, and about missing clothing, shoes, and eyeglasses. DSS stated the facility is going to replace Resident 1's cellphone and will follow up with Resident 1 about the missing clothing, shoes, and eyeglasses. DSS stated she did not document in Resident 1 ' s chart about the arrangements for the replacement of his cell phone. During an interview and concurrent record review on 3/18/2025 at 5:11 p.m., with Director of Medical Records (DMR), DMR stated there was no inventory list in Resident 1's medical chart. 2. During a record review, Resident 2's Admission Record indicated Resident 2 (Resident 1's roommate) was readmitted to the facility on [DATE], with diagnoses of obstructive sleep apnea (breathing is interrupted during sleep), and type 2 diabetes melliltus with hyperglycemia (a condition where your body either doesn't produce enough insulin or can't properly use the insulin it does produce, leading to high blood sugar levels). During a record review, Resident 2's MDS dated [DATE], indicated Resident 2 cognitive skills was moderately intact. During an observation and interview on 3/18/2025 at 1:15 p.m., Resident 2 (roommate for Resident 1) noted in his room sitting up on the side of the bed. Resident 2 stated his 2 pair of khaki pants, 2 dress shirts blue and yellow, 3 pair of white underwear, 3 pair of white diabetic socks, 1 grey sweatpants, and 2 pair of athletic shorts were missing. Resident 2 stated he has requested to speak with the social worker for over a month about his missing clothing and follow up doctor ' s appointments at the Veterans Hospital, however, the social worker has not come to talk to him. Resident 2 stated he is angry because his missing clothing having missed his follow-up doctor's appointments. During an interview on 3/18/2025 at 3 p.m., DSS stated DSS will follow up with Resident 2 about the missing clothing items. During an interview on 3/19/2025 at 10:27 a.m., Administrator stated he was not informed of the missing clothing, shoes, and eyeglasses for Resident 1 nor was Administrator aware of missing clothing items for Resident 2. During an interview on 3/19/2025 at 3:26 p.m., Director of Nursing (DON) stated she was not aware about Resident 1's damaged cell phone or missing clothing items, shoes, and eyeglasses, or Resident 2's missing clothing items. DON stated that upon a resident's admission, the CNA assigned to the resident along with the license nurse are supposed to complete the resident inventory list. DON stated she will follow up on Residents 1 and 2 's missing personal belongings and cell phone replacement. During a record review, the facility policy and procedures titled Theft Prevention dated 1/25/2022, indicated: . Purpose: To assist residents in safeguarding their personal property. Policy: The facility is committed to preventing the misappropriation of resident property. The facility will exercise reasonable care for the protection of the resident ' s property from theft or loss. The facility investigates all reports of lost or stolen property. Upon admission, facility staff provides the resident sections of the health and safety code. All inquires regarding lost or stolen items are reported to the administrator. During a record review, the facility policy and procedures titled Residents Rights-Personal Property revised on 5/1/2023, indicated: . Procedure: V. the Resident ' s personal belongings and clothing are inventoried and documented upon admission. Vl. Facility failed to promptly investigate any complaints of misappropriation, theft, or mistreatment of resident property.

Based on observation, interview, and record review, for one of three sampled residents (Resident 1), facility failed to: 1. Monitored and supervised Resident 1 to prevent elopement (the act of leaving a facility unsupervised and without prior authorization). 2. Ensure the alarm system was functioning on two of five exits doors (Door C- [south side exit door leading to the front of the facility] and Door E [northside door, at the back of the facility leading to the alley]) to alert staff if a resident was eloping and or exiting the facility. 3. Ensure the alarm system was activated/functional on one of five exit doors (Door D- northside back of the facility exit door leading to the side street). 4. Ensure that the alarm system was checked for proper functionality for five of five exit doors. 5. Ensure that Resident 1's care plan was resident specific for possible elopement. These deficient practices resulted in Resident 1 eloping from the facility on 2/27/2025, at 1:40 P.M., placing the resident at increased risk for extreme weather conditions, medical emergencies, accidents, injuries, hospitalization , and/or death. Findings: During a record review, Resident 1's Admission Record indicated the facility admitted Resident 1 on 1/10/2025 with diagnoses including epilepsy (a brain disorder that causes seizure which are abnormal electrical surges in the brain), cardiac pacemaker (a small battery powered device that prevents the heart from beating too slowly), and hypertension (HTN - elevated blood pressure). During a record review, Resident 1's care plan date initiated 1/14/2025, indicated Resident 1 had a history of ETOH (ethyl alcohol -a type of alcohol found on alcoholic beverages) abuse and withdrawal. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 1/17/2025, indicated Resident 1 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required substantial/maximal staff assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review, Resident 1's physician orders dated 1/10/2025 indicated that Resident 1 may go out on pass with responsible party for therapeutic purposes. During a record review, Resident 1's Situation, Background, Assessment, Recommendation (SBAR - situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 2/27/2025 indicated the Infection Preventionist Nurse (IPN) documented that on 2/27/2025 at 1:10 P.M., Certified Nursing Assistant (CNA) 1 saw Resident 1 in the facility lobby. The SBAR indicated that on 2/27/2025 at 1:55 P.M., CNA 1 informed LVN 1 that Resident 1 was out of the facility and LVN 1 then alerted an unidentified facility staff. LVN 1 and the other checked the vicinity and when they could not find Resident 1, LVN 1 and the facility staff went outside the building (facility) and asked the [NAME] (VT) staff if VT had seen Resident 1. The SBAR indicated VT stated that on 2/27/2025 at 1:40 P.M., [NAME] staff (use identifier) saw Resident 1 walking towards the street by the facility and was heading towards the nearby stores. The SBAR also indicated that facility staff (unidentified) checked nearby streets and stores, however, Resident 1's was nowhere to be found. The SBAR indicated the facility also called Resident 1's phone number which went to voicemail. An unidentified facility staff also called Resident 1's family member (FM) emergency contact who said that FM did not know where Resident 1 was. The SBAR further indicated that facility staff called the police, the nearby hospitals and were told that Resident 1 was not with the police or the nearby hospitals. The SBAR further indicated that the facility staff will continue to search for Resident 1. During a record review, Resident 1's Nursing Progress Notes dated 2/28/2025 at 6:48 A.M., indicated, Licensed Vocation Nurse (LVN) 2 documented that on 2/28/2025 at 12 A.M., a staff (unknown) notified the facility that on the way home staff spotted Resident 1 on the street a few blocks away from the facility. The Nursing progress note further indicated that unidentified two staff members went to bring Resident 1 back to the facility. During a record review, Resident 1's Physician's Orders dated 2/28/2025, indicated a physician ordered STAT (STAT -immediate) CBC (CBC -comprehensive blood count [blood work that checks for different types and numbers of cells in the blood]), CMP (CMP -comprehensive metabolic panel [blood test that measures proteins, enzymes, electrolytes, minerals and other substances in the body]) and alcohol levels. During an interview on 2/28/2025, at 2:50 P.M., Resident 1 stated that on 2/27/2025 (unable to remember the time), Resident 1 sneaked out through the main door in the facility lobby. Resident 1 stated they was a crowd of people in the lobby and that is when Resident 1 sneaked out of the facility. During an interview on 2/28/2025, at 3:34 P.M., CNA1 stated CNA 1 last saw Resident 1 on 2/27/2025 at around 1:15 P.M. maybe 1:20 P.M., and that Resident 1 told CNA 1 that Resident 1 was going to the lobby area for a change of scenery (how the place looks). CNA 1 stated that on 2/27/2025 at around 1:30 P.M. maybe 1:40 P.M, CNA 1 went to look for Resident 1 and was not able to find Resident 1 in the facility and immediately notified LVN 1 that Resident 1 was missing. During an interview on 2/28/2025, at 3:57 P.M., LVN 1 stated LVN 1 last saw Resident 1 in his room on 2/27/2025 at around 12 P.M. maybe 1 P.M, during medication pass/administration. LVN 1 stated that on 2/27/2025 at around 1:30 P.M., CNA 1 reported to LVN 1 that Resident 1 was gone, and could not be found. LVN 1 further stated that LVN 1, CNA 1, and other facility staff looked for Resident 1 inside the entire facility and outside the facility but were not able to find Resident 1. LVN 1 stated facility staff including the Facility Administrator (FA) asked the if VT had seen Resident 1. The VT said that on 2/27/2025, at 1:40 P.M., VT saw Resident 1 walking towards the street in front of the facility and was heading towards the nearby stores. LVN 1 stated the facility staff said it had been five minutes maybe seven minutes since the VT last saw Resident 1. LVN 1 stated the VT did not alert/notify LVN 1 that Resident 1 had left the facility building. LVN 1 stated facility staff including LVN 1 searched the surround neighborhood, called nearby hospitals and called Resident 1's phone but Resident 1 was nowhere to be found. LVN 1 stated LVN 1 went home at around 3:50 P.M. maybe 4 P.M., but Resident 1 had not been found. LVN 1 stated that on 2/27/2025, a staff member (unknown) found Resident 1 at a nearby store and called the facility. During a telephone interview on 3/1/2025, at 10:55 A.M., Receptionist (RP) 1 stated RP 1 worked on 2/27/2025. RP 1 stated that on 2/27/2025 at around 2 P.M. maybe 2:30 P.M., LVN 1 informed RP 1 that Resident 1 was not in the facility. RP 1 stated on 2/27/2025 RP 1 went on a lunch break and returned between 12:10 P.M., and 12;15 P.M., and did not see Resident 1 leave the facility. RP 1 stated RP 1 was not sure what RP 1 was doing when Resident 1 was reported missing or having left the facility. RP 1 stated RP 1 may have been assisting another resident, taking a telephone message, or answering the phone. RP 1 stated RP 1 may have gone to a nursing station to deliver a telephone note because the facility staff do not answer the phones when she calls the nursing stations which happens a lot. RP 1 stated RP 1 will leave the front desk without any coverage to deliver the notes to the nursing stations. During a concurrent observation of the facility five exit doors and interview on 3/1/2025, at 12:57 P.M., with the Facility Administrator (FA) and the Registered Nurse Supervisor (RNS), the facility following exit doors did not alarm on exit: 1. Exit door (Door B) on the southside leading to the front of the facility, 2. Exit door (Door D) on the southside of the facility leading to the side street to the facility, 3. Exit door (Door E) on the northside of the facility leading to the back alley (door E). The FA stated Door B has an alarm system that needs to ring when pushed, however, when FA pushed the Door B open, the door opened but did not alarm. FA stated Door B should alarm when pushed open so that when a resident is leaving the facility, facility staff is/are alerted. FA stated failure for the door to alarm when pushed open makes that door a safety risk that can lead to residents wandering, falling, and suffer hypothermia with the cold weather at night. FA stated the exit Door D did not have an alarm system on the door because resident use the small patio by the door to smoke. FA stated there is a small gate that is about two and half feet (ft -unit of length measure) maybe three ft tall and a person that is tall enough may be able to hop over the gate and wander off. RNS stated Door E has an alarm system on the door, however, when the surveyor and RNS pushed the door open, the door did not alarm. RNS stated Inservice for door not alarming was going to be provided to the staff because Door E was not locked, and the alarm was off/not on. RNS stated Door E leads to the alley in the back of the facility and that the door needs to be closed and alarm is on at all times to avoid residents from going out the facility without supervision. RNS stated residents may wander, get lost, get hurt, fall, or get hit by a car. During a record review, the facility 5-Day Summary undated report, indicated that on 2/27/2025 at around 11:30 P.M., a staff (unidentified) spotted Resident 1 at two blocks from the facility and notified the facility. Two staff members brought Resident 1 back to the facility . The 5-Day Summary report indicated In-services for elopement, door alarms and resident safety started on 2/28/2025 . Logs for door alarm checks created and will be kept daily. During a concurrent interview and record review, on 3/1/2025, at 1:55 P.M., with RNS, Resident 1's medical chart was reviewed. The RNS stated the facility process is that immediately on an admission, the Registered Nurse conducts a standalone elopement assessment on every resident and also to assess the residents' current health conditions or diagnosis history that may place a resident to be at risk for elopement. RNS stated the facility did not complete/conduct elopement assessment for Resident 1 on admission, 1/10/2025. RNS stated elopement assessment was completed only after Resident 1 eloped on 2/27/2024. RNS stated Resident 1 had a history of ETOH abuse withdrawal which could pose as a risk factor for Resident 1 to elope from the facility because of craving alcohol. RNS stated Resident 1 should have been monitored closely for possible elopement which was not included in Resident 1's care plan. During an interview on 3/1/2025, at 2:40 P.M., FA stated facility does not have any documented evidence that indicated when the facility checked if the five exits door alarms were functional/operational. FA stated the facility should have a log to show that the exit door alarms are in proper working condition. FA stated if the exit doors do not alarm and or not working condition, could result in residents leaving the facility without staff being aware. During a record review if the facility's policy and procedure (P&P), titled, Door Alarm System, revised 10/16/2024, indicated, the skilled nursing facility will maintain a fully functional alarm system to enhance resident safety and prevent unauthorized exits. Procedure: 1. System Maintenance and Testing a. The door alarm system will be tested daily to ensure functionality. b. Any malfunctioning alarms must be reported immediately to the maintenance department for repair. 3. Resident Safety and Supervision b. Staff must ensure that all exit doors are monitored, and alarms are on at all times Compliance: Failure to adhere to this policy may result in disciplinary action in accordance with facility regulations. Regular audits will be conducted to ensure compliance and effectiveness of the door alarm system. During a record review, the facility P&P, titled, Maintenance Services, revised 10/16/2024, indicated: 1. The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times 8. The Maintenance Department is responsible for maintaining the following reports a. Inspection of building. During a record review, the facility P&P, titled, Wandering and elopement, revised 10/2024, indicated, the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observation, interview, and record review for one of three sampled residents, Resident 2. The facility failed to waste an Ativan (medication used to treat anxiety) 0.5 mg(milligrams) per facility-controlled narcotic (a medication tightly controlled by the government because it may be abused or cause addiction) protocol. This deficient practice resulted in an inaccurate Ativan 0.5mg count for Resident 2. Findings: During record review, Resident 2's Admission Record indicated the facility admitted Resident 2 on 1/15/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), epilepsy (a condition that causes sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), displaced left femur fracture (broken thigh bone), dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), overactive bladder (problem that causes sudden need to urinate), hyperlipidemia (high fat in the blood), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), gastroesophageal reflux disease (indigestion/heartburn), Anxiety (a mental condition of constant worry or fear for unknown reason) presence of cardiac pacemaker. During record review, Resident 2's Physician Order dated 1/15/2025 indicated Ativan 0.5mg, give 1 tablet four times a day for anxiety manifested by inability to relax due to current medical condition. During record review, Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 1/22/2025 indicated Resident 2's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 2 required maximal assistance (helper does less than half the effort. Helper lifts or holds trunk or limb and provides more than half the effort to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. On 2/18/2025 the California Department of Public Health (CDPH) received a complaint alleging narcotic medications intended for residents have gone missing during the day shift. During a concurrent observation, interview, and record review on 2/24/2025 from 11:08 a.m. with the licensed vocational nurse (LVN) at Station # (number) 1 of medication cart #1, Resident 2's Ativan 0.5mg bubble pack was observed with 31 pills. The LVN stated, Oh, I gave one (Ativan 0.5 mg) this morning that is why there are 31 pills left. Resident 2s' controlled medication count sheet for Ativan 0.5mg was reviewed. A circle was observed around #33 on Resident 2's-controlled medication count sheet for Ativan 0.5mg. Also, there was no date or time next to the circle around the #33. The LVN stated, That means there should be 33 pills left. I gave one (tablet) to the resident this morning and I have not documented yet and I dropped one during the count with the off going unnamed nurse that I forgot to waste. The LVN then signed Resident 2s' controlled medication count sheet for Ativan 0.5mg the date and time next to #33. The LVN then took the sheet to another charge nurse at the nursing station and had that charge nurse sign Resident 2's-controlled medication count sheet for Ativan 0.5 mg. The LVN stated, The waste (Ativan) needs to be signed by two licensed nurses. During record review, Resident 2's medication administration record (MAR- a form where medications are documented after they are given) dated 2/24/2025 for Ativan 0.5mg timed 9:00a.m. was blank. During an interview on 2/24/2025 at 12 p.m., the Director of Nursing (DON) stated, Narcotic waste should be witnessed and signed by two licensed nurses. In this case, the LVN should have reported the forgotten waste (Ativan) to the DON and the DON could have called the unnamed off going nurse (charge nurse who co-signed for the Ativan waste) to verify the waste. During record review, the facility policy, and procedures (P&P) titled, Medication Administration dated 1/25/2022 indicated, the time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administered the drug. During record review, the facility P&P titled, Discarding and Destroying Medications , dated 10/2024 indicated: For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses. d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least two witnesses.

Based on interview and record review, for one of three sampled residents (Resident 2), the facility failed to: 1. Follow up and ensure that a physician ordered oxycodone-APAP (controlled medication used to manage moderate to severe pain). 2. Administer Oxycodone-APAP to Resident 2 for 18 of 54 days, The facility was aware Resident 2 had verbalized and was experiencing eight out of 10 (8/10 - numerical pain assessment tool where 0 is no pain and 10 being the worst pain) pain level in both shoulders, neck, and the back. As a result, Resident 2 experienced pain, frustration, and was unable to attend/participate in activities. Findings: During a review of the admission record for Resident 2 indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cervical disc disorder at cervical 6 (C6-neck bone) to C7 level with radiculopathy (also known as pinched nerve is a condition that results in radiating pain, weakness and/or numbness caused by compression of any of the nerve roots in your neck), non-Hodgkin lymphoma (a type of cancer that affects the lymphatic system [immune system] that grow out of control and can form tumors throughout the body), rotator cuff tear of left shoulder (rupture of tendons - tough, fibrous, cord-like tissue that connects muscle to bone or another structure). During a review of a history and physical (a term used to describe a physician's examination of a patient) for Resident 2 dated 10/1/2024 indicated, Resident 2 was alert and oriented to person, place, and time and mental status was at baseline. The H&P indicated Resident 2 had chronic (ongoing) neck pain . During a review of a physician order dated 10/1/2024 indicated to administer to Resident 2, oxycodone-Acetaminophen Oral Tablet 5-325 MG (Oxycodone with Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Moderate Pain 4-7 NTE (not to exceed) 3gms (grams - a unit of measurement for the weight of medicine in a tablet or capsule)/APAP (acetaminophen, medication for pain and fever) 24hrs, and Hold for RR (respiratory rate) <(less than) 12. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/8/2025, indicated Resident 2 had moderate cognitive impairment (a stage of cognitive decline that affects short-term memory and the ability to complete complex tasks). The same MDS indicated Resident 2 required between setup or clean assistant and substantial/maximum assistance for his Activities of Daily Living such as: (ADLs- routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). The same MDS indicated Resident 2 experienced occasional moderate pain. During a review of a physician order dated 1/23/2025 indicated the facility to monitor and assess level of pain before, during, and after administration of treatment using pain scale as follows: zero (0)- No pain; 1-3 mild pain; 4-7 moderate pain; and 8-10 sever pain every shift. During an interview on 1/23/2025 at 11:18 am, Resident 2 stated that nursing staff had not consistently given him pain medication. Resident 2 stated he had 3/10 pain level in both his shoulders, neck, and the back. Resident 2 stated there were several occasions where he so much pain (8/10) and needed to take the oxycodone-APAP but the nursing staff would tell him that the pharmacy did not have the oxycodone-APAP in stock. Resident 2 stated he felt frustrated because the doctor ordered the oxycodone-APAP, but the pharmacy did not have it. Resident 2 stated that he had suggested to the nursing staff to take his prescription for the oxycodone-APAP to another pharmacy, but the nurses did not heed his suggestion. Resident 2 stated that he was able to sleep well but was unable to participate in activities due to the pain. During a concurrent interview and record review of the Medication Administration Record (MAR) for 12/ 2024 and 1/2025 for Resident 2 with Licensed Vocational Nurse (LVN) 1 on 1/23/25 at 1:57 pm, LVN 1 confirmed and stated that the pharmacy did not send the oxycodone/APAP for 18 out of 54 days because the pharmacy had not receive authorization from the ordering physician. LVN 1 stated medications must be ordered before the current medication stock runs out. LVN 1 stated nursing must also call the physician ordering the medication to ensure that authorization for the ordered medication is completed and refilled promptly/timely. LVN 1 confirmed and stated there was no documented evidence that the a physician was informed that Resident 2 had run out of oxycodone-APAP which required urgent attention to have the authorization completed. LVN 1 confirmed and stated that Resident 2 was not administered oxycodone-APAP on the following days: 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/11/24, 12/12/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 1/7/25, 1/8/25, 1/17/25, and 1/20/25. LVN 1 stated that same MAR indicated Resident 2 experienced pain levels range between four out of 10 (4/10-numerical pain assessment where 0 is no pain and 10 is severe pain) and 8/10 on the days Resident 2 received/administered oxycodone-APAP. There was no documented evidence that Resident 2 was assessed for pain on the aforementioned dates and that Resident 2 did not receive pain Oxycodone-APAP for pain. LVN 1 admitted and stated that not ordering and having oxycodone-APAP in stock could lead to Resident 2 experiencing unnecessary pain. LVN 1 admitted that Resident 2 did not participate in activities when he was in pain. During an interview with Registered Nurse Supervisor (RNS) 1 on 1/23/25 at 2:15 pm, RNS 1 stated that in addition to calling in the medications at the pharmacy, nursing staff must reach out to the prescribing physician to ensure prompt authorization of the prescribed medication to avoid medication administration disruption which can result in unnecessary pain. During a concurrent interview and record review of Resident 2's MARs for December 2024 and January 2025 with the Director of Nursing (DON) on 1/23/25 at 4 pm, the DON confirmed and stated the facility did not administer oxycodone-APAP for pain to Resident 2. on the following dates: 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/11/24, 12/12/24, 12/23/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24,1/7/25,1/8/25,1/17/25, and 1/20/25. The DON stated medications must be ordered from the pharmacy before the medication completely runs out. The DON stated nursing must follow up with the pharmacy on the status for medication/s refill and contact the prescribing physician immediately if the issue is related to medication authorization. The DON stated that failure to administer pain medication to a resident experiencing pain can result in the resident suffering unnecessary pain. The DON was unable to provide the oxycodone-APAP pharmacy medication delivery receipts. As of 1/31/2025, the facility did not provide documented evidence/receipts that the pharmacy delivered oxycodone-APAP for Resident 2. During a review of a Policy and Procedures (P&P) titled Pain Management. Reviewed on 10/16/24 indicated, To ensure accurate assessment and management of the resident's pain. A Licensed Nurse will assess residents for pain on admission and routinely as indicated by the resident's health and functional status. Facility Staff is responsible for helping the resident attain or maintain the highest level of well-being while working to prevent or manage the resident's pain. The same P&P indicated under pain management which included the following: -The Licensed Nurse will administer pain medication as ordered and document al medication administered on the Medication Administration Record (MAR). -The Licensed Nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale. i. The shift pain score will indicate the highest pain level that occurred on that shift. During a review of the facility P&P titled, PREPARATION AND GENERAL GUIDELINES, reviewed on 10/16/24 indicated, if a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g., other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit.

Based on interview and record review, the facility failed to ensure that a pre-admission screening Resident Review level I(PASRR -an evaluation to determine if an induvial has a serious mental illness, intellectual disability, developmental disability, or related condition) was obtained and maintained in the residents chart for one of five sampled residents (Resident 61). This deficient practice had the potential to negatively affect the appropriated care and services rendered to the resident. Findings: During a review of Resident 61's Admission Record indicated the facility admitted Resident 61 on 10/10/2024 with diagnoses including Bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) During a review of Resident 61's Minimum Data Set (MDS - a resident assessment tool) dated 10/12/2024, indicated Resident 61 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 61 required substantial maximal assistance to dependency on staff assist for bed mobility, dressing and transfers. During a concurrent interview and record review, on 11/30/2024, at 8:55 A.M., with the Social Services Director (SSD), the facility's policy and procedures (P&P) titled Resident Assessment -Coordination with PASARR Program, dated 6/22/2023 was reviewed. The P&P indicated 6. The Social Services Director or Admissions shall be responsible for keeping track of each residents PASARR screening status, and referring to the appropriate authority. SSD stated she was not aware if Resident 61 had a PASRR I have not been doing the PASRR's, I am not familiar with it. SSD further that if a mental health screening was not done on Resident 61 who has mental health diagnosis, then Resident 61's mental health needs may not be getting met. During a concurrent interview and record review, on 11/30/2024, at 9:22 A.M., with the Admission's Director (AD), Resident 61' chart was reviewed. The AD stated facility process for Resident that have a mental illness, the hospital needs to send a PASRR level I with their clinical records for screening prior to be accepted into the facility, it (PASRR) is a requirement for resident admission to the facility. AD stated the PASARR would be in the resident's admission packet or clinical form in the resident electronic chart under the miscellaneous tab, AD states there is nowhere else the PASRR would be except in the location. AD stated there was no documented evidence that Resident 61 had a PASRR level I on file. AD further stated, a PASRR level I should have been obtained from the hospital prior to Resident 61's admission so that the nurses will know their (Resident 61) mental capacity to know how to care for him when he comes to the facility. During an interview on 11/30/2024, at 11:29 A.M., the Director of Nursing (DON) stated, I cannot find the PASRR. It should be on the resident chart. PASRR is part of the admission process to check if the resident had a need to Psychologist consult for mental health. DON further stated, missing a PASRR on the resident leads to not addressing the resident's mental issues regarding the mental care if the resident. During a review of the facility's P&P titled, Resident Assessment -Coordination with PASARR Program, dated 6/22/2023, indicated, Policy: The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and compliance guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States Medicaid rules for screening . 3. A record of the prescreening shall be maintained in the residents medical chart . 6. The Social Services Director or Admissions shall be responsible for keeping track of each residents PASARR screening status, and referring to the appropriate authority.

Based on observation, interview, and record review, the facility failed to apply neck brace at all times to Resident 122 according to the physician's order. Resident 122 was admitted to the facility with displaced fracture of second cervical vertebra (a broken bone in the neck), This failure had the potential to cause further injury and pain to Resident 122. Findings: During a review of Resident 122's Admission Record indicated Resident 122 was admitted to the facility on [DATE] with a diagnosis of, but not limited to displaced fracture of second cervical vertebra, and abnormalities of gait and mobility (the inability to walk normal). During an observation on 11/29/24 at 9:35 am, with Physical Therapist (PT, a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery) and RN 3, Resident 122 lying in bed without neck brace in place. A neck brace was noted next to Resident 122 and not on the resident's neck. During record review, Resident 122's care plan dated 11/26/24 indicated Resident 122 to wear cervical collar related to C2 (second vertebra of the spine) cervical vertebra fracture. During a review of Resident 122's physician orders with a late entry date of 11/29/24 indicated Resident 122 to wear cervical collar at all times. During an interview on 11/29/24 at 9:35 am, PT stated Resident 122, is supposed to wear the neck brace at all times. PT stated if Resident 122 is not wearing her neck brace at all times it can cause further injury and increase her pain level. During an interview on 11/29/24 at 9:55 am, Registered Nurse (RN) 3 stated Resident 122 is supposed to wear neck collar at all times. RN 3 stated if Resident 122 is not wearing her neck collar at all times it could cause further injury and increase the pain to Resident 122's neck During a review of the facility's policy and procedures (P&P) titled Cervical Collars dated 1/25/2022, indicated: Purpose: to treat an acute injury or to prevent potential cervical spine fracture or cord damage. During a review of the facility's policy titled Cervical Collar, Care of undated, indicated, Cervical collar is based on: 1. Physician order to determine the wearing schedule.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) Abuse Prevention and Prohibition Program to protect residents from abuse by screening and training caregivers (a person who tends to the needs or concerns of a person with short- or long-term limitations due to illness, injury, or disability) two of two caregivers (CG1 and CG2). 2. Implement the facility's P&P Caregiver Policy that all caregivers for resident will undergo an orientation with the Director of Staff Development (DSD) which includes education on abuse, facility policy and procedures, and safety in the facility for two of two caregivers (CG1 and CG2). 3. Ensure the facility's Guest Liaison 1 (GL1- a person that ensures a seamless flow of communication and facilitates efficient utilization of resources) did not leave Resident 1 alone in the facility's patio on 7/23/2024 at 1:09 PM with Care Giver 1 (CG1- another resident's caregiver). 4. Ensure Activities Director 1 (AD1) who entered the facility's patio on 7/23/2024 at 1:13 PM and having heard a verbal altercation (a heated or angry dispute: noisy argument) and witnessed CG1 argue with Resident 1, AD1 did not leave Resident 1 alone with CG1. AD1 did not separate CG1 from Resident 1. AD1 left the patio and allowed the altercation to continue between CG1 and Resident 1. These deficient practices resulted in Resident 1 being subjected to physical abuse by CG1 while under the care of the facility. On 7/23/2024 at 1:15 PM, CG1 slapped Resident 1 on the face twice placing Resident 1 at increased risk to suffer severe pain, emotional distress (a highly unpleasant emotional reaction, severe body injury, serious impairment and/or death. On 8/13/2024 at 2:07 PM, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation in the presence of the Administrator (ADM), Director of Nursing (DON) and Infection Preventionist Nurse (IPN- a certified nursing professional who specializes in preventing and controlling infections in healthcare settings) due to the facility's failure to ensure Resident 1 was free from physical abuse and for the facility's failure to: 1. Implement the facility policy by acquiring and maintaining necessary records caregivers including background checks, abuse training, competency, and complete identifiable and contact information. 2. Ensure the facility's GL1 did not leave Resident 1 alone in the facility's patio on 7/23/2024 at 1:09 PM with CG1. 3. Ensure AD1 did not leave Resident 1 alone with CG1, did not separate CG1 from Resident 1, left the patio, and allowed the altercation to continue between CG1 and Resident 1. On 8/15/2022 at 5:05 p.m., the IJ was removed after the ADM and the DON submitted an acceptable removal plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview, and record review, and determined the IJ situation was no longer present. The acceptable removal plan was as follows: 1. On 8/13/24, the Caregiver for Resident 3 was removed until a background check, orientation, and abuse training could be completed. 2. On 8/13/2024, 8/14/2024, and 8/15/2024, the facility's Nurse Consultant Director Registered Nurse conducted in-service to all schedule staff (Nursing, housekeeping, dietary, rehab, laundry, maintenance, and administration) on types of abuse and screening, and abuse prevention, intervention, investigation, reporting and monitoring. 3. On 8/13/24, the facility created a Caregiver Logbook which was placed at the receptionist desk, whereby all future caregivers will be directed by the receptionist to verify or complete a background check, abuse training, and orientation. Visitors, vendors, family, and transport drivers will check-in at the kiosk. 4. Effective 8/14/24, Social Services shall conduct room rounds 5 days a week, at least 10 residents a day to monitor residents for concerns, grievances, or allegations of abuse. Any report of allegations of abuse will be documented and reported to the administrator immediately. All alleged abuse shall be investigated immediately for proper and appropriate reporting to required agencies. All findings shall be presented and discussed in the QA&A Committee Meetings. QAPI committee shall review and monitor the effectiveness of these processes monthly and then quarterly after three months or until 100% compliance is attained. 5. On 8/13/2024, AD1 was provided in-service by the Nurse Consultant Director RN by phone regarding abuse prevention and abuse policies including not to leave a resident alone after hearing a verbal altercation and must separate caregiver from resident as to not allow the alteration to continue. 6. On 8/13/2024 and 8/14/2024, the Nurse Consultant RN in serviced AD1 regarding not leaving a resident alone during resident-to-resident altercation, 7. On 8/13/2024 and 8/14/2024, the Nurse Consultant RN in-serviced to all working and on-coming staff regarding abuse prevention, review of abuse policy, and the caregiver/visitor log. 8. On 8/13/24, an audit was performed by Medical Records Director for all residents to identify any residents utilizing caregivers - none were found. 9. The Director of Staff Development (DSD) will provide caregiver training for future caregivers starting 8/14/24 and will be on-going. 10. On 8/14/2024 at 2 PM, GL1 was in serviced by phone regarding not leaving a resident alone during resident-to-resident altercation. 11. The Medical Records Director (MRD) will audit monthly compliance of Caregiver Logbook and Visitor check in and report to the ADM all findings. All findings of noncompliance shall be presented and discussed in the QA& A (a systematic method used to ensure that a product or service meets the desired standards and requirements) Committee Meetings. QAPI committee (an interdisciplinary [combination of multiple academic disciplines into one activity] team that is responsible for developing and implementing plans to improve quality and safety in a healthcare organization) shall review and monitor the effectiveness of these processes monthly and then quarterly after three months. QAPI Committee shall focus and discuss further actions by developing a Performance Improvement Plan for areas or issues identified as recurring or trending negatively to implement a new or more effective plan of actions. Findings: During a review of Residents 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 7/15/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 1uses a manual wheelchair for mobility and was dependent on staff to wheel and make turns. During a review of Resident 1's Change of Condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 7/23/2024 at 2:08 P.M., indicated Licensed Vocational Nurse 1 (LVN 1) documented that the administrative assistant saw . the caregiver (CG1) allegedly got up and slapped [Resident 1] in the face. During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 8/3/2024 indicated Resident 1, does not have capacity for medical decision making due to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During an interview on 8/12/2024, at 7:30 A.M., with the Infection Preventionist Nurse (IPN), the IPN stated the facility had two caregivers who provided directed care to one resident (Resident 3). The IPN stated both caregivers were hired privately by the resident's family members. The IPN stated I don't know the full name and phone number of the caregiver who was involved in the incident or the second caregiver coming in (facility) later that is now taking care of [Resident 3]. During an interview on 8/12/2024, at 8:50 A.M., using public health translation services with Resident 1, Resident 1 was unable to recall the abuse incident by Resident 3's caregiver. Resident 1 was unable to confirm or deny if she felt safe in the facility. During an interview on 8/12/2024, at 9:45 A.M., with GL1, GL1 stated Resident 1 is mostly Farsi speaking. She used to speak some English when I first started working here. GL1 stated Resident 1, likes to spend the day on the patio and will typically seat with [Resident 3] and his [Resident 3's] caregiver who are both Farsi speaking. GL1 stated GL1 has been working at the facility for six months and that Resident 3's caregiver (CG1) has been there longer than that [CG1] was there (working in the facility) when I started. GL1 stated that on 7/23/2024 at around 1 P.M., Resident 1 was seating on the patio with other residents and watching television. GL1 stated Resident 1 was sharing a table with Resident 3 and CG1. GL1 stated Resident 1, Resident 3, and CG1's table, table was in the back, so the other residents didn't see what was going on when it (CG1 had the altercation with Resident 1 and then slapped Resident 1). GL1 stated LVN 1 came to the patio to give medications in a cup to Resident 1, but Resident 1 took the cup of medications and threw them in the air. GL1 stated GL1 picked up the medications and LVN 1 took the medications inside the facility. GL1 stated Resident 1 and CG1 started speaking to each other in Farsi, I don't know what they were talking about, but I could tell the conversation was heated (a discussion or quarrel where the people involved are angry and exited). GL1 stated AD1 had heard the commotion between Resident 3 and CG1 and came outside and helped to calm the situation. GL1 stated, [CG1] is gaslighting (a form of emotional abuse where one person manipulates another person into doubting their own perception, memories, and sanity) [Resident 1]. GL1 stated CG1 would normally help translate what Resident 1, is saying, but because the conversation seemed heated, I went into the building to get another Farsi speaking person because I didn't trust that [CG1] would translate the right information in that moment. GL1 stated that when CG1 was inside the facility and on the way back to the patio, I heard the caregiver slap [Resident 1] and then saw [CG1] slap [Resident 1]. GL1 stated when CG1 arrived at the patio, Resident 1 was no longer at the same table with Resident 3 and CG1. GL1 stated, [CG1] had moved [Resident 1] to the back of the patio which is further behind the tables that the residents' seat to watch television, is where she [CG1] slapped her [Resident 1]. GL1 stated she separated CG1 and Resident 1. GL1 stated GL1 informed the ADM who instructed her to inform the social worker about the incident. GL1 stated the social worker called the police officers who came to the facility about 10 minutes later. GL1 stated CG1 left the facility after CG1 spoke with the police officers. During an interview on 8/12/2024, at 12:50 P.M., with the DON, the DON stated that caregivers coming into the facility are provided with orientation which includes abuse training, safety in the facility and provision of credentials such as background check, certificate, or license. The DON stated CG1 and caregiver 2 (CG 2), both have no documented evidence of a background check (search), and orientation which includes abuse training. The DON stated, It's my fault. I should have checked, I don't' have any background or orientation training on her (CG1) or the one (CG2) that is here now. The DON stated the facility did not have CG1 or CG2's last name or contact information. The DON stated, We only have Resident 3's family phone number. We called them (Resident 3's family), and they said they do not have her (CG1's) phone number or last name. The caregiver (CG 2) that is here right now, I will go and ask here for that information for you. The DON stated CG1 has been coming to the facility as Resident 3's caregiver for one year. During a concurrent record review and interview on 8/13/2024, at 2:45 P.M., with the ADM in the ADM's office, the facility's video surveillance (no sound) dated 7/23/2024, was reviewed. The video surveillance indicated the following: 1. On 7/23/2024 at 1:11 P.M., Resident 1 was seating at a table with Resident 3 and CG1, and GL1 was talking to Resident 1. 2. On 7/23/2024 at 1:12 P.M., LVN 1 was seating at the table next to Resident 1, handed Resident 1 a small cup and placed a glass of water on the table in front of Resident 1. Resident 1 then tossed out into the air and onto the ground, white looking particles. GL1 then picked up the white looking particles from the ground. 3. On 7/23/2024 at 1:13 P.M., the AD showed up at the table where Resident 1, Resident 3, CG1, GL1 and LVN 1 were at. The AD spoke to Resident 1 and then CG1. 4. On 7/23/2024 at 1:13 P.M., LVN 1 left and went inside the facility table. 5. On 7/23/2024 at 1:14 P.M., GL1 and the ADS both left the patio leaving Resident 1, Resident 3, and CG1 at the same table. 6. On 7/23/2024 at 1:14 P.M., Resident 1 stretched her right arm with closed fist toward CG1. 7. On 7/23/2024 at 1:15 P.M., Resident 1 was observed picking up a cup in front of her, on the table, and threw a clear liquid substance in the direction of the caregiver and it landed on the caregiver. 8. On 7/23/2024 at 1:15 P.M., CG1 unlocked the brakes of Resident 1's wheelchair (WC), pulled and wheeled Resident 1 on the WC backwards, turned the WC to Resident 1's left and around, and pushed the WC forward toward the patio furniture, that was a few feet away directly opposite the table where Resident 1 was seating, CG1 then locked the left side of Resident 1's WC and slapped the resident twice on the left cheek. During the same record review and interview, the ADM stated the incident between CG1, and Resident 1 could have been avoided by separating CG1 and Resident 1 immediately. During a telephone interview on 8/12/2024, at 9:54 A.M., with AD1, AD1 stated he was coming from the activities room and noticed that Resident 1 was escalated, (when someone becomes more agitated, angry, or violent in a situation) was very, very upset, her body gestures were a little larger than they usually are, her voice was more elevated. She (Resident 1) was yelling which I did not understand what she (Resident 1) was yelling at but apparently it was directed at the caregiver (CG1) that was there for the other resident. I talked to her (Resident 1), she seemed to have come down a little bit, so I continued to assist the residents in the activity room. During a review of facility's undated policy and procedures (P&P) title Caregiver Policy, indicated, Purpose: To ensure staff and caregivers are aware of expectations of the facility and care of resident. All Caregivers for resident will undergo an orientation with the Director of Staff Development. This orientation will include education on abuse, facility policy and procedures, and safety in the facility. In addition, DSD will check caregiver credentialing with appropriate agency. Caregivers on the facility will only be allowed to interact with the resident whom they have been hired for. During a review of facility's P&P dated 10/24/2022, title Abuse Prevention and Prohibition Program, indicated, Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. A.Covered individuals will be trained through orientation and ongoing training sessions, no less that annually .

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) Abuse Prevention and Prohibition Program to protect residents from abuse by screening and training caregivers (a person who tends to the needs or concerns of a person with short- or long-term limitations due to illness, injury, or disability) two of two caregivers (CG1 and CG2). 2. Implement the facility's P&P Caregiver Policy that all caregivers for resident will undergo an orientation with the Director of Staff Development (DSD) which includes education on abuse, facility policy and procedures, and safety in the facility for two of two caregivers (CG1 and CG2). 3. Ensure the facility's Guest Liaison 1 (GL1- a person that ensures a seamless flow of communication and facilitates efficient utilization of resources) did not leave Resident 1 alone in the facility's patio on 7/23/2024 at 1:09 PM with Care Giver 1 (CG1- another resident's caregiver). 4. Ensure Activities Director 1 (AD1) who entered the facility's patio on 7/23/2024 at 1:13 PM and having heard a verbal altercation (a heated or angry dispute: noisy argument) and witnessed CG1 argue with Resident 1, AD1 did not leave Resident 1 alone with CG1. AD1 did not separate CG1 from Resident 1. AD1 left the patio and allowed the altercation to continue between CG1 and Resident 1. These deficient practices resulted in Resident 1 being subjected to physical abuse by CG1 while under the care of the facility. On 7/23/2024 at 1:15 PM, CG1 slapped Resident 1 on the face twice placing Resident 1 at increased risk to suffer severe pain, emotional distress (a highly unpleasant emotional reaction, severe body injury, serious impairment and/or death. Findings: During a review of Residents 1's admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 7/15/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 1uses a manual wheelchair for mobility and was dependent on staff to wheel and make turns. During a review of Resident 1's Change of Condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 7/23/2024 at 2:08 P.M., indicated Licensed Vocational Nurse 1 (LVN 1) documented that the administrative assistant saw . the caregiver (CG1) allegedly got up and slapped [Resident 1] in the face. During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 8/3/2024 indicated Resident 1, does not have capacity for medical decision making due to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During an interview on 8/12/2024, at 7:30 A.M., with the Infection Preventionist Nurse (IPN), the IPN stated the facility had two caregivers who provided directed care to one resident (Resident 3). The IPN stated both caregivers were hired privately by the resident's family members. The IPN stated I don't know the full name and phone number of the caregiver who was involved in the incident or the second caregiver coming in (facility) later that is now taking care of [Resident 3]. During an interview on 8/12/2024, at 8:50 A.M., using public health translation services with Resident 1, Resident 1 was unable to recall the abuse incident by Resident 3's caregiver. Resident 1 was unable to confirm or deny if she felt safe in the facility. During an interview on 8/12/2024, at 9:45 A.M., with GL1, GL1 stated Resident 1 is mostly Farsi speaking. She used to speak some English when I first started working here. GL1 stated Resident 1, likes to spend the day on the patio and will typically seat with [Resident 3] and his [Resident 3's] caregiver who are both Farsi speaking. GL1 stated GL1 has been working at the facility for six months and that Resident 3's caregiver (CG1) has been there longer than that [CG1] was there (working in the facility) when I started. GL1 stated that on 7/23/2024 at around 1 P.M., Resident 1 was seating on the patio with other residents and watching television. GL1 stated Resident 1 was sharing a table with Resident 3 and CG1. GL1 stated Resident 1, Resident 3, and CG1's table, table was in the back, so the other residents didn't see what was going on when it (CG1 had the altercation with Resident 1 and then slapped Resident 1). GL1 stated LVN 1 came to the patio to give medications in a cup to Resident 1, but Resident 1 took the cup of medications and threw them in the air. GL1 stated GL1 picked up the medications and LVN 1 took the medications inside the facility. GL1 stated Resident 1 and CG1 started speaking to each other in Farsi, I don't know what they were talking about, but I could tell the conversation was heated (a discussion or quarrel where the people involved are angry and exited). GL1 stated AD1 had heard the commotion between Resident 3 and CG1 and came outside and helped to calm the situation. GL1 stated, [CG1] is gaslighting (a form of emotional abuse where one person manipulates another person into doubting their own perception, memories, and sanity) [Resident 1]. GL1 stated CG1 would normally help translate what Resident 1, is saying, but because the conversation seemed heated, I went into the building to get another Farsi speaking person because I didn't trust that [CG1] would translate the right information in that moment. GL1 stated that when CG1 was inside the facility and on the way back to the patio, I heard the caregiver slap [Resident 1] and then saw [CG1] slap [Resident 1]. GL1 stated when CG1 arrived at the patio, Resident 1 was no longer at the same table with Resident 3 and CG1. GL1 stated, [CG1] had moved [Resident 1] to the back of the patio which is further behind the tables that the residents' seat to watch television, is where she [CG1] slapped her [Resident 1]. GL1 stated she separated CG1 and Resident 1. GL1 stated GL1 informed the ADM who instructed her to inform the social worker about the incident. GL1 stated the social worker called the police officers who came to the facility about 10 minutes later. GL1 stated CG1 left the facility after CG1 spoke with the police officers. During an interview on 8/12/2024, at 12:50 P.M., with the DON, the DON stated that caregivers coming into the facility are provided with orientation which includes abuse training, safety in the facility and provision of credentials such as background check, certificate, or license. The DON stated CG1 and caregiver 2 (CG 2), both have no documented evidence of a background check (search), and orientation which includes abuse training. The DON stated, It's my fault. I should have checked, I don't' have any background or orientation training on her (CG1) or the one (CG2) that is here now. The DON stated the facility did not have CG1 or CG2's last name or contact information. The DON stated, We only have Resident 3's family phone number. We called them (Resident 3's family), and they said they do not have her (CG1's) phone number or last name. The caregiver (CG 2) that is here right now, I will go and ask here for that information for you. The DON stated CG1 has been coming to the facility as Resident 3's caregiver for one year. During a concurrent record review and interview on 8/13/2024, at 2:45 P.M., with the ADM in the ADM's office, the facility's video surveillance (no sound) dated 7/23/2024, was reviewed. The video surveillance indicated the following: 1. On 7/23/2024 at 1:11 P.M., Resident 1 was seating at a table with Resident 3 and CG1, and GL1 was talking to Resident 1. 2. On 7/23/2024 at 1:12 P.M., LVN 1 was seating at the table next to Resident 1, handed Resident 1 a small cup and placed a glass of water on the table in front of Resident 1. Resident 1 then tossed out into the air and onto the ground, white looking particles. GL1 then picked up the white looking particles from the ground. 3. On 7/23/2024 at 1:13 P.M., the AD showed up at the table where Resident 1, Resident 3, CG1, GL1 and LVN 1 were at. The AD spoke to Resident 1 and then CG1. 4. On 7/23/2024 at 1:13 P.M., LVN 1 left and went inside the facility table. 5. On 7/23/2024 at 1:14 P.M., GL1 and the ADS both left the patio leaving Resident 1, Resident 3, and CG1 at the same table. 6. On 7/23/2024 at 1:14 P.M., Resident 1 stretched her right arm with closed fist toward CG1. 7. On 7/23/2024 at 1:15 P.M., Resident 1 was observed picking up a cup in front of her, on the table, and threw a clear liquid substance in the direction of the caregiver and it landed on the caregiver. 8. On 7/23/2024 at 1:15 P.M., CG1 unlocked the brakes of Resident 1's wheelchair (WC), pulled and wheeled Resident 1 on the WC backwards, turned the WC to Resident 1's left and around, and pushed the WC forward toward the patio furniture, that was a few feet away directly opposite the table where Resident 1 was seating, CG1 then locked the left side of Resident 1's WC and slapped the resident twice on the left cheek. During the same record review and interview, the ADM stated the incident between CG1, and Resident 1 could have been avoided by separating CG1 and Resident 1 immediately. During a telephone interview on 8/12/2024, at 9:54 A.M., with AD1, AD1 stated he was coming from the activities room and noticed that Resident 1 was escalated, (when someone becomes more agitated, angry, or violent in a situation) was very, very upset, her body gestures were a little larger than they usually are, her voice was more elevated. She (Resident 1) was yelling which I did not understand what she (Resident 1) was yelling at but apparently it was directed at the caregiver (CG1) that was there for the other resident. I talked to her (Resident 1), she seemed to have come down a little bit, so I continued to assist the residents in the activity room. During a review of facility's undated policy and procedures (P&P) title Caregiver Policy, indicated, Purpose: To ensure staff and caregivers are aware of expectations of the facility and care of resident. All Caregivers for resident will undergo an orientation with the Director of Staff Development. This orientation will include education on abuse, facility policy and procedures, and safety in the facility. In addition, DSD will check caregiver credentialing with appropriate agency. Caregivers on the facility will only be allowed to interact with the resident whom they have been hired for. During a review of facility's P&P dated 10/24/2022, title Abuse Prevention and Prohibition Program, indicated, Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. A.Covered individuals will be trained through orientation and ongoing training sessions, no less that annually .

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) who has severe cognitive impairment with no capacity to make decisions in accordance with facility's abuse policy and procedures. By failing to: 1. Implement the facility's policy and procedures (P&P) Abuse Prevention and Prohibition Program to protect residents from abuse by screening and training caregivers (a person who tends to the needs or concerns of a person with short- or long-term limitations due to illness, injury, or disability) two of two caregivers (CG1 and CG2). 2. Implement the facility's P&P Caregiver Policy that all caregivers for resident will undergo an orientation with the Director of Staff Development (DSD) which includes education on abuse, facility policy and procedures, and safety in the facility for two of two caregivers (CG1 and CG2). 3. Ensure the facility's Guest Liaison 1 (GL1- a person that ensures a seamless flow of communication and facilitates efficient utilization of resources) did not leave Resident 1 alone in the facility's patio on 7/23/2024 at 1:09 PM with Care Giver 1 (CG1- another resident's caregiver). 4. Ensure Activities Director 1 (AD1) who entered the facility's patio on 7/23/2024 at 1:13 PM and having heard a verbal altercation (a heated or angry dispute: noisy argument) and witnessed CG1 argue with Resident 1, AD1 did not leave Resident 1 alone with CG1. AD1 did not separate CG1 from Resident 1. AD1 left the patio and allowed the altercation to continue between CG1 and Resident 1. These deficient practices resulted in Resident 1 being subjected to physical abuse by CG1 while under the care of the facility. On 7/23/2024 at 1:15 PM, CG1 slapped Resident 1 on the face twice placing Resident 1 at increased risk to suffer severe pain, emotional distress (a highly unpleasant emotional reaction, severe body injury, serious impairment and/or death. Findings: During a review of Residents 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 1's Minimum Data Set (MDS - a standard assessment and care screening tool) dated 7/15/2023, indicated Resident 1 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 1uses a manual wheelchair for mobility and was dependent on staff to wheel and make turns. During a review of Resident 1's Change of Condition (COC -a sudden deviation from person/patient's baseline in physical, cognitive, behavioral or function) dated 7/23/2024 at 2:08 P.M., indicated Licensed Vocational Nurse 1 (LVN 1) documented that the administrative assistant saw . the caregiver (CG1) allegedly got up and slapped [Resident 1] in the face. During a review of Resident 1's History and Physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 8/3/2024 indicated Resident 1, does not have capacity for medical decision making due to dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During an interview on 8/12/2024, at 7:30 A.M., with the Infection Preventionist Nurse (IPN), the IPN stated the facility had two caregivers who provided directed care to one resident (Resident 3). The IPN stated both caregivers were hired privately by the resident's family members. The IPN stated I don't know the full name and phone number of the caregiver who was involved in the incident or the second caregiver coming in (facility) later that is now taking care of [Resident 3]. During an interview on 8/12/2024, at 8:50 A.M., using public health translation services with Resident 1, Resident 1 was unable to recall the abuse incident by Resident 3's caregiver. Resident 1 was unable to confirm or deny if she felt safe in the facility. During an interview on 8/12/2024, at 9:45 A.M., with GL1, GL1 stated Resident 1 is mostly Farsi speaking. She used to speak some English when I first started working here. GL1 stated Resident 1, likes to spend the day on the patio and will typically seat with [Resident 3] and his [Resident 3's] caregiver who are both Farsi speaking. GL1 stated GL1 has been working at the facility for six months and that Resident 3's caregiver (CG1) has been there longer than that [CG1] was there (working in the facility) when I started. GL1 stated that on 7/23/2024 at around 1 P.M., Resident 1 was seating on the patio with other residents and watching television. GL1 stated Resident 1 was sharing a table with Resident 3 and CG1. GL1 stated Resident 1, Resident 3, and CG1's table, table was in the back, so the other residents didn't see what was going on when it (CG1 had the altercation with Resident 1 and then slapped Resident 1). GL1 stated LVN 1 came to the patio to give medications in a cup to Resident 1, but Resident 1 took the cup of medications and threw them in the air. GL1 stated GL1 picked up the medications and LVN 1 took the medications inside the facility. GL1 stated Resident 1 and CG1 started speaking to each other in Farsi, I don't know what they were talking about, but I could tell the conversation was heated (a discussion or quarrel where the people involved are angry and exited). GL1 stated AD1 had heard the commotion between Resident 3 and CG1 and came outside and helped to calm the situation. GL1 stated, [CG1] is gaslighting (a form of emotional abuse where one person manipulates another person into doubting their own perception, memories, and sanity) [Resident 1]. GL1 stated CG1 would normally help translate what Resident 1, is saying, but because the conversation seemed heated, I went into the building to get another Farsi speaking person because I didn't trust that [CG1] would translate the right information in that moment. GL1 stated that when CG1 was inside the facility and on the way back to the patio, I heard the caregiver slap [Resident 1] and then saw [CG1] slap [Resident 1]. GL1 stated when CG1 arrived at the patio, Resident 1 was no longer at the same table with Resident 3 and CG1. GL1 stated, [CG1] had moved [Resident 1] to the back of the patio which is further behind the tables that the residents' seat to watch television, is where she [CG1] slapped her [Resident 1]. GL1 stated she separated CG1 and Resident 1. GL1 stated GL1 informed the ADM who instructed her to inform the social worker about the incident. GL1 stated the social worker called the police officers who came to the facility about 10 minutes later. GL1 stated CG1 left the facility after CG1 spoke with the police officers. During an interview on 8/12/2024, at 12:50 P.M., with the DON, the DON stated that caregivers coming into the facility are provided with orientation which includes abuse training, safety in the facility and provision of credentials such as background check, certificate, or license. The DON stated CG1 and caregiver 2 (CG 2), both have no documented evidence of a background check (search), and orientation which includes abuse training. The DON stated, It's my fault. I should have checked, I don't' have any background or orientation training on her (CG1) or the one (CG2) that is here now. The DON stated the facility did not have CG1 or CG2's last name or contact information. The DON stated, We only have Resident 3's family phone number. We called them (Resident 3's family), and they said they do not have her (CG1's) phone number or last name. The caregiver (CG 2) that is here right now, I will go and ask here for that information for you. The DON stated CG1 has been coming to the facility as Resident 3's caregiver for one year. During a concurrent record review and interview on 8/13/2024, at 2:45 P.M., with the ADM in the ADM's office, the facility's video surveillance (no sound) dated 7/23/2024, was reviewed. The video surveillance indicated the following: 1. On 7/23/2024 at 1:11 P.M., Resident 1 was seating at a table with Resident 3 and CG1, and GL1 was talking to Resident 1. 2. On 7/23/2024 at 1:12 P.M., LVN 1 was seating at the table next to Resident 1, handed Resident 1 a small cup and placed a glass of water on the table in front of Resident 1. Resident 1 then tossed out into the air and onto the ground, white looking particles. GL1 then picked up the white looking particles from the ground. 3. On 7/23/2024 at 1:13 P.M., the AD showed up at the table where Resident 1, Resident 3, CG1, GL1 and LVN 1 were at. The AD spoke to Resident 1 and then CG1. 4. On 7/23/2024 at 1:13 P.M., LVN 1 left and went inside the facility table. 5. On 7/23/2024 at 1:14 P.M., GL1 and the ADS both left the patio leaving Resident 1, Resident 3, and CG1 at the same table. 6. On 7/23/2024 at 1:14 P.M., Resident 1 stretched her right arm with closed fist toward CG1. 7. On 7/23/2024 at 1:15 P.M., Resident 1 was observed picking up a cup in front of her, on the table, and threw a clear liquid substance in the direction of the caregiver and it landed on the caregiver. 8. On 7/23/2024 at 1:15 P.M., CG1 unlocked the brakes of Resident 1's wheelchair (WC), pulled and wheeled Resident 1 on the WC backwards, turned the WC to Resident 1's left and around, and pushed the WC forward toward the patio furniture, that was a few feet away directly opposite the table where Resident 1 was seating, CG1 then locked the left side of Resident 1's WC and slapped the resident twice on the left cheek. During the same record review and interview, the ADM stated the incident between CG1, and Resident 1 could have been avoided by separating CG1 and Resident 1 immediately. During a telephone interview on 8/12/2024, at 9:54 A.M., with AD1, AD1 stated he was coming from the activities room and noticed that Resident 1 was escalated, (when someone becomes more agitated, angry, or violent in a situation) was very, very upset, her body gestures were a little larger than they usually are, her voice was more elevated. She (Resident 1) was yelling which I did not understand what she (Resident 1) was yelling at but apparently it was directed at the caregiver (CG1) that was there for the other resident. I talked to her (Resident 1), she seemed to have come down a little bit, so I continued to assist the residents in the activity room. During a review of facility's undated policy and procedures (P&P) title Caregiver Policy, indicated, Purpose: To ensure staff and caregivers are aware of expectations of the facility and care of resident. All Caregivers for resident will undergo an orientation with the Director of Staff Development. This orientation will include education on abuse, facility policy and procedures, and safety in the facility. In addition, DSD will check caregiver credentialing with appropriate agency. Caregivers on the facility will only be allowed to interact with the resident whom they have been hired for. During a review of facility's P&P dated 10/24/2022, title Abuse Prevention and Prohibition Program, indicated, Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. II. The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. A.Covered individuals will be trained through orientation and ongoing training sessions, no less that annually .