Every finding on record at Heritage Gardens Health Care Center

Based on observation, interview, and record review, the facility failed to ensure medications were secured and administered in accordance with the facility's medication administration policy and procedure (P&P) for one (1) of three (3) sampled residents(Resident 3), when a License Vocational Nurse (LVN 1) left a medication cup containing four (4) tablets unattended on Resident 3's beside table. This failure had the potential to cause medication errors, accidental ingestion and intentional misuse, which jeopardized the health and safety of Resident 3, who had severe cognitive impairment (a person has lost their ability to think, remember, or make decisions so much that they cannot live independently) or any person who could access Resident 3's room.During a review of Resident 3's Face Sheet (contains demographic and medical information) undated, the Face Sheet indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disease, damage, or malfunction), senile degeneration of brain (a severe, progressive decline in brain tissue as you age). During a review of Resident 3 ' s [ Minimum Data Set (MDS - facility assessment tool), dated May 6, 2026, the MDS under Section C (cognitive pattern), indicated Resident 3's Brief Interview for Mental Status (BIMS-memory and thinking test used by to quickly check a person's brain health ) score was 00 (a BIMS score of 00 suggests severe cognitive impairment). During concurrent observation and interview on July 2, 2026, at 10:35 AM, with Resident 3, in Resident 3's room, a medication cup containing four (4) tablets was found left unattended on Resident 3's bedside table. When asked if the medication belongs to her, Resident 3 stated, I don't know, and shook her head in a manner that suggested confusion. During concurrent observation and interview on July 2, 2026, at 10:44 AM, with Registered Nurse (RN1), in Resident 3's room, RN 1 confirmed and verified there were four (4) tablets in the medication cup left unattended on Resident 3's bedside table. RN 1 stated, it is against facility protocol to leave medication unattended at the bedside. RN 1 further stated, the medications had likely been left there by LVN 1 and stated that Resident 3's medications should remain under the direct supervision of LVN1 until administered. During concurrent observation and interview on July 2, 2026, at 10:48 AM with LVN 1, in Resident 3's room, LVN 1 stated the four (4) tablets in the medication cup left unattended on Resident 3's bedside table belonged to Resident 3. LVN 1 further stated, she had placed the medications on the bedside table while she went to obtain juice for Resident 3. LVN 1 stated, it was a mistake, because it was incorrect for her to leave the medications unattended, as another individual could potentially access, take, or dispose of the medications, leading to a missed dose for Resident 3. LVN 1 admitted her actions were not consistent with the facility's medication administration policy. During concurrent interview and record review on July 2, 2026, at 11:40 AM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P), titled Administering Medications, dated April 2019, was reviewed. The P&P indicated, . 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart . The DON stated, this P&P also applies to medication removed from the medication cart and the expectation was that medications should not be left unattended on a resident's bedside table. DON stated, LVN 1's actions violated facility policy and failed to meet the expected standard of practice, placing Resident 3 and others at risk for unauthorized access or ingestion of medications.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and maintained in sanitary conditions when on May 4, 2026 the following was observed:1.Multiple pieces of cooking equipment had significant accumulations of grease, grime, burnt on residue, rust, food debris, discoloration.2.Several food items were stored on the floor. These failures had the potential to facilitate the growth of harmful microorganisms (tiny living organisms too small to be seen with the naked eye, requiring a microscope for viewing), including bacteria, viruses, and fungi significantly increasing the risk for cross-contamination and development of food-borne illnesses, potentially affecting 93 medically vulnerable residents who rely on meals prepared in the facility's kitchen.Findings:1.During a concurrent observation and interview with the Director of Kitchen (DOK) on May 4, 2026, at 6:33 AM in the dishwashing area, a stack of 18 dish drying racks was observed stored on a wheeled dolly under the counter. The racks exhibited heavy mineral buildup, visible grime, worn surfaces, scratches, abrasions and areas of discoloration on the exterior plastic surface. Visible soiling was seen on the interior dividers, which come into direct contact with food contact items (glasses, utensils, cups, plates etc.). The Director of Kitchen (DOK) confirmed the dish-drying racks were not clean and acknowledged the drying racks should be maintained in clean sanitary conditions.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:41 AM of the beverage service station, the coffee and hot water dispensers had visible liquid residue on their exterior surfaces, and multiple stains and spills were present on the counter beneath them. The disposable liner under the hot water dispenser contained dried spills and debris. The condiment organizer held mixed sweetener packets in a cluttered arrangement, with several loose packets scattered on the surrounding surface. The labels on both dispensers were worn, stained, and affixed with multiple layers of tape. The DOK confirmed the beverage station is not clean and acknowledged these conditions create a potential for cross contamination and do not meet basic sanitation and cleanliness standards.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:52 AM in the kitchen, the flat-top griddle had visible layers of grease, black burnt buildup, and dark discoloration across the cooking surface and surrounding areas. During the observation, the DOK acknowledged the flat-top griddle had not been cleaned and stated it should be cleaned after each use and at the end of the day.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:54 AM in the kitchen, the 6 burner stove had accumulated burnt grease and food debris across multiple surfaces. The DOK confirmed the stove appeared not to have been cleaned as required. The DOK further stated that the stove should be thoroughly cleaned after each use and at the end of each day.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:55 AM in the kitchen, oven #1 had accumulations of burnt food particles, grease stains, and dark residue on the interior surfaces, including the oven floor, side panels, and racks, with additional debris and pieces of aluminum foil scattered on the oven floor. The oven had no signage indicating it was out of order. The DOK confirmed oven #1 was not clean and stated the oven had not been used for some time. DOK acknowledged the oven should be cleaned and maintained in sanitary conditions.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:56 AM in the kitchen, oven #2 had heavy blackened residue, accumulated grease, burnt-on food buildup, and rust along the interior walls, racks, and bottom tray. The oven lacked any signage indicating it was out of order. The DOK confirmed oven #2 was not clean and stated the oven had not been used for some time. DOK acknowledged the oven should be cleaned and maintained in sanitary conditions.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:57 AM in the kitchen, the back metal plate behind the stove had visible layers of grease stains and dark discoloration. The DOK confirmed the back metal plate was not clean and stated that the stove and its surrounding surfaces, including the back metal plate, should be cleaned after each use and at the end of the day.During a concurrent interview and record review with the Director of Kitchen (DOK) on May 6, 2026, at 11:20 AM, the document titled, Dietary Cleaning Schedule, dated April 27, 2026, to May 3, 2026, was reviewed. The document indicated, AM [NAME] Stove/Burners - to Dietary Aid . Frequency: Sunday and contained a staff initial for Sunday May 3, 2026. The document further indicated AM [NAME] Grill . Frequency: After each use, and contained staff initials for Monday April 27, 2026, Friday May 1, 2026, and Saturday May 2, 2026. The DOK stated the stove and surrounding areas are typically cleaned after each use and at the end of each day, and that according to the Dietary Cleaning Schedule, the stove, flat-top griddles, and surrounding surfaces were cleaned. The DOK further stated that food frequently spills onto the stove during cooking and that these spills should be wiped up immediately to prevent the build-up of burnt food particles and grease. The DOK was unable to provide an explanation for the significant accumulation of burnt grease, food debris, rust and discoloration observed on the 6-burner stove, the two ovens, the flat-top griddle, the back plate crate and the adjacent surfaces.During a concurrent interview and record review with the Director of Kitchen (DOK) on May 6, 2026, at 11:25 AM, the document titled, Deep Cleaning Schedule, dated April 2026, was reviewed. The document indicated, Areas to be cleaned - under stove, stove burners, oven and has staff initials under the date April 21, 2026. The DOK stated that according to the Deep Cleaning Schedule, the stove burners and the ovens were last deep cleaned on April 21, 2026.During a concurrent interview and record review on May 7, 2026, at 4:07 PM with the DOK, the facility's undated Policy and Procedure (P&P) titled Ranges and Ovens was reviewed. The P&P states, Ranges - Cleaning Procedure: 1. Open top gas range and grill. When top grids are completely cool, remove grills from the range. Immerse grills in a solution of water and grease solvent to soak. 2. Boil grates and burners in salt/soda or other grease solvent/water solution. Clean clogged burners posts with a stiff wire brush. 3. Back apron of the range and other range surfaces should be washed with a hot detergent solution following manufacturer's instructions to remove grease. Rinse and dry with a clean cloth. 4. Range drip pans must be emptied and washed on a routinely scheduled basis. 5. Grills must be cleaned after each use. Allow sufficient time for grills to cool before cleaning. Do not use caustic or acid solutions on grills as they are used will eventually cause sticking and rusting . Ovens - Cleaning Procedure: 1. Allow sufficient time for ovens to cool before cleaning. 2. Weekly, and as often as necessary, racks and shelves should be removed and cleaned in a warm detergent solution following manufacturer's instructions. 3. Use a blunt scraper or wire brush to remove encrusted material from oven surface. 4. When a commercial oven cleaner is used, allow for ample ventilation and follow label directions. 5. Clean the exterior of the oven according to manufacturer's instructions. The DOK acknowledged the facility's P&P was not followed.During a concurrent Interview and record review with the DOK on May 7, 2026, at 4:10 PM, the facility's P&P titled Sanitization, revised on October 2008, was reviewed. The P&P stated, Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen areas and dining areas shall be kept clean . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, correlations, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitizing using hot water and/or chemical sanitizing solution. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. The DOK acknowledged the facility's P&P was not followed.During an interview with the Director of Nursing (DON) on May 7, 2026, at 4:20 PM, the DON stated that staff should follow facility's P&P and the kitchen, and all kitchen equipment is expected to be maintained in sanitary conditions.During an interview with the Administrator (Admin) on May 7, 2026, at 4:22 PM, the Admin stated that the kitchen and all kitchen equipment are expected to be maintained in sanitary working conditions in accordance with facility's policy and procedure. The Admin acknowledged that the facility's P&Ps titled Food Receiving and Storage, Ranges and Ovens, and Sanitization were not followed when cleaning protocols for ranges, ovens, kitchen surfaces and food storage procedures were not consistently implemented as outlined in the facility's policies.Record review of the FDA Federal Food Code, dated 2022, 4-601.11 indicates, (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. in addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted.2.During a concurrent observation and interview with the DOK on May 4, 2026, at 6:59 AM in the Dry Storage Room, several food items were found stored directly on the floor, including one box of Apple Juice for the Juice machine, 2 boxes of honey (200 packets in each box), 2 boxes of Gravy Beef Instant (8x16 oz cans in each box), 6 bags of hot dog buns (16 hot dog buns in each bag) in a crate and 3 bags of Tortilla Chips in another crate. The DOK confirmed that these items are stored on the floor. DOK further stated these items were delivered earlier this morning and the delivery person failed to place them on the shelves. The DOK acknowledged the items should have been stored properly off the floor upon receipt.During a concurring interview and record review on May 7, 2026, at 4:02 PM with the DOK, the facility's Policy and Procedure (P&P) titled, Food Receiving and Storage revised October 2017, was reviewed. The P&P stated, Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 1. Food services, or other designated staff, we'll maintain clean food storage areas at all times. 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted . 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. The DOK acknowledged the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when a cockroach was observed by surveyors in the facility's conference room, multiple staff interviews indicated ongoing sightings of cockroaches on multiple occasions, and the facility's pest control report indicated ongoing, active cockroach activity in the facility's dining area, resident rooms, and boiler room.This failure had the potential for compromising resident health and safety by exposing residents to disease-carrying pests, contamination of food surfaces, and increased risk of infection in a vulnerable population of 98 residents.Findings: During a concurrent observation and interview on May 4, 2026, at 6:10 AM, in the facility's conference room, with Registered Nurse 1 (RN 1), a live brown bug which was approximately one and a half (1.5) inches long and resembled a cockroach was observed to be crawling on the ground underneath the conference table. RN 1 acknowledged the bug was alive and stated it looked like a cockroach.During an interview on May 6, 2026, at 8:53 AM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she had worked in the facility for the last five months and within that time she had seen cockroaches on three or four different occasions. CNA 2 stated the cockroaches she saw were in the restrooms used by staff and visitors.During an interview on May 6, 2026, at 8:58 AM, with CNA 3, CNA 3 stated she had worked in the facility for 3 years and saw cockroaches in resident bathrooms on a few occasions. CNA 3 stated she couldn't recall if she told anyone and stated she would usually just kill the cockroaches.During an interview on May 7, 2026, at 12:11 PM, with Housekeeper 1 (HK 1), HK 1 stated she had worked in the facility for a total of 14 years. HK 1 stated she saw cockroaches in the facility at least once a week. HK 1 stated when she would see the cockroaches, they would be in various resident restrooms and staff restrooms and that it was restrooms in all the facility's hallways and not one particular hallway or area.During a concurrent interview and record review on May 7, 2026, at 12:15 PM, with the Administrator (ADMIN). The ADMIN Stated the facility used a company called [name of pest control company] who came out monthly to treat the facility for pest control. A report of [name of pest control company] titled, Service Report #117922, dated March 30, 2026, was reviewed and indicated, I inspected points of entry, kitchen, kitchen office, dining area, staff offices, boiler room, and restrooms. It is noted that American cockroach activity was located in the dining area, boiler room, and near the billing office restroom. Staff also is reporting American cockroach activity in rooms [ROOM NUMBERS]. These rooms are occupied at this time and unable to be treated .), the ADMIN stated he was not aware of any ongoing cockroach activity in the facility, and he had only been the administrator for the last month. The admin further stated the facility had not yet been able to treat resident rooms [ROOM NUMBERS] for cockroaches because the only way to do that is to remove the residents from the room.During a review of the facility's policy and procedure (P&P) titled, Pest Control, revised May 2008, the P&P indicated, Our facility shall maintain an effective pest control program.1. This facility maintains an on-going pest control program to ensure that the building is monitored and treated. 2. Pest control services are provided by [name of pest control company].During a review of the facility's P&P titled, Homelike Environment, dated February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.

Based on observation, interview, and record review, the facility failed to ensure staff followed the facility's policy and procedure (P&P) for three of six residents (Residents 14, 30, and 73) reviewed for advance directives (a written document that tells your health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself) when:1. Resident 14 was not provided advance directive information on admission.2. Resident 30's medical record had discrepant information regarding if Resident 30 had an advance directive or not. Additionally, there was no evidence the facility requested or attempted to obtain a copy of Resident 30 advance directive.3. Resident 73's POLST (Physician's Orders for Life-Sustaining Treatment - a medical order completed by a healthcare provider that communicates a patient's wishes regarding life-sustaining treatment) was incomplete and left blank for the section regarding advance directives. Additionally, there was no evidence the facility requested or attempted to obtain a copy of Resident 73's advance directive. These failures had the potential to affect Resident 14's right to make informed decisions regarding health care, including the right to formulate an advance directive and the potential for Residents 30 and 73 to receive care that was not consistent with Resident 30 and 73 wishes regarding medical treatment and decision-making.Findings: 1. A review of Resident 14's admission Record, (contains demographic and medical information), indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included, arthrogryposis multiplex congenita (a variety of conditions involving multiple joint contractures or stiffness), muscle weakness, Abnormalities of gait and mobility ( involuntary, irregular walking patterns and difficulties with functional movement), and post-polio syndrome ( slow, progressive muscle weakness, severe fatigue and muscle wasting). During a review of Resident 14's advanced directive acknowledgement form dated December 15, 2025, indicated Resident 14 answered No to having an existing advanced directive and indicated Yes to wanting additional information regarding advanced directive. The form contains a section labeled Refer to SSD (Social Service Department), however, the space designated to document the date and time of the referral was left blank. The form was not signed by the resident and was incomplete. During an interview on May 7, 2026, at 12:00 PM with Resident 14, Resident 14 stated Resident 14 doesn't have an advanced directive and does not recall receiving advanced directive information from the facility. During a concurrent interview and record review on May 7, 2026, at 12:16 PM with Social Service Designee (SSD), Resident 14's Electronic Medical Records (medical information about a person that is stored on a computer) were reviewed. The SSD was unable to locate a social service note or progress note for resident 14 regarding advanced directive information given to residents. SSD stated it's facilities policy for social service to inquire if residents have an advanced directive or would like information regarding an advance directive on admission. She further stated the policy was not followed. During a concurrent interview and record review on May 7, 2026, at 12:32 PM with Administrator (Admin), the facility's Policy and Procedure (P&P) titled, Advance Directives, dated December 2016 was reviewed. The P&P indicated, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 2. Written information will include a description of the facilities policies to implement advanced directives and applicable state law .6. Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his or her family members and/ or his or her legal representative, about the existence of a written advance directive.7. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record.8. If the resident indicates that he or she has not established an advanced directive, the facility staff will offer assistance in establishing advanced directives. The Admin stated the facility policy was not followed. 2. During a review of Resident 30's admission Record (contains medical and demographic information), the admission Record, indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (condition where the heart can't pump blood effectively), Schizoaffective disorder (mental health condition that includes psychotic symptoms like hallucinations [hearing or seeing things that are not there]), delusions (fixed false beliefs), disorganized thinking or speech, and mood disorder symptoms like depression, and anxiety disorder (mental health condition characterized by excessive, persistent, or overwhelming fear, worry, or nervousness that interferes with daily functioning). During a review of Resident 30's POLST, dated June 1, 2023, section D – Information and Signatures indicated a checkmark next to No advance directive indicating the resident did not have an advance directive. During a review of Resident 30's Advance Directive Acknowledgement dated June 1, 2023, the Advance Directive Acknowledgement form indicated Resident 30 did have an advance directive and was initialed by Resident 30. However, the section copy provided and the section copy requested were both left blank. The form was signed by facility staff signature on June 1, 2023. During a review of Resident 30's electronic health record and physical paper medical records, there was no evidence of an advance directive on file. During a concurrent interview and record review on May 7, 2026, at 3:51 PM, with the Director of Nursing (DON), Resident 30's POLST dated June 1, 2023, and Resident 30's Advance Directive Acknowledgement dated June 1, 2023, were reviewed. The DON stated both forms had discrepant information regarding if Resident 30 had an advance directive. The DON stated she did not know why there was a discrepancy and stated the nursing staff completes the POLST form and Social Service department completes the Advance Directive Acknowledgement, form which as a new process. The DON stated she was unsure if Resident 30 had an advance directive and acknowledged the facility did not have an advance directive on file for the resident. During a concurrent observation and interview on May 7, 2026, at 4:00 PM, with the DON inside Resident 30's room, Resident 30 was standing next to his bed. The DON asked if Resident 30 had an advance directive and Resident 30 stated he did have an advance directive that was created in the past and his nephew had a copy of it. The DON then requested a copy of the advance directive and Resident 30 stated he would provide a copy to the facility. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised November 2025, the P&P indicated, .Determining Existence of Advance Directive. 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, their family members and/or their legal representative, about the existence of any written advance directives.1. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care. 3. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. 3. A review of Resident 73's admission Record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure, and bacteremia (presence of bacteria in the bloodstream). During a review of Resident 73's POLST, dated April 15, 2026, the POLST Section D – Information and Signatures section regarding if the resident had an advance directive, was incomplete and left blank. During a concurrent interview and record review on May 7, 2026, at 3:55 PM, with the Director of Nursing (DON), Resident 73's POLST, dated April 15, 2026, was reviewed. The DON stated the POLST form was not completed correctly and section D was supposed to be completed by a Registered Nurse (RN), but was not. The DON further stated she was unsure if Resident 73 had an advance directive or not. The DON stated Resident 73's medical record did not have an advance directive acknowledgement or a copy of an existing advance directive. During a concurrent observation and interview on May 7, 2026, at 3:56 PM, with the DON inside Resident 73's room, Resident 73 was lying in bed. The DON asked Resident 73, if she had an advance directive. Resident 73 stated she had both an advance directive and a Power of Attorney (POA – a legal document that gives one person the authority to act on behalf of another person). The DON stated the facility was not aware the resident had an advance directive and that it was missed. The DON requested a copy of the POA and advance directive from Resident 73 and the resident stated she would provide a copy as soon as possible. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised November 2025, the P&P indicated, .Determining Existence of Advance Directive. 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, their family members and/or their legal representative, about the existence of any written advance directives.1. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care. 3. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings.

Based on observation and interview, the facility failed to help maintain dignity for one of three residents (Resident 115) reviewed for urinary catheters (a thin, flexible tube inserted through the an opening which leads into the bladder allowing urine drainage into an external collection bag) when Resident 115's urinary collection bag (bag connected to a catheter by a tube and is used to collect urine) was left uncovered and urine was visible to individuals entering the resident's room and people passing in the hallway.This failure had the potential to compromise Resident 115's dignity, cause embarrassment, humiliation, and diminish the resident's psychosocial well-being.Findings:During a review of Resident 115's admission Record, (contains medical and demographic information), the admission Record, indicated Resident 115 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (an infection usually caused by bacteria entering the urinary tract), dementia (general term used to describe a decline in memory, thinking, reasoning, and other cognitive abilities severe enough to interfere with a person's daily life and functioning), muscle weakness, and difficulty in walking.During an observation on May 4, 2026, at 12:33 PM, while in the hallway, Resident 115's room door was open, Resident 115 was lying in bed and the resident's urinary collection bag was attached to the side of his bed, was left uncovered, and 150 milliliters (ml - unit of measure) of yellow urine could easily be seen from anyone entering the room, or passing in the hallway.During a concurrent observation and interview on May 4, 2026, at 12:36 PM, with Certified Nursing Assistant 4 (CNA 4), while in the hallway, CNA 4 acknowledged Resident 115's urinary collection bag was not covered and the urine inside the bag could be seen from the hallway. CNA 4 stated all urine collection bags were supposed to have a dignity cover placed over them so you could not see the contents of the bag.During an interview on May 6, 2026, at 2:36 PM, with the facility's Infection Preventionist (IP), the IP stated urinary catheter drainage bags were supposed to have a privacy bag applied to it so you could not see the urine inside the bag. The IP further stated it was important to ensure the urine was covered so nobody could see the urine in order to maintain the residents' dignity.During an interview on May 7, 2026, at 2:08 PM, with the Director of Nursing (DON), the DON stated every resident who had a urinary catheter was supposed to have a dignity bag covering the urinary collection bag to maintain the resident's dignity and respect.A copy of the facility policy and procedure regarding using dignity bags to cover urinary collection bags was requested but not provided by the facility.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of one resident (Resident 52) when Resident 52, who had a known history of verbal aggressive behaviors, was observed to be verbally abusing Resident 56 on May 7, 2026. This failure had the potential to place Resident 56 at risk for physical injury, fear, emotional distress, and psychosocial harm.Findings:A review of Resident 52's admission Record (contains medical and demographic information), indicated Resident 52 was admitted on [DATE], with diagnoses which included cerebral infarction (a serious medical emergency occurring when blood flow to a brain region is blocked, causing oxygen deprivation and tissue death), type 2 diabetes (a chronic condition where the body cannot properly use or make enough insulin, leading to high blood sugar), and muscle weakness (a reduction in the strength of voluntary muscle contractions). A review of Resident 56's admission Record (contains medical and demographic information), indicated Resident 56 was admitted on [DATE], with diagnoses which included encephalopathy (a broad term for any disease, damage, or malfunction that affects the brain's structure or function, resulting in an altered mental state), type 2 diabetes (a chronic condition where the body cannot properly use or make enough insulin, leading to high blood sugar), and acute respiratory failure with hypoxia (a life-threatening emergency where the lungs cannot adequately transfer oxygen to the blood). During a review of the Resident 52 Care Plan, dated October 31, 2025, it indicated, Resident 52 is/has potential to be verbally aggressive with staff r/t Poor impulse control with selective staff. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness and Provide positive feedback for good behavior. Emphasize the positive aspects of compliance During an observation on May 7, 2026, at 11:59 AM in the facility's 300-Hall unit, Resident 52 was observed verbally abusing Resident 56 while both residents were lying in their beds in the same room. Resident 52 called Resident 56 asshole and a liar, and to turn his TV down. A Certified Nursing Assistant 1 (CNA 1) intervened. CNA 1 approached the residents in their room and asked Resident 52 the reason for verbally abusing Resident 56. Resident 52 continued yelling profanities at Resident 56 stating, fuck you, stop talking shit, put your fucking headphones on. You're being a smartass. During an interview with CNA 1 on May 7, 2026, at 12:10 PM, CNA 1 stated staff were aware of Resident 52's verbal aggression and stated, We try to keep a close eye on him when we can and also provide positive feedback for good behavior. During an interview on May 7, 2026, at 1:30 PM, with the Administrator (Admin) about the verbal abuse from Resident 52 to Resident 56. The admin stated the facility's expectation was to provide supervision and interventions necessary to protect residents from abuse, including resident-to-resident altercations. The administrator stated the interventions were not done. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated December 2016, with the Director of Nurses (DON) and the admin, in the administrator's office, the P&P indicated, .1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. The admin stated the policy was not followed and should have been. The DON stated she agreed with the administrator.

Based on observation, interview, and record review, the facility failed to complete a Minimum Data Set (MDS - a computerized clinical assessment) Significant Change in Status Assessment (SCSA) within 14 days for one of five residents (Resident 53), who were reviewed for accidents when Resident 53 experienced a fall with a fracture on April 9, 2026.This failure had the potential to delay identification and implementation of necessary interventions to address the residents' care and support needs.Findings: During a review of Resident 53's admission Record (contains medical and demographic information), the admission Record, indicated Resident 53 was admitted to the facility on [DATE], with diagnosis which included history of falling, presence of left artificial hip joint, muscle weakness, and difficulty in walking.During a concurrent observation and interview on May 4, 2026, at 11:54 AM, with Resident 53, Resident 53 was lying in bed and stated she fell a while ago and thought it may have been a few weeks ago. Resident 53 further stated she fell in her restroom while she was by herself and broke her right arm. Resident 53 had her right arm wrapped with a compression type of bandage from her lower forearm to her fingers.During a review of Resident 53's Electronic Health Record (EHR - electronic medical record), the most recent MDS assessment was dated April 8, 2026 (dated one day prior to Resident 53's fall) and was a quarterly assessment (an abbreviated [shortened] version of a comprehensive MDS assessment). The MDS assessment section GG (section for functional abilities) GG0115 was coded no impairment for upper extremities (shoulder, elbow, wrist, hand). Further review of the quarterly MDS assessment dated [DATE], indicated section J1800 (section for falls) NO for the question has the resident had any falls since admission/entry or reentry or the prior assessment.During a review of Resident 53's nurse's progress notes, a note dated April 9, 2026, indicated .received report from bedside nurse regarding resident fall at 0702 AM [7:02 AM], upon assessment, resident was found kneeling down position on the bathroom. Resident report it was due to black out. She is currently alert and oriented x 3 and complaining pain to right wrist and states she hit her head on the wall. A bump is noted on the right temple.MD made aware and give order to send out patient to ER [emergency room] for further evaluationDuring further review of Resident 53's progress notes, a progress note dated April 9, 2026, titled, Change in Condition, (CIC) for Falls dated April 9, 2026, indicated, .resident alert and oriented x 3. Resident complaining of pain on right wrist, and she states she hit her head on the wall, a bump is noted to right temple.MD made aware and order to send resident to hospital.During a review of Resident 53's progress notes, a progress note dated April 9, 2026, indicated, Patient returned from hospital at 8:05 PM from [name of local hospital].transport with 2 person transfer in gurney, d/t [due to] s/p [status post] fall and splint placed to right wrist r/t distal radius fracture with order to follow up with orthopedist.During a concurrent interview and record review on May 7, 2026, at 2:16 PM, with the Director of Nursing (DON), the DON reviewed Resident 53's EHR and stated a significant change MDS assessment should have been done after Resident 53's change of condition was determined and documented on April 9, 2026, (when the resident fell and sustained a fracture). The DON further stated the significant change MDS assessment should have been done as soon as possible, but it was not. The DON stated the individual who would have been responsible for doing the significant change assessment was the Minimum Data Set Nurse 1 (MDS 1).During an interview on May 7, 2026, at 2:33 PM, with MDS 1, MDS 1 stated she thought a significant change assessment only needed to be done if there were more than two areas of the MDS that would have declined or improved and did not think an MDS assessment needed to be done for Resident 53's fall with fracture. MDS 1 further stated the facility followed the current version of the RAI manual for their policy and procedure.During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised October 2023, the P&P indicated, A comprehensive assessment of each resident is completed at intervals designated by OBRA (Omnibus Budget Reconciliation Act of 1987 - a federal law that established federally mandated resident assessments required to evaluate a resident's physical, psychological, and functional status for care planning and regulatory compliance purposes).1. OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes.5. The RAI User's Manual.provides detailed information on timing and submission of assessments.During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument 3.0 User's manual, dated October 2025, version 1.20.1, the manual indicated on page 2-24, .03. Significant Change in Status Assessment (SCSA).The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline.a significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting, 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. the nursing home may take up to 14 days to determine whether the criteria are met.

Based on observation, interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of two residents (Resident 30) reviewed for behavior and emotional mood, when the Resident 30's RAI-MDS dated [DATE], did not indicate Resident 30 was experiencing hallucinations.This failure had the potential to result in unmet care needs for Resident 30 which can potentially jeopardize the residents' health and safety.Findings: During a review of Resident 30's admission Record (contains medical and demographic information), the admission Record, indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia - such as hallucinations or delusions - with mood disorder symptoms like depression), anxiety disorder (a condition in which feelings of fear, worry, or dread become excessive, persistent and hard to control to the point where they interfere with everyday life), delirium due to known psychological condition (a change in consciousness and thinking caused directly by another illness, medication, or underlying condition which can lead to confusion, trouble focusing, and may include hallucinations, mood swings, or sleep problems).During a concurrent observation and interview on May 4, 2026, at 12:21 PM, Resident 30 was sitting in a wheelchair near the edge of his bed watching TV. Resident 30 calmly stated an individual was currently in his room and was choking him, tripping him and talking to him. There was nobody present in Resident 30's room other than the surveyor and Resident 30 was not assigned a roommate. Resident 30 stated the individual was choking and tripping him during our conversation.During a review of Resident 30's RAI-MDS assessment dated [DATE], the RAI-MDS assessment indicated in section E - Behaviors.E0100 Potential indicators of psychosis - check all that apply A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli) B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality) Z. None of the above. staff had checked none of the above for this section.During a review of Resident 30's physician's orders, an order dated August 26, 2024, indicated, document episodes of auditory hallucinations every shift.During a review of Resident 30's care plan (an individualized plan for the medical care of a resident), titled, Schizoaffective disorder m/b [manifested by] auditory hallucinations. dated August 8, 2024, the care plan indicated, .interventions.when hallucinations are apparent, assess hallucinations (auditory, olfactory, tactile), document episodes of auditory hallucinations.During a review of Resident 30's Medication Administration Record (MAR - a document used to record medication administration and other physician's orders), dated April 1, 2026, through April 30, 2026, the MAR indicated staff had documented Resident 30 had experienced 74 instances of auditory hallucinations in April of 2026. 13 instances of auditory hallucination were documented as having occurred within the 7 day look back period (the span of time during which any resident symptoms, behaviors, or care needs that occurred within this window are documented) from April 9, 2026, through April 15, 2026.During a concurrent interview and record review on May 7, 2026, at 2:24 PM, with the Director of Nursing (DON), Resident 30's MAR dated April 1, 2026, through April 30, 2026, was reviewed. The DON acknowledged the MAR indicated Resident 30 had 74 instances of hallucinations in April 2026, with 13 instances occurring within the 7 day lookback period of the MDS assessment dated [DATE]. Resident 30's RAI-MDS assessment dated [DATE], was then reviewed and the DON stated the MDS was completed incorrectly for section E-Behaviors, since it did not indicate the resident had been experiencing hallucinations. The DON further stated the facility followed the Resident Assessment Instrument manual for instructions on completing MDS assessments.During a concurrent interview and record review on May 7, 2026, at 2:40 PM, with the Social Services Designee (SSD), The SSD reviewed Resident 30's RAI-MDS assessment dated [DATE], and stated she was the individual who completed section E-Behaviors, and indicated Resident 30 did not have hallucinations. Resident 30's MAR dated April 1, 2026, through April 30, 2026, was reviewed and the SSD stated she incorrectly coded Section E-Behaviors, on the MDS assessment because she did not look at the MAR when determining if the resident was experiencing hallucinations.During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, revised October 2023, the P&P indicated, .12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. 13.The results of the assessments are used to develop, review, and revise the resident's comprehensive care plan.During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument 3.0 User's manual, dated October 2025, version 1.20.1, the manual indicated on page E-1, Section E: Behavior. Intent: the items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs preferences or illness.Hallucination.the perception of the presence of something that is not actually there. It may be auditory, or visual or involve smells, tastes or touch. Steps for Assessment.1. Review the resident's medical record for the 7-day look-back period.Coding Instructions.Code based on behaviors and/or thoughts expressed in the last 7 days rather than the presence of a medical diagnosis.Check E0100A, hallucinations: if hallucinations were present in the last 7 days .

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for medication administration for 1 of 14 sampled residents (Resident 116) when Licensed Vocational Nurse 1 (LVN 1) did not to administer Cholecalciferol (a vitamin to treat Vitamin D deficiency) as ordered by the physician. This failure had the potential to result in ineffective treatment, and adverse health outcomes for Resident 116.Findings: During a review of Resident 116's admission Record (contains medical and demographic information), indicated Resident 116 was admitted on [DATE], with diagnoses which included vitamin D deficiency ( a common condition where the body lacks sufficient vitamin D, essential for bone health, immune function, and muscle strength). During a review of Resident 116 physician's orders, dated April 27, 2026, the physician's orders indicated, give Cholecalciferol 2000 units by mouth daily, give 2 tablets of 1000 unit for supplement. During a medication pass observation on May 7, 2026, at 8:12 AM, LVN 1 prepared medications for Resident 116. During a further medication pass observation on May 7, 2026, at 8:12 AM, revealed LVN 1 did not administer Cholecalciferol as ordered by the physician to Resident 116. During an interview on May 7, 2026, at 9:42 AM with LVN 1, LVN 1 reviewed Resident 116 Medication Administration Record (MAR-a legal document used by healthcare professionals to document the administration of drugs to a patient in real-time). The MAR indicated Resident 116 was prescribed Cholecalciferol 2000 units by mouth daily, give 2 tablets of 1000 unit for supplement. LVN 1 acknowledged the medication had been omitted, stating, I missed that medication during the pass. During an interview on May 7, 2026, at 4:14 PM, with the Director of Nursing (DON) in the administrator's office, the DON stated her expectation was for licensed nurses to follow the physician orders and verify all scheduled medications were administered and documented accurately during each medication pass. The DON further stated it was important to ensure medications were administered and documented as ordered by the physician. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated April 2019, with the DON, in the administrator's office, the P&P indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Further review of the facility's P&P, it indicated, 4.Medications are administered in accordance with prescriber orders, including any required time frame. The DON stated the policy was not followed and should have been.

Based on observation, interview, and record review, the facility failed to ensure staff monitored the indwelling foley catheter (a thin, flexible tube inserted through an opening into the bladder allowing continuous urine drainage into an external collection bag) for one of three residents (Resident 115) reviewed for urinary catheters when the tubing for Resident 115's urinary collection bag (bag connected to a catheter by a tube and is used to collect urine) was observed to be touching the floor and documentation of observation and monitoring of Resident 115's catheter was not documented as being performed as ordered by the physician.This failure exposed Resident 115 to increased risk of urinary tract infection and the spread of microorganisms (cross contamination), from the floor to his indwelling foley catheter.Findings:During a review of Resident 115's admission Record, (contains medical and demographic information), the admission Record, indicated Resident 115 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (an infection usually caused by bacteria entering the urinary tract), sepsis (the body's harmful overreaction to an infection which can cause to organ dysfunction, tissue damage, and death if not treated promptly), and bacteremia (presence of bacteria in the bloodstream).During an observation on May 4, 2026, at 12:33 PM, while in the hallway, Resident 115's room door was open, Resident 115 was lying in bed and the resident's urinary collection bag was attached to the side of his bed and the tubing which led to the indwelling foley catheter, was touching the floor.During a concurrent observation and interview on May 4, 2026, at 12:36 PM, with Certified Nursing Assistant 4 (CNA 4), while in the hallway, CNA 4 stated she was unsure of how the positioning of Resident 115's foley catheter tubing was supposed to be. CNA 4 acknowledged the tubing was touching the floor.During a review of Resident 115's physician's orders, an order dated April 23, 2026, indicated, Foley catheter care: monitor for patency, placement and positioning every shift.During a review of Resident 115's Treatment Administration Record (TAR - document used by staff to record treatments administered to the resident), dated May 1, 2026, through May 31, 2026, the TAR had blanks next to two of fifteen (2 of 15) shifts for Foley Catheter Care: monitor for patency, placement, and positioning every shift.During a review of Resident 115's TAR, dated April 1, 2026, through April 30, 2026, the TAR had blanks next to three of 22 (3 of 22) shifts for foley catheter care: monitor for patency, placement, and positioning every shift.During an interview on May 6, 2026, at 2:36 PM, with the facility's Infection Preventionist (IP), the IP stated urinary catheter drainage bags were supposed to be always positioned below the bladder, and the tubing should be free of kinks, should not be coiled, and should not be touching the floor. The IP further stated it was important to ensure the tubing was not touching the floor because the floor was dirty and it could cause increased risk for infection.During an interview on May 7, 2026, at 2:08 PM, with the Director of Nursing (DON), the DON stated the tubing for foley catheter drainage bags should be placed appropriately which included ensuring the tubing was not kinked, the urinary collection bag was lower than the bladder, and the tubing was off the floor. The DON further stated it was important to keep the tubing off the floor for infection control.During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, Revised September 2014, the P&P indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Control.b. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device that allows residents' to communicate with nursing staff when they need assistance) was within resident reach for one of five sampled residents (Resident 91 ) when Resident 91 call light was wedged/stuck between the mattress and the side bed rail and not accessible to Resident 91.This failure had the potential to place Resident 91 at risk for their safety and well-being.Finding:A review of Resident 91's admission Record, (contains demographic and medical information), indicated Resident 91 was admitted to the facility on [DATE], with diagnoses which included epilepsy (a brain disorder that causes repeated, unprovoked seizures), anxiety disorder (persistent, and uncontrollable fear or worry that interferes with daily life) and altered mental status (any sudden or significant change in a person's normal thinking, awareness, or behavior). During a concurrent observation and interview on May 4, 2026, at 11:22 AM, with Resident 91 in the room, observed Resident 91 lying in bed and repeatedly touching and rubbing her head. Resident 91stated she had a headache. When asked whether nursing staff had been notified, resident 91 stated she had not informed staff because she had not seen her nurse. Resident 91 further stated she did not know where her call light was located. An observation of resident call light, it was observed wedged between the mattress and the side bed rail and was not accessible to the resident. As a result, Resident 91 was unable to independently notify staff for assistance and to report pain and request care.During a concurrent observation and interview on May 4, 2026, at 11:27 AM, with Licensed Vocational Nurse 1 (LVN 1), in Resident 91's room, LVN 1 observed and verified Resident 91's call light wedged between the mattress and the side bed rail and not accessible to the resident. The LVN was observed attempting to pull the call light cord from between the mattress and bed frame, noting difficulty retrieving it. The LVN stated the call light should not be there and confirmed that the call light must remain accessible to the resident at all times. The LVN further stated it is important for the call light to be within reach so resident can request assistance when needed, such as now with residents compliant of a headache and request for pain medication. LVN further acknowledge Resident 91 was unable to use the call light to request assistance for resident's headache. During a concurrent interview and record review on May 5, 2026 at 4:23 PM with the Administrator (Admin) and the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Answering the Call Light dated March 2021 was reviewed. The P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's request and needs.1. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident.5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The DON stated the expectation is for call lights to remain within residents' reach at all times and acknowledged the facility's P&P was not followed. The Admin acknowledged the P&P was not followed.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents the results of the most recent survey of the facility. This failure had the potential to prevent residents, family members, and legal representatives from being informed about the facility's compliance with state and federal requirements, which could limit their ability to make fully informed decisions regarding the residents' care.Findings:During the Resident Council Meeting held on May 5, 2026, at 10:30 AM, residents expressed concerns regarding the visibility and accessibility of the most recent survey results of the facility. Further more, multiple residents reported that they were unaware of the location where these results were posted.During an interview with the Director of Nursing (DON) on May 5, 2026, at 11:15 AM, the DON acknowledged the most recent survey of the facility must be visibly posted in an unobstructed area and be accessible to the residents and the public. DON was unable to specify or demonstrate the location where the most recent survey of the facility was posted.During an interview with the facility's Administrator (ADMIN) on May 5, 2026, at 11:25 AM, the ADMIN stated that the most recent survey of the facility was usually posted by the bulletin board located in front of the nursing station. The ADMIN, the DON, and the surveyor proceeded to the specified location and upon inspection, the most recent survey of the facility was not found posted at the bulletin board. The ADMIN explained that a three-ring binder containing the results of the most recent survey was typically placed at this location and was unable to account for its absence at the time of inspection.During a concurrent interview and record review with the Admin on May 5, 2026, at 2:25 PM, the facility's policy and procedure (P&P) titled, Survey results, examination of revised April 2007 was reviewed. The P&P stated, 2. A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plan of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room.The ADMIN acknowledged that the facility's P&P were not properly followed, as the most recent survey results were not posted in a location that was easily accessible to residents, their family members, or legal representatives.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect, kindness, and dignity, when a Certified Nursing Assistant (CNA 1) engaged in a verbal altercation with Resident 1. This failure resulted in Resident 1 ' s basic right to be violated, which had the potential for Resident 1 to feel disrespected and unsafe. Findings: During a review of Resident 1 ' s Admission Record (contains demographic and medical information), it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of hemiplegia (one side of the body paralyzed) and hemiparesis (weakness of one side of the body). During a review of Resident 1 ' s Change in Condition Evaluation, dated April 4, 2025, it indicated on April 4, 2025 at around 3 PM, Resident [Resident 1] had a derogatory verbal altercation with a staff member [CNA 1]. Both staff member and Resident educated on the importance of proper communication, mutual respect. Resident on monitoring for psychosocial well-being. Resident reassured that he is safe and that the CNA in question will no longer be assigned to his care. Resident verbalized feeling safe and does not appear in any distress. During a review of Employee Separation Report dated April 9, 2025, it indicated CNA 1 used the word F*** multiple times in a verbal interaction with a resident. This was witnessed by another staff member and the resident who was alert and oriented. There is no circumstance where any expletive may be used in a verbal interaction with a resident. This is expressly against facility policy and practice . During an interview on April 11, 2025, at 2:38 PM, with the Administrator (Admin), the Admin stated CNA 1 validated the incident had occurred. The Admin further stated although Resident 1 initiated the use of profanity, CNA 1 ' s response was inappropriate and not permitted under facility policy. The Admin stated staff were expected to walk away and report such incidents, rather than engage in verbal altercations with residents. During an observation on April 11, 2025, at 4:00 PM, Resident 1 was lying down in bed, with his eyes open. Resident 1 stated on April 4, 2025, at approximately 11:30 AM, CNA 1 was providing care for him, when CNA 1 pulled his pillow really hard, which upset him and led him to use the F-word first toward CNA 1. Resident 1 further stated, in response, CNA 1 replied F*** you, and continued to exchange offensive language with him. Resident 1 stated This should not happen in places like this. During a concurrent phone interview and record review. on May 2, 2025, at 4:16 PM with the Director of Nurses (DON), the facility ' s policy and procedure (P&P) titled Resident Rights, dated revised December 2016, was reviewed. The P&P indicated, Employees shall treat all residents with kindness, respect and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .b. Be treated with respect, kindness and dignity . The DON stated staff were expected to follow this policy, and acknowledged CNA 1 failed to do so during the incident involving Resident 1.

Based on observation, interview, and record review, the facility failed to ensure the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner as required by the facility's policy. This failure posed potential risk for contamination of ice, which could lead to foodborne illness (food poisoning, is a sickness caused by eating food or drinking water that is contaminated with harmful bacteria, viruses, parasites, or chemicals.) and negatively impact the health and safety of 96 of 96 vulnerable residents who received food and beverages from the kitchen. Findings: During a concurrent observation and interview, on January 14, 2025, at 8:20 AM, with the Dietary Services Supervisor (DSS), in the kitchen, the ice machine was inspected. The ice scoop was found resting inside an uncovered blue container located near the ice machine. The DSS stated the ice scoop must always be stored in a clean, covered container to ensure safety and prevent contamination. During a concurrent observation and interview on January 14, 2025, at 8:30 AM, in the kitchen, with the Maintenance Director, (MD-1), the MD-1 stated, It's not my job to place the ice scoop back properly. The MD-1 acknowledged the ice scoop should have been stored on the side of the ice machine in a covered container. During a concurrent interview and record review, on January 16, 2025, at 8:55 AM, with the MD-1, the MD-1 reviewed the facility's policy and procedure (P&P) titled, Ice Machines and Ice Storage Chest dated January 2012, which indicted 1. Ice-making machines, ice storage chest/containers, and ice call all become contaminated by: a. Unsanitary manipulation by employees .2. To help prevent contamination of ice machines, ice storage chest/containers or ice, staff shall follow these precautions .e. keep the ice scoop/bin in a covered container when not in use ., clean and sanitize the tray and ice scoop daily . The MD-1 acknowledged the policy was not followed. During an interview with the Infection Control Prevention Nurse (ICP Nurse), on January 16, 2025, at 9:32 AM, the ICP Nurse stated the ice scoop placement did not follow the protocol. She further stated it should be placed in a designated area and covered with a lid because leaving it uncovered can lead to contamination. The IP Nurse further stated ice was considered a food item, and for infection control purposes, it must be protected with a lid to prevent contamination.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were being followed for six of 25 sampled residents (Residents 44, 33, 65, 4, 484 and 47) when: 1. Resident 44's Central Venous Catheter (CVC- thin, flexible tube inserted into a vein to provide access to the heart) dressing was not changed in accordance with facility policy. 2. Resident 44's Intravenous tubing (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) was not dated in accordance with facility policy. 3. Resident 33's oxygen tubing (flexible plastic tube that is used to deliver oxygen from an oxygen supply to a person who needs extra oxygen) was not changed in accordance with facility policy. 4. Resident 65's oxygen tubing was not dated in accordance with facility policy 5. License Vocational Nurse 1 (LVN 1) did not perform hand hygiene (practice of washing hands with soap and water or using an alcohol-based hand sanitizer to remove germs) during medication administration for Resident 5. 6. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene when assisting Residents 484 and 47 with breakfast. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 101 highly vulnerable residents whose health conditions were already compromised. Findings: 1. During a review of Resident 44's clinical record, the Face Sheet (contains demographic and medical information), indicated Resident 44 was admitted to the facility on [DATE], with diagnoses which included bacteremia (bloodstream infection that occurs when bacteria enter the blood) and hypertension (high blood pressure). During a concurrent observation and interview, on January 13, 2025, at 11:55 AM, with a Registered Nurse 1 (RN 1), Resident 44's CVC, which was located on her right upper arm, was inspected. RN 1 confirmed the CVC dressing was dated January 1, 2025, indicating when the dressing was last changed. RN 1 stated the facility's practice required the dressing to be changed every seven days or when it becomes soiled or dislodged. RN 1 further stated that the dressing should have been changed on January 8, 2025 (five days ago), but it had not been. A concurrent interview and record review, on January 16, 2025, at 10:30 AM, with the Director of Nursing (DON) and Infection Control Prevention Nurse (ICP Nurse), the DON and the ICP Nurse reviewed the facility's policy and procedure (P&P) titled, Central Venous Catheter Dressing Changes, revised on April 20, 2016, which indicated, Purpose. The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings General Guidelines . 5. Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN [as needed] wet, soiled, or not intact) . The DON stated the facility should have a system to ensure CVC dressings were changed according to policy, but no system were currently in place to monitor this. The ICP Nurse confirmed the policy was not followed. 2. During a review of Resident 44's clinical record, the Face Sheet indicated Resident 44 was admitted to the facility on [DATE], with diagnoses which included bacteremia and hypertension. During a review of Resident 44's physician's order, dated January 13, 2025, it indicated Resident 44 had an order for Vancomycin (a prescription antibiotic used to treat serious bacterial infections) . IV solution .1 gram (GM - unit of measure) intravenously one time a day . During a concurrent observation and interview, on January 13, 2025, at 11:40 AM, with RN 1, in Resident 44's room, Resident 44's Vancomycin 1 GM IV solution, which was hanging on the IV pole, was inspected. The IV solution was connected to an undated IV tubing. RN 1 stated that he administered Resident 44's IV medication that morning around 9:15 AM. RN 1 explained that facility practice required dating the IV tubing once it was opened and assembled for use. RN 1 further stated he should have dated, timed, and initialed the IV tubing, but he did not. A concurrent interview and record review, on January 16, 2025, at 10:14 AM, with the DON and ICP Nurse, they reviewed the facility's policy and procedure (P&P) titled, Administration Set/Tubing Changes, revised on April 20, 2016, which indicated, Purpose The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment. Preparation 1. Label new tubing with date, time, and initials. If facility requires, label may include the date and time that tubing was initiated and when tubing should be discontinued. General Guidelines: . 6. All tubing is labeled with start and change date and time. Any tubing that is observed not to have a label must be changed and then labeled accordingly . Both the DON and ICP Nurse stated the facility did not follow this policy. 46917 3. During a review of Resident 33's Admission Record, it indicated Resident 33 was admitted to the facility with the diagnoses of dementia (medical condition that causes a person to lose ability to think, remember, and reason), retropharyngeal and parapharyngeal abscess (severe infection in the neck that involve a collection of pus in the deep neck spaces), and shortness of breath (difficulty breathing). During an observation on January 13, 2025, at 10:11 AM, in Resident 33's room, Resident 33 was lying in bed, talking nonchalantly to the wall. Resident 33 was wearing oxygen cannula with its tubing attached to an oxygen concentrator, which was running at 2 liters per minute (amount of oxygen given to a patient). The date on oxygen tubing was December 27, 2024. (17 days ago) During an interview on January 13, 2025, at 3:26 PM, with the Infection Control ICP Nurse, the ICP Nurse stated Resident 33's oxygen tubing should have been changed sooner than 17 days. The ICP Nurse further stated it was all the nurse's responsibility to check the labels and change as needed. During a concurrent interview and record review, on January 13, 2025, at 3:48 PM, with the DON, the facility's P&P titled, Oxygen Administration dated revised October 2010 was reviewed. The P&P indicated, .Steps in the Procedure . 23. Change the oxygen cannula and tubing every seven (7) days, or as needed . The DON stated the P&P was not followed. The DON further stated it should not have been left unchanged for 17 days due to the risk of infection. 4. During a review of Resident 65's Admission Record, it indicated Resident 65 was admitted to the facility with the diagnoses of chronic obstructive pulmonary disease (COPD-lung disease that makes it difficult to breath), acute respiratory failure with hypoxia (medical condition when there is not enough oxygen in the body), and asthma (lung disease that causes inflammation in the airways of the lungs). During a review of Resident 65's Physician Order dated September 17, 2024, the Physician Order indicated, Titrate (slowly increase or decrease over a period of time) O2 (oxygen) via n/c (nasal cannula- a type of oxygen tubing) between 2-5 L/min (L-liters- unit of measurement/min-minutes) to keep oxygen saturations (levels of oxygen in the blood) above 92% (95-100 is considered normal, with lower levels being acceptable for COPD) . During an observation on January 13, 2025, at 10:35 AM, in Resident 65's room, Resident 65 was lying in bed, watching television. Resident 65's oxygen tubing was adjacent to Resident 65's bed. There was no label on the oxygen tubing. During an interview on January 13, 2025, at 3:26 PM, with the ICP Nurse, the ICP Nurse stated Resident 65's oxygen tubing should have been labeled with the date. The ICP Nurse further stated it was the nurse's responsibility to label oxygen tubing. During a concurrent interview and record review on January 13, 2025, at 3:48 PM, with the DON, the DON reviewed the facility's P&P titled, Oxygen Administration revised on October 2010, which indicated .Steps in the Procedure . 23. Change the oxygen cannula and tubing every seven (7) days, or as needed . Documentation . After completing the oxygen setup or adjustment, the following information should be recorded . 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure . The DON stated the P&P was not followed. 5. During a review of Resident 5's Admission Record, it indicated Resident 5 was admitted to the facility with the diagnoses of hemiplegia (condition that causes weakness or paralysis on one side of the body) and hemiparesis (condition that causes weakness or an inability to move on one side of the body) following cerebral infarction (athologic process that results in an area of necrotic tissue in the brain) affecting right dominant side, aphasia (loss of ability to understand or express speech) following cerebral infarction, and gastrostomy status (a tube inserted into the stomach that delivers food and liquids). During a medication administration observation, on January 15, 2025, at 9:11 AM, with LVN 1, LVN 1 checked Resident 5's blood pressure then touched the computer, which was by the medication cart. LVN 1 then proceeded with administering Resident 5's medication, without performing hand hygiene. During a follow up interview on January 15, 2025, at 11:10 AM, with LVN 1, LVN 1 stated she should have performed hand hygiene after touching Resident 5. During an interview on January 15, 2025, at 11:25 AM, with the ICP Nurse, the ICP Nurse stated the expectation was for nurses to wash their hands after touching a patient. The ICP Nurse stated LVN 1 should have performed hand hygiene before administering Resident 5's medication. During a concurrent interview and record review on January 16, 2025, at 2:24 PM, with the DON, the DON reviewed the facility's P&P titled, Handwashing/Hand Hygiene revised on August 2019, which indicated, . 7. Use an alcohol-based hand rub . ; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the follow situations; . b. before and after direct contact with residents; c. before preparing or handing medications . The DON stated the P&P was not followed. 51583 6. During a concurrent observation and interview, on January 15, 2025, at 7:38 AM, with CNA 1, CNA 1 walked into Residents 47 and 484's shared room. (Both residents were placed on Enhanced Barrier Precaution [EBP- set of infection control measures that use gowns and gloves to reduce the spread of resistant organism.]) An isolation cart (mobile storage unit that holds protective equipment such as gloves, mask, gown) was near the entrance of their room. CNA 1 donned on gown and gloves prior to entering room, then opened the curtain divider and set up Resident 47's breakfast tray. CNA 1 then cut up Resident 47's food and proceeded on feeding Resident 47. CNA 1 wore the same gown and gloves. Without performing hand hygiene, CNA 1 proceeded to set up the breakfast tray and feed Resident 484. Resident 47 stated CNA 1 comes in every morning to feed me and Resident 484 at the same time. CNA 1 acknowledged when residents were on EBP, the staff should not wear the same gown and gloves for the care of more than one person. During a concurrent interview and record review on January 15, 2025, at 8:30 AM, with the ICP Nurse, the IPN Nurse reviewed the facility's P&P titled, Handwashing/ Hand Hygiene policy, revised on August 2019, which indicated Use an alcohol-based hand rub . ; or, alternatively, soap (antimicrobial and non-antimicrobial) and water for the following situations: before and after assisting a resident with meals . The ICP Nurse stated CNA 1 should have followed the P&P, but she did not.

Based on interview and record review, the facility failed to ensure the Significant Change of Status Assessments (SCSA- comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline) Minimum Data Set (MDS- a computerized assessment instrument) were completed within 14 days for one of two residents (Resident 5) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.). This failure resulted on Resident 5's care plan not being updated and revised to reflect her current status, and had the potential to delay identification and implementation of the resident's care and support needs. Findings: During a review of Resident 5's Admission Record (a document that contains demographic and clinical data), it indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included cerebrovascular disease (condition that affects the blood vessels in the brain, lead to stroke) and atherosclerosis heart disease (condition where the blood vessels clogged, and lead to heart attacks or strokes). During a concurrent interview and record review, on January 16, 2025, at 10:10 AM, with the Minimum Data Set Nurse 1 (MDS Nurse 1), the MDS Nurse 1 reviewed and acknowledged Resident 5's physician's order, dated May 24, 2024, which indicated . Admit to [Name of the Hospice Company] Hospice on routine level of care . During a follow-up concurrent interview and record review, on January 16, 2025, at 10:15 AM, with the MDS Nurse 1, the MDS Nurse 1 reviewed Resident 5's clinical record, which indicated the SCSA assessment was not completed 14 days after hospice admission. The MDS Nurse 1 stated, The SCSA MDS assessment should have been completed on June 6, 2024, and we missed it. (Six months and 11 days past due). During a concurrent interview and record review, on January 16, 2025, at 10:15 AM, with the MDS Nurse 1, the MDS Nurse 1 reviewed the facility's policy and procedure titled Change in Resident's Condition or Status revised May 20, 2017, which indicated .2. A significant assessment is major decline or improvement in resident status that will: a. Will not normally resolve itself without intervention . c. requires interdisciplinary review and/or revision of the care plan .9. If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [is a federal law that establishes regulations for nursing facilities] regulation governing resident assessment and as MDS RAI [Resident Assessment Instrument] instruction manual . The MDS Nurse 1 stated the facility did not follow the policy. During a review of CMS (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) manual, dated October 2024, it indicated .An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing .

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for two of two residents (Residents 9 and 19) reviewed for insulin (hormone that helps the body use sugar and starches for energy or store them for later use) and antibiotic (medication used to treat bacterial infections) use when: 1. Resident 9's insulin injections were not coded on the MDS assessment. 2. Resident 19's antibiotic therapy was not coded on the MDS assessment. These failures had the potential to cause inaccuracy in identifying Residents 9 and 19's care and support needs. Findings: 1. During a review of Resident 9's Admission Record (contains demographic and medical information), it indicated Resident 9 was admitted to the facility on [DATE], with diagnoses of Type 2 diabetes mellitus (when the body has trouble using insulin properly, causing high blood sugar levels.), and long term use of insulin. During a review of Resident 9's Physician's Orders, dated July 12, 2023, it indicated . Humalog injection solution (insulin Lispro- type of insulin) 100 unit/mL (units of insulin in each milliliter of the liquid) inject as per sliding scale (: if 70 - 150 = 0 UNITS;151 - 200 = 2 UNITS; 201 - 250 = 4 UNITS; 251 - 300 = 6 UNITS; 301 - 350 = 8 UNITS; 351 - 400 = 10 UNITS; 401 - 450 = 12 UNITS, subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus without complications .IF OVER 400 GIVE 12 UNITS AND CALL MD .-Start Date 08/01/2024 (August 1, 2024) 0600 (6 AM) . During a concurrent interview and record review, on January 14, 2025, at 10:12 AM, with the MDS Nurse 2, the MDS Nurse 2 reviewed and acknowledged Resident 9's Medication Administration Record (MAR) for the month of October 2024, which indicated Resident 9 has received insulin injections on October 1, 2024, October 3, 2024, October 4, 2024, October 5, 2024, October 6, 2024, and October 7, 2024. (A total of 6 days from October 1, 2024 through October 7, 2024.) During further interview and record review, on January 14, 2025, at 10:18 AM, with the MDS Nurse 2, the MDS Nurse 2 reviewed and acknowledged Resident 9's MDS Section N - Medications dated October 7, 2024, which indicated Resident 9 did not receive any insulin injection from the seven day look back period (October 1, 2024 through October 7, 2024). The MDS Nurse 2 stated the MDS Assessment was inaccurately coded and further stated it should have reflected the six days of insulin use. During a concurrent interview and record review on January 16, 2025, at 8:20 AM, with the Director of Nursing (DON), the DON reviewed the facility's policy and procedure (P&P) titled Certifying Accuracy of the Resident assessment dated [DATE], which indicated 2. Any person who completes any portion of the MDS assessment, tracking form or correction request form is required to sign the assessment certifying the accuracy of the portion of that assessment . The DON stated the policy was not followed. During a concurrent interview and record review, on January 16, 2025, at 9:38 AM, with the MDS Nurse 2, the MDS Nurse 2 reviewed of the CMS (Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2024, which indicated, .The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) . The MDS Nurse 2 stated that the RAI Manual guidelines were not followed. 46917 2. During an observation on January 13, 2025, at 2:48 PM, in Resident 19's room, Resident 19 was lying in bed, watching television. Resident 19 stated she had no concerns with her care. During a review of Resident 19's Admission Record, it indicated Resident 19 was admitted to the facility with the diagnoses of other mechanical complication of other internal orthopedic devices, implants, and grafts (issues that arise due to complications on an internal orthopedic implant), generalized muscle weakness (decreased strength or weakness in most of muscles), and osteomyelitis (OM- bone infection). During a review of Resident 19's Physician's Order, dated October 16, 2024, it indicated Bactrim (antibiotic medication) DS (Double Strenght) Oral Tablet 800 - 160 MG (milligram-unit of measurement) Give 1 tablet by mouth in the morning for Chronic LLE (left lower leg) hardware/OM infection for 52 weeks. During a review of Resident 19's Infection Note, dated December 18, 2024, it indicated .per dr (doctor) . resident is to continue current antibiotic regime and continue to follow infectious disease MD's (Medical Doctor) directives without a time out (scheduled review of the patient antibiotic treatment) at this time . During a review of Resident 19's MDS - Section N: Medications, dated January 1, 2025, it indicated Resident 19 did not receive any antibiotics. During a review of Resident 19's MAR for the month of December 2024, it indicated Resident 19 received her antibiotic medications everyday for the whole month. During a concurrent interview and record review, on January 15, 2025, at 2:12 PM, with the MDS Nurse 1, the MDS Nurse 1 reviewed Resident 19's MAR for the month of December 2024 and MDS- Section N dated January 1, 2025, and stated Resident 19's MDS was not coded correctly. The MDS Nurse 1 further it was her mistake. During a concurrent interview and record review, on January 16, 2025, at 2:26 PM, with the DON, the DON reviewed the facility's P&P titled, Certifying Accuracy of the Resident Assessment revised on November 2019, which indicated . Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion . 3. The information captured on the assessment reflects the status of the resident during the observation (look back) period for that assessment . The DON stated the P&P was not followed. During a review of the CMS RAI manual, dated October 2024, it indicated, .The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident . N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) .

Based on observation, interview, and record review, the facility failed to ensure a physician's order was carried out timely for one of two residents (Resident 62) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care) when Resident 62's order for a Speech Therapy (ST- assessment and treatment of communication problems and speech disorders) evaluation was not communicated with the hospice provider. This failure had the potential to place Resident 62 at risk for aspiration (when food, liquid, or other material is accidentally inhaled into the lungs), weight loss and further nutritional decline. Findings: During an observation on January 13, 2025, at 8:29 AM, outside of Resident 62's room, Resident 62 was yelling out nonsensically. During a review of Resident 62's Admission Record (contains demographic and medical information), it indicated Resident 62 was admitted to the facility with the diagnoses of cerebral atherosclerosis (disease that occurs when fatty plaque builds up in the arteries of the brain), unspecified dementia (group of brain diseases that cause a decline in thinking, memory, and reasoning skills), and encounter for palliative care (specialized care aimed at improving the quality of life for patients with serious illnesses). During a review of Resident 62's Minimum Data Set [MDS- a computerized assessment instrument] Section C - Cognitive Patterns, dated October 30, 2024, it indicated a Brief Interview for Mental Status (BIMS - test used to screen cognitive impairment in long term care facilities) score of 6, indicating severe cognitive impairment (medical term referring to problems with thinking, learning, remembering, and making decisions). During a review of Resident 62's Nutrition/Dietary Note dated November 22, 2024, it indicated .per IDT (Interdisciplinary Team- a team mixed of different professions who come together to make recommendations for patient care), pt (patient) had difficulty chewing meats, however pt reported being able to chew normally. Will refer to ST for precaution . RECS: (recommendations) . 3) ST eval d/t [due to] difficulty chewing. During a review of Resident 62's Physician's Order dated November 23, 2024, it indicated ST eval (evaluation) d/t difficulty chewing. During a review of Resident 62's Nurses Note dated November 23, 2024, it indicated Carried out RD (Registered Dietician) recommendations as follows: . 2. ST eval d/t difficulty chewing. Orders noted and carried out . MD (Medical Doctor) and resident made aware. During a concurrent interview and record review, on January 15, 2025, at 10:07 AM, with the Director of Nursing (DON), the DON reviewed Resident 62's clinical record and was not able to find documentation of Resident 62's ST evaluation. The DON stated the Registered Nurse from the registry (independent contractors hired through a third party) was the one who carried out Resident 62's physician's order and the nurse did not communicate with the facility nor with Resident 62's hospice provider. During a concurrent interview and record review on January 16, 2025, at 2:20 PM, with the DON, the DON reviewed the facility's policy and procedure (P&P) titled, Hospice Program revised on July 2017, which indicated . 10. In general, it is the responsibility of the facility to meet the president's personal care and nursing in needs in coordination with the hospice representative . c. Notifying the hospice about the following: . (2) clinical complications that suggest a need to alter the plan of care . d. communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day . The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure necessary care and services to ensure activities of daily living were being provided for two of four residents (Residents 44 and 54) reviewed for position and mobility when: 1. Resident 44's Restorative Nursing Program (RNP- planned healthcare approach within long-term care facilities that aims to help residents maintain or regain their independence by providing targeted interventions to improve their functional abilities) recommendation from the Physical Therapist (PT- healthcare provider who helps you improve how your body performs physical movements) was not implemented. 2. Resident 54's RNP recommendation from the PT and Occupational Therapist (OT- healthcare provider who helps you improve your ability to perform daily tasks) were not implemented. These failures had the potential to delay the continuity of care for Residents 44 and 54, which could prevent them from maintaining or improving the activities of daily living. Findings: 1. During a concurrent observation and interview on January 13, 2025, at 11:55 AM, in Resident 44's room, Resident 44 was lying on her bed. She stated she has not been working with anyone on walking or exercises. During a review of Resident 44's Admission Record (contains demographic and medical information), it indicated Resident 44 was admitted to the facility on [DATE], with diagnoses which included muscle (a part of your body that helps you move by stretching and contracting) weakness and difficulty of walking. During a review of Resident 44's PT discharge summary, dated June 4, 2024, it indicated . discharged status and recommendation . Prognosis to maintain CLOF [Current Level of Function] = Good with consistent staff follow through . discharged recommendations: RNP . ambulation [walk] w/ [with] fww [front wheel walker (a type of walker with wheels in the front to help people walk more easily)] During a concurrent interview and record review, with the Director of Nursing (DON), on January 15, 2025, at 10:30 AM, the DON reviewed Resident 44's clinical records, and was not able to find documented evidence to indicate the PT's recommendation for RNP had been implemented for Resident 44. The DON stated I was not aware of the PT recommendation. The DON further stated the recommendation was not communicated to the nursing department, hence it was not followed up and implemented. During a follow up interview and concurrent record review with the Director of Rehabilitation (DOR), on January 15, 2025, at 2:15 PM, the DOR reviewed Resident 44's clinical records and confirmed the PT had recommended ambulation with a front wheel walker for Resident 44. The DOR stated she had just learned about the recommendation (seven months and thirteen days after it was made). The DOR further explained there should have been communication between the nursing and rehabilitation departments regarding this recommendation, but there was not. 2. During a concurrent observation and interview, on January 14, 2025, at 9:55 AM, in Resident 54's room, Resident 54 was lying on his geriatric chair (large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility). He stated that he has not been working with anyone on any exercises. During a review of Resident 54's Admission Record, it indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included contracture (a condition where muscles or joints become tight and stiff, making it hard to move them) of muscle and muscle weakness. During a review of Resident 54's PT discharge summary, dated September 9, 2022, it indicated . discharged status and recommendation . Prognosis to maintain CLOF = Good with consistent staff follow through . discharged recommendations: RNP . ROM (Range of Motion- type of exercise that helps you move your joints as far as they can go, like stretching or bending your arm or leg) . During a review of Resident 54's OT discharge summary dated October 1, 2022, it indicated . discharged status and recommendation . Prognosis to maintain CLOF = Good with consistent staff follow through . discharged recommendations: d/c [discharged ] to nsg [nursing] care . ROM to BUE [bilateral (both) upper extremities] as tolerated. During a concurrent interview and record review, with the DON, on January 15, 2025, at 10:45 AM, the DON reviewed Resident 54's clinical records, and was not able to find documented evidence to indicate the PT's and OT's recommendations had been implemented for Resident 54. The DON stated, I was not aware of the PT and OT recommendation. The DON further stated the recommendation was not communicated to the nursing department, hence it was not followed up and implemented. During a follow up interview and concurrent record review with the DOR, on January 15, 2025, at 2:40 PM, the DOR reviewed Resident 54's clinical records and confirmed that PT had recommended ROM and OT had recommended ROM to BUE for Resident 54. The DOR stated she had just learned about the recommendation. The DOR further explained that there should have been communication between the nursing and rehabilitation departments regarding this recommendation, but there was not. During a concurrent interview and record review, with the DOR, on January 15, 2025, at 3:05 PM, the DOR reviewed the facility's policy and procedures titled Restorative Nursing Services, revised on July 2017, which indicated, Policy Statement Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care . The DOR stated the facility policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen therapy (administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of decreased perfusion of oxygen to the tissues) was obtained for one of three residents (Resident 33) reviewed for oxygen. This failure had the potential for Resident 33 to develop oxygen toxicity (conditions that occurs when someone breaths too much oxygen, damaging lungs and potential for death) from the lack of monitoring from a physician. Findings: During a review of Resident 33's Admission Record, it indicated Resident 33 was admitted to the facility with the diagnoses of dementia (medical condition that causes a person to lose ability to think, remember, and reason), retropharyngeal and parapharyngeal abscess (severe infection in the neck that involve a collection of pus in the deep neck spaces), and shortness of breath (difficulty breathing). During an observation on January 13, 2025, at 10:11 AM, in Resident 33's room, Resident 33 was lying in bed, talking nonchalantly to the wall. Resident 33 was wearing nasal cannula tubing (a flexible plastic tube that delivers oxygen through small tubes that sit in the nose) attached to an oxygen concentrator, which was running at 2 liters per minute (amount of oxygen given to a patient). During an interview and concurrent record review, on January 13, 2025, at 2:41 PM, with the Director of Nursing (DON), the DON reviewed Resident 33's clinical record and was unable to find a physician's order for Resident 33's oxygen therapy. The DON stated there should have been an order. During a concurrent interview and record review, on January 13, 2025, at 3:48 PM, with the DON, the DON reviewed the facility's policy and procedure (P&P) titled, Oxygen Administration revised on October 2010, which indicated, . Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's order . for oxygen therapy . The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure for two of 22 sampled residents (Resident 1 and 36) they were free from neglect when prescribed medications were not provided as follows: 1.For Resident 1, the medication atorvastatin (a medication used for high cholesterol levels) was not available to be administered, because it had not been reordered for 74 days and the nurses were documenting they were administering the medication from (MONTH) 10, 2019, through (MONTH) 22, 2019. 2.For Resident 36, the medication [MEDICATION NAME] (a medication used for a heart condition) was not available for 32 days because it had not been reordered and was not available for administration and the nurses were documenting they were administering the medication as being given from (MONTH) 21, 2019 through (MONTH) 8, 2019, and from (MONTH) 7, 2019 through (MONTH) 22, 2019. This failure to provide necessary medication as prescribed by the doctor, failure to reorder the medication timely from the pharmacy, and failure to notify the attending physician's that these residents had missed prescribed doses resulted in Residents 1 and 36's medical need being neglected which had the potential to cause harm. Findings: 1.During a review of the clinical record for Resident 1, indicated Resident 1 was admitted on (MONTH) 8, 2019, with [DIAGNOSES REDACTED]. A review of Resident 1's physician's orders [REDACTED]. During a medication review for Resident 1 in the 400 hall medication cart on (MONTH) 22, 2019 at 1:45 PM, with Licensed Vocational Nurse (LVN 3), the medication Atorvastatin 80 mg was not located in the cart to be available for administration. LVN 3 confirmed the medication Atorvastin 80 mg was not available in the medication cart. LVN 3 stated, I will call the pharmacy and re-order the medication. During an interview with pharmacy technician (PHT-a person who keeps track of medications delivered to the facility from the pharmacy) on (MONTH) 22, 2019 at 3:10 PM, she stated the last time the medication was re-ordered by the facility and sent by the pharmacy was on (MONTH) 19, 2019. The PHT stated the pharmacy had sent a 21-day supply which would last through (MONTH) 9, 2019. There was no documented evidence the medication has been refilled after the completion of the 21-day supply. The PHT stated there was no Atorvastin 80mg available for administration for (MONTH) 10 through (MONTH) 30, 2019, or for the months of (MONTH) or (MONTH) 2019. During a review of the document titled, E-Script New Prescription Request, dated (MONTH) 19, 2019, indicated, Atorvastin 80 mg by mouth daily for 21 days. Further review of the document indicated a note from the pharmacy. It indicated, Need to clarify why there is a stop date. Tried calling nurse to clarify but left on hold. Please follow-up with M.D. During a review of the Electronic Medication Administration Record [REDACTED]. It was documented as not being administered on (MONTH) 26 and 27, 2019, without explanation for the medication not being given. It was documented as being given from (MONTH) 28 through (MONTH) 30, 2019. There was no documented evidence the physician had been notified the medication had not been available or evidence that it had been re-ordered from the pharmacy. During a review of the E-MAR for the month of (MONTH) 2019, the E-MAR indicated the nurses were documenting the medication Atrovastin 80 mg was available and administered on (MONTH) 1 through (MONTH) 31, 2019. There was no documented evidence the physician had been notified the medication had not been available or that it had been re-ordered from the pharmacy. During a review of the E-MAR for the month of (MONTH) 2019, the E-MAR indicated the nurses were documenting the medication Astrovastin 80 mg. was available and administered from (MONTH) 1 through (MONTH) 21, 2019. There was no documented evidence the physician had been notified the medication had not been available or that it had been re-ordered from the pharmacy. During an interview with the Director of Staff Development/Infection Control Preventionist (DSD/ICP) on (MONTH) 22, 2019 at 4 PM, she confirmed the medication was not available to be administered and the nurses were documenting the medication as having been available and having been administered evidenced by their signature on the E-MAR. The DSD stated, They should not document the medication as being given when the medication is not available. During an interview with the Director of Nurses (DON) on (MONTH) 22, 2019 at 4:30 PM, he confirmed there is no documented evidence the nurses clarify the order with the doctor why there is a stop date on Resident 1's Atorvastin 80 mg by mouth for 21 days. The DON stated, The nurses should have clarified the order. During a review of the facility's policy and procedure titled, Abuse Prevention, dated (MONTH) 11, 1999, indicated, Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals. All staff participate in Abuse Prevention activities to ensure that all is being done within the facilities control to prevent occurrences Under the section titled, Procedure .2 Employee training on abuse prevention will be conducted during orientation on an on-going basis .which includes .d. What constitutes abuse, neglect and misappropriation of property.11. The administrator or his/her appointed designee will report to the State Nurse Aide Registry of Licensing authorities any knowledge it has of any action .which would indicate an employee is unfit for service including known incidents of resident abuse . During a review of the facility's policy and procedure titled, Administering Medications, undated, indicated, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed . 15. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document Medication not administered for that drug and dose. During a review of the facility's Policy and Procedure titled, Physician Medication Orders, undated, indicated, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than (3) days prior to the last dosage being administered to ensure that refills are readily available. 2.During a review of the clinical record for Resident 36, indicated Resident 36 was admitted on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 36's physician's orders [REDACTED]. During a medication review for Resident 36 in the 300 hall medication cart on (MONTH) 22, 2019 at 2:45 PM, with Licensed Vocational Nurse (LVN 4), the medication [MEDICATION NAME] 100 mg PO QD was not located in the cart. LVN 4 confirmed the medication [MEDICATION NAME] 100 mg was not located in the medication cart. LVN 4 stated, I gave the last dose and I threw the bubble pack in the shredder. I ordered the medication from the pharmacy today. During an interview with the MDS Director (MDS-minimal data set- MDSD-a nurse who performs an assessment on a resident) on (MONTH) 22, 2019 at 5:10 PM, she stated, I checked the shredder to see if I could find the bubble pack, but I couldn't find it. It was not there. During an interview with the pharmacy technician (PHT-a person who keeps track of medications delivered to the facility from the pharmacy) on (MONTH) 22, 2019 at 3:10 PM, she stated the last time the medication was re-ordered and sent was on (MONTH) 21, 2019. She stated the pharmacy had sent a 30-day supply which would last until (MONTH) 20, 2019. During a review of the Electronic Medication Administration Record [REDACTED]. The medication was not administered on (MONTH) 26 and (MONTH) 27. There was no documented reason the medication was not administered. There was no documented evidence the physician had been notified the medication had not been available or evidence that it had been re-ordered from the pharmacy. During a review of the E-MAR for the month of (MONTH) 2019, the nurses were documenting the medication was available and being administer on (MONTH) 1, (MONTH) 2, (MONTH) 3, (MONTH) 4, (MONTH) 5, (MONTH) 6, (MONTH) 7, and on (MONTH) 8, 2019. There was no documented evidence the physician had been notified the medication had not been available or evidence that it had been re-ordered from the pharmacy prior to (MONTH) 8, 2019. During a review of the pharmacy delivery manifest, dated (MONTH) 8, 2019, the form indicated Resident 36's medication [MEDICATION NAME] 100 mg 30-day supply was delivered to the facility. The facility had medication through (MONTH) 6, 2019. During a review of the E-MAR for the month of (MONTH) 2019, the E-MAR indicated the nurses were documenting the medication was available and being administered on (MONTH) 7, (MONTH) 8, (MONTH) 9, (MONTH) 10, (MONTH) 11, (MONTH) 12, (MONTH) 13, (MONTH) 14, (MONTH) 15, (MONTH) 16, (MONTH) 17, (MONTH) 18, (MONTH) 19, (MONTH) 20, and (MONTH) 21. During an interview with the Director of Staff Development/Infection Control Preventionist (DSD/ICP) on (MONTH) 22, 2019 at 4 PM, she confirmed the medication was not available to be administered and the nurses were documenting the medication as having been available and having been administered evidenced by their signature on the E-MAR. The DSD stated, They should not document the medication as being given when the medication is not available. During a review of Resident 36's electrocardiogram (ECG- a test to identify problems in conduction of the heart) dated (MONTH) 22, 2019, the ECG which was ordered following the identification of the amiodorone not being administered indicated Resident 36 had [MEDICAL CONDITION] Fibrillation with rapid ventricular response . Abnormal EC[NAME] During a review of the facility's policy and procedure titled, Abuse Prevention, dated (MONTH) 11, 1999, indicated, Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians, sponsors, friends, or other individuals. All staff participate in Abuse Prevention activities to ensure that all is being done within the facilities control to prevent occurrences. Under the section titled, Procedure .2 Employee training on abuse prevention will be conducted during orientation on an on-going basis .which includes .d. What constitutes abuse, neglect and misappropriation of property.11. The administrator or his/her appointed designee will report to the State Nurse Aide Registry of Licensing authorities any knowledge it has of any action .which would indicate an employee is unfit for service including known incidents of resident abuse . During a review of the facility's policy and procedure titled, Administering Medications, dated undated, indicated, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribe 15. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and document Medication not administered for that drug and dose. During a review of the facility's policy and procedure titled, Physician Medication Orders, undated, indicated, Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than (3) days prior to the last dosage being administered to ensure that refills are readily available. An immediate Jeopardy (IJ-a situation with the potential to harm the health and safety of the patients) was called under 483.12 (a) (1) F 600 Freedom from Abuse, Neglect, and Exploitation on (MONTH) 22, 2019 at 3:15 PM, in the presence of the Administrator (ADM) and Director of Nursing (DON). The ADM and the DON were verbally notified of the IJ situation identified based on the facility's failure to ensure Resident's 1 and 36 were free from neglect when prescribed medications which were not provided as follows: 1.For Resident 1, the medication atorvastatin (a medication used for high cholesterol levels) was not available to be administered, because it had not been reordered and was not available for administration for 74 days and the nurses were documenting they were administering the medication from (MONTH) 10, 2019, through (MONTH) 22, 2019. 2.For Resident 36, the medication [MEDICATION NAME] (a medication used for a heart condition) was not available for 32 days, because it had not been reordered and was not available for administration and the nurses were documenting they were administering the medication as being given from (MONTH) 21, 2019 through (MONTH) 8, 2019, and from (MONTH) 7, 2019 through (MONTH) 22, 2019. This failure to provide necessary medication as prescribed by the doctor, failure to reorder the medication timely from the pharmacy, and failure to notify the attending physician's that these residents had missed prescribed doses resulted in Residents 1 and 36's medical need being neglected which had the potential to cause harm. The facility submitted a corrective action plan (CAP) which was reviewed and accepted on (MONTH) 25, 2019 at 4:15 PM, in the presence of the ADM and DON. After interviews to confirm implementation of the CAP and a review of medication availability for Resident 1 and 36, and interviews with staff regarding the in-services on neglect, and medication administration, the IJ was lifted on (MONTH) 25, 2019 at 4:55 PM, in the presence of the ADM and DON.

Based on interview, and record review, the facility failed to provide safeguards for one of three sampled Residents (Resident A) when the tab alarm (A device placed on back of the wheelchair with a string attached to residents clothes, if the resident stands it releases magnet and sets off the alarm) was not applied to alert the staff of Resident A's attempt to get up unassisted. This resulted in Resident A sustaining a fall with a laceration (deep cut to skin) to the left forehead and a left sided subdural hemorrage (a collection of blood outside the brain, usually caused by severe head injury) and requiring hospitalization . Resident A's condition worsened requiring intubation (the insertion of a tube into the airway to assist a patient who is not breathing adequately) and Resident A expired two days later. Findings: A clinical record review for Resident A was conducted on [DATE] at 2:30 PM. A document titled, Face sheet (includes demographic information), indicated Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was discharged on [DATE], to the general acute care hospital (GACH) after a fall with injury. Continued review of the clinical record for Resident A indicated a document titled, Departmental Notes, which reflected on [DATE], .At 11:32 AM, Resident was found on the floor with her head on bedside table, blood on the floor. When checked, noted that resident hit her left head close to eyebrow on the side table with injury .Resident has cervical (neck bone) collar in place . During an interview with an Occupational Therapy Aide (OTA), on [DATE] at 1:30 PM, the OTA stated she helped Resident A on [DATE] to be lifted up while in the wheelchair and placed a pommel wedge (A cushion with a saddle horn used to prevent sliding from a wheelchair). The OTA stated she does not remember seeing a tab alarm on her wheelchair nor removing any from the chair except to add the pommel wedge. During a concurrent interview with the physical therapist (PT), she stated she never noticed a tab alarm on Resident A's wheelchair and no alarm sounded when they lifted the resident to put the pommel cushion under her. During an interview with Licensed Vocational Nurse 1 (LVN) on [DATE] at 2:30 PM, she stated she was one of the first nurses to arrive and find Resident A on the floor on [DATE] at 11:32 AM. She stated she never heard her tab alarm on her wheelchair go off nor did she notice if there was a tab alarm on Resident A's wheelchair. During a concurrent interview with Registered Nurse 1 (RN), she stated she never heard the tab alarm for Resident A go off. She stated she did not notice the tab alarm being on Resident A's wheelchair when she fell on [DATE]. During an interview with Certified Nursing Assistant 1 (CNA) on [DATE] at 5:30 PM, she stated she was the one assigned to Resident A on [DATE]. She stated, I do not recall putting Resident A's tab alarm on her wheelchair before I sent her to rehab that morning. CNA 1 stated, I left to attend to another resident who was across from her room, I can visually see her. She said, I was attending in the room opposite her room when I saw and heard her scream and fall. CNA 1 stated, I did not hear her tab alarm go off. A review of Resident A's care plan titled, Risk for Falls, dated [DATE] indicated, . Bed and/or W/C (wheelchair) alarm as ordered to alert staff to unassisted transfer . A review of the fall assessment done for Resident A on admission, dated [DATE], indicated a score of 8 (Residents with a score of ,[DATE] = high risk for falls). The clinical record for Resident A was reviewed. A document titled, Physician order, dated [DATE] indicated, May have tab alarm on w/c to alert staff of unassisted transfer. A review of the Physical Therapist progress notes for Resident A, dated [DATE], indicated, Sitting balance: Static Sitting =Poor .(maintains balance with maximum assist and upper extremity support). During a review of Resident A's Interdisciplinary Team Notes dated [DATE], the notes indicated, .Per husband she had multiple falls at home .Patient stable at this time. A review of the paramedic's narrative summary dated [DATE], indicated, .PT (patient) had mechanical fall from wheelchair at SNF (skilled nursing facility) and landed on floor onto head. PT found with hematoma (A localized swelling that is filled with blood caused by a break in the wall of a blood vessel. The breakage may be spontaneous or from trauma) to forehead. Negative L(NAME) (loss of consciousness) and PT recalls entire event . During a review of the general acute care hospital (GACH) records where Resident A was transferred, a document titled, Physician Discharge Summary, dated [DATE], indicated, .Principal Diagnosis: [REDACTED]. A review of the section of the discharge summary titled, Hospital Course, indicated . CT (CAT scan- an x-ray with sliced images) head demonstrated a subdural hematoma .Patient was the admitted to SICU (Surgical Intensive Care Unit) on the evening of ,[DATE] ([DATE]) for worsening mental status requiring intubation . The discharge disposition was listed as deceased . The facility policy and procedure titled, Falls and Fall Risk Managing, undated, indicated under Policy Statement, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under Monitoring Subsequent Falls and Fall Risk, 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or risk of falling .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received the necessary care and services for wound care in a timely manner, to promote wound healing. This failure resulted in Resident 1's stage II (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) sacrum (tail bone) pressure sore (wound-bed sore), which progressed to a stage IV ( is very deep, reaching into muscle and bone and causing extensive damage) with additional two pressure sores on buttocks. Finding: A review of Resident 1's clinical record on February 4, 2015, noted Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's admitting assessment entitled, Nursing Admission Record and Assessment, dated December 16, 2014, indicated Resident 1 did not have pressure sores at the time of admission. Resident 1 was totally dependent on staff for all ADL's (activities of daily living which included bed mobility, dressing, transfer, toileting, hygiene, etc). Resident 1 was noted to be incontinent of both bowel and bladder. Resident 1 was identified as a Decubitus (pressure sores/ pressure ulcers) Risk. During an interview with Resident 1's family member (FM) on May 20, 2015 at 11:35 AM, the FM stated she had visited Resident 1 at the facility everyday. The FM stated Resident 1 had a very poor meal intake and that she fed Resident 1 at least 2 out of 3 meals everyday. The FM said Resident 1 ate between 50 % or less of her meals. The FM stated the staff had not provided Resident 1 with a high protein supplement. A review of the nursing notes dated December 18, 19, 21, 28, 2014, documented the dietitian had been notified of Resident 1's decrease in meal intake. Further review of the clinical record reflected in the one month period Resident 1 had been in the facility, the dietitian had not assessed Resident 1's nutritional needs. The Director of Nursing (DON) verified the finding at the time of record review. A review of Resident 1's clinical record showed on December 30, 2014, Resident 1 had developed a Stage II (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) pressure sore, on the sacrum area. A review of the interdisciplinary team (IDT) dated December 30, 2014, documented, IDT is requesting to have an [MEDICATION NAME] (protein) level .if its low to give pro-stat (protein supplement) to help wound healing. Further review of Resident 1's clinical record, reflected there was no documentation to show the IDT recommendation, dated December 30, 2014, was communicated to the physician, until January 10, 2015. This was 10 days from the date the IDT made the recommendation. Licensed Vocational Nurse (LVN) 1 verified the finding at the time of record review on March 25, 2015. During an interview with the DON on March 25, 2015 at 3:40 PM, she stated the licensed nurse should have notified the physician of the IDT recommendation immediately. A review of the Weight Variance Committee's, dated January 9, 2015, documented the pressure sore on Resident 1's sacrum had been assessed to now be a Stage III (pressure sore that involves tissues beneath the outer skin layer, may show some fat tissue but no muscle) pressure sore. The IDT had recommended a fortified diet, increase fluids, and a folic acid supplement. Further review of Resident 1's clinical record showed there was no evidence the IDT recommendation dated January 9, 2015, had been communicated to the physician. LVN 1 confirmed the finding at the time of record review on March 25, 2015. A review of Resident 1's sacrum wound assessment report, showed the following: On December 30, 2014, stage II with measurement; length (L) 3.50 cm (centimeter), width (W) 1.70 cm, depth (D) 0.0 cm. On January 9, 2015, stage III with measurement (L) 4.20 cm , (W) 2.10 cm, (D) 0.0 cm, slough (dead skin) 50 %. On January 16, 2015, stage IV with measurement (L) 4.20 cm, (W) 3.50 cm, (D) 2.0 cm, slough 80 %. A review of Resident 1's clinical record showed the Stage II pressure sore on the sacrum had progressed to a Stage III pressure sore by January 9, 2015, 10 days after the wound was initially identified on December 30, 2014. The wound continued to worsen and 7 days later (January 16, 2015), the wound became a Stage IV [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus- severe bacterial infection) and needed to be debrided (the medical removal of dead, damaged or infected tissue to improve the healing potential of the remaining tissue). During this same period of time on January 12, 2015, Resident 1 had developed additional skin breakdown. There were two new Stage II pressure sores, one on the left buttock and one on the right buttock. Further review of the clinical record showed there was no documentation to show the dietitian assessed Resident 1's nutritional needs, despite Resident 1's poor meal intake and skin break down. The sacrum wound continued to worsen and two additional wounds were found on Resident 1's buttocks. A review of the [MEDICATION NAME] and pre-[MEDICATION NAME] lab result levels for Resident 1, dated January 12, 2015, indicated Resident 1's [MEDICATION NAME] and pre-[MEDICATION NAME] were low. The serum [MEDICATION NAME] level was 2.6 gm/dl, the normal range is 3.7-4.9 gm/dl. The pre-[MEDICATION NAME] level was 8 mg/dl, the normal range is 17-33 mg/dl. A pre-[MEDICATION NAME] level lower than eleven indicates a severe protein calorie malfunction. A review of the facility's undated policy and procedure, titled Prevention of Pressure Ulcers under 7. Risk Factor---Poor Nutrition notes the following: a. Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. b. Monitor nutrition and hydration status. c. Monitor laboratory values, notify physician when appropriate. d. Encourage proper dietary and fluid intake. .f. Administer vitamins, mineral and protein supplement in accordance with physician orders and dietitian recommendations. During an interview with the DON on March 25, 2015 at 3:40 PM, she stated she could not find a nutritional assessment by the dietitian in Resident 1's records. The DON confirmed the dietitian had not made a dietary assessment or recommendation for Resident 1, even after Resident 1 developed pressure sores, and had been reported to have a poor nutritional intake. The DON stated the facility policy indicates all new admits should be assessed by the dietitian which included all residents with pressure sores/wounds and/or poor intake. A review of the physician's order dated January 13, 2015, indicated Turn and reposition every hour all day.due to open wound to .buttocks until further information. A review of Resident 1's care plan dated January 13, 2015, indicated Resident 1 had to be repositioned every hour due to the wound on the left and right buttock. Review of the licensed nurses notes documentation dated January 14, 2015 through January 17, 2015, reflected Resident 1 was repositioned/ turned at least every 2 hours, instead of every 1 hour. LVN 1 verified the finding at the time of record review on March 25, 2015. A review of the facility policy and procedure titled, Prevention of Pressure Ulcers, (undated), indicated The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate.

Based on interview and record review, the facility failed to provide the necessary supervision and interventions to prevent fall for 1 of 3 sampled residents (Resident A), by failing to assess the effectiveness of the tab alarm (Fall prevention device that can be used on wheelchair, chair, or bed to alert caregiver when fall risk patient attempts to ambulate. This type of alarm is clipped to the resident's clothing and with the string attached to the clip, a small piece of metal is magnetically in place in the tab alarm. If the patient gets up or moves further than the string length, the metal/magnet connection is broken and the alarm sounds) when it was identified Resident A was capable of removing the tab alarm independently. This failure resulted in Resident A to experience a fall on February 9, 2015, and sustain a fracture of the left femur (leg bone). Findings: During an interview with the complainant on March 10, 2015 at 4:00 PM, the complainant stated Resident A had fallen at the facility on February 9, 2015 at 6:30 AM. Resident A was sent to the acute hospital where Resident A was found to have a fractured femur (leg bone). Resident A received surgery to repair the fracture. An unannounced visit was made to the facility on [DATE] at 1:52 PM and April 16, 2015 at 8:15 AM to investigate a complaint regarding quality of care for Resident A. A review of Resident A's clinical records, reflected Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the history and physical, completed by the physician on January 10, 2015, indicated Resident A does not have the capacity to understand and make her own decisions. A review of the Fall Risk assessment dated [DATE] indicated Resident A's fall risk score was 12. A score of 8 or more is considered a fall risk. During a review of the care plan for ADL (activities of daily living which includes transfers and ambulation) dated January, 2015, documentation showed Resident 1 required assistance with ambulation and toileting. A review of the RAI (Resident Assessment Instrument which is a tool used for assessment) section G, dated February 5, 2015, documented Resident A required limited assistance with 1 person physical assist for toilet use and supervision for transfer. A review of Resident A's physician's orders [REDACTED]. A review of the licensed nurse's progress notes, dated February 9, 2015 at 7:30 AM, reflected the following documentation, 6:30 AM, CNA found patient in the bathroom floor in a sitting position. CNA immediately called supervisor. Came immediately and found patient in sitting position in the bathroom by the sink.Dr. aware of the incident with new orders of X-ray on left hip. During an interview on April 16, 2015 at 9:15 AM, Registered Nurse (RN) 1 stated he was working on the floor passing medication at the time in close proximity of the incident when Resident A fell on [DATE]. He stated the resident (Resident A) was known and capable of removing the tab alarm independently. RN 1 stated the tab alarm was attached to Resident A's bed. He stated, The alarm did not go off at the time of the fall. During an interview with Certified Nursing Assistant (CNA) 1 on April 16, 2015 at 9:00 AM, she stated she was the CNA who found Resident A on the floor on the morning of February 9, 2015 at 6:30 AM. CNA 1 stated Resident A can ambulate with staff assistance. Resident A was capable of removing the tab alarm herself. She had seen Resident A removing the tab alarm several times prior to her fall on February 9, 2015. Resident A removed the tab alarm at the time of the incident. A review of the CNA documentation dated February 9, 2015 at 2:40 AM, indicated Resident A's tab alarm was checked and functioning. A review of the facility summary report of the incident dated February 13, 2015 indicated on February 9, 2015, Resident A was asleep from 11 PM through approximately 6 AM. A review of Resident A's care plan dated January 10, 2015, reflected Resident A was at risk for falls. The intervention listed included a tab alarm while in bed and in wheelchair. There was no evidence to show the fall care plan was updated to indicate Resident A was able to independently remove the tab alarm nor that new appropriate interventions were developed to prevent Resident A from getting out of bed or wheelchair unassisted to prevent falls. The Director of Nurses (DON) verified the finding at the time of record review. During an interview with the DON on April 16, 2015 at 9:55 AM, she stated Resident A had a history of [REDACTED]. She further stated the care plan should have been updated and revised to reflect Resident A's capability of removing the tab alarm independently. The appropriate interventions to prevent fall should have been initiated. A review of the facility's investigation report dated February 13, 2015, indicated, when staff were interviewed, Resident was known to remove her own tab alarm. A review of the X-ray result for the left hip, dated February 9, 2015, indicated Resident A sustained a left hip fracture, an acute fracture of the proximal left femur. During a review of a policy and procedure titled, Safety and Supervision of Residents, undated, indicates Under Resident Oriented Approach to Safety: 2. staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history.observation of the resident.3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accidents hazards or risks for that residents. The care team shall develop interventions to reduce the potential for accidents. The policy and procedure further indicates 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. e. documenting interventions.

Based on observation, interview, and record review, the facility failed to protect residents from verbal abuse and verbal threats of physical harm. The facility failed to thoroughly investigate allegations of abuse, and failed to report all allegations of abuse to CDPH (The California Department of Public Health) for 2 of 8 Unsampled Residents (Residents C and D). 1. The facility failed to protect all residents from verbal abuse and verbal threats of physical harm from Resident C. The facility failed to thoroughly investigate allegations of abuse, and failed to implement and revise behavior modification care plans for Resident C and failed to report all allegations of abuse to CDPH due to Resident C's threats of physical harm not deemed as being credible by the facility. 2. For Resident D, the SSD (Social Service Designee) failed to investigate Resident D's allegation that his roommate had sex with his roommate, and Resident D was made to watch. These failures resulted in multiple residents of the facility feeling unsafe and fearful and prevented CDPH from ensuring that the facility was taking the appropriate actions to protect the residents and investigate all allegations. These failures also had the potential to put Resident D at risk for abuse and had the potential for ongoing verbal and physical abuse for a universe of 92 residents of the facility (the total number of residents residing in the facility). Because of the facility's failure to have a system in place to ensure that residents of the facility were protected, and allegations of resident abuse were investigated and reported, Immediate Jeopardy was called on February 10, 2014 at 4:45 PM with the Administrator and the DON (Director of Nursing). Findings: 1. During an interview with the Administrator on February 6, 2014, at approximately 11:30 AM, he was asked to provide a list of allegations of abuse from the past year in order to select samples for review of how the facility handled alleged violations. The Administrator stated, "I don't keep a list or log of any type. I will have to pull some files, and write down the events and I will provide a list for you to choose from." During an interview and a concurrent observation with the Administrator on February 6, 2014, at approximately 11:30 AM, when asked if it made it difficult to track and trend patterns of alleged abuse, he didn't answer and shrugged his shoulders. A review of a hand written piece of paper, written by the Administrator on February 6, 2014, contained a list of allegations of abuse and mistreatment was provided by the Administrator, on February 6, 2014, showed the following: April 1, 2013: Sampled Resident 14 complaint about Unsampled Resident C. "(Resident 14), came to me and said (Resident C) verbally challenged him and told him when he goes to the (name of a hospital) he was going to cut the tubes and kill him. I told him to stay out of (Resident C's) way. We (facility administration) are trying to get him back on medication so that he would be more controlled. (Resident 14) demanded something be done about (Resident C) I told him if (Resident C) confronts him he should let a nurse handle it." The back of the same document reviewed on February 6, 2014, showed the following documented summary with the Administrators signature: "No blows were exchanged. Both parties agreed to use separate patios so they stay away from each other." During an interview with the Administrator on February 6, 2013, at 3:20 PM, when asked about his investigation and his response to the allegation made by Resident 14 regarding Resident C, he stated, "I talked to both residents and they agreed to stay away from each other. That was my investigation. (Resident C) has a history of making verbal threats. I don't need to investigate any further because it won't get me anywhere." During an interview with the Administrator on February 6, 2013, at 3:20 PM, he stated, "I don't report all allegations of abuse. I only investigate credible allegations. (Resident C) has a psychiatric [DIAGNOSES REDACTED]. condition and is unable to act out his threats of harm." The Administrator further stated, "I am following our policy regarding investigating and reporting abuse. I investigate credible reports of abuse and I will report substantiated reports of abuse." During an interview with the Administrator on February 6, 2014 at 3:20 PM, when asked how he determined an allegation was credible if it had not been investigated, he said, "I have been doing this a long time." During an interview with LVN 3 on February 5, 2014 at 3:40 PM, LVN 3 stated that she did not have to report all allegations of abuse. She further stated that the staff was to investigate them first and then report them. A review of the clinical record for Resident C on February 6, 2014, indicated the resident was admitted to the facility on [DATE], with diagnosis of bi-polar disorder (a mood disorder characterized by mood swings) and [MEDICAL CONDITION] (unable to move one side of the body). Resident C was on [MEDICATION NAME] (medication used for mood stabilization), 250 milligrams, by mouth, every day, for [MEDICAL CONDITION] disorder, manifested by mood swings. A review of the clinical record for Resident 14 on February 6, 2014, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with Resident 14, on February 7, 2014, at 12:00 PM, he stated, "I remember the incident with (Resident C) he threatened me before going to the hospital. He said that he was going to have someone kill me." During further interview with Resident 14, on February 7, 2013, he stated, "I don't feel safe here and at times I am scared because (Resident C) makes threats all the time, to me and to others in the facility. He has also hit me, as well as other people in the facility. I (Resident 14) tell the Administrator when something happens, but what can they do about it? Nothing really changes. I worry about him (Resident C) and my safety, but my family really worries." Resident 14 further stated, "One time he (Resident C) hit me with his power wheelchair and broke the wheel off my wheelchair." During an interview with the Administrator and DON on February 7, 2014, at 2:15 PM, the Administrator stated, "He (Resident C) is an angry, course individual, who over reacts to provocation. He does make verbal threats at times, and tends to pinpoint certain residents." During further interview with the Administrator and DON on February 7, 2014, at 2:15 PM, the DON stated, "Once staff has knowledge of an allegation of abuse or have witnessed any type of resident to resident abuse, they should report it to the charge nurse, it should be discussed as a stand-up meeting the next day or on Monday if the event happened over the weekend. It then will be discussed at our IDT (Interdisciplinary team-different specialty group or area of knowledge) meetings that take place once a week." The DON further stated, "The ID team will suggest changes to the plan of care or add interventions to prevent reoccurrence's." When asked how the facility staff ensured the safety of the other residents from further altercations and threats made by Resident C, the DON stated, "We observe for signs and symptoms of agitation and closely monitor." During a record review of social service, charge nurse and interdisciplinary notes and care plans for Resident C, with the DON on February 10, 2014, the following documentation was noted: a. Social service notes: April 1, 2013, "SSD (Social Service Designee) informed that (Resident C) has been verbally abusive towards another patient. SSD attempted to speak with (Resident C) regarding his behavior to see what is the cause of his anger." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility documented the altercation between Resident C and another resident or that Resident C's care plan was updated. There was no other evidence provided to show that the facility investigated the incident or reported the incident to CDPH or the Ombudsman (a resident representative or advocate). b. Social service notes: April 4, 2013, late entry note. "On April 3, 2013, it was reported to SSD that (Resident C's name) made threats to his roommate. SSD spoke with (Resident C) and he admitted to threats and stated it was over the television being on too late and resident can't sleep. SSD spoke with resident's roommate who said he would turn television off at 10:00 PM." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility documented the altercation and threats Resident C made to his roommate or that Resident C's care plan was updated. There was no additional evidence provided to show the facility thoroughly investigated the incident or reported the incident to CDPH or the Ombudsman. c. Social service notes: April 25, 2013. "(Resident C) had an episode of being verbally abusive towards a female resident. He was smoking outside the door and she had asked him to smoke in the smoking area. He became upset and started cursing her." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility documented the altercation between Resident C and the female resident or that the facility updated Resident C's care plan. There was no additional evidence provided to show that the facility investigated or reported the incident to CDPH or the Ombudsman. d. Social service notes: May 15, 2013. "(Resident C) had an incident being verbally abusive towards an elder female resident who was sitting in hallway innocently when he started vulgarly yelling at her to move. He was moved and told his behavior is not acceptable." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility documented the altercation between Resident C and the elder female resident or Resident C's care plan was updated. There was no additional evidence provided to indicated the facility investigated the or reported the incident to CDPH. e. Social service notes: May 28, 2013. "(Resident C) came to SSD office and he was placing a threat to his roommate regarding the television program the other resident watches. SSD informed the resident he could buy his own television. Risks and benefits of his behavior explained." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility documented the threat Resident C made against his roomate or that Resident C's care plan was updated. No documented evidence was available regarding what risks and or benefits were explained by the SSD or that the facility investigated and reported the incident to CDPH or the Ombudsman. f. Social service notes: July 5, 2013. "It was reported to SSD that (Resident C's name) was involved in an altercation with another resident. SSD visited (Resident's C) and he stated that he (Resident C) went to (Resident 14) to see another resident. (Resident 14) began waving a scratcher stick at (Resident C) and was yelling at him to leave his room. (Resident C) became upset and was placing verbal threats to (Resident 14). A nurse came in and separated the two residents. SSD reminded (Resident C's name) of his altercation a year ago with (Resident 14) and has been asked to stay away from that room due to (Resident 14) does not feel well." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility updated Resident C's care plan to include any new interventions. g. General nurses notes (notes made by nurses that describe the residents condition and treatment given or planned): July 7, 2013. "Sheriff came at 4:30 PM and interviewed Resident C about the incident with another resident (Resident 14). In addition, sheriff also interviewed (Resident 14). Sheriff asked about any witnesses regarding the incident, but no one was there to witness the incident. Sheriff mentioned that Resident C denied kicking (Resident 14). Spoke with sheriff at 5:30 PM, sheriff said that a report will be filed and a copy will be given within 2 weeks and according to the sheriff, (Resident C) was given a citation for battery misdemeanor. Sheriff left facility at 5:45 PM. Resident reminded to keep a distance from (Resident 14)." h. Interdisciplinary notes: July 18, 2013. Date of incident-July 7, 2013. Type of incident - Patient to patient contact. IDT (Interdisciplinary) Recommendations noted: "Care plan updated at the time of incident. At this time current interventions are working. IDT attempted to discuss behaviors with patient and patient declined. Sheriff and ombudsmen notified of incident. Staff frequently reminds resident to avoid any contact with residents that he had conflicts with." Further review indicated there was no additional documented entries in Resident C's clinical record to demonstrate that licensed personnel or CNA's (certified nurses aides) redirected Resident C. A review of a care plan titled, "Resident exhibit aggressive behavior as manifested by kicking the wheelchair of another resident." Dated July 7, 2013, showed the following interventions: "Use calm approach when communicating with the resident. Introduce resident to supportive community services. Establish consistent, structured routine. Allow resident to express feelings. Observe early signs and symptoms of agitation to prevent escalation of behavior. Continue to closely monitor resident's whereabouts. Advise resident to stay away from resident he has altercation with." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility implemented the interventions listed on the care plan for Resident C. i. Social service notes: July 15, 2014. "Verbal altercation this time with his roommate and the family members. Apparently his roommate had children visiting as well. (Resident C) went off on his (roommate's) son, stating children are not allowed to visit. (Resident C) continues to refuse his medications. SSD faxed psychiatric evaluation due to his continued verbal altercations and refusing medications. IDT meeting will be held today." j. General nurse's notes: July 14, 2013: "Around 4:00 PM, (Resident C's name) started to verbally abuse (Unsampled Resident E) family and grandchildren of (Resident E). Resident E was crying and scared. Went into the room and asked for (Resident C) to step out of the room. (Resident C) yelled "I want to get away from that syphilis man" as he went out the room via motorized scooter. (Resident C) left the faciity on his motorized scooter and refused to sign out. (Resident E's} family requested to be changed to another room. Informed and called Administrator and informed of incident. (Resident E) agreed to be moved to another room." On February 10, 2014, a review of Resident E's clinical record was reviewed and indicated Resident E was admitted to the facility on February 16, 2011. During a review of the Social Services Notes, dated July 17, 2013, on February 10, 2014, it noted that the social worker (SW) met with Resident E's sons to discuss the verbal altercation that occurred over the weekend (weekend of July 14th). The documentation included the following: "Resident C was cursing at Resident E's family (included his grandkids) over the weekend; Resident E requested a room change because he was tired of Resident C's "mouth."; Resident E's son stated that he was going to contact law enforcement due to Resident C's behavior." Further review indicated there was no documented evidence that the facility protected Resident E from further altercations with Resident C, besides moving Resident E to another room and there was no documentation provided to indicate the facility investigated the incident and reported the incident to CDPH or the Ombudsman. k. Social service notes: October 2, 2013: "(Resident C) had a verbal altercation with a peer who he has had several altercations with. The other resident was sitting in the shade reading a book and (Resident C) rode up on his power chair and started yelling foul things to the other resident. (CNA 1) (Certified Nurse Assistant) separated them right away and assisted the other resident back in the facility. (Resident C) approached him again when the other resident was sitting in hallway by his own room. (Resident C) started yelling fowl language again and (Resident 14) yelled back, "F** you and grow up." Staff was present and in between both of them keeping them apart. Administrator and SSD spoke with (Resident C) about his behavior and reminded him he already has a court date due to a physical altercation with this resident. Will monitor (Resident C's) whereabouts' and behavior." Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility documented the altercation between Resident C and Resident 14, or that facility staff was monitoring Resident C's whereabouts. There was no other evidence provided that indicated the altercation involving Resident C and Resident 14 was investigated by the facility and reported to CDPH and the Ombudsman. l. General nurse's notes dated January 10, 2014 at 6 PM: "At 5:30 PM, (CNA 2) came and told the writer that (Resident C) is fighting (Resident E) in the dining room. The writer ran to the dining room immediately and they were already separated. When asked what happend, (CNA 3 and CNA 4) stated that (Resident C) just came in and started cursing and calling names on (Resident E). Staff told him to stop. After a few minutes, he (Resident C) picked up a cup of coffee on the table and threw it at (Resident E's) face. Staff ran in between them and separated them. The writer instructed (Resident C's name) to go to his room. [MEDICATION NAME] (a medication used to treat anxiety) 0.25 milligram was administered. Frequent visual checks throughout the shift to ensure the two residents are separated. m. Interdisciplinary notes: January 16, 2014. Date of incident-January 10, 2014. Type of incident- Verbal contact. Comment section noted: "(Resident C) was noted to be yelling at and calling another resident names that was in the dining room getting ready to eat. When staff asked this resident to stop with his behavior, the resident threw a cup of cold coffee on the other resident. Residents were immediately separated and staff informed the resident that his behavior is completely unacceptable and cannot be tolerated." IDT Recommendation noted: "IDT recommends to continue plan, to ensure that these residents are not sitting or playing activities together, to help prevent further altercation and continue to educate this resident (Resident C) on his behavior not being acceptable. (Resident C) would not explain why he was attempting to start a fight with the other patient and stated he could do what he wants." Further review indicated there was no additional documentation or evidence provided to indicate the facility protected Resident E from further altercation and abuse from Resident C and there was no evidence available or provided to show the facility reported the incident on January 10, 2014, to CDPH or the Ombudsman. On February 10, 2014, a review of Resident C's care plans showed the following plan, dated, October, 2012, titled, "Alteration in Mood Patterns or Behavioral Symptoms Manifested by:" * "Negative comments. * Frequent complaints. * Hostility. * Abusive language. * History of resident to resident altercation." The interventions were listed as: * "Discuss Resident's interest. * Encourage involvement in meaningful activity inside and outside of the room. * Provide tip to family members to assist in residents adjustment. * Give positive reinforcement for appropriate behaviors. Encourage involvement in previously enjoyed activities. * Psych (Psychiatric) follow up as indicated. * Administer medications as ordered and monitor effectiveness for behavior management. * Support Resident for use of or attempts to use appropriate ways of expressing needs. * Observe Resident frequently-assess resident's needs. * Review goals with Resident for appropriate behavior. * Maintain Resident personal space. * Intervene before Resident agitation escalates. * SSD to meet with Resident intermittently to encourage to vent feelings or concerns. * Staff to encourage Resident to come to them if he is feeling angry or upset about circumstances." The care plan showed the plan was updated in April, 2013 and in October, 2013. Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the facility implemented the interventions for Resident C. On February 10, 2014, a care plan titled, "Behavior Problem", dated October, 2013, showed the following problems: * "Verbally abusive behavior. * Resists care. * Hostility. * Episodes of false accusations. * Resident has episodes of threatening and patient to patient contact." The care plan showed the following interventions: * "Speak in calm way. * Discuss concerns with Resident. * Explain all procedures. * Administer medications as ordered. * Continue to explain risks of refusing care." The care plan was dated and re-evaluated on January, 2014. Further review indicated there was no additional documentation in Resident C's clinical record to demonstrate that the interventions listed on the care plan were consistently implemented. During an interview with the DON, on February 10, 2014, at 10:40 AM, she stated, "I wasn't sure what else we could do, but I can see the problem now with this time line you created. No new care plans were added, or no other interventions were tried. We should have tried something else to prevent reoccurrence's or to protect the residents." During further interview with the DON, on February 10, 2014, at 10:40 AM, when asked if she would consider the reviewed notes regarding Resident C's altercations as abuse, the DON stated, "Yes, I guess you could say that. We could have done more to protect the residents and the interventions of just talking to the resident and monitor his whereabouts is not working to prevent the behavior from interfering with the other residents." During an interview with the SSD, on February 10, 2014, at 10:30 AM, she stated that when she documented altercations or verbal threats of abuse from Resident C, she usually received the information from one of the nurses. The SSD further explained that she could not remember any of the nurse's names that reported any of the incidents and stated, "I don't document the names of who reports things to me but I guess I should start." During further interview with the SSD, on February 10, 2014, at 10:30 AM, she stated, "I do remember the incident on April 25, 2013, with the female resident, it was the female resident herself (Unsampled Resident H) who reported it to me." The SSD further stated, "Not every incident is documented or care planned. Resident C has many outbursts or threatening behavior. I didn't realize verbal threats are considered verbal abuse." During an interview with the Administrator on February 7, 2014, at 12:10 PM, he stated, "Whoever witnesses an incident should complete an incident report. The report is given to the MDS (Minimum Data Set- an assessment tool) Nurse. If the incident is regarding an altercation, I should receive it, and then it is discussed at the daily stand up meeting or IDT meetings." During further interview with the Administrator, on February 7, 2014, at 12:10 PM, he stated, "I don't have an incident report on an incident between Resident C and Resident E from January in the dining room. I wasn't aware of it. I don't know if I would consider throwing a coffee cup at someone abuse." During an interview with the DON on February 10, 2014, with the MDS nurse present, she stated, "(Administrators name) knew about the incident in the dining room regarding Resident C and Resident E in January. He (Administrator) was at the stand up meeting the following Monday and we talked about it." During an interview with Resident H, on February 10, 2014, at approximately 12:00 PM, in the dining room, when asked if she had any altercations with Resident C, she stated, "Yes, he has verbally cussed at me and called me foul names when I ask him not to smoke around me. It has happened many times. He treats many people badly. I don't feel safe with him here. I try to be a tough bird though. On February 10, 2014 at 12:20 PM, an interview was conducted with Resident E in the dining room. Resident E stated that he had multiple verbal altercations with Resident C when they were roommates. Resident E stated that one day when his grandkids were visiting him, Resident C yelled and cursed at them. Resident E stated that Resident C's behavior scared his grandkids. Resident E stated that he requested a room change after that because he no longer felt safe sharing a room with Resident C. During the interview, Resident E heard Resident C yelling and cursing at another resident who was in the dining room. Resident E stated, "see that is what he does." During an observation made on February 10, 2014 at 12:25 PM, Resident C was observed entering the facility dining room. Upon entering in a motorized wheel chair he kicked the back of the wheelchair of a resident sitting in his way, causing the chair to be move a few inches. He then proceeded to go over to Resident D, who was sitting at a table. Resident C began yelling at Resident D and then raised his arm to strike Resident D. Staff then walked Resident D out of the dining room. Resident C continued to follow Resident D and the staff out of the dining room and called Resident D a "little [***] ." The staff informed Resident C that he could not continue to follow Resident D and he proceeded down another hallway. A review of the facility's policies and procedures for their abuse prevention program showed the following policies: "Reporting Abuse to Facility Management", dated January , 2014, stipulated "It is the responsibility of our employees facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property, to facility management." Section 2. "To help with recognition of incidents of abuse, the following definitions of abuse are provided:" 2b. "Verbal abuse- defined as any use of oral, written or gesture language that willfully incudes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability." 2.e. "Mental abuse- defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services." "Abuse Investigations" dated, January, 2014, stipulated "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Section 3, The individual conducting the investigation will, as a minimum: Review the completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person (s) reporting the incident, interview any witnesses to the incident, interview the resident, interview staff members, and visitors, interview other residents to whom the accused employee provides care or services, review all events leading up to the alleged incident." "Reporting Abuse," dated, January, 2014, "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law." Section 1. "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a.The State licensing/certification agency responsible for surveying/licensing the facility; b.The local/State ombudsman; c.The Resident's Representative; d. Law enforcement officials; e. The resident's Attending Physician. "Protection of Residents during Abuse Investigations", dated, February 6, 2013, stipulated "Our facility will protect residents from harm during investigations of abuse allegations. During abuse investigations, residents will be protected from harm by the following measures:" Section d "If the alleged abuse involves another resident, the accused resident's representative and Attending Physician will be informed of the alleged abuse incident and that there may be restricitons on the accused resident's ability to visit other resident rooms unattended. If necessary, the accused resident's family members may be required to help meet this requirement." "Resident-to-Resident Altercations - All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nursing Services, and to the Administrator. Section 2. If two residents are involved in an altercation, staff will: Separate the residents, and institute measures to calm the situation. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. Notify each resident's representative. Review the events with the Nursing Supervisor and Director of Nursing, including interventions to prevent additional incidents, Make any necessary changes in the care plan approaches to any or all of the involved individuals. Document in the resident's clinical record all interventions and their effectiveness. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the ID team. If after carefully evaluating the situation, it is determined that care cannot be readily given with the facility, transfer the resident and report incidents, findings, and corrective measures to appropriate agencies." 2. On February 3, 2014 at 8 AM, Resident D was observed in the facility dining room sitting in his wheel chair. The resident was alert, oriented and able to make his needs known. Resident D was noted to have left arm weakness. On February 6, 2014, a review of Resident D's medical record was conducted. Resident D's face sheet noted that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. weakness on one side of the body). A review of the Social Services Notes, dated January 29, 2014 was conducted. It was noted that Resident D told the SSD that his roommate had sex with a staff member last night and they made him watch. There was no documented evidence to show that the SSD investigated the resident's allegation. On February 10, 2014 at 4 PM, an interview was conducted with SSD. The SSD stated that she did not take the resident's allegation seriously due to his altered thought process. She also stated that she did not inform the DON or Administrator. The SSD stated that she should have started an investigati

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to ensure that all residents of the facility were protected from abuse. The facility failed to thoroughly investigate allegations of abuse, and failed to report all allegations of abuse to CDPH (The California Department of Public Health) for 2 of 8 unsampled residents (Residents C and D). 1. The facility failed to protect all residents from verbal abuse and verbal threats of physical harm from Resident C. The facility failed to thoroughly investigate allegations of abuse, and failed to report all allegations of abuse to CDPH due to Resident C's threats of physical harm not deemed as being credible. 2. For Resident D, the SSD (Social Service Designee) failed to investigate Resident D's allegation that his roommate had sex with his roommate, and Resident D was made to watch. These failures resulted in 3 residents (Residents 14, Unsampled Residents H and E) of the facility feeling unsafe and fearful and prevented CDPH from ensuring that the facility was taking the appropriate actions to protect the residents and investigate all allegations of abuse. These failures also had the potential for ongoing verbal and physical abuse for a universe (total number of residents in the facility) of 92 residents of the facility. Findings: 1. During an interview with LVN 3 on February 5, 2014 at 3:40 PM, LVN 3 stated that she did not have to report all allegations of abuse. She further stated that the staff was supposed to investigate them first and then report them. During the review of the policy titled, "Abuse Reporting and Investigation," undated, "Section 3" of the policy and procedure indicated: "All incidents of abuse must be reported to the administrator, as well as to the resident's representative (sponsor), within twenty four hours of the occurrence of such incident. An immediate investigation must be made, and the findings of such investigation must be reported to the Administrator within five working days of the occurrence of such incidents." During further review of "Section 4" of the same policy and procedure, indicated: "Should the investigation reveal that suspected or actual abuse occurred, the administrator must report such findings to the resident's representative, local police department,ombudsman (a person who assists individuals and groups in the resolution of conflicts or concerns) and the state licensing agency, and others that may be required by state and federal laws." During an interview and concurrent record review with the Administrator on February 6, 2014, at approximately 11:30 AM, when asked if the policy titled, "Abuse Reporting and Investigating", undated, was the policy regarding abuse the facility utilized or if there were other policy's for review, the Administrator stated, "No (there were no other policies), that is the policy we (facility) are using." During an interview, the Administrator was asked to provide a list of allegations of abuse from the past year in order to select samples for review of how the facility handles alleged violations. The Administrator stated, "I don't keep a list or log of any type. I will have to pull some files, and write down the events and I will provide a list for you to choose from." During an interview and a concurrent observation with the Administrator on February 6, 2014, at approximately 11:30 AM, when asked if it made it difficult to track and trend patterns of alleged abuse, he didn't answer and shrugged his shoulders. A review of a hand written piece of paper, written by the Administrator on February 6, 2014, contained a list of allegations of abuse and mistreatment was provided by the Administrator, on February 6, 2014, showed the following: April 1, 2013: Sampled Resident 14 complaint about Unsampled Resident C. "(Resident 14) came to me and said (Resident C) verbally challenged him and told him when he goes to the (name of a facility) he was going to cut the tubes and kill him. I (Administrator) told him to stay out of (Resident C's) way. We (facility Administration) are trying to get him back on medication so that he would be more controlled. (Resident 14) demanded something be done about (Resident C). I (Administrator) told him if (Resident C) confronts him he should let a nurse handle it." The back of the same document reviewed on February 6, 2014, showed the following documented summary with the Administrators signature: "No blows were exchanged. Both parties agreed to use separate patios so they stay away from each other." During an interview with the Administrator on February 6, 2013, at 3:20 PM, when asked about his investigation and his response to the allegation made by Resident 14 regarding Resident C, he stated, "I talked to both residents and they agreed to stay away from each other. That was my investigation. (Resident C) has a history of making verbal threats. I don't need to investigate any further because it won't get me anywhere." During further interview with the Administrator on February 6, 2013, at 3:20 PM, he stated, "I don't report all allegations of abuse. I only investigate credible allegations. (Resident C) has a psychiatric [DIAGNOSES REDACTED]. condition and is unable to act out his threats of harm." During further interview with the Administrator, he stated, "I am following our policy regarding investigating and reporting abuse. I investigate credible reports of abuse and I will report substantiated reports of abuse." When asked if the facility policy follows the federal regulations, which includes reporting all allegations of abuse and all substantiated reports of abuse, the Administrator did not answer and again repeated, "I am following our policy regarding investigating and reporting abuse." On further interview with the Administrator on February 6, 2014 at 3:20 PM, when asked how he determined an allegation was credible if it has not been investigated, and he said, "I have been doing this a long time." A review of the clinical record for Resident C on February 6, 2014, indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. disorder characterized by mood swings) and [MEDICAL CONDITION] (unable to move one side of the body). Resident C was on [MEDICATION NAME] (medication used for mood stabilization), 250 milligrams, by mouth, every day, for [MEDICAL CONDITION] disorder, manifested by mood swings. During an interview with Resident 14, on February 7, 2014, at 12:00 PM, he stated, "I remember the incident with (Resident C's name), he threatened me before going to (hospital name). He said that he was going to have someone kill me." On further interview with Resident 14, on February 7, 2013, he stated, "I don't feel safe here and at times I am scared because (Resident C) makes threats all the time, to me and to others in the facility. He has also hit me, as well as other people in the facility. I (Resident 14) tell the (Administrator) when something happens, but what can they do about it? Nothing really changes. I worry about him (Resident C) and my safety, but my family really worries." Resident 14 further stated, "One time he (Resident C) hit me with his power wheelchair and broke the wheel off my wheelchair." During an interview with the Administrator and DON (Director of Nursing), on February 7, 2014, at 2:15 PM, the Administrator stated, "He (Resident C) is an angry, coarse individual, who overreacts to provocation. He does make verbal threats at times, and tends to pinpoint certain residents." During further interview with the Administrator and DON on February 7, 2014, at 2:15 PM, the DON stated, "Once staff has knowledge of an allegation of abuse or have witnessed any type of resident to resident abuse, they should report it to the charge nurse, it should be discussed at a stand-up meeting the next day or on Monday if the event happened over the weekend. It then will be discussed at our IDT (Interdisciplinary team- different specialty group or area knowledge) meetings that take place once a week." The DON further stated, "The ID team will suggest changes to the plan of care or add interventions to prevent reoccurrence's." When asked how the facility staff ensures the safety of the other residents from further altercations and threats made by Resident C, the DON stated, "We observe for signs and symptoms of agitation and closely monitor." During a record review of social service, charge nurse, interdisciplinary notes and care plans for Resident C, with the DON on February 10, 2014, the following documentation was noted: a. Social service notes: April 1, 2013, "SSD (Social Service Designee) informed that (Resident C) has been verbally abusive towards another patient. SSD attempted to speak with (Resident C) regarding his behavior to see what is cause his anger." During further review, there was no other evidence provided to show that the facility followed their policy and investigated and reported the incident to CDPH or the Ombudsman. b. Social service notes: April 4, 2013, late entry note. "On April 3, 2013, it was reported to SSD that (Resident C's name) made threats to his roommate. SSD spoke with (Resident C) and he admitted to threats and stated it was over the television being on too late and resident can't sleep. SSD spoke with resident's roommate who said he would turn television off at 10:00 PM." During further review, there was no other evidence provided to show that the facility followed their policy and thoroughly investigated and reported the incident to CDPH or the Ombudsman. c. Social service notes: April 25, 2013. "(Resident C) had an episode of being verbally abusive towards a female resident. He was smoking outside the door and she had asked him to smoke in the smoking area. He became upset and started cursing her." During further review, there was no other evidence provided to show that the facility followed their policy and investigated and reported the incident to CDPH or the Ombudsman. d. Social service notes: May 15, 2013. "(Resident C) had an incident being verbally abusive towards an elderly female resident who was sitting in hallway innocently when he started vulgarly yelling at her to move. He was moved and told his behavior is not acceptable." During further review, there was no other evidence provided to show that the facility followed their policy and investigated and reported the incident to CDPH or the Ombudsman. e. Social service notes: May 28, 2013. "(Resident C) came to SSD office and he was placing a threat to his roommate regarding the television program the other resident watches. SSD informed the resident he could buy his own television. Risks and benefits of his behavior explained." During further review, there was no other evidence provided to show that the facility followed their policy and investigated and reported the incident to CDPH or the Ombudsman. f. Social service notes: July 5, 2013. "It was reported to SSD that (Resident C) was involved in an altercation with another resident. SSD visited (Resident's C) and he stated that he (the resident) went to (Resident 14) to see another resident. (Resident 14) began waving a scratcher stick at (Resident C) and was yelling at him to leave his room. (Resident C) became upset and was placing verbal threats to (Resident 14). A nurse came in and separated the two residents. SSD reminded (Resident C) of his altercation a year ago with (Resident 14) and has been asked to stay away from that room due to (Resident 14) does not feel well." g. General nurse's notes: (notes made by nurses that describe the residents' condition and treatment given or planned: July 7, 2013. "Sheriff came at 4:30 PM and interviewed resident about the incident with another resident (Resident 14). In addition, sheriff also interviewed (Resident 14). Sheriff asked about any witnesses regarding the incident, but no one was there to witness the incident. Sheriff mentioned that the resident denied kicking resident in (Resident 14). Spoke with sheriff at 5:30 PM, sheriff said that a report will be filed and a copy will be given within 2 weeks and according to the sheriff, (Resident C) was given a citation for battery misdemeanor. Sheriff left facility at 5:45 PM. Resident reminded to keep a distance from (Resident 14)." i. Social service notes: July 15, 2014. "Verbal altercation this time with his roommate and the family members. Apparently his roommate had children visiting as well. (Resident C) went off on his (roommate's) son, stating children are not allowed to visit. (Resident C) continues to refuse his medications. SSD faxed psychiatric evaluation due to his continued verbal altercations and refusing medications. IDT meeting will be held today." j. General nurse's notes: July 14, 2013: "Around 4:00 PM, (Resident C) started to verbally abuse (Unsampled Resident E) family and grandchildren of (Resident E). Resident E was crying and scared. Went into the room and asked for (Resident C) to step out of the room. (Resident C) yelled "I want to get away from that syphilis man" as he went out the room via motorized scooter. (Resident C) left the faciity on his motorized scooter and refused to sign out. (Resident E)'s family requested to be changed to another room. Informed and called Administrator and informed of incident. (Resident E) agreed to be moved to another room." On February 10, 2014, a review of Resident E's clinical record was reviewed and indicated Resident E was admitted to the facility on February 16, 2011. During a review of the Social Service Notes, dated July 17, 2013, on February 10, 2014, it noted that the social worker (SW) met with Resident E's sons to discuss the verbal altercation that occurred of the weekend (weekend of July 14th). The documentation included the following: "Resident C was cursing at Resident E's family (including his grandkids) over the weekend; Resident E requested a room change because he was tired of Resident C's "mouth". Resident E's son stated that he was going to contact law enforcement due to Resident C's behavior." During further review, there was no other evidence provided to show that the facility followed their policy and investigated and reported the incident to CDPH or the Ombudsman. k. Social service notes: October 2, 2013: "(Resident C) had a verbal altercation with a peer who he has had several altercations with. The other resident was sitting in the shade reading a book and (Resident C) rode up on his power chair and started yelling foul things to the other resident. (CNA 1's name) (Certified Nurse Assistant) separated them right away and assisted the other resident back in the facility. (Resident C) approached him again when the other resident was sitting in hallway by his own room. (Resident C) started yelling foul language again and (Resident 14) yelled back, "F** you and grow up." Staff was present and in between both of them keeping him apart. Administrator and SSD spoke with (Resident C) about his behavior and reminded him he already has a court date due to a physical altercation with this resident. Will monitor (Resident C) whereabouts and behavior." During further review, there was no other evidence provided to show that the facility followed their policy and investigated and reported the incident to CDPH or the Ombudsman. l. General nurse's notes dated January 10, 2014 at 6 PM: "At 5:30 PM, (CNA 2) came and told the writer that (Resident C) is fighting (Resident E) in the dining room. The writer ran to the dining room immediately and they were already separated. When asked what happend, (CNA 3 and CNA 4) stated that (Resident C) just came in and started cursing and calling names on (Resident E). Staff told him to stop. After a few minutes, he (Resident C) picked up a cup of coffee on the table and threw it at (Resident E) face. Staff ran in between them and separated them. The writer instructed (Resident C) to go to his room. [MEDICATION NAME] (a medication used to treat anxiety) 0.25 milligram was administered. Frequent visual checks throughout the shift to ensure the two residents are separated." m. Interdisciplinary notes: January 16, 2014. Date of incident-January 10, 2014. Type of incident- "Verbal contact". Comment section noted: "(Resident C) was noted to be yelling and calling another resident names that was in the dining room getting ready to eat. When staff asked this resident to stop with his behavior, the resident threw a cup of cold coffee on the other resident. Residents were immediately separated and staff informed the resident that his behavior is completely unacceptable and cannot be tolerated." During an interview with the DON, on February 10, 2014, at 10:40 AM, when asked if she would consider the reviewed notes regarding Resident C's altercations as abuse, the DON stated, "Yes, I guess you could say that. We could have done more to protect the residents and the interventions of just talking to the resident and monitor his whereabouts is not working to prevent the behavior from interfering with the other residents." During an interview with the SSD, on February 10, 2014, at 10:30 AM, she explained that when she documented altercations or verbal threats of abuse from Resident C, she usually received the information from one of the nurses. The SSD further stated that she could not remember any of the nurse's names that reported any of the incidents and stated, "I don't document the names of who reports things to me but I guess I should start." During further interview with the SSD, on February 10, 2014, at 10:30 AM, she stated, "I do remember the incident on April 25, 2013, with the female resident, it was the female resident herself (Unsampled Resident H) who reported it to me." The SSD further stated, "Not every incident is documented or care planned. Resident C has many outbursts or threatening behavior. I didn't realize verbal threats are considered verbal abuse." During an interview with the Administrator on February 7, 2014, at 12:10 PM, he stated, "Whoever witnesses an incident should complete an incident report. The report is given to the MDS (Minimum Data Set- an assessment tool) Nurse. If the incident is regarding an altercation, I should receive it and then it is discussed at the daily stand up meeting or IDT meetings." On further interview with the Administrator, on February 7, 2014, at 12:10 PM, he stated, "I don't have an incident report on an incident between Resident C and Resident E from January in the dining room. I wasn't aware of it. I don't know if I would consider throwing a coffee cup at someone abuse." During an interview with Resident H, on February 10, 2014, at approximately 12:00 PM, in the dining room, when asked if she had any altercations with Resident C, she stated, "Yes, he has verbally cussed at me and called me foul names on many occasions. It has happened many times. He treats many people badly. I don't feel safe with him here. I try to be a tough bird though." During an observation made on February 10, 2014 at 12:25 PM, Resident C was observed entering the facility dining room. Upon entering in a motorized wheel chair he kicked the back of the wheelchair of a resident sitting in his way causing the chair to move a few inches. He then proceeded to go over to Resident D, who was sitting at a table. Resident C began yelling at Resident D and then raised his arm to strike Resident D. Staff then walked Resident D out of the dining room. Resident C continued to follow Resident D and the staff out of the dining room and called Resident D a "little [***] ." The staff informed Resident C that he could not continue to follow Resident D and he proceeded down another hallway. During an interview with the DON, on February 10, 2014, at 2:45 PM, she presented abuse policies and procedures that were approved by the patient care policies committee on January, 2014, and stated, "These are the policies that we (the facility) are currently using." During an interview with the DON, on February 10, 2014, at 4:05 PM, with the MDS nurse present, she stated, "(Administrator' name) knew about the incident in the dining room regarding Resident C and Resident E. He (Administrator's name) was at the stand- up meeting the following Monday and we talked about it." During an interview with the Administrator, on February 10, 2014, at 4:20 PM, he stated, "I did give you an old policy by mistake, I'm not sure why I had that one (initial policy reviewed). Again, it was my mistake. The current policy does indicate that all allegations of abuse should be investigated and reported to the state." A review of the facility's policies and procedures for their abuse prevention program showed the following policies: "Reporting Abuse to Facility Management", dated January, 2014, indicated "It is the responsibility of our employees facility consultants, Attending Physicians, family members, visitors, etc, to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property, to facility management." Review of Section 2 indicated, "To help with recognition of incidents of abuse, the following definitions of abuse are provided:" 2b. "Verbal abuse - defined as any use of oral, written or gesture language that willfully incudes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability." 2.e. "Mental abuse- defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services." "Abuse Investigations" dated, January, 2014, indicated, "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Section 3, The individual conducting the investigation will, at a minimum:, Review the completed documentation forms, review the resident's medical record to determine events leading up to the incident, interview the person (s) reporting the incident, interview any witnesses to the incident, interview the resident, interview staff members, and visitors, interview other residents to whom the accused employee provides care or services, review all events leading up to the alleged incident." "Reporting Abuse" dated, January, 2014, indicated, "All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law." Section 1. "Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State ombudsman; c. The Resident's Representative; d. Law enforcement officials; e. The resident's Attending Physician. "Protection of Residents during Abuse Investigations", dated, February 6, 2013, indicated, "Our facility will protect residents from harm during investigations of abuse allegations. During abuse investigations, residents will be protected from harm by the following measures:" Section D "If the alleged abuse involves another resident, the accused resident's representative and Attending Physician will be informed of the alleged abuse incident and that there may be restrictions on the accused resident's ability to visit other resident rooms unattended. If necessary, the accused resident's family members may be required to help meet this requirement." "Resident-to-Resident Altercations", dated January, 2014, indicated, "All altercations, including those that may represent resident-to-resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nursing Services, and to the Administrator." Review of Section 2 indicated, "If two residents are involved in an altercation, staff will: Separate the residents, and institute measures to calm the situation. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation. Notify each resident's representative. Review the events with the Nursing Supervisor and Director of Nursing, including interventions to prevent additional incidents, Make any necessary changes in the care plan approaches to any or all of the involved individuals. Document in the resident's clinical record all interventions and their effectiveness. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the ID team. If after carefully evaluating the situation, it is determined that care cannot be readily given with the facility, transfer the resident and report incidents, findings, and corrective measures to appropriate agencies." 2. On February 3, 2014 at 8 AM, Resident D was observed in the facilities dining room sitting in his wheel chair. The resident was alert, oriented and able to make his needs known. Resident D was noted to have left arm weakness. On February 6, 2014, a review of Resident D's medical record was conducted. Resident D's face sheet noted that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. weakness on one side of the body). A review of the Social Services Notes, dated January 29, 2014 was conducted. It was noted that Resident D told the SSD that his roommate had sex with a staff member last night and they made him watch. There was no documented evidence to show that the SSD investigated the resident's allegation. On February 10, 2014 at 4 PM, an interview was conducted with SSD. The SSD stated that she did not take the resident's allegation seriously due to his altered thought process. She also stated that she did not inform the DON or Administrator.The SSD stated that she should have started an investigation, as well as informed the DON and/or Administrator of the resident's allegation. On February 10, 2014 at 5 PM, an interview was conducted with the Administrator. The Administrator stated that he was unaware of Resident D's allegation of sexual abuse. He stated that the SSD should have informed him of Resident D's allegation.

Based on interview and record review the facility failed to ensure 2 of 3 abuse allegations and injuries of unknown origin (Incidents #1 and #2) were investigated and reported to CDPH (California Department of Public Health), as required by state law. This system failure resulted in an increased risk for abuse to occur in the facility without detection and investigation for a universe of 103 residents. Findings: During a review of the facility's abuse allegations and injuries of unknown origin, on March 26, 2014, at 1:00 PM, it was noted that Incident #1, an allegation of mistreatment by facility staff, occurred on March 19, 2014. According to the incident summary, the facility became aware of the allegation on March 19, 2014. The allegation was not reported to CDPH until March 21, 2014, which was 2 days after the facility became aware of the allegation. Incident #2 was an injury of unknown origin (a bruise found on a resident that had no known origin and could therefore be a result of possible abuse). The facility discovered the injury of unknown origin on March 6, 2014 and was reported to CDPH March 11, 2014. During an interview with the Administrator on March 26, 2014, at 1:24 PM, 3 incidents of alleged abuse or injury of unknown origin were discussed. The Administrator stated he had completed the investigations before he reported the incidents to CDPH. He confirmed facility staff had become aware of Incident #1 on March 19, 2014, but was unsure if he was aware of it on March 19 or March 20, 2014. The Administrator confirmed he did not report the incident until March 21, 2014. He stated Incident #2, the injury of unknown origin, was not reported to CDPH until March 11, 2014. The Administrator stated he was not sure why the incident was not reported sooner. He stated a report was made to CDPH after the facility completed the investigation. The facility policy and procedure titled, "Reporting Abuse", dated 2/6/13, reflected, "If reportable event does not result in serious bodily injury, Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone."