Every finding on record at Infinity Care of East los Angeles

Based on interview and record review, the facility failed to ensure that a designated Infection Preventionist Nurse (IP- a nurse who helps to prevent patients from catching new illnesses) was on duty on 7/11/2026 until 7/29/2026 (19 days) and 7/31/2026 until 8/5/2026 (6 days). This failure had the potential to cause spread of communicable diseases (tiny germs like viruses and bacteria that can cause illness) to the 88 residents at the facility and result in making more resident sick. Findings: During a review of Resident 2's admission record, dated 5/18/2026, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses but not limited to dementia (a decline in mental ability), acute kidney failure (stoppage of kidney's ability to filter out waste and fluid from the blood), and dysphagia (difficulty swallowing). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 7/18/2026, indicated Resident 2's cognition (ability to understand and make decisions) was severely impaired (major loss in brain function). During a review of Resident 2's History and Physical (H&P), dated 7/27/2026, the H&P indicated Resident 2 was Covid-19 (Coronavirus 2019- an illness that causes flu-like symptoms) positive and had symptom of diarrhea (loose or watery stool) for two days. During a review of Resident 3's admission record, dated 6/16/2026, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses but not limited to dementia (a decline in mental ability), depression (a mental illness that causes a person to feel very sad and hopeless), and diabetes mellitus (a disorder that causes poor blood sugar control and poor wound healing). During a review of Resident 3's Situation Background Assessment Recommendation (SBAR- a tool used by healthcare staff to give resident medical information) Notes, dated 7/31/2026, indicated Resident 3 with symptoms but not limited to fever, cough, congestion, shortness of breath (hard work getting air into your lungs), and diarrhea. During a review of Resident 3's facility Covid-19 Test Form, dated 7/31/2026, indicated Resident 3 was Covid-19 positive. During an interview on 8/6/2026 at 10:28 A.M. with the Director of Nursing (DON), the DON stated there is a current Covid-19 outbreak (a sudden increase in number of sick people with the same disease) which started on 7/31/2026. The DON stated 6 residents were Covid-19 positive and in isolation (keeping a sick patient separate from others to prevent spread of the disease), including Residents 2 and 3. The DON also stated the facility's previous IP Nurse had resigned (stopped working) from the facility on 7/10/2026. During an interview on 8/6/2026 at 10:45 A.M. with the Medical Records Director (MR), the MR did not know if there was a current Covid-19 outbreak at the facility. During an interview on 8/6/2026 at 4:40 P.M. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that she joined 3 P.M. staff huddle (a short meeting with healthcare staff at start of the work shift) today and stated there are no positive Covid-19 residents at the facility. LVN 1 stated it is important for the facility to have an IP Nurse to keep the residents safe from spread of infectious diseases. During an interview on 8/7/2026 at 1:10 P.M. with the DON, the DON stated if there is no designated IP nurse at the facility, the Covid-19 virus can potentially spread during the current outbreak, resulting in more residents becoming sick. The DON stated there were days (unable to recall specific dates) that there was no designated IP nurse or designated staff who covered for the IP nurse duties and responsibilities. During a review of an electronic mail (e-mail) from the DON sent to the surveyor, dated 8/10/2026, the email indicated, Unfortunately, we (the facility) do not have IP hours (infection prevention duties) for: From 7/11/2026 until 7/29/2026, From 7/31/2026 until 8/5/2026. During a review of the facility's policy and procedures (P&P) titled, Infection Preventionist, with a review date of 7/2016, indicated, The infection preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 1/16/2025, indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to protect residents' right to be respected with dignity and in an environment that promotes quality of life for one (1) of three (3) sampled residents (Resident 1) by not preventing Resident 2 from exposing his penis and masturbating (the touching or stimulating of one's own genitals or other sensitive body parts for sexual pleasure) in front of Resident 1 on 7/25/2026 at 4 pm. This deficient practice has the potential to result in feelings of decreased dignity and self-worth for Resident 1. Findings, During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that including but not limited to type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control), secondary hypertension (high blood pressure caused by another medical problem or specific medication), and other hyperlipidemia (abnormal excess of fats or lipids in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/26/2026, the MDS indicated Resident 1 was assessed having moderately impaired (decisions poor; cues/supervision required) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, upper body dressing, toileting hygiene, sit to stand, toilet transfer and walking 10 feet (ft.- unit of measurement). The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with lower body dressing, putting on/taking off footwear, and tub/shower transfer. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a document that provides a framework for communication between members of the health care team about a Resident's condition), dated 7/26/2026, the SBAR indicated Resident 1 reported at 11:45 AM on 7/26/2026 that on the evening of 7/25/2026 at approximately 4 PM, Resident 1 witnessed Resident 2 masturbating in the hallway outside of Resident 1's room. Resident 1 stated she was seating in her wheelchair, in the doorway of her room. Resident 1 stated she witnessed Resident 2 wheel himself to the front of her room and began masturbating. Resident 1 stated she told Resident 2 to go away. Resident 1 then stated Resident 2 wheeled himself away from her room towards his room. Resident 1 stated that she then wheeled herself to the nurse's station to report the incident with a staff member but no one was present at the nurse's station at the time. Resident 1 stated she did not tell any staff about the incident until 7/26/2026 at approximately 11:45 AM, while being transported to the third floor to participate in activities. Resident 1 reported the incident to the Activity Coordinator (AC) who reported to the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included but not limited to cerebral infarction (when the blood supply to part of the brain is blocked or reduced), unspecified dementia (a decline in mental ability severe enough to interfere with daily life), and cognitive communication deficit (trouble with talking, listening, or sharing meaning caused by a problem with brain thinking skills rather than a direct problem with speech muscles or basic language rules). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was assessed having severely (never/rarely made decisions or able to made decisions for himself) impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required partial/moderate assistance with oral/personal hygiene, upper body dressing, sit to stand, and toilet transfer. The MDS indicated Resident 2 required substantial/maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, tub shower transfer, and wheel manual wheelchair 150 feet. During a review of Resident 2's SBAR, dated 7/26/2026, the SBAR indicated (Resident 1) reported on 7/26/2026 at 11:45 AM that Resident 2 with episode of sexual inappropriate behavior on 7/25/2026) at 4 PM. Resident 2 stated something happened when asked about the incident. Resident 2 stated that I don't know when asked specifically what happened last night in the hallway. Resident 2 has a history of sexually inappropriate behavior and dementia. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included but not limited to spinal stenosis, type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema of right eye (when the resident's DM has caused mid-level damage to the blood vessels in the retina of the right eye, including fluid swelling in the central part of the vision area), and chronic pulmonary edema (long-term condition where fluid slowly builds up in the air sacs of the lungs) During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was assessed to have intact memory and cognitive skills for daily decision making. The MDS indicated Resident 3 required setup or clean-up assistance with oral hygiene and personal hygiene. The MDS indicated Resident 3 required partial/moderate assistance with toileting hygiene, shower/bathe self, sit to stand, and toilet transfer. During an interview on 8/4/2026, at 12:02 AM, Resident 1 stated that on 07/25/2026, at approximately 4:00 PM, Resident 1 was sat in her wheelchair by the doorway in front of her room. Resident 1 stated that Resident 2 wheeled his wheelchair in front of her, pulled zipper of his pants down, and started playing with his penis. Resident 1 stated she called Resident 2 a cochino (to describe someone as a pervert, or someone acting in a gross, lewd, or inappropriate) and a dirty man and told Resident 2 to go away. Resident 1 stated there was no facility staff present in the hallway when the incident happened. Resident 1 stated she wheeled herself to the nurse's station to report the incident, but no one was there. She then told Resident 3 about the incident with Resident 2. Resident 1 stated she also informed an unidentified staff member on 7/26/2027 about Resident 2's inappropriate behavior on 7/25/2026. During an interview on 8/4/2026, at 12:19 PM, with Resident 3, Resident 3 stated Resident 1 informed her that Resident 2 played with his penis in front of Resident 1 on 7/25/2026. During an interview on 8/4/2026, at 12:19 PM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 2 had a history of playing with his penis inside his room. CNA 1 stated she has never seen Resident 2 touch himself inappropriately outside his room or in front of other female residents. CNA 1 stated it was inappropriate for Resident 2 to play with his penis in front of Resident 1. CNA 1 stated it can make Resident 1 feel uncomfortable. During an interview on 8/4/2026, at 1:51 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2 behaved inappropriately in front of Resident 1 on 7/25/2026. LVN 1 stated there was no facility staff around during the time the incident happened to make sure Resident 2 did not behave inappropriately in front of Resident 1. During an interview on 8/4/2026, at 2:48 PM, with Registered Nurse 1 (RN 1), RN 1 stated Resident 2 was moved from the second floor to the first floor of the facility because he exposed himself to another resident on the second floor. RN 1 stated Resident 2 has not exposed himself to other residents since he moved to the first floor. RN 1 stated seeing Resident 2 play with himself in front of her and not have staff around to stop Resident 2 can make Resident 1 feel bad. During an interview on 8/4/2026, at 4:15 PM, with Business Office Manager (BOM), BOM stated Resident 1 informed her on 8/4/2026 that she told Resident 2 to go away on 7/25/2026 because his behavior was dirty and inappropriate. During an interview on 8/4/2026, at 4:23 PM, with the Director of Nursing (DON), the DON stated on 7/25/2026, Resident 2 inappropriately touched his penis in front of Resident 1. The DON stated Resident 1 told Resident 2 to stop and go away and that was what made Resident 2 leave. The DON stated that Resident 1 attempted to notify the facility staff about the incident on 7/25/2026, but there were no staff present around the hallway and at the nurse's station. The DON stated Resident 1 informed facility staff about Resident 2's inappropriate behavior in the morning of 7/26/2026. The DON stated the facility's policy for dignity was not followed to protect Resident 1. During a review of the facility's policy and procedure (P&P), titled, Dignity, reviewed on 1/21/2026, the P&P indicated:Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times.The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.

Based on observation, interview, and record review, the facility failed to assess and complete a daily skin assessments for one of two sampled residents (Resident 2) who was assessed to be at high risk for developing pressure injury (PI-a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear, and/or friction, or a combination of these factors) from 2/11/2026 to 2/16/2026 in accordance with the facility's policy and procedures. These deficient practices may result into Resident 2's worsening of current PI and or developing new PI. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 7/1/2024 and readmitted on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), PI stage 4 (most severe stage of skin and tissue breakdown, meaning there is full-thickness skin and tissue loss with directly exposed or palpable muscle, tendon, ligament, cartilage, or bone) of the sacral (the lower back region located directly above the tailbone and between the hip bones), and type 2 DM with foot ulcer (an open sore or skin break on the foot that happens to people with DM). During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 7/9/2026, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) skills for daily decision making. The MDS indicated Resident 2 required partial/moderate assistance (Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing. The MDS indicated Resident 2 required substantial/maximal assistance (Helper does more than half the effort) with eating, oral and personal hygiene, and rolling left and right. The MDS also indicated Resident 2 was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for resident to complete the activity) with toileting hygiene shower/bathing self, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 2 was at risk for developing PIs, had unhealed PI, and had diabetic foot ulcers. During a concurrent interview and record review on 7/30/2026 at 2:33 PM with Treatment Nurse 1 (TN 1), Resident 2's Care Plan initiated 10/7/2024 focused on risk for development of skin breakdown or pressure sore (PI), was reviewed. TN 1 stated the interventions included observing the resident's skin for redness, circulatory problems, and skin check every shift. During a concurrent interview and record review on 7/30/2026 at 2:36 PM with TN 1, Resident 1's Situation Background, Assessment, and Recommendation (SBAR-a structured communication tool used to share clear, concise information quickly in healthcare for patient handoffs and critical updates) dated 2/18/2026, was reviewed. TN 1 stated the SBAR dated 2/18/2026 indicated non blanchable redness (red or discolored area of skin that does not turn white when pressed. This sign usually shows that blood flow to the tissue is hurt and early skin damage has begun) to bilateral (both) heels. TN 1 stated there were no reports from Certified Nurse's Assistants (CNAs) or Licensed Vocational Nurses (LVNs) of any skin abnormalities for Resident 2 before 2/18/2026. During an interview on 7/30/2026 at 4:34 PM with Wound Care Nurse Practitioner (WCNP), WCNP stated there is a risk for developing non-blanchable redness when residents have diabetes, poor circulation, and not being turned for long periods of time and can even deteriorate. WCNP also stated for residents that cannot move and with poor nutrition, these residents are at very high risk for developing PI or a lower stage PI to become worse and therefore the skin assessment or check should have been done daily. WCNP stated, a non-blanchable redness on the heel will not develop overnight and Resident 2's daily skin check should have been done to ensure to capture early signs of skin impairment During a concurrent interview and record review on 7/30/2026 at 3:57 PM with the DON, the Daily Body Check Report worksheet from 2/11/2026 to 2/16/2026 were reviewed. The DON confirmed there were no records of Daily Body Check reports done on 2/11/2026 to 2/16/2026. The DON stated that if there were no records of the Daily Body Check Report Worksheet, no assessment or skin checks were done. During a concurrent interview and record review on 7/30/2026 at 4:05 PM with the DON, the facility's Policy and Procedure (P&P) titled Wound Prevention: Skin and Wound Management, undated, was reviewed. The DON stated the P&P indicated the purpose of the program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure (PI) as well as, non-pressure related wounds. The DON stated the P&P also indicated weekly skin checks will be conducted by the licensed nurse and documented in the resident's electronic medical record; daily, during routine care, the CNA will observe the resident's skin and when abnormalities are noted, this will be communicated to the licensed nurse. The DON stated the policy was not followed as the Daily Body Check Report Worksheet for 2/11/2026 to 2/16/2026 were not completed or performed as indicated in the P&P and the resident's care plan. The DON stated if daily body check were not performed, skin impairments or injuries may be missed and by the time the impairment/injuries are discovered, the skin impairment/injuries may already be worse and treatment and services are already delayed.

Based on interview and record review, the facility failed to ensure one (1) of two (2) sample residents (Resident 1) received Tramadol Hydrochloride (a prescription drug that helps reduce pain by acting on the brain's pain receptors) as indicated on the physician's order. This deficient practice had the potential to result in over medicating Resident 1 and causing respiratory depression (breathing too slowly or shallow) and sedation (stated of calm, relaxation, or sleepiness caused by certain drugs).Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs), stiff-man syndrome (known as stiff person syndrome, a rare autoimmune neurological disorder [a group of conditions where the body's immune system mistakenly attacks healthy cells and tissues in the nervous system] that mostly causes muscle stiffness and painful spasms that come and go and can worsen over time), and muscle weakness. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment and tool), dated 6/5/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, upper and lower body dressing, and lying to sitting on side of bed. During a record review of Resident a's Order Summary Report for the month of June 2026, the order indicated as follows:5/20/2026: Monitor for pain level every shift using zero (0) to ten (10) pain scale: 0 no pain 1 to three (3) mild pain Four (4) to six (6) moderate pain Seven (7) to eight (8) severe pain Nine (9) to 10 worst possible pain every shift.6/17/2026: Tramadol Hydrochloride (HCl) oral tablet 50 milligrams (mg, unit of measurement): Give 1 tablet by mouth every eight hours as needed for severe pain *hold for sedation or if respiratory rate is less than 12.During a record review of Resident 1's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the month of June 2026, the MAR indicated Resident 1 received Tramadol 50 mg on 6/20/2026 for pain scale of 6/10 and on 6/21/2026 for pain scale of 5/10. During a concurrent interview with the Director of Nursing (DON) and record review of Resident 1's MAR on 6/24/2026 at 3:57 PM, the DON stated Tramadol was ordered to be given as needed for severe pain. The DON stated that based on standardized levels of pain, the pain level from 4 to 6 is considered moderate and not severe pain (7 to 10). The DON stated the licensed nurse should not have administered the Tramadol medication for pain level of five (5) on 6/20/2026 for a pain level of 6 on 6/21/2026, since the pain medication was prescribed for severe pain and not moderate pain. The DON stated the licensed nurse should have called the doctor to clarify the order and ask the doctor for medication to be administered for moderate pain. The DON stated administering a medication that was meant for severe pain and not moderate pain could result in adverse effects and cause drowsiness in the resident. During a record review of the facility's policy and procedure (P&P) titled, Administering Medications, reviewed 1/29/2026, the P&P indicated medications are administered in accordance with the prescriber's orders. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's medical Director to discuss the concerns. During a record review of the facility's policy and P&P titled, Pain Assessment Management, reviewed 1/29/2026, the P&P indicated assess pain using a consistent approach and a standardized pain assessment instruction appropriate to the resident's cognitive level. When opioids are used for pain management, the resident is monitored for medication effectiveness, adverse effects, and potential overdose. Due to the risk of fatal respiratory depression, opioids and benzodiazepines (medications that slow down activity in the brain and nervous system) are not administered together unless a clinical indication for the resident is documented and the resident is carefully monitored. The medication regimen (a structured, prescribed plan for taking drugs) is implemented as ordered.

Based on observation, interview, and record review, the facility failed to follow its policy requiring notification of the Administrator and the local police department when, on 6/15/2026 at 9 PM, the facility received a report from a neighbor in an apartment building across the street that a suspicious person had been seen on the facility's rooftop. On 6/15/2026 at 11:40 PM, a fire occurred on the facility's rooftop.This deficient practice placed a potential risk to the health, safety, and security of all residents and staff.Findings:During a record review on 6/16/2026 at 3:15 PM of the Preliminary Investigation Report binder, the Registered Nurse Supervisor's (RNS 1) Statement of the Event, dated 6/16/2026 was reviewed. The Statement of the Event indicated RNS 1 received a report from RNS 2 informing RNS 1 that on 6/15/2026 at 9 PM, a neighbor from an apartment building across the street informed RNS 2 that an unknown male was observed by the neighbor exiting the rooftop of the facility via the side stairwell/gate. The statement also indicated that at approximate 11:40 PM, a fire on the rooftop was reported to RNS 1 and 911 (a universal emergency telephone number used in the United [NAME] to quickly contact local police, fire, and medical responders). During a concurrent observation and interview on 6/16/2026 at 3:18 PM with the Maintenance Supervisor (MS), the metal door that serves as a side entry and exit to and from the street was observed unlocked. The MS stated the metal door remains unlocked all day and all night. The MS further stated that a homeless person may have accessed the facility premises through the unlocked metal door and acknowledged the door should always be kept locked. During an interview with the Director of Nursing (DON) on 6/16/2026 at 2:50 PM, the DON stated a fire had broken out on the facility's rooftop on 6/15/2026 at 11:40 PM. The DON stated she had not been made aware of the report from the neighbor regarding a suspicious person seen on the facility's rooftop. During a concurrent observation of the facility's rooftop and interview on 6/16/2026 at 3PM with the Director of Nursing (DON), Director of Staff Development (DSD), and Nurse Consultant, the rooftop was observed to be a cemented surface containing multiple air conditioning units and tarps. In the north area of the rooftop, where the fire had occurred, remaining debris (loose fragments or remnants resulting from destruction, breakage, or deterioration of a structure, object, or material) from the burnt shed (which stored activity supplies) was observed. No other area, including the activity room and offices of the medical records and business office, of the rooftop showed fire damage. During a concurrent observation and interview on 6/16/2026 at 3:30 PM, at the side entry of the facility, with the DSD, two (2) cameras were observed mounted on the side of the building, one facing the parking lot on the south side of the building and the other facing the side entrance and street. The DSD stated the facility had no working surveillance cameras. During an interview on 6/17/2026 at 3:39 PM with RNS 2, RNS 2 stated a neighbor from across the street came to the facility and notified RNS 2 that the neighbor had seen an unknown person leaving the facility's roof top and exiting to the street. RNS 2 stated he went outside the facility and saw that the roof top door was closed, however RNS 2 did not go up to check if it was locked. RNS 2 stated he did not check the third floor for unauthorized people. RNS 2 further stated he did not notify the police department, the Administrator, or the DON. RNS 2 stated he was not aware of any policies and procedures regarding presence of unauthorized people on the facility premises. During a concurrent interview and record review on 6/17/2026 at 4:40 PM with the DON, the P&P titled, Building Security/Prowlers (someone who is lurking or creeping around a property without permission, which can suggest they might be attempting theft, trespassing, or other unauthorized activity) and Unauthorized Entry/Civil Disturbance, revised 1/21/2026, was reviewed. The P&P indicated:When staff stay alert, report potential security problems, and consistently follow procedure, many security problems can be prevented or diverted.Suspicious persons on the grounds must be reported to the supervisor immediately. An incident report must be completed and sent to the Administrator's Office immediately.If a prowler comes on the property or an unauthorized person or group of persons attempt to enter the building: immediately call the police, do not hesitate.The administrator must be notified as soon as possible. The DON stated the P&P was not followed when RNS 2 failed to call the police, notify the Administrator and/or DON. The DON stated an unauthorized person on the rooftop, it placed residents' safety and security at risk and potentially could have prevented the fire incident that followed after an unauthorized person was observed at the roof top between 8:30 PM to 9 PM on 6/15/2026.The DON stated that having an unauthorized person on the rooftop placed residents' safety and security at risk and that reporting the incident could potentially have prevented the fire that occurred after an unauthorized person was observed on the rooftop between 8:30 PM and 9:00 PM on 6/15/2026.

Based on observation, interview, and record review, the facility failed to ensure residents received reasonable accommodation of needs for two (2) of 2 sampled residents (Residents 12 and 92) reviewed for environment/call devices by failing to ensure:Resident 12's call light (a visible and audible alarm activated by a call button) was within reach and was functioning.Resident 92's call light was within reach. This deficient practice had the potential to result in the delay or inability for Residents 12 and 92 to obtain necessary care and services, which could negatively affect the residents' overall wellbeing. Findings: 1. During a review of Resident 12's admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE], with the diagnoses including but not limited to absence of right leg above knee, pressure ulcer (an injury that breaks down the skin and underlying tissue) of sacral region (bone at the end of the spine) stage four (pressure injury is very deep, reaching into muscle and bone and causing extensive damage), and type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel). During a record review of Resident 12's Minimum Data Set (MDS, a resident assessment and tool), dated 4/16/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS indicated Resident 12 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, lower body dressing, and chair/bed-to-chair transfer. During a concurrent observation in Resident 12's room and interview on 6/8/2026 at 8:18 AM, Resident 12 was observed lying in bed with the call light wrapped around the right-hand side rail (metal or plastic bars installed along the sides of a bed) and dangling close to the floor. Resident 12's breakfast tray was placed on a bedside table near the wall at the foot of the bed. Resident 12 stated he wanted to eat but could not reach his breakfast tray. Resident 12 also stated he could not reach his call light to call for assistance. Resident 12 stated his call light did not work and has not worked since he was admitted to the facility (on 1/1/2026). During a concurrent observation in Resident 12's room and interview on 6/8/2026 at 8:20 AM with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 12 stated he could not reach his call light. CNA 2 stated Resident 12's call light was hanging from the side rail. CNA 2 pressed Resident 12's call light and noted that the light Infront of the resident's door did not turn on. CNA 2 stated when the call light is pressed, the light in front of the door should turn on. During an interview on 6/11/2026 at 1:19 PM with the Director of Nursing (DON), the DON stated the call light should be kept within reach and should function properly so the resident could call staff for assistance. The DON stated call lights are used to prevent episodes of incontinence, prevent falls, and provide assistance to residents when they are in pain. 2. During a review of Resident 92's admission Record, the admission Record indicated Resident 92 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD- is a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and excess fluid from the blood), cirrhosis of the liver (the permanent scarring of the liver caused by long-term, continuous damage), and anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities). During a review of Resident 92's Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Care Plan, initiated 9/30/2025, the Care Plan indicated a goal for Resident 92's needs to be met and anticipated daily. The staff intervention included maintaining a call light within easy reach. During a review of Resident 92's MDS, dated [DATE], the MDS indicated Resident 92 had intact cognitive skills for daily decision making. The MDS also indicated Resident 92 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathing self and supervision or touching assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene. During a concurrent observation in Resident 92's room and interview on 6/8/2026 at 11:26 AM, Resident 92's call light cord was observed hanging on the back of Resident 92's bed and out of reach. Resident 92 stated she could not reach the call light cord. During an interview on 6/11/2026 at 10:26 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 92's call light should always be accessible for the resident to contact staff and get help in case she needs assistance with anything including food, bathroom assistance. LVN 1 also stated if Resident 92 does not have access to a call light, staff will not be able to know if she needs anything and would be unaware of her needs. During a review of the facility's P&P titled Call System, Residents, revised 9/2022, the P&P indicated residents are provided with a means to call staff directly for assistance, from his/her bed, from toileting/bathing facilities and from the floor through a communication system that directly calls a staff member or a centralized workstation. The P&P also indicated the resident call system will always remain functional.

Based on observation, interview and record review, the facility failed to provide a safe, sanitary and homelike environment for three (3) of five (5) sampled residents (Residents 47, 48 and 92), in the environment task, by failing to ensure: 1. Resident 47's bathroom sink was not leaking, and the ceiling light above the bathroom sink was functioning.2. Resident 92's ceiling was clean and free of dirt.3. Resident 48's bed was maintained in a safe condition.These failures had the potential to negatively affect Resident 47, 48, and 92's quality of life and psychosocial well-being.Findings: 1. During a review of Resident 47's admission Record indicated Resident 47 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses other encephalopathy (a group of conditions that cause brain dysfunction, such as confusion, memory loss and personality changes), dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), and muscle weakness (a reduced ability of one or more muscles to generate force, making it harder to perform tasks that require strength) During a review of the Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 4/25/2026, it indicated Resident 47 had had moderate impairment (decisions poor, cues/supervision required) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. It also indicated, Resident 47 required partial or moderate assistant, (helper does less than half the effort) with the toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated, Resident 47 needed supervision or touching assistance (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, and Resident 47 needed setup or clean-up assistance (helpers sets up or cleans up, resident completes activity) for eating. During an observation of Resident 47's room on 6/9/2026 at 1:39 PM, Resident 47's bathroom sink was observed to have a white linen underneath the sink with yellow water mark and water stain that shows sign of water leaking to the bottom of the sink. In addition, there was no light bulbs on the ceiling light above the bathroom sink. During a concurrent observation and interview on 6/9/2026 at 1:42 PM with Resident 47 in her room, Resident 47 stated she told the staff and the supervisor about the water leak from the resident's bathroom sink and there was no light on top of the bathroom sink(unable to recall since when), and no one ever come to fix it. Resident 47 stated she stopped complaining and she used the bathroom sink since that is the only sink the resident could use. During a concurrent observation and interview on 6/10/2026 at 2:55 PM with Infection Preventionist Nurse (IPN) in Resident 47's room, IPN stated the white sheet under the bathroom sink was not supposed to be left underneath the sink to absorb leaking water from the sink. IPN also stated the ceiling light needed light bulbs, so the resident has a light when using the bathroom sink. IPN stated this was not a home-like environment for Resident 47. During an interview with Interim Maintenance Director (IMD) on 6/11/2026 at 9:46 AM, IMD stated Resident 47's leaking sink in the bathroom should have been repaired and it was not supposed to have a water leak. IMD also stated, the ceiling light needs light bulbs so the resident can use it. IMD stated this is not a homelike environment to Resident 47. IMD stated the residents like it when everything in their room is fixed and homelike. During a review of the facility's P&P titled, Homelike Environment revised on February 2021, the P&P indicated the following residents are provided with a safe, clean, comfortable and homelike environment. The P&P also indicated the facility staff, and management will maximize characteristics that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. In addition, the P&P indicated comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable and homelike environment and the lighting design emphasizes sufficient general lighting in resident-use areas. A review of the facility's P&P titled, Maintenance Service, revised on 1/29/2026, indicated, maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of the maintenance personnel include but are not limited to: maintaining the building in good repair and free from hazards. 2. During a review of Resident 92's admission Record, the admission Record indicated Resident 92 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (CKD- is a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and excess fluid from the blood), cirrhosis of the liver (the permanent scarring of the liver caused by long-term, continuous damage) and anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities). During a review of Resident 92's MDS dated [DATE], the MDS indicated Resident 92 had intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 92 was substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathing self and supervision or touching assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident completes activity) with eating and oral hygiene. During an observation on 6/8/2026 at 11:26 AM, at Resident 92's bedside, a splatter of brown spots was observed on the ceiling above Resident 92's bed. During a concurrent observation and interview on 6/11/2026 at 10:43 AM with Housekeeping Supervisor (HS), at Resident 92's bedside, a splatter of brown spots was observed on the ceiling above Resident 92's bed. HS stated there were brown spots on the ceiling located above Resident 92's bed and HS was not sure if it was food or stool but should not be there. HS stated it was important to ensure Resident 92's environment was clean and not dirty because that is what was good for the resident. HS further added the facility is supposed to make sure every resident had a safe, clean and homelike environment. During a review of the facility's policy titled Quality of Life- Homelike Environment, revised 5/2017, the policy indicated residents are provided with a safe, clean, comfortable and homelike environment. The policy also indicated the facility staff, and management will maximize characteristics that reflect a personalized, homelike setting including a clean, sanitary and orderly environment. 3. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a chronic disorder of the brain characterized by recurrent brief episodes of involuntary movement that may involve a part of the body or the entire body, and are sometimes accompanied by loss of consciousness), cerebral infarction (a life-threatening medical emergency that occurs when a blood clot or plaque blocks an artery supplying blood to the brain), fracture (a complete or partial break) of the right femur (thigh bone), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 48 was dependent (helper does all effort to complete activity) with oral, toileting, and personal hygiene, eating, dressing and transfers. During an observation on 6/8/2026 at 8:36 AM at Resident 48's bedside, a black box, powered on with multiple cords, was seen under Resident 48's bed, with a white plastic bag wrapped around it and tied to the bed frame. During a concurrent observation and interview on 6/11/2026 at 9:59 AM with Licensed Vocational Nurse 1 (LVN 1), at Resident 48's bedside, the same observation from 6/8/2026 of black box, powered on with multiple cords, was seen under Resident 48's bed, with a white plastic bag wrapped around it and tied to the bed frame was observed. LVN 1 stated the black box under Resident 48's bed was the main control for the bed's movements going up and down, including the head of the bed. LVN 1 stated the control was tied to the bed frame with a plastic bag and it should not be. LVN 1 further stated this should not have been done because it causes electrical hazards and is dangerous for Resident 48. During an interview on 6/11/2026 at 10:34 AM with IMD and the Maintenance Assistant (MA), IMD stated the black box tied to Resident 48's bed with a plastic bag was the bed's motor. Both IMD and MA stated the motor should not have been tied to the bed and was unsafe for Resident 48. The IMD further stated the motor had a broken part that would allow it to be properly and safely connected to bed frame and should have been replaced instead of tied to the bed. IMD stated if the motor was to drop and break, Resident 48 would be stuck in the bed and whatever position the bed was in. During a review of the facility's policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, (undated), the P&P indicated all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The P&P also indicated environmental hazards to include devices and equipment that are improperly used or poorly maintained. During a review of the facility's P&P titled, Assistive Devices and Equipment, dated 1/21/2026, the policy indicated that the facility would maintain and supervise the use of assistive devices and equipment for residents. The P&P also indicated that defective devices are discarded or repaired.

Based on interview and record review, the facility failed to ensure a comprehensive, resident-centered care plan (integrated health care services delivered in a setting and manner that is responsive to individuals and their goals, values, and preferences, in a system that supports good provider-resident communication and empowers individuals receiving care and providers to make effective care plans together) was developed for two (2) of 2 sampled residents (Residents 3 and 74) reviewed under care planning as indicated on the facility's policy:Resident 3 did not have a care plan for Restorative Nursing Assistant (RNA) services (provided by certified nursing assistants [CNAs] who specialize in rehabilitation and restorative care for residents with limited mobility).Resident 74 did not have a care plan to address the resident's behavior of removing, throwing the resident's clothes off and preferring to be naked. These deficient practices have the potential for a delay in the necessary care and services for Residents 3 and 74, which could cause harm and complications resulting in negatively affecting the residents' overall wellbeing. Findings: 1. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE], with the diagnoses including but not limited to unspecified fracture (break in the bone) of left calcaneus (large bone forming the heel), acute osteomyelitis (infection of bones) of the left ankle and foot, and heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a record review of Resident 3's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, lower body dressing, lying to sitting on side of bed, and sitting to standing. During a record review of Resident 1's Physician Order Summary Report, dated 4/20/2026, the order indicated RNA to provide active assisted range of motion (AAROM, a type of therapeutic exercise used in physical therapy and rehabilitation to improve joint flexibility, muscular strength, and joint mobility) to bilateral upper extremities (BUE, both arms from shoulder to hands) and bilateral lower extremities (BLE, both legs from hip to foot) every day five times a week or as tolerated, one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday. A review of Resident 3's care plan dated from 4/20/2026 to 6/11/2026, it did not indicate a care plan for Resident 3's RNA services. During a current interview and record review on 6/11/2026 at 8:44 AM with Licensed Vocational Nurse 1 (LVN 1) of Resident 3's care plans dated from 4/20/2026 to 6/11/2026, LVN 1 stated Resident 3 did not have a care plan for the resident's RNA services and the resident should have a care plan for RNA services since the resident was receiving RNA services. During an interview on 6/11/2026 at 10:53 AM with Minimum Data Set Nurse (MDSN), MDSN stated once Resident 3 was started with RNA services the licensed nurse should have updated the care plan to include the RNA services. During an interview on 6/11/2026 at 1:53 PM with the Director of Nursing (DON), the DON stated Resident 3 should have RNA services included in her care plan. The DON stated RNA services were performed to maintain the resident's functionality and prevent any decline in her range of motion. During a review of the facility's P&P titled, Restorative Nursing Services, revised 7/2017, the P&P indicated restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 2. During a review of Resident 74's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD; a chronic inflammatory lung disease that causes obstructed airflow from the lungs), cirrhosis (scarring) of liver and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had intact cognitive (ability to think and process information) ability. The MDS indicated Resident 74 was dependent for toileting hygiene, showering, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 74 required maximal assistance (helper does more than half the effort) for eating, oral hygiene and upper body dressing. During an observation on 6/8/2026 at 10:12 AM, Resident 74 was observed sleeping on his bed naked and without a blanket. During a concurrent observation and interview on 6/8/2026 at 10:16 AM with LV 3, Resident 74 was observed sleeping on the resident's bed naked and without blanket. LVN 3 stated Resident 74 is sleeping naked and the resident refuses to wear clothes. LVN 3 stated Resident 74 throws his diaper and blankets off. During a concurrent record review and interview on 6/8/2026 at 10:18 AM with LVN 3, Resident 74's CP history dated 4/9/2026 to 6/8/2026 was reviewed. LVN 3 stated Resident 74 does not have a CP for the resident behavior of removing, throwing clothes off and preferring to be naked. LVN 3 stated Resident 74 should have a CP to address the resident's behavior of taking clothes off and preferring to be naked. LVN 3 stated if there is no CP, interventions are not monitored and the behavior may worsen. During a concurrent interview and record review on 6/11/2026 at 12:11 PM with the Director of Nursing (DON), the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, was reviewed. The P&P indicated: A comprehensive, person-centered CP that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Reflects currently recognized standards of practice for problem areas and conditions. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The DON stated that the policy indicated, a resident should have a CP that has measurable objectives and goals to address the resident's needs and behaviors. The DON stated, a behavior of not wearing clothes should have a CP to address possible underlying issues and try to resolve them.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and/or assistive devices to maintain vision and/or hearing abilities for two (2) of 2 sampled residents (Residents 6 and 51) reviewed for vision/hearing to ensure:Resident 6 receive a proper assistive device to maintain hearing and have a comprehensive person-centered care plan to address the resident's hearing loss. The medical doctor (MD) for Resident 51 was informed of the resident's missed ophthalmology (the specialized field of medicine that focuses on the health of the eye appointment) to ensure alternative ophthalmology care, services and/or appointments were provided to maintain the resident's vision health. These deficient practices may result in Resident 6 not being able to hear adequately and resulted in a delay in care and services, with the potential for worsening or untreated vision problems for Resident 51. Findings: 1. During a review of Resident 6's admission Record, the admission record indicated Resident 6 was admitted to the facility on [DATE], with the diagnoses including but not limited to sensorineural hearing loss (damage to the inner ear or auditory nerve [sensory fibers that conduct impulses from the organs of hearing to the brain] that affects sound perception), glaucoma (damage to optic nerve causing vision loss or blindness), and acute pulmonary edema (an abnormal accumulation of fluid in the lungs, making it hard to breathe). During a record review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 3/6/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was moderately impaired. The MDS indicated Resident 6's ability to hear was highly impaired (absence of useful hearing). The MDS also indicated Resident 6 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, upper and lower body dressing, lying to sitting on side of bed, and chair/bed to chair transfer. During a review of Resident 6's Social History & Initial Assessment, dated 3/3/2026, the assessment indicated the resident has hearing difficulty. The assessment also indicated Resident 6 liked listening to music and watching television. During a review of Resident 6's Hearing Aid Delivery Report, dated 3/24/2026, the report indicated the facility received Resident 6's right and left hearing aids (a small, electronic device worn in or behind the ear that amplifies sound). During an interview on 6/8/2026 at 3:35 PM with Resident 6 in the resident's room, Resident 6 stated she cannot hear and wanted to communicate via writing, using a notebook and black marker. During an interview on 6/10/2026 at 10:50 AM with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 6 used a notebook and markers while communicating with staff. CNA 3 stated he had been taking care of Resident 6 routinely for three to four months and Resident 6 was hard of hearing. During a concurrent interview and record review on 6/10/2026 at 2:03 PM with Director of Social Service (DSS), Resident 6's Hearing Aid Delivery Report dated 3/24/2026 was reviewed. DSS stated staff had to talk really loud when talking to Resident 6 and she recommended that Resident 6 receive hearing aids. DSS stated Resident 6's hearing aids were delivered to the facility on 3/24/2026 but it was not given to Resident 6 and education was not provided to Resident 6 on how to use it. DSS stated staff should have given Resident 6 the resident's hearing aids and should have educated Resident 6 on how to operate the hearing aids. DSS stated Resident 6 should be using the hearing aids daily since it was delivered last 3/24/2026. During a follow up interview on 6/10/2026 at 2:16 PM with CNA 3, CNA 3 stated Resident 6 did not have any hearing aids. During an interview on 6/10/2026 at 2:36 PM with Registered Nursing Supervisor 2 (RNS 2), RNS 2 stated she communicated with Resident 6 by getting close to Resident 6's right side, pulling down RN 2's facemask, and speaking louder. During an interview on 6/10/2026 at 3:44 PM in Resident 6's room, Resident 6 stated she did not have a hearing aid since she was admitted at the facility. Resident 6 stated she was never given a hearing aid and really needed a hearing aid. During an interview on 6/11/2026 at 8:02 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 6 was hard of hearing. LVN 1 stated he (LVN 1) communicated with Resident 6 by talking and using his (LVN 1) hands gestures. LVN 1 stated hearing aids would be beneficial for Resident 6. LVN 1 stated he was not aware if Resident 6 had any hearing aid. During a concurrent interview and observation on 6/11/2026 at 8:08 AM with LVN 1 in the storage room, Resident 6's box of hearing aid was located on the shelf. LVN 1 stated Resident 6 had a right and left hearing aids which were placed in a box and stored in the storage room. LVN 1 stated Resident 6 should be given the resident's hearing aids so that the resident could hear and make it easier for the resident to communicate with staff and other residents. During a concurrent interview and record review on 6/11/2026 at 8:10 AM with LVN 1, Resident 6's Social Service History & Initial assessment dated [DATE], Hearing Aid Delivery Report dated 3/24/2026, and Care Plans dated from 8/25/2025 to 6/11/2026 were reviewed. LVN 1 stated Resident 6 had hearing difficulties since admission to the facility. LVN 1 stated Resident 6's preference is music and since the resident was hard of hearing this could affect the resident. LVN 1 stated Resident 6's hearing aids were delivered on 3/24/2026 and it was not given to Resident 6 so the resident did not have her hearing aids for almost three months. LVN 1 also stated there were no hearing aids included in Resident 6's care plan. LVN 1 stated Resident 6's hearing aids should be included in the resident's care plan since it was one of the interventions staff should be providing to Resident 6. LVN 1 stated including Resident 6's hearing aids into the care plan would inform the nurses Resident 6 had hearing aids so that staff could offer the hearing aids for Resident 6 to use. During an interview on 6/11/2026 at 10:53 AM with Minimum Data Set Nurse (MDSN), MDSN stated the resident's care plan should be updated to include the need of Resident 6 to use hearing aid as soon as the facility received the ordered hearing aids for Resident 6. MDSN stated the hearing aid availability needed to be communicated with staff in order to clearly inform the nurses what Resident 6's needs were. During an interview on 6/11/2026 at 1:47 PM with the Director of Nursing (DON), the DON stated the hearing aids should be labeled with the resident's name and given to the resident as soon as the hearing aid was delivered to the facility. The DON stated it was important for residents to use their hearing aids so the residents could hear what was going on and communicate effectively. The DON also stated when residents had hearing aids, the hearing aids should be updated in the care plan to allow staff to be aware the resident had a hearing deficient and know how to communicate effectively with the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial (combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) well-being. During a review of the facility's P&P titled, Hearing Impaired Resident, Care of, revised 2/2018, the P&P indicated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. 2. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was readmitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dry eye syndrome (a chronic condition where the eyes do not produce enough tears, or the tears evaporate too quickly), fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, profound fatigue, sleep disturbances, and cognitive issues) and dementia (a progressive state of decline in mental abilities). During a review of Resident 51's Dry Eyes, Risk for Impaired Visual Acuity care plan, revised 5/18/2025, the care plan indicated for ophthalmology and optometry examinations as needed to monitor progressive vision changes/loss. During a review of Resident 51's Ophthalmology Chart Note, dated 2/3/2026, the Ophthalmology Note indicated Resident 51 with significant dry eye syndrome and to return in three (3) to four (4) months for a follow up. During a review of Resident 51's Order Listing Report, dated 2/3/2026, the Order Listing Report indicated an order for a follow up appointment with Ophthalmologist 1 (a medical doctor [MD] who specializes in comprehensive eye and vision care) on 6/2/2026 at 9:45 AM. During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 had adequate vision (sees fine detail) with corrective lenses (contacts, glasses or magnifying glass). The MDS indicated Resident 51 had intact cognitive skills for daily decision making. The MDS also indicated Resident 51 required setup or clean up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, and shower/bathing self. During an interview on 6/8/2026 at 12:21 PM with Resident 51, Resident 51 stated she is having trouble with her vision and had an ophthalmology appointment on 6/2/2026 and has been going to Ophthalmologist 1 for at least 30- 40 years, and needed this appointment. Resident 51 stated she was told her appointment was cancelled due to her insurance but was not told anything else of the next plan. During a concurrent interview and record review on 6/10/2026 at 2:19 PM with Registered Nurse 1 (RN 1), Resident 51's medical chart was reviewed from 2/3/2026 through 6/10/2026. The medical chart did not indicate a reason for Resident 51's missed ophthalmology appointment on 6/2/2026 and that Resident 51's MD was notified of the missed appointment. RN 1 stated there was no documentation including a progress note or MD notification regarding Resident 51's missed ophthalmology appointment on 6/2/2026. During an interview on 6/10/2026 at 2:25 PM with Social Services Assistant (SSA), the SSA stated Resident 51 had an ophthalmology appointment on 6/2/2026, that was cancelled due to the resident's medical insurance that is now pending approval. SSA stated he informed Resident 51 of the cancelled appointment but did not inform any other staff or documented it in the resident's medical records or any notes about the cancelled appointment. During an interview on 6/10/2026 at 2:40 PM with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated there should have been a progress note completed when Resident 51 missed her ophthalmology appointment that indicated the resident's MD was informed and any new orders for treatment and care. LVN 5 further stated it was important to make sure that Resident 51 vision care is provided, and the MD is informed to prevent the resident's eyesight from worsening and ensure the resident receives the care she needs. During an interview on 6/11/2026 at 1:02 PM with the (DON, the DON stated the MD should have been notified of Resident 51's missed ophthalmology appointment on or after 6/2/2026 because MD could have arranged an alternate plan of care to address Resident 51's eyes/vision concern. The DON further stated it was important to follow up and notify Resident 51's MD after the missed appointment to prevent a delay in services, because a delay can cause negative outcomes like eye pain or even worsened eyesight. During a review of the facility's policy titled Visually Impaired Resident, Care of, dated 3/2021, the policy indicated it was the facility's responsibility to assist the resident and representatives in locating available resources, scheduling appointments and arranging transportation to obtain needed services.

Based on observation, interview, and record review, the facility failed to monitor the intake and output for two (2) of three (3) sampled residents (Residents 3 and 34) reviewed for dialysis (a lifesaving treatment for residents with kidney failure) treatment in accordance with the resident's care plan and the facility's policy and procedure (P&P). This deficient practice had the potential for Residents 3 and 34 to have fluid overload (harmful amount of fluid in the body) which could cause complications such as swelling, high blood pressure, shortness of breath, and pulmonary edema (an accumulation of fluid in the lungs) or fluid deficit (condition where fluid output exceeds the fluid intake) which could cause complications such as low blood pressure, electrolyte imbalances (occurs when levels of essential minerals in the body are too high or too low disrupting normal bodily functions), reduced dialysis efficiency, or cardiac arrest (sudden and unexpected cessation of heart function causing the heart to stop pumping blood to the brain and other vital organs). Findings: 1. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including but not limited to end stage renal disease (advanced stage kidney failure), heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), and dependence on renal (relating to the kidneys) dialysis. During a record review of Resident 3's Order Summary Report, dated 3/28/2026, the report indicated hemodialysis (medical procedure that filters the blood of waste products when the kidneys are not able to) on Monday, Wednesday, and Friday. During a record review of Resident 3's Care Plan, dated 3/28/2026, the Care Plan indicated Resident 3 has end stage renal disease with hemodialysis. The care plan interventions were to monitor intake and output every shift and monitor access area for redness, pain, signs and symptoms of infection, presence and absence of bruit (abnormal whooshing or swishing sound heart with a stethoscope over an arteriovenous fistula [AV, abnormal connection or link between an artery and a vein that allows blood to flow directly from one vessel to the other bypassing the normal capillary network] or shunt [a surgically created connection between an artery and a vein that provides long-term access for hemodialysis]), bleeding and notify physician at once. During a record review of Resident 3's Care Plan, dated 3/28/2026, the Care Plan indicated Resident 3 was at risk for dehydration (medical condition in which the body loses more fluids than it takes in, leading to an insufficient amount of water and essential electrolytes needed to perform vital functions) or potential fluid deficit related to weakness, use of laxative (medicine that loosens the bowels and encourages bowel movements), diabetes mellites (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel), and end stage renal disease. The care plan interventions were to monitor and document intake and output as per facility policy and monitor vital signs as ordered/per protocol and record and to notify physician of significant abnormalities. During a record review of Resident 3's Minimum Data Set (MDS, a resident assessment and tool), dated 4/13/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 3 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for toileting hygiene, lying to sitting on side of bed, and chair/bed to chair transfer. The MDS also indicated Resident 3 received dialysis. During a record review of Resident 3's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) and medical records for the months of May 2026 and June 2026, there was no documented evidence that Resident 3's intake and output were monitored. During an interview on 6/11/2026 at 8:49 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated dialysis residents should be placed on intake and output monitoring when admitted to the facility. LVN 1 stated monitoring intake and output was done to prevent fluid overload. During a concurrent interview and record review on 6/11/2026 at 9 AM with LVN 1, Resident 3's physician order, care plans, and MAR were reviewed. LVN 1 stated there was no order for intake and output monitoring. LVN 1 stated the admitting nurse should ask the physician for intake and output monitoring when the resident was admitted to the facility to ensure that this is done every shift. LVN 1 stated the care plan indicated to monitor the fluid intake every shift since Resident 3 had end stage renal disease with dialysis. LVN 1 stated monitoring of intake and output was documented done on the MAR. LVN 1 stated there was no intake and output monitoring documented in the MAR. 2. During a review of Resident 34's admission Record, the admission record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses including but not limited to type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidney's filtering system resulting from diabetes), acute on chronic diastolic congestive heart failure (a long term condition where the heart's left ventricle becomes stiff and cannot fill properly, leading to reduced blood flow despite normal pumping strength), end stage renal disease, and dependence on renal dialysis. During a record review of Resident 34's Care Plan, dated 3/30/2026, the Care Plan indicated Resident 3 has end stage renal disease with hemodialysis. The care plan interventions were to monitor intake and output every shift and monitor access area for redness, pain, signs and symptoms of infection, presence and absence of bruit, bleeding and to notify physician at once. During a record review of Resident 34's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was intact. The MDS indicated Resident 34 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, upper and lower body dressing, lying to sitting on side of bed, and sitting to standing. The MDS also indicated Resident 34 received dialysis. During a record review of Resident 34's Order Summary Report, dated 3/31/2026, the report indicated hemodialysis on Monday, Wednesday, and Friday. During a record review of Resident 34's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) and medical records for the months of May 2026 and June 2026, there was no documented evidence that Resident 34's intake and output were monitored. During a concurrent interview and record review on 6/11/2026 at 9:12 AM with LVN 1, Resident 34's physician order, care plans, and MAR were reviewed. LVN 1 stated Resident 34's care plan for end stage renal disease indicated to monitor for intake and output. LVN 1 stated there was no documentation that Resident 34's intake and output was monitored. LVN 1 stated if monitoring was done, this should have been documented in the MAR. LVN 1 stated when a dialysis resident is admitted to the facility, the admitting nurse should include all orders pertaining to dialysis such as fluid restriction, intake and output monitoring, medications, and the time and day for dialysis treatment. LVN 1 stated it was important to monitor intake and output of fluids for dialysis residents since their kidneys are not working effectively. LVN 1 stated when there is too much fluid, it could result in the residents experiencing fluid overload which causes edema and difficulty in breathing. LVN 1 stated when residents do not have enough fluids, this could cause a fluid deficit which leads to dehydration, low blood pressure, muscle cramping, and an electrolyte imbalance. During an interview on 6/11/2026 at 1:31 PM with the Director of Nursing (DON), the DON stated dialysis residents should have an order for intake and output monitoring along with a care plan. The DON stated it was important to monitor the residents' intake and output to avoid fluid overload since the residents' kidneys could not filter out the fluid. The DON also stated fluid overload could affect the residents' blood pressure, could go into shock (when the body is not getting enough blood flow, so organs do not get the oxygen they need, and it becomes life threatening) and may also result in resident needing extra dialysis treatments. During a follow up interview on 6/11/2026 at 2:34 PM, the DON stated there should be an order to monitor the intake and output. The DON stated the intake and output monitoring should be documented on the MAR to ensure that monitoring was done. During a review of the facility's P&P titled, End-Stage Renal Disease, Care of a Resident with, revised 9/2010, the P&P indicated residents with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care. Agreements between this facility and the contracted ESRD facility will include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. During a record review of the facility's P&P titled, Intake, Measuring and Recording, revised 10/2010, the P&P indicated to review the resident's care plan to assess for any special needs of the resident. The information should be recorded in the resident's medical record: the date and time the resident's fluid intake was measured and recorded. During a record review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated the comprehensive, person-centered care plan will reflect treatment goals, timetables, and objectives in measurable outcomes. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making.

Based on observation, interview, and record review, the facility failed to take timely action on a Medication Regimen Review (MRR, also known as a Drug Regimen Review-is a structured, comprehensive evaluation of all medications a resident is taking, conducted typically by a pharmacist to ensure medications are appropriate, safe, effective, and used correctly) irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) for two (2) of five (5) sampled residents (Resident 36 and Resident 51) reviewed for unnecessary medications by failing to ensure:Resident 36's Depakote level (refers to the measured concentration of valproic acid (the active ingredient in Depakote) in the blood, used to ensure the dose is effective yet safe. It helps verify the medication is working as intended without causing toxicity.) monitoring order was obtained from the physician.The physician addressed Resident 51's dose frequency for the use of Ativan (Lorazepam, prescription medication used to treat anxiety disorders [refers to a condition characterized by excessive, persistent, and uncontrollable worry or fear about everyday situations, accompanied by physical and cognitive symptoms that interfere with normal functioning).These deficient practices increased Residents 36 and 51's risk to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy, potentially leading to impairment or decline in their mental, functional, and psychosocial wellbeing. Findings: 1. During a review of Resident 36's admission Record, the admission Record indicated Resident 36 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Resident 36's diagnoses included paranoid schizophrenia ( a chronic mental health condition marked primarily by intense, irrational suspicions [paranoia], persecutory delusions [false beliefs that are not based in reality], and auditory hallucinations [experiencing sensations that aren't real, most commonly hearing voices]), unspecified anxiety disorder, and chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) During a review of Resident 36's Minimum Data Set (MDS, resident assessment tool), dated 4/12/2026, the MDS indicated Resident 36 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 36 needed substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self. Resident 36 needed partial or moderate assistance, (helper does less than half the effort) with lower body dressing, putting on/ taking off footwear, and personal hygiene. Resident 36 needed supervision or touching assistance (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) with eating, oral hygiene and upper body dressing. During a review of Resident 36's MRR, dated 5/11/2026, the MRR indicated a recommendation to monitor the Depakote (divalproex sodium, a prescription medication used as a mood stabilizer, anticonvulsant, and vascular headache suppressant) level in the blood stream. During a concurrent interview and record review on 6/11/2026 at 8:55 AM with the Director of Staff Development (DSD), Resident 36's MRR, dated 5/11/2026, and medical records were reviewed. The DSD stated Resident 36's MRR, dated 5/11/2026, indicated a recommendation to monitor Resident 36's Depakote level. DSD stated there was no current monitoring for Depakote level. DSD stated it is very important to monitor Resident 36's Depakote level to ensure the dose stays safe and effective. During a concurrent interview and record review on 6/10/2026 at 4:55 AM with the Director of Nursing (DON), Resident 36's MRR dated 5/11/2026 was reviewed. The DON stated it is very important to follow up with the instructions indicated on the MRR to monitor Resident 36's Depakote level to prevent serious side effects, such as severe drowsiness, confusion, or organ damage like liver toxicity to Resident 36. 2. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was readmitted to the facility on [DATE] with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dry eye syndrome (a chronic condition where the eyes do not produce enough tears, or the tears evaporate too quickly) , fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, profound fatigue, sleep disturbances, and cognitive issues), and dementia (a progressive state of decline in mental abilities). During a review of Resident 51's Diagnosis of Anxiety care plan, revised 2/6/2025, the care plan indicated interventions included were for pharmacist to conduct a MRR and to follow up on recommendations with the medical doctor (MD). During a review of Resident 51's MDS, dated [DATE], the MDS indicated Resident 51 had adequate vision (sees fine detail) with corrective lenses (contacts, glasses or magnifying glass). The MDS indicated Resident 51 had intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 51 required setup or clean up assistance (helper sets up or cleans up; resident completes activity) with eating and oral hygiene and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, and shower/bathing self. The MDS also indicated Resident 51 was receiving an antianxiety medication (a medication used to anxiety). During a review of the facility's Consultant Pharmacist's MRR, dated 4/12/2026 and 4/13/2026, the MRR indicated to inform the medical doctor (MD) and or psychiatrist if routine order for Ativan (Lorazepam, prescription medication used to treat anxiety disorders) is clinically indicated instead of renewing every 14 days, if Resident 51 is asking [in need of] frequently. During a review of Resident 51's Medication Administration Records (MARs - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/1/2026 to 4/31/2026, 5/1/2026 to 5/30/2026 and 6/1/2026 to 6/10/2026), the MARs indicated lorazepam (Ativan) oral tablet 0.5 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) give 1 tablet by mouth every six (6) hours as needed for anxiety for 30 days; manifested by persistent feeling of panic (pacing heart rate). The MARs also indicated Lorazepam 0.5 mg was administered to Resident 51 on the following: 4/1/2026 to 4/31/2026, except on 4/4/2026, 4/22/2026, 4/24/2026 and 4/29/2026. 5/1/2026 to 5/30/2026, except on 5/9/2026, 5/24/2026 and 5/27/2026. 6/1/2026 to 6/10/2026. During a concurrent interview and record review on 6/11/2026 at 12:33 PM with the Director of Nursing (DON), Resident 51's physical and electronic medical records, dated 4/12/2026 through 6/11/2026, were reviewed. The medical records failed to indicate that Resident 51's physician and/or psychiatrist were informed of the MRR report. There was no written response from the physician or psychiatrist if a routine order for lorazepam was clinically indicated. The DON stated it was important to follow up with the pharmacist's recommendations for Resident 51's well-being, to ensure the goal to administer the lowest prescribed dose and for continuity of care. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, revised 2/2025, the MRR indicated: A licensed pharmacist reviews the medication regimen of each resident at least monthly. The purpose of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record. Upon receiving the MRR report from the pharmacist, the attending physician reviews and responds to the report. The physician documents in the resident's medical record that the pharmacist's recommendations have been reviewed and what (if any) actions were taken to address them.

Based on observation, interview, and record review, the facility failed to monitor the signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for two (2) of 2 sampled residents (Residents 34 and 57) reviewed for insulin (a natural hormone that turns food into energy and manages your blood sugar level, can be produced by the body or given artificially via medication). This deficient practice had the potential for Residents 34 and 57 to experience episodes of hypoglycemia and hyperglycemia without proper monitoring while receiving insulin which could result in harm, hospitalization, and diabetic coma (a life-threatening state of unconsciousness caused by extremely high or low blood sugar levels). Findings: 1. During a review of Resident 34's admission Record, the admission record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses including but not limited to type 2 diabetes mellitus (a disease that occurs when there is a problem in the way the body regulates and uses sugar as fuel) with diabetic chronic kidney disease (damage to the kidney's filtering system resulting from diabetes), acute on chronic diastolic congestive heart failure (a long term condition where the heart's left ventricle becomes stiff and cannot fill properly, leading to reduced blood flow despite normal pumping strength), and end stage renal disease (advanced stage kidney failure). During a record review of Resident 34's Care Plan, dated 3/30/2026, the Care Plan indicated Resident 34 had diabetes mellitus and was at risk for hypoglycemia or hyperglycemia. The care indicated, interventions were to observe for polyuria (abnormally large volumes of dilute urine), polydipsia (excessive or uncontrollable thirst), polyphagia (excessive or extreme hunger), change in level of consciousness, blurred vision, profuse sweating, irritability, tremors and notify medical doctor if noted. During a record review of Resident 34's Minimum Data Set (MDS, a resident assessment and tool), dated 4/6/2026, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. The MDS indicated Resident 34 required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, upper and lower body dressing, lying- to- sitting on side of bed, and sitting- to- standing. The MDS also indicated Resident 34 received six insulin injections during the last seven (7) days or since admission/entry if less than 7 days. During a record review of Resident 34's Order Summary Report, dated 5/6/2026, Novolog FlexPen (pre-filled, rapid acting insulin pen used to control blood sugar in residents with diabetes) subcutaneous (SQ, a shot that delivers medicine into the fatty tissue layer just under the skin, above the muscle, using a short, small needle for slow, steady absorption) solution pen-injector 100 unit/milliliter (ml, unit of volume) (Insulin Aspart): Inject as per sliding scale. During a record review of Resident 34's Medication Administration Record (MAR, a medical record used by healthcare providers to document the administration of a medication or treatment) for the months of May 2026 and June 2026, there was no monitoring for signs and symptoms of hypoglycemia and hyperglycemia. During a concurrent interview and record review on 6/11/2026 at 8:19 AM with Licensed Vocational Nurse 1 (LVN 1), Resident 34's Order Summary, Care Plans, and MAR dated from 5/1/2026 to 6/11/2026 were reviewed. The forms did not indicate Resident1 was monitored for signs and symptoms of hypoglycemia and hyperglycemia. LVN 1 stated Resident 34 received insulin since the resident had diabetes. LVN 1 stated, when residents receive an order for insulin, the license nurse should ask the doctor for orders for monitoring of signs and symptoms of hypoglycemia and hyperglycemia. LVN 1 stated there was no monitoring done for May 2026 and June 2026 for Resident 34 while the resident was receiving insulin. LVN 1 stated the care plan indicated to observe the resident for signs and symptoms of hypoglycemia and hyperglycemia and it was not done. LVN 1 stated monitoring for signs and symptoms of hypoglycemia and hyperglycemia was important to prevent anything bad from happening to the residents. LVN 1 stated signs and symptoms of hypoglycemia were altered level of consciousness, sweating excessive and signs and symptoms of hyperglycemia were polydipsia, polyphagia, polyuria which could lead to diabetic ketoacidosis (DKA, a serious and potentially life-threatening complication of diabetes that occurs when the body lacks sufficient insulin leading to high blood sugar and the production of ketones [acids that can accumulate in the blood resulting in dangerous levels]) and Resident 34 was not observed and monitored for these signs and symptoms from 5/1/2026 to present. 2. During a review of Resident 57's admission Record, the admission record indicated Resident 57 was admitted to the facility on [DATE], with diagnoses including but not limited to type 2 diabetes mellitus with foot ulcer (an open wound that fails to heal properly), chronic obstructive pulmonary disease (COPD, disease that causes obstructed airflow from the lungs), and neuralgia (nerve pain) and neuritis (inflammation of nerves usually causing pain and loss of function). During a record review of Resident 57's Order Summary Report for the month of June 2026 indicated as follows:9/24/2025: Caution for risk of hypoglycemia monitor for signs and symptoms of hypoglycemia i.e.: confusion, dizziness, feeling shaky, irritability, hunger, pale skin, sweating, trembling, weakness, anxiety, headache, poor coordination, coma, server case and for fall. 9/24/2025: Trulicity (injectable type 2 diabetes medication that helps release insulin when blood glucose rises at mealtime) 4.5 mg/0.5 ml pen injection 0.5 mg subcutaneous every week every Wednesday for diabetes.9/24/2025: Novlin R (short-acting insulin used to help control blood sugar) injection solution (Insulin Regular (Human)): Inject as per sliding scale. During a record review of Resident 57's Care Plan, dated 9/26/2025, the Care Plan indicated Resident 57 has diabetes mellitus and was at risk for hypoglycemia, hyperglycemia, visual impairments, pain, wounds and poor wound healing. The care plan interventions for staff were to caution for risk of hypoglycemia monitor for signs and symptoms of hypoglycemia i.e. confusion, dizziness, feeling shaky, irritability, hunger, pale skin, [NAME], trembling, weakness, anxiety, headache, poor coordination, coma, sever case and for fall. The care plan also indicated intervention to administer Glucagon (an injectable medication used primarily for the emergency treatment of severe hypoglycemia in residents with diabetes) subcutaneous solution inject 1 mg subcutaneously every 24 hours as needed for severe hypoglycemia; and observe for polyuria, polydipsia, change in level of conscious, blurred vision, profuse [NAME], irritability, tremors and notify medical doctor (MD) if noted. During a record review of Resident 57's MDS, dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making were intact. The MDS indicated Resident 57 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for toileting hygiene, upper and lower body dressing, and sit to lying. The MDS also indicated Resident 57 received 7 insulin injections during the last seven 7 days or since admission/entry if less than 7 days. During a record review of Resident 57's MAR for the months of May 2026 and June 2026, there was no monitoring for signs and symptoms of hypoglycemia and hyperglycemia. During a concurrent interview and record review on 6/11/2026 at 8:37 AM with LVN 1, Resident 57's order summary report for the month of June 2026, MAR for the month of May and June 2026 were reviewed. LVN 1 stated Resident 57 had a diagnosis of type 2 diabetes mellitus and the resident had a physician order for monitoring the signs and symptoms of hypoglycemia. LVN 1 stated Resident 57's care plan indicated to monitor the signs and symptoms of hypoglycemia and hyperglycemia, but there was no monitoring and documentation in the MAR for signs and symptoms of hypoglycemia and hyperglycemia for the months of May 2026 and June 2026. During an interview on 6/11/2026 at 1:36 PM with the Director of Nursing (DON), the DON stated when residents had orders for insulin there should be monitoring done for hypoglycemia and hyperglycemia. The DON stated documentation on the MAR would indicate that monitoring was being done. The DON stated both hypoglycemia and hyperglycemia could result in resident's serious illness and/ or death. During a record review of the facility's policy and procedure (P&P) titled, Insulin Administration, revised 9/2014, the P&P indicated notify the physician if the resident has signs and symptoms of hypoglycemia that are not resolved by following the facility protocol for hypoglycemia management. During a record review of the facility's P&P titled, Diabetes - Clinical Protocol, dated 1/21/2026, the P&P indicated the staff, and provider will monitor for and manage hypoglycemia appropriately. The P&P indicated for hyperglycemia the staff will notify the practitioner as soon as possible when the resident has two or more blood glucose readings higher than 250 mg/deciliter (dL, unit of volume) within a 24-hour period accompanied by a new medical problem or a change in condition or functional status.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored per facility policy and procedure (P&P) by failing to ensure:1. One eye drop bottle was stored in the refrigerator and not in Medication Cart A.This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. 2. One insulin pen had a pharmacy label to indicate the drug name, dose, and expiration date.This deficient practice had the potential for the residents to receive the wrong formulation of the medication and be administered to the wrong resident. 3. Two boxes of apple juice were not stored in the medication refrigerator in Medication Storage Room A.This deficient practice had the potential for cross contamination of hazardous materials with the medications, and for the potential for the residents of receiving contaminated medications. 4. Two medication cups with opened unidentified medication tablets were stored in Medication Cart B.This deficient practice had the potential for increased risk of medication errors, theft, and contamination. 5. Three expired medications were discarded and not stored in Medication Cart B.This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings: During a concurrent interview and observation of Medication Cart A on 6/11/2026 at 11:24 AM with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated the Xalatan Solution (medication for the treatment of high eye pressure) 0.005% eye drop was placed inside a plastic zip lock bag, which was labeled to refrigerate. LVN 6 stated the eye drop was unopened and was supposed to be kept in the refrigerator inside the medication room until it was opened. LVN 6 also stated there was also an insulin pen stored in Medication Cart A that was not properly labelled. LVN 6 stated the insulin pen only contained a resident's last name written in permanent marker. LVN 6 stated the resident's last name was not adequate for identification when using an insulin pen and should contain the first and last name of the resident and the medication. LVN 6 stated the insulin pen should have a pharmacy label to include the resident's name, drug name, dose, and expiration date. During a concurrent interview and observation on 6/11/2026 at 11:50 AM with LVN 1 in Medication Storage Room A, LVN 1 stated there were two (2) boxes of apple juice in the medication room refrigerator. LVN 1 stated the 2 boxes of apple juice should be kept in the break room refrigerator and not stored in the medication room refrigerator. During a concurrent interview and observation of Medication Cart B on 6/11/2026 at 12:05 PM with LVN 1, LVN 1 stated there were 2 cups with opened unidentified medication tablets stored in Medication Cart B. LVN 1 stated one medication cup, labeled Room A, had a total of 3 opened unidentified medication tablets. There was another medication cup labeled Room B which had a total of 3.5 medications. LVN 1 stated Medication Cart B also had expired medications of Glucagon (an emergency medication for very low blood sugar) one (1) milligram with expiration date of 3/2026, Elder Tonic Liquid Multivitamin/Mineral Supplement with expiration date of 1/2026, and Iron Supplement Liquid with expiration date of 5/2026. LVN 1 stated the opened medication tablets in the medication cups should not have been stored in the medication cart if the residents refused to take it. LVN 1 further stated the medications should have been discarded because this could result in losing the medications and forgetting to give the medications. LVN 1 stated expired medications if administered could result in the residents not getting the therapeutic effect. LVN 1 stated the Glucagon is used when a resident experiences severe hypoglycemia (low blood sugar) and used in an emergency. LVN added since the Glucagon was expired, the medication might now work or be effective when administered. During an interview on 6/11/2026 at 1:24 PM with the Director of Nursing (DON), the DON stated the insulin pens should include the resident's name, name of the medication, the dosage of the medication, and the expiration date so licensed nurses know who the medication belonged to. The DON stated if the medication indicated it should be refrigerated, the medication should stay in the refrigerator instead of room temperature since it could impact the integrity of the medication. The DON also stated apple juice should not be stored in the medication refrigerator because it could result in cross contamination. The DON stated medications were not supposed to be left in medication cups with the resident's room numbers. The DON stated prepared medications that were not administered should have been destroyed. The DON stated leaving resident medications in medication cups could lead to an inability to identify the medications and increase the risk of them spilling out of the cups. The DON also stated expired medications should be discarded because if they are not, a licensed nurse might accidentally administer them to residents, which could result in a negative outcome and reduced medication effectiveness. During a record review of the facility's P&P, revised 2/2023, the P&P indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Medication and biologicals are stored in the packaging containers or other dispensing systems in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. Medications are stored separately from food and are labeled accordingly. The medication label includes, at a minimum:Medication name (generic and/or brand);Prescribed dose;Strength;Expiration date, when applicable;Resident's name;Route of administration; andAppropriate instructions and precautions.If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. Only the dispensing pharmacy may label or alter the label on a medication container or package.

Based on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure (P&P) by:Failing to ensure staff put on gloves before taking cooked food's temperatureTo sanitize the food thermometer with an alcohol swab before using it to check the cooked food's temperature.Failing to ensure staff keep the kitchen floor dry and ensure water was not leaking from the kitchen floor. These deficient practices had the potential to result in food born illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to 96 residents. During a concurrent observation and interview on 6/10/2026 at 11:45 AM in the facility kitchen during tray line assembly, observed [NAME] 1 did not sanitize the food thermometer before taking temperature of pureed vegetables and [NAME] 1 was not wearing gloves. [NAME] 1 stated it is important to put gloves on and sanitize the food thermometer before using it to take the temperature of cooked food on the tray line to prevent cross-contamination ( physical, unintentional transfer of harmful bacteria, viruses, or allergens from one surface, person, or food item to another), stopping germs and pathogens on the skin from transferring directly to the meals being served to residents. During a concurrent observation and interview on 6/10/2026 at 12:15 PM in the facility kitchen with Dietary Service Supervisor (DSS), observed kitchen floor near the sink area was wet and a small amount of water was leaking from the kitchen floor near the exit area. DSS stated kitchen floor should be kept dry to prevent slip-and-fall injuries and inhibit the growth of dangerous bacteria or mold. DSS also stated it is very important for [NAME] 1 to wear gloves and sanitize the food thermometer with an alcohol swab before [NAME] 1 was check the food temperature. to prevent physical, unintentional transfer of harmful bacteria, viruses, or allergens from one surface, person, or food item to another. During a review of the facility's Policy and Procedure (P&P) titled, Food Preparation and Service, revised November 2022, the P&P indicated, food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy.Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces -Infection Control, revised 1/21/2026, was reviewed. The P&P indicated housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.

Based on observation, interview and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy by failing to ensure:1. A trash bag containing soiled gauze with bodily fluids and wipes with the resident's bowel movement were not placed on top of Resident 5's bed, next to the resident's left leg during dressing change. This deficient practice had the potential to contaminate clean items and can place Resident 5 at risk for infection. 2. All facility linens and resident gowns were stored appropriately to maintain infection control.This deficient practice exposed the linens and resident gowns to environmental contamination, including dust, dirt, airborne particles, insects, moisture, and microorganisms resulting to unsanitary linens and gowns which are not safe for resident use.3. The facility completed infection surveillance (a continuous, systematic process of collecting, analyzing, and interpreting health data to monitor and control the spread of infections) from 2/1/2026 through 6/9/2026.4. Registered Nurse 1 (RN 1) performed hand hygiene (cleaning hands with the use of alcohol-based hand rubs containing 60%-95% alcohol or hand washing with soap and water) while touching food containers during the process of residents' lunch meal tray distribution on 6/11/2026.5. Certified Nurse Assistant 5 (CNA 5) wore gown while providing high contact care (routine, hands-on activities requiring prolonged close contact between a staff member and a resident) to Resident 9. These deficient practices have the potential to increase the risk of disease transmission, cross-contamination (the unintentional transfer of harmful bacteria, viruses, or allergens from one surface, object, to another), and severe occupational illness to other residents and staff in the facility. Findings: 1. During a review of Resident 5's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unstageable (a full-thickness pressure injury where the base of the ulcer is obscured by dead skin or a dark, dry scab, making it impossible to determine the depth of the tissue damage) pressure ulcer of sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 1 was severely impaired cognitive (ability to think and process information) ability. The MDS indicated Resident 5 was dependent (helper does all the effort) for eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, personal hygiene and rolling left and right. The MDS indicated Resident 3 was at risk of developing new pressure ulcers and had two (2) unstageable pressure ulcers. The MDS indicated Resident 5's pressure ulcer treatments included a pressure reducing device for bed. During a record review of Resident 5's Order Summary Report dated 6/1/2026, the Order Summary Report indicated Resident 5 will have sacral pressure ulcer cleaned every day and have Santyl (a medication that helps treat pressure ulcers) ointment applied. During a concurrent observation and interview on 6/10/2026 at 8:48 AM with Licensed Vocational Nurse (LVN) 2, a trash bag containing soiled gauze from wound care and wipes with the resident's bowel movement were observed on top of Resident 5's bed next to Resident 5's left leg. LVN 2 stated that the trash bag should not have been placed on the Resident 5's bed because it puts the resident at risk of getting an infection. During a concurrent observation and interview on 6/10/2026 at 8:50 AM with Certified Nursing Assistant (CNA) 1, Resident 5's left leg was observed touching the trash bag that was placed on top of his bed. CNA 1 stated that Resident 5's left leg touched the trash bag. CNA 1 stated the trash bag should not have been placed on top of the bed because the trash is dirty and it puts the resident at risk of infection. During a concurrent interview and record review on 6/10/2026 at 9:10 AM with the Infection Prevention Nurse (IPN), the facility's P&P titled, Infection Prevention and Control Program, dated 1/29/2026 was reviewed. The P&P indicated: An infection prevention and control program is established and maintained to provide a safe and sanitary environment and to help prevent the spread of infections. Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures. The IPN stated that the policy indicated that residents are to be provided with a sanitary environment to prevent the spread of infections. The IPN stated that a trash bag should not be placed on top of a resident's bed while doing a dressing change because it puts the resident at risk of infection. 2. During an observation on 6/8/2026 at 8:43 AM in Room A, a pile of folded white towels and bed linens were observed stored on top of the resident's closet. During an observation on 6/8/2026 at 8:43 AM in the bathroom of Room A, a used white towel was observed on top of the toilet. During a concurrent observation in the laundry area, which was located in a separate building outside the facility, and interview on 6/9/2026 at 1:15 PM with the Housekeeping Supervisor (HS), a linen cart with folded resident gowns was observed outside the laundry area (in an area with no overhead cover). The linen cart was uncovered exposing the resident gowns to the environment. The HS stated the gowns in the linen cart were clean, waiting to go into the facility. The HS stated since the linen cart was outside, it should have been covered, and the gowns should have been placed inside a bag to maintain infection control and prevent contamination of the clean gowns from dust or dirt. During a continued interview on 6/9/2026 at 1:20 PM with the HS, the HS stated per facility policy, clean linen should be stored inside the linen carts, and not on top of the resident's closets to prevent contamination from dust or dirt. The HS further stated any clean gowns or linen found on top of the residents' closets should be considered dirty and should not be used. During an interview on 6/10/2026 at 9:01 AM with the IPN, the IPN stated clean linens are to be stored in linen carts and not on top of resident closets to prevent debris from contaminating them. The IPN also stated clean linens that are stored outside the building should be placed inside a bag and covered to prevent contamination from the environment. The IPN stated that not storing clean linens appropriately can put the residents at risk if they or staff use the contaminated linen believing it was still clean. The IPN further stated according to facility protocol, used (dirty) linens are to be removed and placed into a bag after use and not left in the resident areas to prevent contamination from a resident using or reusing the dirty linen. During a review of the facility's policy and procedure (P&P) titled, Laundry and Linen, dated 1/29/2026, the P&P indicated: The purpose of the P&P was to provide a process for the safe and aseptic handling, washing and storage of linen. All soiled linen must be placed directly into a covered laundry hamper. Clean linen will remain hygienically clean (free of pathogens in sufficient number to cause human illness) through measures designed to protect it from environmental contamination, such as covering linen carts. 3. During a concurrent interview and record review on 6/9/2026 at 2:27 PM with the IPN, the facility's infection control binder was reviewed. The binder failed to show any completed infection surveillance documentation from 2/1/2026 through 6/9/2026. The IPN stated the facility did not and should have an infection surveillance from 2/1/2026 through 6/9/2026. The IPN stated infection surveillance was not done because there were no infection surveillance logs, trackers, mapping, and reports. The IPN stated there were residents who received antibiotics from 3/2026 to 6/2026. The IPN further stated it was important to ensure that infection surveillance was being carried out per facility policy to keep residents, visitors and staff safe. The IPN stated the infection surveillance will assist the facility to know if there are infection control issues including widespread infections. The IPN also stated that infection surveillance is done to prevent the spread of infections and determine infection trends. During a review of the facility's P&P titled, Surveillance for Infections, dated 1/21/2026, the P&P indicated: The Infected Preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. The purpose of surveillance of infections is to identify both individual cases and trends of HAIs and epidemiologically significant organisms to guide appropriate interventions and to prevent future infections. Infections that will be included in routine surveillance include those with evidence of transmissibility in a healthcare environment, available processes and procedures that prevent or reduce the spread of infection, clinically significant morbidity or mortality associated with infection and pathogens associated with serious outbreaks. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. Targeted surveillance will be done: Daily (as indicated): Record detailed information about the resident and infection on an individual report form. Monthly: Collect information from individual resident infection reports and enter line listing infections by resident for the entire month). Monthly: Summarize monthly data for each nursing unit by site and pathogen (any organism or agent—such as a virus, bacterium, fungus, or parasite—that can produce disease in a host). Monthly/Quarterly: Identify predominant pathogens or sites of infection among residents in the facility or in particular units by recording them month to month and observing trends. Monthly/Quarterly: Compare incidence of current infections to previous data to identify trends and patterns, using an average infection rate over previous time period as the baseline. During an observation in the 2nd floor hallway on 6/9/2026 from 12:15 p.m. to 12:23 p.m., and interview with Registered Nurse 1 (RN 1), RN 1 was observed touching her surgical face mask and hair with her bare hands while also touching and opening the lids of the food containers on the 2nd floor meal cart. RN 1 did not perform hand hygiene after touching her hair and/or mask. RN 1 stated she was opening the food containers to check for correct food textures for the residents and stated she did not perform hand hygiene between touching her hair and/or mask and handling the food containers but should have. RN 1 stated it was important to perform hand hygiene to prevent or reduce the spread of bacteria to residents. During an interview on 6/11/2026 at 1:02 PM with the DON, the DON stated it was important for staff to follow the infection control and prevention measures to make sure they are decreasing the risk of spreading bacteria and infection to residents, visitors and staff. During a review of the facility's P&P titled, Infection Prevention and Control Program (IPCP), dated 1/29/2026, the P&P indicated an IPCP is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 5. During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included encounter for attention to gastrostomy (a medical appointment for routine maintenance, evaluation, or troubleshooting of a feeding tube [G-tube, a medical device used to safely deliver liquid nutrition, hydration, and medications directly into the stomach or small intestine) and dysphagia oropharyngeal phase (difficulty moving food and liquids from the mouth into the throat and esophagus). During a review of Resident 9's Minimum Data Set (MDS, resident assessment tool), dated 9/23/2026, the MDS indicated Resident 9 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 9 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with toileting hygiene, lower body dressing, putting on/ taking off footwear. Resident 9 needed substantial/maximal assistance (helper does more than half the effort) with shower/bathe self and personal hygiene. Resident 9 needed partial or moderate assistance, (helper does less than half the effort) with oral hygiene and upper body dressing. During a review of the Physician's Order (PO), dated 1/20/2026, the PO indicated Resident 9 is on enhanced barrier precautions ( EBP, an infection control strategy implemented in nursing homes to prevent the spread of multidrug-resistant organisms [bacteria and other germs that have evolved to resist multiple classes of antimicrobial drugs]) for his G-tube (a medical device inserted directly through the abdomen into the stomach. It provides a direct route to deliver food, liquids, and medications for individuals who cannot eat or swallow safely by mouth). During a concurrent observation and interview on 6/9/2026 at 8:45 AM in Resident 9's room, CNA 5 was observed changing Resident 9's diaper and gown. CNA 5 was observed without an isolation gown. CNA 5 stated he should have worn a gown while rendering care to Resident 9 to prevent the transmission of bacteria and germs to other residents in the facility. During a concurrent interview and record review on 6/9/2026 at 9:15 AM with Infection Preventionist Nurse (IPN), Resident 9's PO, dated 1/20/2026, was reviewed. IPN stated Resident 9's PO indicated Resident 9 was on enhanced barrier precautions and that it requires healthcare staff to wear gowns and gloves during high-contact resident care activities, such as changing diaper and gown, and during shower care. IPN also stated that it was very important for CNA5 to wear a gown during high-contact care activities to prevent the spread of multidrug-resistant organisms (bacteria and other germs that have mutated to survive the medications designed to kill them). IPN stated the facility does not have a specific policy on EBP that will also include the use of PPE. IPN stated the facility uses the Multidrug-Resistant Organisms policy as a guide for their EBP. During a review of the facility's Policy and Procedure (P&P) titled, Multidrug-Resistant Organisms, revised on August 2019, the P&P indicated Appropriate precautions are taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism. Environmental surfaces and medical equipment, especially those in close proximity to the resident, may be contaminated, don gowns and gloves before or upon entry to the resident's room or cubicle.

Based on interview and record review, the facility failed to educate and offer the pneumococcal vaccine (a medical injection that protects against the bacteria Streptococcus pneumoniae, [a bacterium that colonizes the respiratory tract causing serious infections, including Pneumonia {PNA, lung infection}) and/or influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (an annual vaccine that helps protect the body from the influenza virus) to four (4) of five (5) sampled residents (Residents 48, 14, 3, and 34), reviewed for infection prevention, control, and immunizations (process of protecting a person from a disease by giving a vaccine that helps the body build immunity) upon admission and when appropriate, as indicated in the facility's policy. These deficient practices have the potential to increase Residents 48, 14, 3, and 34 risk of infection such as PNA, bacteremia (infection of the blood), meningitis (infection of the tissue covering the brain and spinal cord), influenza, and suffer from severe complications, hospitalization, and death. Findings:1. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) protein-calorie malnutrition (a condition resulting from inadequate intake of protein and calories), dysphagia (difficulty swallowing), and type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 48's Minimum Data Set (MDS - a resident assessment tool), dated 5/15/2026, the MDS indicated Resident 48 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 48 was dependent (helper does all effort to complete activity) with oral, toileting, and personal hygiene, eating, dressing and transfers. During a concurrent interview and record review on 6/9/2026 at 2:30 PM with the Infection Preventionist Nurse (IPN), Resident 48's electronic medical chart, from 8/5/2025 to 6/9/2026 was reviewed. Resident 48's electronic chart failed to indicate Resident 48's immunization history. There was no documented evidence that Resident 48/Responsible Party was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no documentation that education was provided, or the vaccines were offered per facility policy. During a concurrent interview and record review on 6/9/2026 at 4:35 PM with the IPN, Resident 48's physical medical chart, from 8/5/2025 to 6/9/2026 was reviewed. Resident 48's physical medical chart failed to indicate that Resident 48/Responsible Party was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no declination, consent or documentation that vaccine education was provided and they should have been in the medical chart and documented if done. 2. During a review of Resident 14's admission Record, the admission Record indicated Resident 14 was admitted to the facility on [DATE] with diagnoses that included PNA, chronic respiratory failure (an ongoing condition where the lungs cannot effectively take in enough oxygen or remove enough carbon dioxide from your bloodstream), and major depressive disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 with severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 2 was dependent with toileting, bathing, and lower body dressing, Resident 14 required partial/moderate assistance (helper does less than half the effort) with oral hygiene and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. During a review of Resident 14's Immunization History Report, the Immunization History Report indicated Resident 14's most recent influenza vaccine was administered on 10/11/2024, Resident 14's Immunization History Report did not have a documented evidence that pneumococcal vaccine was administered or that Resident 24 refused it. During a concurrent interview and record review on 6/9/2026 at 2:35 PM with the IPN, Resident 14's electronic medical chart from 12/1/2025 to 6/9/2026 was reviewed. Resident 14's electronic chart failed to indicate that Resident 14/Responsible Party was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no documentation that education was provided or the vaccines were offered. During a concurrent interview and record review on 6/9/2026 at 4:23 PM with the IPN, Resident 14's physical medical chart, from 12/1/2025 to 6/9/2026 was reviewed. Resident 14's physical medical chart failed to indicate that Resident 14/Responsible party was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no declination, consent or documentation that vaccine education was provided and they should have been in the medical chart and documented if done. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was originally admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), heart failure (a condition where the heart muscle becomes too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), and type 2 DM. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had intact cognitive skills for daily decision making. The MDS also indicated Resident 3 was dependent with toileting, bathing, and lower body dressing and supervision or touching assistance with eating. During a review of Resident 3's Immunization History Report, the Immunization History Report indicated Resident 3 was administered with influenza vaccine on 9/30/2023, and no documented history of pneumococcal vaccination administrations or refusals. During a concurrent interview and record review on 6/9/2026 at 2:42 PM with the IPN, Resident 3's electronic medical chart from 3/28/2026 to 6/9/2026 was reviewed. Resident 3's electronic medical chart failed to indicate that Resident 3 was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no documentation that education was provided, or the vaccines were offered per facility policy. During a concurrent interview and record review on 6/9/2026 at 4:54 PM with the IPN, Resident 3's physical medical chart, from 3/28/2026 to 6/9/2026 was reviewed. Resident 3's physical medical chart failed to indicate that Resident 3 was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no declination, consent or documentation that vaccine education was provided and they should have been in the medical chart and documented if done. 4. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood or remove enough carbon), chronic pulmonary edema (the slow, long-term accumulation of excess fluid in the lungs' air sacs, making it progressively difficult to breathe) and chronic kidney disease (CKD- a long-term condition where the kidneys are damaged and slowly lose their ability to filter waste and excess fluid from the blood). During a review of Resident 34's MDS, dated [DATE], the MDS indicated Resident 34 had intact cognitive skills for daily decision making. The MDS also indicated Resident 34 required substantial/maximal assistance (helper does more than half the effort needed to complete the activity) with oral, toileting and personal hygiene, dressing and set up or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 34's Immunization History Report, the Immunization History Report indicated Resident 34's most recent influenza vaccine was administered on 10/2/2024, and the pneumococcal vaccine on 10/1/2024. During a concurrent interview and record review on 6/9/2026 at 2:46 PM with the IPN, Resident 34's electronic medical chart, from 3/30/2026 to 6/9/2026 was reviewed. Resident 34's electronic chart failed to indicate that Resident 34 was educated and offered the influenza vaccine. The IPN stated there was no documentation that education was provided, or the influenza vaccine was offered per facility policy. During a concurrent interview and record review on 6/9/2026 at 4:57 PM with the IPN, Resident 34's physical medical chart, from 3/30/2026 to 6/9/2026 was reviewed. Resident 34's physical medical chart failed to indicate that Resident 34 was educated and offered the influenza and pneumococcal vaccines. The IPN stated there was no declination, consent or documentation that vaccine education was provided and they should have been in the medical chart and documented if done. During an interview on 6/10/2026 at 9:00 AM with the IPN, the IPN stated it was important to ensure vaccines are offered and given to residents to ensure patient safety, prevent the spread of contagious agents, and to lessen the severity of symptoms if Residents were to get sick. The IPN further stated it was important to ensure the vaccine information statements (VIS- an information sheet produced by the Centers for Disease Control and Prevention [CDC] that explains the benefits and risks of a specific vaccine) was provided to the residents and responsible parties to ensure they are making an informed decision when they give their consent or decline the vaccines. During an interview on 6/11/2026 at 12:53 PM with the Director of Nursing (DON), the DON stated vaccinations are given to decrease outbreaks and the spread of communicable diseases (illness caused by pathogens [bacteria, viruses, fungi, or parasites] that spreads from one person another), to prevent the residents from being more at risk to illness, and to ensure the safety of residents, visitors and staff. The DON stated it was important to provide the VIS to residents to ensure residents and RPs understand when deciding to accept or decline the vaccines. During a review of the facility's Policy and Procedure (P&P) titled, Pneumococcal Vaccine, dated 1/21/2026, the P&P indicated all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The P&P also indicated prior to, upon admission, or within five (5) working days, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, offered the vaccine series within 30 days of admission to the facility. The P&P indicated if a resident refuses, appropriate information will be documented in the resident's medical record indicating the date of refusal, and if administered, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. During a review of the facility's P&P titled, Influenza, Prevention and Control of Seasonal, dated 1/21/2026, the P&P indicated the facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. The P&P indicated the Infection Preventionist organizes and oversees an annual influenza vaccine campaign and that all residents are offered the vaccine prior to the onset of the influenza season. During a review of the facility's P&P titled, Vaccination of Residents, dated 1/21/2026, the P&P indicated:All residents are offered recommended vaccines unless the vaccine id medically contraindicated or the resident has already been vaccinated.Upon admission residents are evaluated for current vaccination status and when indicated, residents are offered recommended vaccines.Prior to receiving vaccinations, the resident or legal representative is provided with information and education regarding the risks, benefits, and potential side effects of the vaccinations.The resident (or representative) is provided with the most current vaccine information statement (VIS) prior to vaccine administration.Provision of information, education and the VIS are documented in the resident's medical record.The resident (or representative) has the right to refuse vaccines, and the date and reason for refusal are documented in the resident's medical record.Administration of vaccines are made in accordance with current advisory Committee on Immunization Practices (ACIP) and CDC recommendations at the time.

Based on observation, interview, and record review, the facility staff failed to ensure Resident 96's foley bag (the external collection pouch attached to a thin, sterile tube inserted into the bladder to drain urine) was covered with a dignity bag for one (1) of two (2) sampled residents (Residents 96) reviewed for dignity. This deficient practice may compromise Resident 96 's psychological well-being, social interaction, personal privacy and dignity.Findings:During a review of Resident 96's admission Record, the admission Record indicated Resident 96 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 96's diagnoses included type 2 diabetes mellitus (high blood sugar in the bloodstream), neuromuscular dysfunction of bladder unspecified (refers to a condition occurs when brain, spinal cord, or nerve issues disrupt the signals between the brain and bladder, leading to poor control, leakage, or incomplete emptying), and presence of urogenital implants ( a medical device has been surgically placed in the urinary or reproductive organs to support or restore their function). During a review of Resident 96's Minimum Data Set (MDS, resident assessment tool), dated 5/14/2026, the MDS indicated Resident 96 had no impairment for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. The MDS indicated Resident 96 required partial or moderate assistance, (helper does less than half the effort) with the toileting hygiene, lower body dressing, and putting on/taking off footwear. Resident 96 needed supervision or touching assistance (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene, upper body dressing and personal hygiene. Resident 96 needed setup or clean-up assistance (helpers sets up or cleans up, resident completes activity) for eating. The MDS also indicated Resident 96 use of foley (urinary indwelling catheter) to drain the bladder and collect urine. During a concurrent observation and interview on 6/9/2026 at 4:16 PM with Certified Nursing Assistant 4 (CNA 4) in front of Resident 96's room, Resident 96 was observed sitting in the wheelchair. Resident 96 had a urinary bag (a medical device that attaches to a catheter to collect urine) that was not covered with a dignity bag hanging on the left side of Resident 96's wheelchair. CNA 4 stated Resident 96's urinary bag was supposed to be covered with a dignity bag to provide privacy and dignity to the resident. During an interview on 6/9/2026 at 4:37 PM with Director of Staffing Development (DSD), the DSD stated it is very important to cover Resident 96's urinary bag with a dignity bag to maintain privacy, independence, and dignity. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, reviewed 1/21/2026, the P & P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with respect at all times. It also indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example:helping the resident to keep urinary catheter bags covered.

Based on interview and record review, the facility failed to ensure three (3) of 3 sampled residents (Residents 57, 72 and 103) who were discharged from Medicare Part A (a type of insurance that covers skilled nursing home stays) coverage in the last six (6) months received a Notice of Medicare Non-Coverage (NOMNC; form that notifies someone when their Medicare Part A benefits will expire and allows them to file an appeal) before their Medicare Part A coverage ended. This deficient practice had the potential to result in resident and/ or resident's responsible party not being able to exercise their right to file an appeal. Findings: During a review of Resident 72's Census and Rates (CR) report I(undated), it indicated, the resident's last covered day for Medicare Part A Skilled Services was [DATE]. During a review of Resident 103's CR (undated), the report indicated the resident's last covered day for Medicare Part A Skilled Services was [DATE]. During a review of Resident 57's CR (undated), the report indicated the resident's last covered day for Medicare Part A Skilled Services was [DATE]. During an interview on [DATE] at 8:05 AM with Resident 57, Resident 57 stated the facility did not notify him of his Medicare Part A benefits were about to expire before the expiry date on [DATE]. During an interview on [DATE] at 8:13 AM with Resident 72, Resident 72 stated the facility did not notify him of his Medicare Part A benefits were about to expire before the expiry date on [DATE]. During a concurrent interview and record review on [DATE] at 9:06 AM with the facility's Business Office Manager (BOM), Residents 72, 103 and 57's CR were reviewed. The BOM stated that Residents 72, 103 and 57 all had their Medicare Part A benefits expired but the resident's did not receive a NOMNC or any notification that their benefits would expire. During a concurrent interview and record review on [DATE] at 9:13 AM with the BOM, the facility's P&P titled, Medicare Advance Beneficiary and Medicare Non- Coverage Notices, review date on [DATE] was reviewed. The P&P indicated:A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change is likely.Written notices of the likelihood of Medicare payment denial are provided to the resident far enough in advance of an event so that the beneficiary can make a rational, informed decision without undue pressure. BOM stated the policy indicated that residents will be notified in advance and in writing when their Medicare benefits will expire but there is no evidence that Residents 57, 72 and 103 were notified before their Medicare benefits expired. Bon stated the facility should have notified the residents to ensure the residents can make informed decisions and the residents will not be billed for services they do not want and to allow the residents or resident representative to file an appeal.

Based on interview and record review, the facility failed to ensure an ordered orthopedic (ortho- the branch of medicine focused on the diagnosis, treatment, prevention, and rehabilitation of the musculoskeletal system) appointment was scheduled for (1) of 31 sampled residents (Resident 48) per physician's order. This failure resulted in a delayed evaluation, services and care related to Resident 48's left hip pain.Findings:During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses that included left hip arthritis (a disease that causes damage in your joints), pain in left hip, and chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure). During a review of Resident 48's Order Summary Report, an order dated 4/1/2026 on the Order Summary Report indicated to make an appointment [for] left hip pain with Orthopedic Doctor 1 (OD 1); will need transportation wheelchair with return. During a review of Resident 48's Pain Consultation Physician's Note, dated 4/13/2026, the Physician's Note indicated Resident 48 reported muscle stiffness, tenderness and worsening pain on the left hip. The Physician's Note indicated a plan to send to OD 1 for a possible left hip replacement (a surgical procedure where an orthopedic surgeon removes a damaged or worn-out hip joint and replaces it with an artificial implant). During a review of Resident 48's Authorization Request Form, dated 4/13/2026, the Authorization Request Form indicated an urgent request was submitted for an appointment with OD 1.During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool), dated 5/2/2026, the MDS indicated Resident 84 had intact cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 48 required setup or clean up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral hygiene and substantial/maximal assistance (helper does more than half the effort) with toileting hygiene and shower/bathing self. During an interview on 6/8/2026 at 8:19 AM with Resident 48, Resident 48 stated he needed a hip replacement due to his medical condition (left hip pain/ arthritis), and was told he would have an appointment for an evaluation, but the facility had not scheduled a follow up appointment nor provided any further information since his last appointment with his doctor. During an interview on 6/11/2026 at 10:13 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 48 was admitted to the facility with hip pain and has severe arthritis, in which the resident sees a pain specialist for. LVN 1 stated as of 6/11/2026, LVN 1 did not know the status of Resident 48's pending appointment with OD 1 or if it has been scheduled. LVN 1 stated the Social Services Department would have called to arrange an appointment. LVN 1 stated he has not followed up with anyone since the order for the ortho appointment was given on 4/1/2026 and that LVN 1 should have made a follow up. LVN 1 stated licensed nurses should have followed up after the order was placed, so that Resident 48 would have a confirmed appointment. LVN 1 further stated, without any follow up regarding the ordered appointment with OD 1, Resident 48 could be negatively affected because the appointment was to evaluate for hip replacement surgery and a delayed appointment would delay treatment and the needed surgery. LVN 1 further stated Resident 48 could have experienced severe pain, decreased quality of life due to the delayed appointment and services. During an interview on 6/11/2026 at 11:01 AM with Registered Nurse 3 (RN 3), RN 3 stated she did not know the status of Resident 48's ordered ortho appointment with OD 1, because the social services department were supposed to follow up and handle the scheduling of the appointment. During an interview on 6/11/2026 at 11:03 AM with Social Services Assistant (SSA), SSA stated there was an authorization request submitted for Resident 48's ortho appointment on 4/13/2026, and the facility did not follow up for the status of the approval from the day it was submitted until 6/11/2026. During multiple interviews on 6/11/2026 at 11:06 AM, and 12:00 PM with Admissions Coordinator (AC), AC stated she submitted an authorization request form for Resident 48's ortho appointment on 4/13/2026 but had not followed up with an approval status prior to today, 6/11/2026. AC stated it had been two (2) months with no follow up on the approval status. AC stated after calling for an approval status on 6/11/2026 after realizing no follow up was done, Resident 48 had been approved for an appointment with OD 1 since 5/15/2026, but the facility was unaware of the resident's approval status. AC further stated this caused a delay of scheduling for Resident 48 from 5/15/2026 to 6/11/2026 and the facility staff should have followed up sooner to allow Resident 48 to have continued care which could have also helped with the resident's hip pain. During an interview on 6/11/2026 at 1:02 PM with the Director of Nursing (DON), the DON stated nursing, social services and the business office staff should have all followed up with Resident 48's ordered appointment with OD 1, sooner than 6/11/2026. The DON further stated it was important to follow up with orders and appointment authorizations to prevent a delay of services, and that a delay in services could have negatively affected Resident 48 with a decline in health and/or increased in pain. During a review of the facility's Policy and Procedure (P&P) titled, Referral, Social Services, revised 12/2008, the P&P indicated social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) for one (1) of 1 sampled residents (Resident 5) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was at the correct settings in accordance with the facility's policy and procedure (P&P) and physician's order. On 6/8/2026, Resident 5, who weighed 159 pounds (lbs, unit of measurement for weight) LALM setting was set at 180 lbs. This deficient practice placed Resident 5 at risk for deterioration of the resident's current pressure ulcer.Findings: During a review of Resident 5's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and unstageable (a full-thickness pressure injury where the base of the ulcer is obscured by dead skin or a dark, dry scab, making it impossible to determine the depth of the tissue damage) pressure ulcer of sacrum (lower end of the spinal area at the base of the spine). During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 3/10/2026, the MDS indicated Resident 1 had severely impaired cognitive (ability to think and process information) ability. The MDS indicated Resident 5 was dependent (helper does all the effort) for eating, oral hygiene, toileting hygiene, showering, upper/lower body dressing, putting on/taking off footwear, personal hygiene and rolling left and right. The MDS indicated Resident 3 was at risk of developing new pressure ulcers and has two (2) unstageable pressure ulcers. The MDS indicated Resident 5's pressure ulcer treatments included a pressure reducing device for bed. During a concurrent observation and interview on 6/8/2026 at 9:52 AM in Resident 5's room, Resident 5's LALM was observed set at 180 lbs. Resident 5 stated the bed feels uncomfortable. During a concurrent observation in Resident 5's room and interview on 6/8/2026 at 9:56 AM with Licensed Vocational Nurse (LVN) 1, Resident 5's LALM was observed to be set at 180 lbs. LVN 1 stated Resident 3's LALM was set at 180 lbs., but it should be set to 159 lbs. LVN 1 stated if the LALM is set to a higher weight it adds more pressure and can make Resident 5's pressure ulcer get worse. During a concurrent interview and record review on 6/8/2026 at 10:00 AM with LVN 1, Resident 5's weight record dated 6/4/2026 was reviewed. Resident 5's weight record indicated Resident 5 weighed 159 lbs. on 6/4/2026. LVN 1 stated Resident 5's most recent weight is 159 lbs. During a concurrent interview and record review on 6/8/2026 at 10:02 AM with LVN 1, Resident 5's Order Summary Report dated 4/23/2026 was reviewed. The Order Summary Report indicated that Resident 5 may have a LALM for wound management set at resident's current weight. LVN 1 stated the order is to set the LALM at resident's current weight, but it was not set at the resident's current weight. During a concurrent interview and record review on 6/11/2026 at 12:00 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Support Surface Guidelines, revised 9/2013 was reviewed. The P&P indicated:The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices at risk of skin breakdown.Redistributing support surface is to provide pressure relief or reduction.Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution.The DON stated the policy indicated that support surfaces are meant to redistribute pressure but if a LALM is not set correctly, it does not redistribute pressure but adds more pressure to a wound. The DON stated this can possibly cause the resident's wound to worsen. During a concurrent interview and record review on 6/11/2026 at 12:09 PM with the DON, Resident 5's LALM manufacture's guidelines manual (Brand 1 Manual) was reviewed. The Brand 1 Manual indicated:Brand 1 LALM is indicated for the prevention and treatment of any and all pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program.Determine the patient's weight and set the control knob to that weight setting on the control unit.The DON stated Brand 1 Manual indicated that the LALM must be set the same as the resident's weight.

Based on observation, interview, and record review, the facility failed to protect one (1) of six (6) sampled residents (Resident 1) right to be free from sexual abuse (non-consensual [without the person's permission] sexual contact of any type with a resident who does not wish to engage in sexual activity or may not have the capacity to consent) when Resident 2 was observed playing with Resident 1's private part on 1/10/2026. This failure resulted in Resident 1 being sexually abused by Resident 2 on 1/10/2026 and had the potential to result in Resident 1 experiencing negative psychosocial effects (a person's mental, emotional, social and spiritual health and hopelessness) based on the reasonable person concept (refers to a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome [psychosocial effects] of the deficiency may have had on a reasonable person in the resident's position), due to Resident 1's severely impaired cognitive skills (never/rarely made decisions). An individual subjected to abuse may have psychological (mental or emotional) effects including the feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). *Cross referenced w/ F609Findings:1. During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1'S Minimum Data Set (MDS - a resident assessment tool), dated 12/8/2025, the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 1 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of two (2) or more helpers is required for the resident to complete the activity) with tub/shower transfers (the ability to get in and out of a tub/shower). Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with lower body dressing (the ability to dress and undress below the waist) and putting on/taking off footwear. Resident 1 needed partial/moderate assistance (helper does less than half the effort) with upper body dressing (the ability to dress and undress above the waist) and personal hygiene. Resident 1 also needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with chair/bed-to-chair transfers, rolling left and right in bed, going from sitting to lying down in bed and with eating. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR; a standardized communication tool used in healthcare to provide concise, relevant information during critical situations) Documentation dated 1/10/2026, timed at 5:30 PM, Resident 1's SBAR documentation indicated Certified Nursing Assistant 1 (CNA 1) reported that while Resident 1 was lying in bed, his roommate Resident 2 approached him and played with his (Resident 1) private part. CNA 1 moved Resident 2 right away from Resident 1 and reported the incident to Registered Nurse 1 (RN 1). RN 1 interviewed Resident 1 and Resident 1 was only able to state his name. During a review of Resident 1's Care Plan dated 1/10/2026, Resident 1's Care Plan indicated Resident 1 experienced unwanted touching behavior.During a review of Resident 1's Care Plan dated 1/13/2026, Resident 1's Care Plan indicated Resident 1 was at risk for emotional/psychological distress due to possible unwanted touching behavior by another resident.2. During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of dementia and polyneuropathies (a condition involving widespread damage to many peripheral nerves - those outside the brain and spinal cord). During a review of Resident 2'S MDS, dated [DATE], the MDS indicated the resident was severely impaired with cognitive skills for daily decision making. Resident 2 needed partial/moderate assistance with chair/bed-to-chair transfers, upper and lower body dressing, putting on/taking off footwear and personal hygiene. Resident 2 needed supervision or touching assistance with rolling left and right in bed and going from lying down to sitting on the side of the bed. Resident 2 also needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a review of Resident 2's SBAR documentation dated 1/10/2026, timed at 5:44 PM, Resident 2's SBAR documentation indicated on 1/10/2026 CNA 1 had reported that Resident 2 was seen playing with Resident 1's private part. CNA 1 stopped Resident 2 and reported to RN 1. RN 1 interviewed Resident 2 and Resident 2 did not remember what happened.During a review of Resident 2's Care Plan dated 1/10/2026, Resident 2's Care Plan indicated possible unwanted touching behavior.During a review of Resident 2's Physician (MD) Order from 1/10/2026 at 6:53 PM, Resident 2's MD Order indicated to transfer Resident 2 to general acute care hospital (GACH) for escalating dementia.During a review of Resident 2's MD Order from 1/10/2026 at 6:58 PM, Resident 2's MD Order indicated to place Resident 2 on one-on-one (1:1; direct monitoring) until ambulance arrives.During a concurrent review of the Admission/Transfer/Discharge (ATD) log for 1/2026, and interview with the Director of Staff Development (DSD) on 1/22/2026 at 10:30 AM, the DSD stated according to the ATD log, Resident 2 was picked up by an ambulance on 1/10/2026 at 10 PM. During an observation in Resident 1's room and interview on 1/22/2026 at 1PM, Resident 1 was lying in bed. Resident 1 was asked about the alleged sexual abuse that occurred on 1/10/2026; however, Resident 1 was only able to state his name. During a concurrent review of the 1:1 Monitoring log and interview with the Director of Nursing (DON) on 1/22/2026 at 2 PM, the DON stated the log indicated Resident 2 had a 1:1 supervision from 5:30 PM to 10 PM on 1/10/2026. The DON further stated CNA1 stayed with Resident 1 until 7 PM, after which another CNA provided 1:1 supervision from 7 PM to 10 PM, until Resident 1 was picked up by ambulance for transfer to GACH. During an interview on 1/23/2026 at 1:21 PM, CNA 1 stated on 1/10/2026 at around 5:15 PM, she was passing out dinner trays when she went to assist Resident 1 with dinner. CNA 1 stated as she opened the curtains, she witnessed Resident 2 on his knees on the left side of Resident 1's bed and was touching Resident 1's private parts with both his hands while Resident 1's diaper was open. CNA 1 stated she immediately put the dinner tray down right outside the resident's room and went back to Resident 2 who was still touching Resident 1's private parts for a duration of approximately 10 seconds from when CNA1 observed him when she first entered the resident's room. CNA1 stated she grabbed Resident 2's left arm and helped him crawl back to bed since Resident 2 was unable to walk. CNA 1 stated she then went out and grabbed a linen cart and placed it between Resident 1 and Resident 2's bed to prevent Resident 2 from crawling back to Resident 1. CNA 1 stated she reported the incident to RN 1 who was at the nurses' statio and when she returned to Resident 1 and 2's room, Resident 2 was still in bed. CNA 1 stated she then started assisting Resident 1 with his dinner.During an interview on 1/23/2026 at 2:32 PM with the DON, the DON stated Resident 1 was severely impaired in cognitive skills for daily decision making and did not have the ability to consent to sexual activity with Resident 2. 3. During a review of Resident 3's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of acute respiratory failure (when the lungs suddenly cannot get enough oxygen into the blood or remove enough carbon dioxide making it a life-threatening emergency) with hypoxia (a dangerous condition where the body tissues and organs do not receive enough oxygen to function properly) and heart failure (when the heart cannot pump enough oxygen-rich blood to meet the body's needs). During a review of Resident 3'S MDS, dated [DATE], the MDS indicated the resident had intact cognitive (ability to think, remember, and reason) skills for daily decision making. Resident 3 needed supervision or touching assistance with walking 150 feet, chair/bed-to-chair transfers, going from sitting to standing, upper and lower body dressing, putting on/taking off footwear, personal hygiene and eating. During an interview on 1/22/2026 at 1:25 PM with Resident 3, Resident 3 stated as he was walking down the hallway, he witnessed Resident 2 lowering Resident 1's diaper and touching Resident 1's buttock while in Residents 1 and 2's room. Resident 3 stated he does not remember the date and time when this incident happened. Resident 3 stated he reported what he saw to an unidentified staff member. During an interview with the DSD on 1/22/2026 at 10:30 AM, the DSD stated the facility investigated Resident 3's report of alleged sexual abuse by Resident 2 but was unable to identify the staff member to whom Resident 3 claimed to have reported the sexual abuse. The DSD stated the facility was unable to substantiate Resident 3's allegation. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, revised 6/2/2025, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment (the use of physical force intended to cause pain or discomfort as a way to discipline or correct behavior), involuntary seclusion (separation of a resident from others against their will or without their consent, often by confining them to a room or specific area), verbal, mental, sexual or physical abuse, and physical or chemical restraint (use of medication to control a person's behavior or restrict their freedom of movement, when the drug is not required to treat a medical condition) not required to treat the resident's symptoms. The P&P also indicated:As part of the resident abuse prevention, the administration will: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 individual.Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.Identify and assess all possible incidents of abuse;Investigate and report any allegations of abuse within timeframes as required by federal requirements.

Based on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 1), who has a diagnosis of nontraumatic (not caused by trauma or injury to the body) intracerebral hemorrhage (ICH, also known as hemorrhagic stroke [medical emergency where bleeding occurs within the brain tissue]) in brain stem (the lower part of the brain that connects to the spinal cord [a tube of tissue that carries nerve signals from the brain to the rest of the body]), assessed with severe cognitive impairment (ability to think, remember and reason) for daily decision making, and at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) was supervised to prevent injury and did not elope on 5/30/2025 between 8:40 AM to 9:30 AM by failing to: 1. Immediately reassess Resident 1, who was assessed as low risk for elopement on 5/8/2025, after Resident 1 was observed by Certified Nurse Assistant (CNA) 1 packing his belongings and verbalizing wanting to leave the facility on 5/30/2025 from 8:40 AM to 9:30 AM, in accordance with the facility's Resident Elopement Policy. 2. Implement interventions such as detailed monitoring plan to prevent elopement after Resident 1 was observed packing his belongings and verbalizing wanting to leave the facility on 5/30/2025 at around 8:40 AM in accordance with the facility's Resident Elopement Policy. 3. Supervise Resident 1 by ensuring the facility doors was being monitored to prevent Resident 1 from leaving the facility unsupervised, as instructed by the Director of Nursing (DON) after Resident 1 was observed packing his belongings and verbalizing wanting to leave the facility on 5/30/2025 at around 8:40 AM. These failures resulted in Resident 1 eloping from the facility on 5/30/2025 around 9:30 AM and had the potential to expose Resident 1 to harsh environmental conditions including excessive heat and or cold, the potential to be hit by a car as well as experiencing medical complications including malnutrition (a condition that occurs when a person does not consume enough nutrients or calories to meet their body's needs), dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally), heat stroke (a life-threatening condition where the body's temperature rises dangerously high), and death. Resident 1 returned to the facility on [DATE] at 3:45 PM (six [6] hours and 15 minutes after resident eloped), accompanied by an unidentified individual. On 5/30/2025 at 6:26 PM, while onsite, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious harm, impairment, or death of a resident) due to the facility's failure to immediately supervise Resident 1 to prevent Resident 1's elopement from the facility. The surveyor notified the DON of the IJ situation on 5/30/2025 at 6:26 PM, due to the facility's failure to ensure Resident 1 was immediately supervised to prevent injury and did not elope on 5/30/2025 between 8:40 AM to 9:30 AM. On 5/31/2025 at 12:58 PM the facility submitted an acceptable IJ removal plan (IJRP). After verification of the IJRP implementation through observation, interview and record review, the IJ was removed in the presence of the DON. Following the removal of the IJ, noncompliance remained at a scope (refers to how widespread a deficiency is) and severity (no actual harm, with potential for more than minimal harm) of a D (isolated [one or a very limited number of residents are affected], actual harm, that is not immediate jeopardy). The IJ Removal Plan dated 5/31/2025, included the following: Part A 1. Resident 1 agreed to be transferred to the acute care hospital for further evaluation. The attending physician (MD 1) issued the order for transfer on 5/30/2025 at 7:50 PM. 2. Resident 1 will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document. 3. The facility will implement on 5/30/2025, 24-hour monitoring immediately of the doors to strive and prevent harm to all our patients. 4. Resident 1 refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived at 12:15 AM on 5/31/2025. 5. Received orders from MD 1 to apply a wander guard (a system that uses a wearable device such as a bracelet to monitor the movement of a resident residing within a nursing home by alerting caregivers if they exit the facility) to Resident 1 on 5/31/2025 at 8:00 AM. 6. Obtained informed consent from Resident 1's Responsible Party (RP) on 5/31/2025 at 8:10 AM. 7. Resident 1 continued to refuse the wander guard despite several attempts and education on safety. MD 1 and Resident 1's RP made aware. 8. Resident 1 will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring. 9. Resident 1's elopement assessment was updated to reflect Resident 1 being at high risk for elopement. 10. Situation, Background, Assessment Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) documentation initiated on 5/31/2025 for Resident 1's and 72-hour SBAR documentation initiated. 11. Resident 1's care plan was updated with interventions implemented to prevent a repeat event. 12. Resident 1 spoke with a psychiatrist via (by) resident's telephone for evaluation for psychological support and emotional distress on 5/31/2025 at 10:45 AM. The psychiatrist ordered a follow-up with social services for discharge. Resident 1 was placed on psychological monitoring starting 5/30/2025. 13. Resident 1 will be seen by a psychologist on 5/31/2025 for evaluation for psychosocial distress related to the recent event of elopement. Part B 1. All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated. 2. Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee to identify other residents who have the potential to be affected. 3. Care plans will be updated for all 93 residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety. 4. The facility has identified only one resident at high risk for elopement which is Resident 1. 5. The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring. Part C 1. The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur. 2. The facility employs a total of 58 staff members (Registered Nurses [RN], Licensed Vocational Nurses [LVN], and Certified Nursing Assistants [CNA]). The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced 25 staff members on 5/30/2025 and 5/31/2025 concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff within 48-hours and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well. 3. The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement. 4. The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises. 5. The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and CDPH. 6. The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in brain stem and type two (2) diabetes mellitus (DM2, a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (damage to the kidneys caused by long-standing high sugar levels leading to impaired kidney function and potentially kidney failure). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/14/2025, the MDS indicated the Resident 1 had severe impairment with cognitive skills for daily decision making. Resident 1 needed substantial/maximal assistance (helper does more than half the effort) with walking 10 feet. Resident 1 needed partial/moderate assistance (helper does less than half the effort) with transfers (how resident moves to and from bed, chair, wheelchair, standing position), personal hygiene, putting on/taking off footwear, upper and lower body dressing (the ability to dress and undress above and below the waist), and needed setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating. During a review of Resident 1's Elopement Risk Evaluation, dated 5/8/2025, the Elopement Risk Evaluation indicated Resident 1 was evaluated as low risk for elopement. During a review of Resident 1's Health Status Note, dated 5/30/2025, timed at 11:42 AM, the Health Status Note indicated on 5/30/2025 at 8:45 AM (22 days from Resident 1's initial Elopement Risk Evaluation), The AD stated resident (Resident 1) voiced he would like to leave the facility. During a review of Resident 1's SBAR documentation, dated 5/30/2025 at 2:19 PM, the SBAR documentation indicated Resident 1 left the building by walking without notifying anyone. The SBAR did not indicate the time Resident 1 left on 5/30/2025. During an interview on 5/30/2025 at 2:48 PM with the DON, the DON stated on the morning of 5/30/2025, she was informed by the AD that Resident 1 was packing his clothes and wanted to leave. The DON stated she called the Social Services Assistant (SSA) to speak with Resident 1 regarding Resident 1 wanting to leave. The DON then stated the SSA verified that Resident 1 wanted to leave and was going to call Resident 1's family so that Resident 1 could speak with them. The DON told the SSA to monitor the resident to monitor Resident 1 and ensure Resident 1 does not walk out of the facility's doors unsupervised. During the same interview on 5/30/2025 at 2:48 PM with the DON, the DON stated after the 9:30 AM meeting with all the facility department heads, CNA1 came up to all the department heads to ask if they have seen Resident 1. The DON stated she called a code silver (a signal used to alert staff of an older resident who has gone missing) and all staff started looking for Resident 1 around the facility premises and two blocks away from the building both on foot and by car. The DON stated that they had gone to the store across the street from the facility and the owner of the store had informed them that they saw Resident 1 walk out through the doors of the facility and walk towards the bus stop. The DON then stated around 11:45 AM, they received a call from a staff at Resident 1's previous residence (apartment) that Resident 1 was outside the apartment building. During the same interview on 5/30/2025 at 2:48 PM with the DON, the DON stated she had called 9-1-1 emergency response to go to Resident 1's previous residence to check on the resident. The DON stated after a while, paramedics told her that they could not force Resident 1 to go back to the hospital or facility since Resident 1 refused to leave his apartment. The DON then stated she called the Psychiatric Emergency Team (PET, a mobile team that provides crisis intervention and stabilization for individuals experiencing a mental health crisis) to go check on Resident 1 at his apartment. During the same interview on 5/30/2025 at 2:48 PM with the DON, the DON stated the doors of the facility is always to be monitored by the receptionist or another staff member. The DON added that if the facility staff monitoring the doors needs to step away or leave, she/he needs to be properly relieved by other staff, so the doors is continuously monitored to ensure residents do not walk out of the facility unsupervised. During an interview on 5/30/2025 at 3:54 PM with the DON, the DON stated Resident 1 returned to the facility at 3:45 PM on 5/30/2025 with an unknown individual. During an interview on 5/30/2025 at 4:01 PM with the DSD, the DSD stated a staff member should always be monitoring the door to help prevent resident elopement. DSD stated the receptionist normally comes in around 9:30 AM to 10 AM and works until 6 PM. DSD stated if the receptionist is not there to monitor the facility doors, another staff member should be assigned to monitor the door. During an interview on 5/30/2025 at 4:08 PM with AD, AD stated on 5/30/2025 around 8:50 AM to 9:05 AM while he was doing his rounds in the hallway, he passed CNA 1 who told him that Resident 1 wanted to leave the facility and was observed packing his belongings into a bag. AD stated he went straight to the DON to notify her of what Resident 1 was doing and the DON went to check on the situation right away. During an interview on 5/30/2025 at 4:13 PM with CNA 1, CNA 1 stated on 5/30/2025 around 8:40 AM, she observed Resident 1 gathering his belongings and asked him what he was doing. CNA 1 stated Resident 1 told her it was none of her business and she proceeded to inform AD of what she saw and continued with her assignment. CNA 1 then stated she noticed Resident 1 was gone (could not recall the exact time) after she went to follow-up after working with another resident. During an interview on 5/30/2025 at 4:22 PM with Resident 1, Resident 1 stated he left the faciity on the morning of 5/30/2025 because he needed to do some things at home and when he asked if he could leave, he was told no and so he left on his own. Resident 1 stated when the staff walked away from the doors, he stated he walked out of the building. Resident 1 then stated when he left the facility, he went to the bus stop and went to his apartment. Resident 1 stated that a friend of his picked him up from his apartment and brought him back to the facility. During an interview on 5/30/2025 at 4:31 PM with the DON, the DON stated residents who are high risk for elopement are the residents verbalizing wanting to leave or showing signs, such as packing their clothes. The DON stated interventions included are applying a wander guard (bracelets that residents wear, which is a tracking device to alert staff when a resident exits the facility), having a bed alarm (monitors resident's movement and alerts the staff when movement is detected) and a binder at the nurse's station to indicate who the high risk for elopement residents are. During the same interview with the DON on 5/30/2025 at 4:31 PM, a concurrent record review of Resident 1's elopement risk evaluation, dated 5/8/2025 was conducted. The DON stated the elopement risk evaluation indicated Resident 1 was assessed at low risk. The DON stated Resident 1's elopement risk should have been reassessed as soon as Resident 1 was observed packing his belongings and wanting to leave the facility, which could have increased Resident 1's risk of leaving the facility unsupervised. During an interview on 5/30/2025 at 4:37 PM with SSA, SSA stated around 8:45 AM to 8:50 AM, CNA 1 told him that Resident 1 was packing up his belongings and stated for CNA 1 to mind her own business. SSA stated the DON called him around 8:55 AM to also notify him of Resident 1 wanting to leave. DON instructed SSA to speak with Resident 1. SSA stated around 8:56 AM, he went to speak with Resident 1 to ask the resident why he was packing his belongings and Resident 1 told him it was none of his business. SSA stated around 9:05 AM, he gave the facility's cordless phone to Resident 1 so that he could speak with his family member. SSA then stated he left to go to the DON's office and was instructed by the DON to ensure the facility doors was monitored. SSA stated he went to the doors, but the receptionist was not there yet since she was running late. SSA stated there were staff (not specified) within the vicinity of the doors, but no one was specifically watching the doors. During an interview on 5/30/2025 at 5:09 PM with SSA, SSA stated on 5/30/2025 around 9:12 AM, he went to the facility front entrance, and no one was there, so he went to his office to grab his papers to get ready for the department head meeting which he attended at 9:34 AM. SSA stated once the meeting was over around 10 AM, CNA 1 approached all the department heads and asked if anyone had seen Resident 1 since he was not in his room. During a concurrent interview and record review of the facility's undated Policy and Procedure (P&P) titled, Resident Elopement and Resident 1's Care Plan dated 5/30/2025 on 5/30/2025 at 5:31 PM, the DON stated the P&P did not indicate that the facility's doors should be monitored. The DON stated the facility's doors being monitored for 24 hours and seven (7) days a week (24/7) should be included in the elopement policy to prevent residents from eloping. During the same interview on 5/30/2025 at 5:31 PM with the DON, the DON stated the facility doors should have been monitored as instructed which could have prevented Resident 1 from eloping. During a review of the facility's undated P&P titled, Resident Elopement, the P&P indicated, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Under policy interpretation and implementation, the P&P also indicated: A. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). B. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. C. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Intervention to try to maintain safety, such as a detailed monitoring plan will be included.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) for abuse (the willful infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm) prevention, reporting, and investigation for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Report physical abuse (any intentional act causing injury or trauma to another person) by Resident 3 to Resident 2 within two hours from when the Activities Assistant (AA) witnessed Resident 3 punching (strike with a fist) Resident 2 on the chest while waiting inside the elevator on 4/15/2025. There was no documented evidence that the facility reported the incident to State Survey agency (SA or California Department of Public Health [CDPH]- a governmental body or institution established by a state government to perform specific functions or responsibilities like enforcing laws), Ombudsman (a designated official who advocates for the rights and well-being of residents in long-term care facilities), and law enforcement from 4/15/2025 to 5/8/2025. 2. Investigate and provide documentation of investigation of Resident 3's physical abuse to Resident 2. 3. Protect Resident 1 and other residents in the facility from further abuse and/or another abuse by Resident 3 when the facility did not report to SA, Ombudsman, and law enforcement when Charge Nurse 1 (CN 1), Restorative Nursing Assistant 1 (RNA 1), and Housekeeping Staff (HKS) witnessed Resident 3 touch Resident 1's inner thigh and inside the resident's shirt touching Resident 1's upper back. 4. Investigate and provide documentation of investigation of the sexual abuse (non-consensual touching of one person for the sexual gratification of another) incident by Resident 3 towards Resident 1 on 5/6/2025. These deficient practices resulted in Resident 2 experiencing physical abuse from Resident 3 on 4/15/2025 and Resident 1 experiencing sexual abuse from Resident 3 on 5/6/2025. It also placed other residents in the facility potential for physical and sexual abuse from Resident 3 due to Resident 3's inappropriate behavior. On 5/8/2025, Resident 1 expressed feeling scared and did not feel safe in the facility since the incident occurred with Resident 3. Resident 2 was placed at risk for physical and/or psychosocial (having to do with the spiritual, emotional, social, and mental aspects of a person's life) effects such as experiencing fear. On 5/8/2025 at 6:36 PM, the California Department of Public Health (CDPH) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance [not following rules] with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident) with regards to the facility's failure to implement their policy and procedure for abuse prevention, reporting and investigation for Resident 1 and Resident 2. The facility submitted an acceptable IJ Removal Plan (action to correct the deficient practice), to CDPH on 5/11/2025 at 5:21 PM. The IJ was removed on 5/11/2025, after the surveyor verified and confirmed the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Administrator Consultant (ADMC) and the Director of Staff Development (DSD). The acceptable IJ Removal Plan included the following information: 1) Resident 3 was transferred to General Acute Care Hospital (GACH) for psychiatric (relating to mental illness) evaluation on 5/8/2025 at 10:51 PM. The attending physician issued the order for transfer at 5/8/2025, at 7:09 PM. 2) Resident 3 was on one-on-one watch on 5/8/2025 until transportation arrived for pickup. An order was obtained from the physician, and a log was used by the staff to document. 3) On 5/8/2025 at 7:14 PM, Psychiatrist Physician Assistant (PPA- a licensed healthcare professional who practices medicine under the supervision of a physician, specializing in the diagnosis and treatment of mental illness) evaluated Resident 1 for psychological support and emotional distress. On 5/8/2025 at 7:40 PM, the PPA evaluated Resident 2 for psychological support and emotional distress. On 5/8/2025 at 7:11 PM, the PPA evaluated Resident 3 as well for psychosocial support (the provision of emotional, social, and mental health assistance to individuals or groups experiencing challenges) and emotional distress. 4) The Psychologist (mental health professional who specializes in the study of the mind and behavior) vendor came to the facility on 5/9/2025 at 10:04 AM to evaluate Resident 1 for psychosocial distress (the emotional, social, and/or spiritual discomfort an individual experiences when overwhelmed by stressful situations, particularly those that impact their quality of life) related to the recent case of sexual abuse. The Psychologist vendor came to the facility on 5/9/2025 at 10:59 AM to evaluate Resident 2 for psychosocial distress related to the recent case of physical abuse. According to the psychologist's notes for Resident 1, the psychologist notes indicated, The recent incident of alleged sexual misconduct appears to be managed by the facility's safety protocols. On 5/10/2025 at 8:26 AM, Resident 1 was transferred to GACH for psychiatry (psych) evaluation, per the attending physician's order. According to the psychologist notes for Resident 2, the psychologist notes indicated, patient is currently stable and not experiencing significant psychological distress related to the reported incident. 5) 72 Hours SBAR (Situation, Background, Assessment, Recommendation - a structured communication tool used to improve clean and efficient communication, especially in critical situations or when transferring information between health-care professionals) initiated for Resident 1 on 5/8/2025, including assessment of emotional distress. 6) 72 Hours SBAR initiated for Resident 2 on 5/8/2025, including assessment of emotional distress. 7) (Late) Report of SOC-341 (Report of Suspected Dependent Adult/Elder Abuse form- a mandated form used to document reports of suspected elder and dependent adult abuse) was completed on 5/8/2025 and faxed to the LTC (long-term care) Ombudsman (a designated official who advocates for the rights and well-being of residents in long-term care facilities) on 5/8/2025 at 10:05 PM and faxed to CDPH on 5/8/2025 at 10 PM for the incident of sexual abuse experienced by Resident 1. The local police department came to the facility to follow up on the telephonic report on 5/9/2025 at 9:40 AM for the incident of sexual abuse to Resident 1. 8) (Late) Report of SOC-341 was completed on 5/8/2025 and faxed to LTC Ombudsman on 5/8/2025 at 9:38 PM and faxed to CDPH on 5/8/2025 at 9:40 PM for the incident of physical abuse experienced by Resident 2. Local Police Dept. came to the facility to follow up on the telephonic report on 5/9/2025 at 9:40AM for the incident of physical abuse to Resident 2. 9) On 5/8/2025, 5/9/2025, and 5/10/2025, the DSD in-serviced all staff for abuse prevention, reporting, and investigation. 10) On 5/10/2025, ADMC in-serviced the following staff: 7 AM - 3 PM Licensed Nurses and Department Heads regarding Abuse Prevention, Investigation, and Reporting with emphasis placed on the importance of staff knowing how to report telephonically to CDPH, LTC Ombudsman, Local PD and how to complete and fax the SOC-341 form to CDPH and LTC Ombudsman. 11) On 5/10/2025, ADMC in-serviced the following staff: 3 PM to 11 PM Licensed Nurses regarding Abuse Prevention, Investigation, and Reporting with emphasis placed on the importance of staff knowing how to report telephonically to CDPH, LTC Ombudsman, Local PD and how to complete and fax the SOC-341 form to CDPH and LTC Ombudsman. 12) On 5/10/2025, the ADM attended an approved training course for abuse prevention and reporting. Training course is approved by the [NAME] (National Association of Long Term Care Administrator Boards- the authority for leadership core competencies in long term care) for 1 hour ([NAME] Approval- #A-DL) and administered via Website Address A, the training course was completed by the Administrator on 5/10/2025. On 5/10/2025, the ADMC gave a one-on-one in- service to the ADM regarding F600 and F607. 13) Beginning 5/10/2025, Daily Room Rounds sheets will include questions such as: Do you feel safe? and Are you getting along with your roommate? and Do you feel safe in all areas of the facility, such as hallways, elevator, activities room, rehab room, and dining areas? 14) The incident of sexual abuse experienced by Resident 1 was care planned by the MDS Nurse on 5/8/2025. 15) The incident of physical abuse experienced by Resident 2 was care planned by the MDS Nurse on 5/8/2025. 16) If Resident 3 is readmitted to the facility, the resident can have in-room activities to ensure other residents are not subjected to unwanted touching or view of the resident touching himself. 17) The daily resident census for 5/9/2025 was surveyed by Social Services Director (SSD) and assistants to ensure that no other residents experienced abuse at the hands of Resident 3 during their stay in the facility. The answers of the residents will be documented. 18) Evaluation of the Abuse Prevention Program will be discussed with the board of physicians in the monthly Quality Assessment (QA- the specification of standards for quality of service and outcomes, and systems throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards)/Utilization Review (UR-a process that evaluates the appropriateness and necessity of healthcare services, treatments, and procedures) meeting with emphasis on all cases of abuse being reported within 2 hours. The abuse log will be reviewed in the monthly QA/UR meeting to ensure all cases of abuse are documented for their given month. 19) Interviews were conducted on 5/9/2025 with Resident 1 and associated witness as part of the facility's sexual abuse investigation. 20) Interviews were conducted on 5/9/2025 with Resident 2 and associated witness as part of the facility's physical abuse investigation. 21) The Medical Director (MD) was called and visited the facility on 5/9/2025 and discussed solutions regarding the deficient practices (an action, error, or lack of action on the part of the facility that leads not non-compliance with a regulatory requirement or standard). 22) Facility appointed temporarily an Abuse Coordinator on 5/10/2025, in consultation with the ADMC. The new Abuse Coordinator will be Business Office Manager (BOM). An alternate abuse coordinator will be made available in the event the Business Office Manager is unavailable. The alternate abuse coordinator will be: Central Supply Director (CSD). The ADMC in-serviced the new Abuse Coordinator and the alternate Abuse Coordinator regarding the role of an abuse coordinator. Please see attached the acknowledgement letter. The in-coming Director of Nursing (DON) who will start on 5/12/2025 will be the new Abuse coordinator. The ADMC will in-service the incoming DON regarding the role of Abuse Coordinator and the F-Tag 600 and F-Tag 607 starting tomorrow, 5/12/2025. Please see attached application and offer letter for the DON that will start on 5/12/2025. 23) Beginning 5/10/2025, while the facility is not in compliance with F600 and F607, ADMC will be employed as an ADMC to oversee the current facility ADM and give guidance on implementation of the immediate Plan of Action (POA) to ensure total compliance is achieved. 24) On 5/10/25 at 4:00pm, the ADMC, in consultation with the President of the facility, suspended the assigned facility administrator for 5 days. If the conditions of counseling are not met further disciplinary actions up to termination are recommended. 25) On 5/11/2025, the ADMC recommended to the President and Chief Executive Officer (CEO) to terminate the ADM and to start looking for a new ADM. The CEO agreed with the recommendation and will start looking for a new candidate as soon as possible. The CEO expects to hire a qualified candidate within 30 days. 26) The in-coming DON who will start on 5/12/2025 will serve as the interim Nursing Home ADM, while the current ADM is on suspension. The ADMC will provide oversight to the interim NH ADM/DON regarding F607 starting on 5/12/25. Once the facility hired a new ADM, the new ADM will be the Abuse Coordinator. Cross reference F600, F684, and F842 Findings: 1. During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included other recurrent depressive disorder (persistent sadness and loss of interest in activities, affecting thoughts, behaviors, feelings, and well-being), schizophrenia (a mental illness that can affect thoughts, moods, and behavior), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1's History and Physical Examination (H&P), dated 4/30/2024, the H&P indicated Resident 1 could make needs known but could not make medical decisions due to cognitive (mental action of process of acquiring knowledge and understanding) decline. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/3/2025, the MDS indicated Resident 1 was assessed having moderately impaired cognitive skills for daily decision making. Resident 1 required partial/moderate assistance (helper does more than half the effort) with upper body dressing, personal hygiene, sit to stand, and chair/bed-to-chair transfer. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. During a review of Resident 1's Care Plan Report, dated 10/31/2024, the care plan indicated Resident 1 had a history (hx) and episodes of verbalizing, I don't want to live anymore (no suicidal ideation plan verbalized) and was a potential/at risk for injury to self. Resident 1's care plan interventions indicated the following: Psychology (study of human mind and its functions especially those affecting behavior in a given context) consult and treatment (tx) as/if indicated Social Services Director (SSD) for psychosocial support Stay with Resident if Resident shows signs and symptoms of sadness, notify physician (MD) of change in condition (COC) During a review of Resident 1's Diagnostic Evaluation (Psychology) report, dated 5/9/2025, the report indicated the following: Resident 1 was referred following an allegation that another male Resident touched her inner thigh and rubbed her back on 5/6/2025. The referral also includes a review of her current risk statements, which include recurrent declarations of I want to die. Observed engaging in repetitive rocking behavior, which may be indicated of internal distress (state of unease or discomfort experienced within oneself often stemming from thoughts, feelings and experiences rather than outside factors) or an anxiety (an emotional state characterized by feelings of unease such as worry or fear that can range from mild to severe)-regulating mechanism. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing, bilateral (affecting both sides) primary osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) of knee, and other specified polyneuropathies (damage to multiple nerves typically affecting both sides of the body and often starting in the hands and feet). During a review of Resident 2's MDS indicated Resident 2 was assessed having intact memory and cognitive skills for daily decision making. Resident 2 required set up or clean up assistance with oral/personal hygiene, upper/lower body dressing, and eating. Resident 2 was independent with toileting hygiene, sit to lying, sit to stand, and toilet transfer. Resident 2 required supervision or touching assistance with walking 150 ft. 3. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), recurrent depressive disorder, and specified anxiety disorder. During a review of Resident 3's H&P, dated 3/22/2025, the H&P indicated Resident 3 had a fluctuating capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was assessed having moderately impaired cognitive skills for daily decision making. Resident 3 required supervision or touching assistance with oral hygiene, upper body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident 3 was independent with wheeling his manual wheelchair at least 50 feet (ft- unit of measurement) and make two turns and 150 ft in a corridor or similar space. During an observation on 5/8/2025, at 10:58 AM, Resident 3 was observed sitting in his room watching television. Resident 3's room was located on the same floor as Resident 1. Resident 3 refused to be interviewed. During an interview on 5/8/2025, at 10:59 AM, with Charge Nurse 1 (CN 1), in the presence of the DON, CN 1 stated on 5/6/2025, at around 1 PM, Resident 1 and Resident 3 were sitting on their wheelchairs and were placed next to each other in the hallway in front of Room A. CN 1 stated Resident 1 and Resident 3 were waiting to be taken to the Activity Room. CN 1 stated she was sitting in the nurse's station and when she stood up, observed Resident 3 touch Resident 1 on her inner thigh. CN 1 stated she called Resident 3's name and observed Housekeeping Staff (HKS) pull Resident 3's wheelchair away from Resident 1 and parked it on the opposite side of the hallway. CN 1 stated Resident 3 wheeled his wheelchair to Resident 1 and rubbed her back from behind. CN 1 stated she walked towards Resident 1 and Resident 3 and wheeled Resident 3 to the nurse's station. CN 1 stated Resident 3 denied touching Resident 1 when she asked him why he touched her. CN 1 stated Resident 1 stated she did not feel comfortable being touched by Resident 3 after the incident happened. CN 1 stated Restorative Nursing Assistant 1(RNA 1) HKS also witnessed the incident. CN 1 stated Activities Assistant (AA) arrived and brought Resident 1 and Resident 3 to the activity room. CN 1 stated she followed Resident 1 and Resident 3 to the Activity room and informed AA that Resident 1 and Resident 3 were not allowed to sit next to each in the activity room. CN 1 stated AA informed her that Resident 3 was always placed away from the female residents in the activity room because of past incidences where Resident 3 had been touchy. CN 1 stated she did not know what AA meant by touchy and did not ask AA. During the same interview with CN 1 on 5/8/2025, at 10:59 AM, CN 1 stated AA was aware of the incident between Resident 1 and 3 that happened on 5/6/2025, and did not report Resident 3's inappropriate behavior to the ADM. CN 1 stated she was a mandated reporter (a person who is required by law to report suspected cases of abuse and neglect to the authorities) and reported the incident between Resident 1 and 3 to the ADM five minutes after she left the activity room. CN 1 stated the ADM told her he was not going to report the incident to CDPH. CN 1 stated the process in the facility regarding abuse was to report the abuse to the abuse coordinator immediately. CN 1 stated the facility's abuse coordinator was the ADM. CN 1 stated abuse should be reported to CDPH, LTC Ombudsman, and the police within 2 hours from when the abuse was witnessed/suspected, or the allegation was made. During the same interview on 5/8/2025, at 11:10 AM, with CN 1 and the DON, CN 1 stated on 4/15/2025, Resident 3 punched Resident 2 on the chest while Residents 3, 2 and AA were in the elevator. CN 1 stated Resident 3 stated he punched Resident 2 in retaliation to a prior incident when Resident 2 got upset at Resident 3 for walking between Resident 2 and another resident in the facility. The DON stated Resident 3 had a history of causing problems with other residents at a different facility. During a concurrent observation and interview on 5/8/2025, at 11:32 AM, with Resident 1, Resident 1 was sitting on her wheelchair outside of her room. Resident 1 was alone and was rocked back and forth during the interview. Resident 1 stated that a couple of days ago Resident 3 touched her and pointed to her scapular (the flat triangular bone located on the back of the upper body) area when asked where she was touched. Resident 1 stated the incident occurred in the hallway close to the nurse's station while waiting to go to the activity room. Resident 1 stated she told Resident 3 to stop touching her and to leave her alone. Resident 1 stated she did not feel safe in the facility because she was raped (a type of sexual assault involving sexual intercourse, or other forms of sexual penetration, carried out against a person without their consent) before when she was living in the streets. Resident 1 stated only CN 1 talked to her about the incident since it happened. Resident 1 stated she was brought to the Activity room after the incident happened. Resident 1 stated Resident was also brought to the Activity room after the incident happened. Resident 1 stated she felt scared that Resident 3 was in the same room as her but felt like there was nothing she could do about it. During an interview on 5/8/2025, at 12:05 PM, with RNA 1, RNA 1 stated on 5/6/2025, she observed Resident 3 wheel his wheelchair towards Resident 1 and touch her inner thigh. RNA 1 stated she called Resident 3's name to get his attention. RNA 1 stated she did not stop Resident 3 from touching Resident 1 because she was pushing another resident towards the nurse's station. RNA 1 stated Resident 3 had a history of verbally abusing and talking about female body parts to the Certified Nursing Assistants (CNA). RNA 1 stated she spoke to Resident 1 after the incident and Resident 1 stated she felt scared because the incident with Resident 3 reminded her of what happened in the past. RNA 1 stated she was a mandated reporter and reported the incident to CN 1 but RNA 1 was not sure what happened after. RNA 1 stated abuse should be reported to CDPH, LTC Ombudsman, and the police right away or within two hours from when it happened. RNA 1 stated it was important to investigate and report the abuse to CDPH to ensure the safety of the residents. RNA 1 stated the ADM never interviewed RNA 1 about what she witnessed between Resident 1 and 3. During an interview on 5/8/2025, at 12:39 PM with CNA 1, CNA 1 stated about a month ago Resident 2, and Resident 3 had a fight in the elevator. During an interview on 5/8/2025, at 1:50 PM, with HKS, HKS stated on 5/6/2025, she was cleaning Room A and saw Resident 1 and 3 sitting next to each other in the hallway. HKS stated she observed Resident 3 touch Resident 1's inner thigh as she walked out of Room A. HKS stated she told Resident 3 not to touch Resident 1 and immediately pulled his wheelchair on the other side of the hallway. HKS stated she walked to the nurse's station and informed CN 1 about the incident. HKS stated she saw Resident 3 wheel himself back to Resident 1's wheelchair and observed Resident 3 place his hand inside Resident 1's shirt and touched Resident 1's upper back. HKS stated Resident 1 looked scared during the incident and rocked back and forth in her wheelchair. HKS stated Resident 3 always spoke dirty (use sexually explicit language) whenever a female staff enters Resident 3's room. During a concurrent interview and record review on 5/8/2025, at 2:25 PM with the Minimum Data Set Nurse (MDSN), MDSN stated on 5/6/2025, an unknown CNA reported to CN 1 that Resident 3 touched Resident 1 inappropriately on Resident 1's inner thigh and upper back. MDSN stated on 5/6/2025, CN 1 informed the ADM regarding the incident between Resident 1 and Resident 3. MDSN stated that inappropriate touching was considered sexual abuse. MDSN stated abuse allegations should have been investigated by the ADM who was the facility's abuse coordinator. MDSN stated abuse allegations should be reported immediately or within two hours to CDPH, LTC Ombudsman, and the police. MDSN stated the ADM was the person responsible in the facility for reporting abuse to the SAs. MDSN stated she did not know if the ADM reported the incident between Resident 1 and 3 to the SAs. MDSN stated the incident between Resident 1 and Resident 3 should have been investigated by the ADM. MDSN stated she did not know if the ADM reported and investigated the incident between Resident 1 and Resident 3 that happened on 5/6/2025. MDSN stated she has not seen the police in the facility to investigate the incident between Resident 1 and Resident 3. MDSN stated Resident 1 and Resident 3 did not have an investigation report or a copy of the faxed SOC 341 (State of California's form used to report elderly abuse) about the incident on 5/6/2025 in the residents' charts. During the same concurrent interview and record review on 5/8/2025, at 2:25 PM, with the MDSN, MDSN stated she has not seen the police in the facility to investigate the physical abuse between Resident 2 and Resident 3 that happened on 4/15/2025. MDSN stated Resident 2 and 3 did not have an investigation report or a copy of the faxed SOC 341 about the physical abuse on 4/15/2025 in their charts. During an interview, on 5/8/2025, at 3 PM, with AA, AA stated approximately 4 weeks ago (around April) she was inside the elevator in the Activity room with Resident 2 and Resident 3. AA turned her back away from Resident 2 and Resident 3 to operate the elevator when she heard a noise. AA stated she turned around and saw Resident 3 punching Resident 2 at least three times on Resident 2's chest. AA stated Resident 2 attempted to punch Resident 3 back but could not reach him because of the resident's walker. AA stated she stood between Resident 2 and Resident 3 to stop them from punching each other. AA stated she reported the physical abuse immediately to Licensed Vocational Nurse 1 (LVN 1). AA stated the Activities Director (AD) and Medical Record Director (MRD) witnessed and assisted AA in separating Resident 2 and Resident 3 in the elevator. AA stated abuse needed to be reported immediately to the ADM. AA stated she reported the physical abuse to LVN 1 but not to the ADM. AA stated after the incident, the ADM met with the DON, MDSN, Resident 2 and Resident 3 in the ADM's office. AA stated she did not know if the ADM reported the physical abuse to CDPH, ombudsman and/or the police after the meeting. AA stated all facility staff are mandated reporters. During an interview, on 5/8/2025, at 4:56 PM, with Resident 2, Resident 2 stated Resident 3 punched him on his right chest in the elevator last month (unable to recall when) and the incident took place inside the elevator. Resident 2 stated Resident 3 was his roommate before, but they never got along. Resident 2 stated Resident 3 always got mad and yelled at him for waking up early and making noise. Resident 2 stated Resident 3 was a problematic resident and did not want to have anything to do with him. During an interview, on 5/8/2025, at 6:14 PM, with the ADM, in the presence of the DON, the ADM stated the alleged sexual abuse between Resident 1 and Resident 3 happened on 5/6/2025. ADM stated he did not investigate the incident that took place on 5/6/2025 between Resident 1 and Resident 3. The ADM stated he did not report the incident between Resident 1 and Resident 3 to CDPH, police, and LTC Ombudsman. During the same interview, on 5/8/2025, at 6:14 PM, with the ADM, in the presence of the DON, the ADM stated he was informed on 4/15/2025 that Resident 2 and Resident 3 had an altercation in the elevator after attending activities. The ADM stated Resident 3 punched Resident 2 for an unknown reason. The ADM stated he did not report the altercation between Resident 2 and Resident 3 to CDPH, LTC Ombudsman, and the police. The ADM stated he did not have an investigation report about the altercation between Resident 2 and Resident 3. During an interview, on 5/9/2025, at 12:05 PM, with MRD and Medical Records Assistant (MRA), MRD stated on 4/15/2025, she heard AA yell ayuda (help) in the Activity room elevator. MRD stated she and MRD ran to the elevator and saw Resident 3 trying to punch Resident 2. MRD stated she pulled Resident 3 out of the elevator and AA proceeded to take Resident 2 to his room. MRD stated she reported the altercation to LVN 1, SSD, and the DSD. MRD stated she did not report the incident to the ADM because he was not available. MRD stated abuse should be reported by all facility staff immediately or within 2 hours to CDPH, LTC Ombudsman, and police. MRD and MRA both stated they knew how to call the police and the LTC Ombudsman but stated they did not know how to report to CDPH. MRD and MRA both stated they did not know what an SOC 341 was and how to fill out a SOC 341 form. MRD stated it was important to report and investigate abuse for the safety of the residents in the facility. During an interview, on 5/9/2025, at 1:55 PM, with LVN 1, LVN 1 stated on 4/15/2025, AA notified him about the incident in the elevator between Resident 2 and Resident 3. LVN 1 stated the incident between Resident 2 and Resident 3 should have been reported to CDPH, the police and Ombudsman. LVN 1 stated the DON, and the ADM should fill out and send the SOC 341 form to CDPH for all alleged/witnessed abuse. LVN 1 stated he did not know if the ADM reported the altercation between Resident 2 and 3 to CDPH. LVN 1 stated he never saw the police come to the facility to investigate the altercation between Resident 2 and Resident 3. LVN 1 stated he did not know if the ADM investigated the incident between Resident 2 and Resident 3. During the same interview, on 5/9/2025, at 1:55 PM, with LVN 1, LVN 1 denied any knowledge about the incident that took place on 5/6/2025 between Resident 1 and Resident 3. LVN 1 stated the investigation should have included interviews from the witnesses, Resident 1, and Resident 3. LVN 1 stated it was the responsibility of the abuse coordinator to investigate abuse once it was reported. LVN 1[TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) right to be free from sexual abuse (non-consensual [without the person's permission] touching of one person for the sexual gratification of another) on 5/6/2025 by failing to ensure: 1. Resident 1 was protected from sexual abuse by Resident 3. On 5/6/2025, while Resident 1 was sitting on her wheelchair along the hallway in front of Room A, Resident 3 touched Resident 1 on her inner thigh and later Resident 3 was witnessed touching Resident 1's upper back by placing his hands inside Resident 1's shirt. 2. Resident 1 was protected from further abuse by Resident 3 when facility staff did not separate Resident 1 from Resident 3. On 5/6/2025, Resident 1 and Resident 3 attended the same recreational group activity in the Activities Room. 3. Further abuse was to Resident 1 and other residents in the facility from Resident 3 when the facility failed to address Resident 3's behavior of touching his private part (a person's external sexual organs or genitals) during group activities in the Activity Room. These deficient practices resulted in Resident 1 experiencing sexual abuse, expressed feeling scared and not feeling safe in the facility since the incident occurred with Resident 3 on 5/6/2025. On 5/8/2025 at 6:31 PM, the California Department of Public Health (CDPH) called an Immediate Jeopardy situation (IJ, a situation in which the facility's noncompliance [not following rules] with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a Resident) due to the facility's failure to protect Resident 1 from sexual abuse. The facility submitted an acceptable IJ Removal Plan (action to correct the deficient practice), to CDPH on 5/11/2025 at 5:20 PM. The IJ was removed on 5/11/2025, after the surveyor verified and confirmed the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Administrator Consultant (ADMC) and the Director of Staff Development (DSD). The acceptable IJ Removal Plan included the following information: 1) Resident 3 was transferred to General Acute Care Hospital (GACH) for psychiatric (relating to mental illness) evaluation on 5/8/2025 at 10:51 PM. The attending physician issued the order for transfer at 5/8/2025, at 7:09 PM. 2) Resident 3 was on one-on-one watch on 5/8/2025 until transportation arrived for pickup. 3) On 5/8/2025 at 7:14 PM, Psychiatrist Physician Assistant (PPA- a licensed healthcare professional who practices medicine under the supervision of a physician, specializing in the diagnosis and treatment of mental illness) evaluated Resident 1 for psychological support and emotional distress. On 5/8/2025 at 7:11 PM, the PPA evaluated Resident 3 as well for psychosocial support (the provision of emotional, social, and mental health assistance to individuals or groups experiencing challenges) and emotional distress. 4) The Psychologist (mental health professional who specializes in the study of the mind and behavior) vendor came to the facility on 5/9/2025 at 10:04 AM to evaluate Resident 1 for psychosocial distress (the emotional, social, and/or spiritual discomfort an individual experiences when overwhelmed by stressful situations, particularly those that impact their quality of life) related to the recent case of sexual abuse. According to the psychologist's notes for Resident 1, the psychologist notes indicated, The recent incident of alleged sexual misconduct appears to be managed by the facility's safety protocols. On 5/10/2025 at 8:26 AM, Resident 1 was transferred to GACH for psychiatry (psych) evaluation, per the attending physician's order. According to the psychologist notes for Resident 2, the psychologist notes indicated, patient is currently stable and not experiencing significant psychological distress related to the reported incident. 5) 72 Hours SBAR (Situation, Background, Assessment, Recommendation - a structured communication tool used to improve clean and efficient communication, especially in critical situations or when transferring information between health-care professionals) initiated for Resident 1 on 5/8/2025, including assessment of emotional distress. 6) (Late) Report of SOC-341 (Report of Suspected Dependent Adult/Elder Abuse form- a mandated form used to document reports of suspected elder and dependent adult abuse) was completed on 5/8/2025 and faxed to the LTC (long-term care) Ombudsman (a designated official who advocates for the rights and well-being of residents in long-term care facilities) on 5/8/2025 at 10:05 PM and faxed to CDPH on 5/8/2025 at 10 PM for the incident of sexual abuse experienced by Resident 1. The local police department came to the facility to follow up on the telephonic report on 5/9/2025 at 9:40 AM for the incident of sexual abuse to Resident 1. 7) On 5/8/2025, 5/9/2025, and 5/10/2025, the DSD in-serviced all staff for abuse prevention, reporting, and investigation. 8) On 5/10/2025, ADMC in-serviced the following staff: 7 AM - 3 PM Licensed Nurses and Department Heads regarding Abuse Prevention, Investigation, and Reporting with emphasis placed on the importance of staff knowing how to report telephonically to CDPH, LTC Ombudsman, Local PD and how to complete and fax the SOC-341 form to CDPH and LTC Ombudsman. 9) On 5/10/2025, ADMC in-serviced the following staff: 3 PM to 11 PM Licensed Nurses regarding Abuse Prevention, Investigation, and Reporting with emphasis placed on the importance of staff knowing how to report telephonically to CDPH, LTC Ombudsman, Local PD and how to complete and fax the SOC-341 form to CDPH and LTC Ombudsman. 10) On 5/10/2025, the ADM (Administrator) attended an approved training course for abuse prevention and reporting. Training course is approved by the [NAME] (National Association of Long Term Care Administrator Boards- the authority for leadership core competencies in long term care) for 1 hour ([NAME] Approval- #2862013-1.05-3574-DL) and administered via: https://ltctrainer.com/product/elder-abuse-1011.cfm, the training course was completed by the Administrator on 5/10/2025. On 5/10/2025, the ADMC gave a one-on-one in-service to the ADM regarding F600 and F607. 11) Beginning 5/10/2025, Daily Room Rounds sheets will include questions such as: Do you feel safe? and Are you getting along with your roommate? and Do you feel safe in all areas of the facility, such as hallways, elevator, activities room, rehab room, and dining areas? 12) The incident of sexual abuse experienced by Resident 1 was care planned by the MDS Nurse on 5/8/2025. 13) The incident of physical abuse experienced by Resident 2 was care planned by the MDS Nurse on 5/8/2025. 14) If Resident 3 is readmitted to the facility, the resident can have in-room activities to ensure other residents are not subjected to unwanted touching or view of the resident touching himself. 15) The daily resident census for 5/9/2025 was surveyed by Social Services Director (SSD- a person responsible for ensuring the resident's social, emotional, and physical needs are met in the facility ) and assistants to ensure that no other residents experienced abuse at the hands of Resident 3 during their stay in the facility. The answers of the residents (from the daily census) will be documented. 16) The Medical Director (MD) was called and visited the facility on 5/9/2025, and discussed solutions regarding the deficient practices (an action, error, or lack of action on the part of the facility that leads not non-compliance with a regulatory requirement or standard). 17) Facility appointed temporarily an Abuse Coordinator on 5/10/2025, in consultation with the ADMC. The new Abuse Coordinator will be Business Office Manager (BOM). An alternate abuse coordinator will be made available in the event the Business Office Manager is unavailable. The alternate abuse coordinator will be: Central Supply Director (CSD). The ADMC in-serviced the new Abuse Coordinator and the alternate Abuse Coordinator regarding the role of an abuse coordinator. Please see attached the acknowledgement letter. The in-coming Director of Nursing (DON) who will start on 5/12/2025 will be the new Abuse coordinator. The ADMC will in-service the incoming DON regarding the role of Abuse Coordinator and the F-Tag 600 and F-Tag 607 starting tomorrow, 5/12/2025. Please see attached application and offer letter for the DON that will start on 5/12/2025. 18) Beginning 5/10/2025, while the facility is not in compliance with F600 and F607, ADMC will be employed as an ADMC to oversee the current facility ADM and give guidance on implementation of the immediate Plan of Action (POA) to ensure total compliance is achieved. 19) On 5/10/2025 at 4 PM, the ADMC in consultation with the President of the facility, suspended the assigned facility ADM for 5 days. If the conditions of counseling are not met further disciplinary actions up to termination are recommended. 20) On 5/11/2025, the ADMC recommended to the President and Chief Executive Officer (CEO) to terminate the ADM and to start looking for a new ADM. The CEO agreed with the recommendation and will start looking for a new candidate as soon as possible. The CEO expects to hire a qualified candidate within 30 days. 21) The in-coming DON will serve as the interim Nursing Home ADM while the current ADM is on suspension. The ADMC will provide oversight to the interim ADM and the abuse coordinator regarding F-Tag 600 starting on 5/12/2025. Once the facility hires a new ADM, the new ADM will be the Abuse Coordinator. Cross reference F607, F684, and F842 Findings: During a review of Resident 1's admission Record, it indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included other recurrent depressive disorder (persistent sadness and loss of interest in activities, affecting thoughts, behaviors, feelings, and well-being), schizophrenia (a mental illness that can affect thoughts, moods, and behavior), and unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 1's History and Physical Examination (H&P), dated 4/30/2024, the H&P indicated Resident 1 could make needs known but could not make medical decisions due to cognitive (mental action or process of acquiring knowledge and understanding) decline. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/3/2025, the MDS indicated Resident 1 was assessed having moderately impaired cognitive skills (decisions poor; cues/supervision required) for daily decision making. Resident 1 required partial/moderate assistance (helper does more than half the effort) with upper body dressing, personal hygiene, sit to stand, and chair/bed-to-chair transfer. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, and lower body dressing. During a review of Resident 1's Recreational Group Participation Record (a record that indicates resident participation in a recreational activity or event), dated 5/2025, the record indicated Resident 1 participated in activities in the Activity Room from 5/1/2025 to 5/8/2025. During a review of Resident 1's Care Plan Report, dated 10/31/2024, the care plan indicated Resident 1 had a history (hx) and episodes of verbalizing, I don't want to live anymore (no suicidal ideation plan verbalized) and was a potential/at risk for injury to self. Resident 1's care plan interventions indicated the following: Psychology (study of human mind and its functions especially those affecting behavior in a given context) consult and treatment (tx) as/if indicated SSD for psychosocial support Stay with Resident if Resident shows signs and symptoms of sadness, notify physician (MD) of change in condition (COC) During a review of Resident 1's Diagnostic Evaluation (Psychology) report, dated 5/9/2025, the report indicated the following: Resident 1 was referred following an allegation that another male resident touched her inner thigh and rubbed her back on 5/6/2025. The referral also includes a review of her current risk statements, which include recurrent declarations of I want to die. Observed engaging in repetitive rocking behavior, which may be indicated of internal distress (state of unease or discomfort experienced within oneself often stemming from thoughts, feelings and experiences rather than outside factors) or anxiety (an emotional state characterized by feelings of unease such as worry or fear that can range from mild to severe)-regulating mechanism During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included unspecified dementia (a progressive state of decline in mental abilities), recurrent depressive disorder, and specified anxiety disorder. During a review of Resident 3's H&P, dated 3/22/2025, the H&P indicated Resident 3 had a fluctuating capacity (when a resident may sometimes have the capacity to make certain choices and other times not, depending on their cognitive state) to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was assessed having moderately impaired cognitive skills for daily decision making. Resident 3 required supervision or touching assistance with oral hygiene, upper body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Resident 3 was independent with wheeling his manual wheelchair at least 50 feet (ft- unit of measurement) and making two turns and 150 ft in a corridor or similar space. During a review of Resident 3's Recreational Group Participation Record, dated 5/2025, the record indicated Resident 3 participated in activities in the Activity Room from 5/1/2025 to 5/6/2025. During an observation on 5/8/2025, at 10:58 AM, Resident 3 was observed sitting alone in his room watching television. Resident 3's room was located on the same floor as Resident 1. Resident 3 refused to be interviewed. During an interview on 5/8/2025, at 10:59 AM, with Charge Nurse 1 (CN 1) and the DON, CN 1 stated, on 5/6/2025, at around 1 PM, Resident 1 and Resident 3 were sitting on their wheelchairs and were placed next to each other in the hallway in front of Room A. CN 1 stated Resident 1 and Resident 3 were waiting to be taken to the Activity Room. CN 1 stated she was sitting in the nurse's station and when she stood up, observed Resident 3 touch Resident 1 on her inner thigh. CN 1 stated she called Resident 3's name and observed Housekeeping Staff (HKS) pull Resident 3's wheelchair away from Resident 1 and parked it on the opposite side of the hallway. CN 1 stated Resident 3 wheeled his wheelchair to Resident 1 and rubbed her back from behind. CN 1 stated she walked towards Resident 1 and Resident 3 and wheeled Resident 3 to the nurse's station. CN 1 stated Resident 3 denied touching Resident 1 when she asked him why he touched her. CN 1 stated Resident 1 stated she did not feel comfortable being touched by Resident 3 after the incident happened. CN 1 stated Restorative Nursing Assistant 1(RNA 1) and HKS also witnessed the incident. CN 1 stated Activities Assistant (AA) arrived and brought Resident 1 and Resident 3 to the activity room. CN 1 stated she followed Resident 1 and Resident 3 upstairs (in the activity room) and informed AA that Resident 1 and Resident 3 were not allowed to sit next to each other in the activity room. CN 1 stated AA informed her the Resident 3 was always placed away from the female residents in the activity room because of past incidences where Resident 3 had been touchy. CN 1 stated she did not know what AA meant by touchy and did not ask AA. During a concurrent observation and interview on 5/8/2025, at 11:32 AM, with Resident 1, Resident 1 was sitting on her wheelchair outside of her room. Resident 1 was alone and was rocking back and forth during the interview. Resident 1 stated that a couple of days ago Resident 3 touched her and pointed to her scapular (the flat triangular bone located on the back of the upper body) area when asked where she was touched. Resident 1 stated the incident occurred in the hallway close to the nurse's station while waiting to go to the activity room. Resident 1 stated she told Resident 3 to stop touching her and to leave her alone. Resident 1 stated she did not feel safe in the facility because she was raped (a type of sexual assault involving sexual intercourse, or other forms of sexual penetration, carried out against a person without their consent) before when she was living in the streets. Resident 1 stated only CN 1 talked to her about the incident since it happened. Resident 1 stated she was taken to the Activity room after the incident (Resident 3 inappropriately touching Resident 1 on 5/6/2026) happened. Resident 1 stated Resident 3 was also taken to the Activity room after the incident happened. Resident 1 stated she felt scared that Resident 3 was in the same room as her and felt like there was nothing she could do about it. During an interview on 5/8/2025, at 12:05 PM, with RNA 1, RNA 1 stated on 5/6/2025, she observed Resident 3 wheel his wheelchair towards Resident 1 and touch her inner thigh. RNA 1 stated she called Resident 3's name to get his attention. RNA 1 stated she did not stop Resident 3 from touching Resident 1 because she was pushing another resident towards the nurse's station. RNA 1 stated Resident 3 had a history of verbally abusing and talking about female body parts to the Certified Nursing Assistants (CNA). RNA 1 stated she reported the incident to CN 1. RNA 1 stated it was important to separate the residents to make them feel safe when there is suspected abuse. RNA 1 stated she spoke to Resident 1 after the incident. RNA 1 stated Resident 1 stated she felt scared because the incident with Resident 3 reminded her of what happened in the past. During an interview on 5/8/2025, at 1:50 PM, with HKS, HKS stated on 5/6/2025, she was cleaning Room A and saw Resident 1 and Resident 3 next to each other in the hallway. HKS stated she observed Resident 3 touch Resident 1's inner thigh on her way out of Room A. HKS stated she told Resident 3 not to touch Resident 1 and immediately pulled his wheelchair to the other side of the hallway. HKS stated she walked to the nurse's station and informed CN 1 about the incident. HKS stated while reporting to CN 1 she saw Resident 3 wheel himself back to Resident 1's wheelchair. HKS stated she observed Resident 3 place his hand inside Resident 1's shirt and touched Resident 1's upper back. HKS stated Resident 1 looked scared during the incident and rocked back and forth in her wheelchair. HKS stated Resident 3 always speaks dirty (use sexually explicit language) whenever a female staff enters his room. During a concurrent interview and record review on 5/8/2025, at 2:23 PM with the Minimum Data Set Nurse (MDSN), MDSN stated no documentation in Resident 1's chart about the incident on 5/6/2025 between Resident 1 and Resident 3. MDSN stated there was no documentation in Resident 3's chart about the incident on 5/6/2025 between Resident 1 and Resident 3. MDSN stated Resident 1 and Resident 3 documentation should have included an SBAR, progress note, care plan, and a 72-hour monitoring (a period of increased observation and assessment after a suspected incident of abuse or neglect, lasting 72 hours). MDSN stated no documentation was found in the charts that indicated Resident 1 and Resident 3's physicians and responsible parties were notified about the incident. MDSN stated it was important to notify the physician about sexual abuse so Resident 1 and Resident 3 could get the proper and necessary treatment or evaluation. MDSN stated Resident 1 and Resident 3 should have been separated and not attend activities at the same time and the same day. During an interview on 5/8/2025, at 3:23 PM, with AA, AA stated Resident 3 always rubbed his private part over Resident 3 clothes in the Activity room. AA stated when Resident 3 rubs his private part it looked like he was masturbating (stimulate one's own genitals for sexual pleasure). AA stated Resident 3 also liked looking at female residents and blow air kisses (to purse the lips as if kissing someone without making contact) at them. AA stated Resident 3's behavior made the female residents in the Activity room uncomfortable, so she would move Resident 3 away from the female residents and cover Resident 3 private area with a towel. AA stated Resident 3 would get mad every time AA told him to stop rubbing his private area. AA stated she reported Resident 3's behavior to the Activities Director (AD) and CNA 2. AA stated AD informed AA that AD would talk to Resident 3 about his behavior. AA stated she did not know if AD informed the DON or ADM about Resident 3's behavior. During the same interview on 5/8/2025, at 3:23 PM with AA, AA stated Resident 1 and Resident 3 arrived separately in the Activity room on 5/6/2025, at around 1 PM. AA stated CN 1 followed Resident 1 and Resident 3 to the Activity room and informed AA both residents needed to be seated away from each other but did not tell her why. During an observation in Resident 1's room on 5/8/2025 at 5:32 PM, the DON was observed asking Resident 1 if she felt safe in the facility. Resident 1 informed the DON she did not really feel safe in the facility because of what Resident 3 did to her. Resident 1 informed the DON that Resident 1 had a history of being raped before being admitted at the facility. During an interview on 5/8/2025, at 6:14 PM, with the ADM, the ADM stated the alleged sexual abuse between Resident 1 and Resident 3 happened on 5/6/2025. ADM stated there was no documentation that an assessment, monitoring or development of a care plan was done for Resident 1 and Resident 3 after the incident. The ADM stated facility staff should have assessed, monitored, and developed a care plan about the abuse incident between Resident 1 and Resident 3. During a concurrent interview and record review with AA on 5/9/2025, at 11:36 AM, Resident 1 and Resident 3's Recreational Group Participation Record, dated 5/2025 were reviewed. AA stated on 5/6/2025 Resident 1 and Resident 3 were both in the Activity room to watch a movie. AA stated she would not have had Resident 1 and Resident 3 in the Activity room at the same time if she knew about the incident in front of Room A. During an interview on 5/9/2025, at 11:54 AM, with AD, AD stated Resident 3 sat by the Medical Records (MR) room with a towel on his lap whenever he came to the Activity room. AD stated AA informed him about Resident 3 rubbing his private area around four months ago. AD stated he told Resident 3 to stop rubbing his private area as soon as he learned about it because there were female residents also went to the Activity room. AD stated Resident 3 told him he was just scratching his private area because he had a rash when AD told him to stop. AD stated he informed an unknown licensed nurse to check on Resident 3's rash. AD did not inform the ADM about Resident 3's behavior in the Activity room. During an interview on 5/9/2025, at 12:05 PM, with the Medical Record Director (MRD), the MRD stated Resident 1 and Resident 3 should not have been placed in the same room after the suspected abuse incident. MRD stated facility staff should have reported and documented Resident 3's behavior so that everyone was aware of his behavior. MRD stated facility staff could protect and prevent abuse from Resident 3 if everyone was aware of his behavior. During an interview on 5/9/2025, at 1:55 PM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 2 touching Resident 1 on Resident 1's inner thigh and back without her consent was considered sexual abuse. LVN 1 denied knowing about the incident but stated Resident 1 and Resident 3 should not have been placed in the Activity room after the incident because Resident 1 can re-live the trauma that she experienced from being touched by Resident 3. LVN 1 stated trauma can be repeated in the presence of the abuser. LVN 1 stated it was also possible that Resident 3 can abuse Resident 1 again by being in the same room as her. LVN 1 stated the facility staff who observed the sexual abuse should have assessed the resident, written an SBAR, documented what was seen in the progress notes, and monitored the resident for 72 hours. LVN 1 stated the physician should have been notified of the incident. LVN 1 stated the SSD should have talked to Resident 1 to assess her psychosocial status after the incident. LVN 1 stated a care plan should have been developed for Resident 1 and Resident 3 to address resident-centered interventions to care for a resident who experienced abuse and prevent abuse. During a follow- up interview on 5/9/2025, at 2:25 PM, CN1 stated she did not write an SBAR or a care plan regarding the inappropriate touching of Resident 3 towards Resident 1. CN 1 stated it was important to write a care plan for abuse to know what interventions are needed to prevent another abuse incident. During a concurrent follow up interview and record review on 5/9/2025, at 2:54 PM, with MDSN, MDSN stated Resident 3 did not have a progress note, interdisciplinary team meeting (IDT- a group of healthcare professionals from different disciplines who collaborate to provide comprehensive and coordinated care for a resident), or care plan indicating his behavior of touching himself inappropriately in the Activity room. During an interview on 5/9/2025, at 3:23 PM, with the MD, MD stated the facility did not inform him that Resident 1 was the victim of Resident 3's inappropriate behavior on 5/6/2025. The MD stated Resident 3's inappropriate behavior towards Resident 1 should have been reported to the police and CDPH. The MD stated Resident 1 and Resident 3 should not have been placed in the Activity room at the same time. The MD stated Resident 1 seeing Resident 3 in the same room can physically and emotionally affect her since she was alert and oriented. The MD stated the facility's policy and procedure (P&P) for abuse prevention and reporting was not followed. During an interview on 5/9/2025, at 4:47 PM, with SSD, SSD stated she was informed by an unknownstaff that Resident 3 touched Resident 1's thigh and upper back on 5/6/2025. SSD stated the ADM was informed of the incident but believed it was not considered abuse because Resident 1 was wearing pants and Resident 3 just touched her thigh. SSD stated she did not assess or talk to Resident 1 after the incident. SSD stated Resident 1 and Resident 3 should not have been placed in the Activity room together at the same time to ensure Resident 1's safety. SSD stated she should have advocated for Resident 1's safety in the facility. During an interview on 5/10/2025, at 11:53 AM with the ADM, in the presence of the ADMC, the ADM stated he was informed by several staff that Resident 3 had a history of inappropriately touching females at a different facility. The ADM stated CN 1 informed him on 5/6/2025 that Resident 3 touched Resident 1's inner thigh and upper back in the hallway. The ADM stated if Resident 3 touched Resident 1 on her inner thigh and upper back without Resident 1's consent then it was considered abuse. The ADM stated the facility staff did not follow the process for abuse involving Resident 1 and Resident 3. The ADM stated it was important for facility staff to prevent further interactions and incidents between Resident 1 and Resident 3. The ADM stated Resident 1 or Resident 3 should have been moved to a different floor in the facility to prevent them from seeing each other. The ADM also stated Resident 1 and Resident 3 should not have attended activities at the same time in the Activity room on 5/6/2025. The ADM stated there was potential harm to Resident 1's physical and emotional health because the memories from her previous rape can come back after the incident with Resident 3. The ADM stated the facility staff did not follow the facility's goal for Resident 1 which was to provide proper care, keep her safe and free from abuse, and take care of her emotional and physical well-being. The ADM stated he was the abuse coordinator in the facility. The ADM stated the responsibility of the abuse coordinator was to ensure abuse is prevented and investigated. The ADM stated the facility's P&P for abuse prevention was not followed. During a review of the facility's P&P, titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 03/2025, the P&P indicated the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to other residents. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Protect residents from any further harm during investigations.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary living environment to prevent the spread of Coronavirus (COVID-19, a respiratory illness that can spread through respiratory droplet from an infected person a non-infected to person) for 61 of 61 residents as indicated in the facility's infection control policies and COVID-19 mitigation plan (plan to reduce loss of life and limit the impact of COVID-19 in the facility) during the COVID-19 pandemic (spread of a disease worldwide) when the facility's administrative staff failed to: 1. Cohort (to group) residents who tested positive for COVID-19 from residents who tested negative for COVID-19. 2. Ensure there were designated breakrooms, restrooms, entrances, exits, personal protective equipment (PPE, gown, gloves masks worn to minimize exposure to COVID) donning (putting on) and doffing (taking off) areas for staff who were taking care the COVID-19 positive residents (COVID staff). 3. Ensure Resident 1, who tested positive for COVID 19, was wearing a face cover while sharing the same room with Resident 2 who tested negative for COVID-19. 4. Designate an interim (temporary) Infection Prevention Nurse (IPN who helps prevent and identify the spread of infectious agents like bacteria [MEDICAL CONDITION] in a healthcare environment) to manage, prevent and control the spread of COVID-19 in the facility while the full time IPN was out sick. 5. Ensure staff perform hand hygiene (wash or sanitize hands) after contacting with objects in the room of a COVID-19 positive resident. 6. Ensure Quality Assurance meeting (meeting to review and improve care and services to the residents) was conducted with staff regarding the COVID-19 outbreak. These deficient practices resulted in the spread of COVID 19 that led to 45 residents had tested positive for COVID 19. These deficient practices also had the potential to result in further spread of COVID-19 to other residents and staff. On 6/24/20 at 3:40 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) for the facility's failure to implement measures to prevent infection that threatened the health and safety of 61 residents and staff. On 6/27/20 at 5:36 p.m., the immediate jeopardy was lifted after the facility submitted an acceptable plan of action (POA, actions to correct deficient practices), the survey team verified the implementation of the POA by observation, interview and record review then confirmed the removal of the immediate jeopardy in the presence of the ADM and the DON. The POA included the following actions: 1. On 6/24/20 and 6/25/20, facility's staff moved all confirmed positive COVID-19 residents to the second floor (Station 2, designated area for positive COVID-19 residents) and all non-COVID-19 residents to the 1st floor (Station 1, designated area for negative COVID-19 residents ). Facility's staff moved persons under investigations (PUI, residents suspect to have COVID-19) to room [ROOM NUMBER]. The provided inservice regarding green zone (non COVID area), yellow zone (PUI area) and red zone (COVID area). 2. On 6/26/20, The Fire Department Operator #175 approved the use of the fire exit door. Staff who were taking care of COVID positive residents had their own entrance and exit into the red zone. Dining room on the 1st floor was converted to Nursing Station and break room for COVID staff. Signages were put in-place to remind staff to wash their hands, to don and doff their PPE. Staff in the yellow zone has designated restroom. The IPN provided in services for donning and doffing of PPE. The ADM and the DON provided in services for staff to ensure non-COVID staff must not use the breakrooms and restroom dedicated for COVID staff. 3. On 6/24/20 and 6/25/20, the ADM and the DON provided in services for staff to provide face masks to positive COVID-19 residents. 4. On 6/27/20, the administrator hired an interim IPN to work 40 hours a week. 5. On 6/24/20, the ADM and DON provided in services for staff to perform hand hygiene before and after contact with residents or objects in the residents' environment. 6. On 6/29/20, the AMD conducted a Quality Assurance (QAA, refers to the identification, assessment, correction and monitoring of important aspects of patient care designed to enhance the quality of care) meeting to discuss about the COVID-19 outbreak with facility's staff. Findings: 1. During the observation and interview on 6/24/20 at 11:26 a.m., the facility did not have a define (specify) green zone, yellow zone, and red zone. The Administrator (ADM) stated there were more than twenty residents who tested positive for COVID-19. The ADM stated Residents 1, 8, 10, 12, 13, 16, 18, 22, 25, 27, 28, 33, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 had tested positive for COVID-19. The ADM stated he had not separated these positive residents from the resident who had tested negative for COVID-19. The ADM did not answer to why he failed to cohort these residents During a tour of the facility, a review of the facility's Daily Roster Census and a concurrent interview with the ADM on 6/24/20 at 12:18 p.m., he stated the following: a. Resident 1 was tested positive for COVID-19 and had symptoms of shortness of breath, sharing a room with Resident 2 who tested negative for COVID-19. b. Resident 8 was tested positive for COVID-19, sharing a room with Resident 9 who tested negative for COVID-19. c. Resident 13 was tested positive for COVID-19, sharing a room with Resident 14 and Resident 15 who both tested negative for COVID-19. d. Resident 18 was tested positive for COVI-19, sharing a room with Resident 19 who tested negative for COVID-19. e. Resident 22 was tested positive for COVID-19, sharing a room with Resident 23 who tested negative for COVID-19. f. Resident 25 was tested positive for COVID-19, sharing a room with Resident 26 who tested negative for COVID-19. g. Resident 33 was tested positive for COVID-19, sharing a room with Resident 35 who tested negative for COVID-19. A review of the laboratory reports dated 6/23/20, indicated on 6/23/20 at 11:30 a.m., the Laboratory Clinical Specialist (LCS, staff works in the lab) notified the ADM via email that the facility had more than 20 residents who tested positive for COVID 19. The LCS reminded the ADM that the facility is having an outbreak (a certain increase in the number of positive COVID 19 cases) and he needed to implement the proper protocols to prevent further spread of COVID-19. The CLS received an email receipt indicating the ADM opened the email on 6/23/20 at 5:43 p.m. (the survey team entered the facility on 6/24/20, 18 hours after). A review of the facility's Mitigation Plan, titled COVID-19 Testing & Cohorting, dated 6/1/20, indicated the facility would place the residents into three separate cohorts (red, green and yellow zones) based on the test results. According to the Centers for Disease Control and Prevention at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, indicated if the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. 2. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 6/24/20 at 11:40 a.m., there was no designated area for staff to don their PPE outside of the red zone. LVN 1 stated staff need to go inside the plastic barrier (the red zone) to don their PPE. During an observation inside the red zone, on 6/24/20 at 12:30 p.m., there were no posters/signages to remind staff to wash their hands or don and doff their PPE. There was no breakrooms or restroom designated for staff who worked in the red zone (COVID area). LVN 1 stated that: 1. Staff assigned to the red zone would don the PPE inside the plastic barrier. 2. There was no breakrooms or restroom designated for the staff who care for positive COVID-19 residents. 3. There was no doffing area in the red zone. 4. There were no specific entrance and exit for the COVID area. During an interview on 6/24/20 at 12:35 p.m., the ADM stated there were no designated donning and doffing area for the red zone. The ADM stated the red zone with confirmed COVID-19 positive residents was on the first floor. The ADM stated the ambulance entered and accessed the facility by the hallway in the red zone area. A review of the facility's Mitigation Plan, titled COVID-19 Testing & Cohorting, dated 6/1/20, indicated residents who tested positive with COVID-19 would have dedicated health care providers and staff would use separate break rooms and restrooms. A review of the facility's undated policy and procedure, titled Designation of Space, indicted for the facility to ensure separation of infected residents and for eliminating movement of health care workers among those spaces to minimize transmission risk. According to the Centers for Disease Control and Prevention at https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, indicated to place signages at the entrance to the COVID-19 care unit to instruct health care professionals they must wear eye protection and an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) or higher-level respirator or facemask if a respirator is not available at all times while on the unit. Gowns and gloves should be worn when entering resident rooms. 3. A review of Resident 1's Laboratory Report, dated 6/23/20, indicated the resident tested positive for COVID-19. A review of Resident 2's Laboratory Report, dated 6/24/20, indicated the resident tested negative for COVID-19. During an observation on 6/24/20 at 11:45 a.m., Resident 1 was lying in bed with no face covering. Resident 1 was sharing the same room with Resident 2. During an interview and a review of the facility's Daily Roster Census on 6/24/20 at 12:18 p.m., the ADM stated Resident 1 had symptoms of shortness of breath and was tested positive for COVID-19. The ADM stated Resident 1 was sharing a room with Resident 2 who tested negative for COVID-19. A review of the facility's Mitigation Plan, titled COVID-19 Infection Prevention and Control, dated 6/1/20, indicated all residents and staff are required to wear face covering while residing in the facility. 4. During an interview on 6/24/20, at 11:30 a.m., the DON stated the facility's IPN was out sick and there was no certified IPN available in the facility to perform the IPN's job functions. The DON stated she did not know which residents were tested positive for COVID-19. The DON stated she was not familiar with the process on how to cohort residents who tested positive for COVID 19. During an interview with the DON on 6/24/20 at 11:38 a.m., she stated five COVID-19 positive residents were the red zone on the first floor. The DON stated there were 18 other residents on the first floor waiting for their COVID-19 test results, but she could not identify these 18 residents nor the room where they resided. During an interview on 6/24/2020, at 12:35 p.m., the ADM stated the IPN's last day of work was on 6/10/20 and that he had not hired an interim IPN since 6/10/20. A review of the facility's Mitigation Plan, titled COVID-19 Infection Prevention and Control, dated 6/1/20, indicated the facility had a full-time dedicated IP nurse. 5. A review of Resident 1's Laboratory Report, dated 6/23/20, indicated the resident tested positive for COVID-19. During a concurrent observation on 6/24/20 at 11:45 a.m., Resident 1 had a plastic nasal cannula (flexible plastic tubing used to deliver oxygen through nostrils) with oxygen at 2 liters per minute (LPM, velocity at which air flows). The plastic tubing was on the floor. The DON stated the plastic tubing should not be on the floor. The DON proceeded to pick the plastic tubing from the floor with her bare hands and placed it on the resident's bed. The DON did not perform hand hygiene and left the room. The DON proceeded to use her contaminated bare hand touching the doorknob to open the door that lead to the stairs to the second floor. A concurrent interview was conducted; the DON stated she did not perform hand hygiene after she touched Resident 1's nasal cannula tubing. A review of the facility's undated policy and procedure, titled General Standard Precautions, indicated for staff to wash their hands aft her contact with objects and surfaces in the resident's environment. A review of the facility's Mitigation Plan, titled COVID-19 Infection Prevention and Control, dated 6/1/20, indicated for staff to wash their hands or use alcohol-based hand sanitizer. 6. During an interview on 6/24/20 at 11:26 a.m., the ADM stated Residents 1, 8, 10, 12, 13, 16, 18, 22, 25, 27, 28, 33, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 had tested positive for COVID-19 but he had not notified his staff. The ADM stated his staff did not know which residents were tested positive for COVID-19. During an interview on 6/26/20 at 4:10 p.m., the ADM stated the facility did conduct a Quality Assessment and Assurance meeting to discuss about the COVID-19 outbreak with his staff. During a telephone interview on 6/26/20 at 4:23 p.m., the facility's Medical Director 1 (MD 1, a physician who provides guidance and leadership on the use of medicine in a healthcare organization) stated he was not aware that the facility had a COVID-19 outbreak and was under an IJ related to infection control due to the spread of COVID-19 in the facility. During an interview on 6/26/20 at 4:31 p.m., the ADM stated he did not inform MD 1 regarding the IJ on infection control because he did not have a chance to call MD 1. A review of the facility's undated policy and procedure, titled Communication, indicated the facility will communicate the prevalence of confirmed cases of COVID-19 to staff, daily. A review of the facility's undated policy and procedure, titled Quality Assessment and Assurance Program, indicated the administrator or designee shall be responsible for overseeing the Quality Assessment and Assurance (QAA) Program in order to meet the needs, goals and objectives of the resident population that it serves and meet the standard of care. The policy indicated the QAA committee shall consist of the medical director and other key facility's staff members as may assigned or deemed appropriate.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices for one of one sampled resident ( Resident 1). The facility failed by not: 1. Placing Resident 1 in a room closed to the nursing station for increased visual check and using bed mobility monitors such as bed alarm and bed sensor as per their policy and procedure. 2. Providing Resident 1 a pad alarm to remind the resident not to get up unassisted and a bed sensor to alarm the staff everytime the resident tries to get up, as per physician's orders [REDACTED].>3. Updating the resident's care plan to reflect measures that would prevent future falls of same nature from one fall to another. Resident 1 had 2 prior falls (on 7/16/16 and 8/16/16 ) before the fall on 9/16/16. These failures resulted in Resident 1, who was assessed to be at high risk for falls, falling again on 9/16/16, where she sustained a left intertrochanteric (hip) fracture that required transport to the acute care hospital. Findings: On 10/5/16 at 11:40 a.m., a review of Resident 1's clinical record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS/an assessment and care screening tool) dated 7/25/16, indicated Resident 1 was cognitively intact, but required a Chinese speaking interpreter. Resident 1 required extensive assistance ( one person physical assist ) for bed mobility, transfers, ambulation, dressing, bathing and toilet use. The initial fall risk assessment dated [DATE], identified Resident 1 to be at risk for falls due to multiple medications (use of three different medications that could contribute to her risk for falls) and hypnotic (medication used to induce sleep) use, inability to walk and history of fall. During an interview on 10/5/16 at 11:50 a.m., the Director of Nurses (DON) stated on 9/25/16 at around 115 p.m., Resident 1 had an unwitnessed fall while using a walker to go to the bathroom. The DON stated the Certified Nurse Assistant (CNA 1) heard the resident fell , ran to her side and called for help. The DON stated Resident 1 did not have a bed alarm and the bed sensor only alarmed at the nurses' station. The DON stated Resident 1 was placed closer to the nurses' station after the third fall. The DON stated Resident 1 did not complain of pain initially, but the staff called the doctor, who ordered 72 hour neuro checks, and notification of the family. The DON also stated Resident 1 went to activities the next morning after the fall and started complaining of hip pain in the presence of the physician who ordered X-rays and transport to an acute facility. On 10/5/16 at 12:05 p.m., during an interview, Resident 1's family member (FM 1) who was interpreting for Resident 1, stated Resident 1 was attempting to go to the bathroom when she fell at the foot of her bed. FM1 stated Resident 1 stated she could not remember to use the call light. During an interview on 10/12/16 at 1:37 p.m., CNA 1 stated Resident 1 was in the back hallway (in a room far from the nurses' station) when she fell . CNA 1 stated she did not hear any alarm from Resident 1's room, but heard a noise and Resident 1 called out. CNA 1 stated she was not assigned to Resident 1, but ran into the room, called for help and assisted Resident 1 back to bed with other staff members. CNA 1 also stated Resident 1 was frightened but did not appear to be in pain. On 10/12/16, a review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. On 10/12/16, a review of the care plan titled, Resident found sitting on the floor due to unwitnessed fall / High risk for repeated fall and injury dated 7/1/2016, included intervention to maintain call light within easy reach and answer promptly. The care plan dated 8/31/16 ,titled Actual fall , indicated interventions to maintain call light within reach, answer promptly and assist resident to bathroom. After the third fall, a review of the care plan dated 9/25/16, titled Actual Fall , indicated the same interventions, but now placed Resident 1 closer to the nurses' station with frequent observations. The care plan did not indicate how frequently. A review of the facility's policy and procedures titled, Administrative Policies and Procedures for Long Term Care; Nursing Services, dated 8/4/07, indicated monitoring a high risk resident may be done by placing the resident near the nurses' station for increased visual monitoring, and doing a visual check of the resident at least every 15 minutes, using mobility monitors (i.e. Voice Sentry Bed & Chair Monitoring Device, Sensor Floor Mat, Drop Seat with Alarm, Sensor Pad Alarms), others.