Every finding on record at Kern Valley Healthcare District DP SNF

Based on observation, interview and record review, the facility failed to implement effective infection control practices when:Facility staff did not provide hand hygiene to three of five sampled residents (Resident 26, Resident 30, and Resident 15). This failure had the potential to spread infection to residents. Housekeeping staff did not follow Enhanced Barrier Precautions (EBP - gown and gloves are used during care of residents with indwelling medical devices and open wounds, to prevent infection) for one of one sampled resident (Resident 6) when cleaning Resident 6's room. This failure had the potential to result in Resident 6 developing an infection. Findings: 1. During an observation on 4/20/26 at 12:26 p.m. with Certified Nursing Assistant (CNA) 3 in Resident 26's room, CNA 3, delivered a lunch tray to Resident 26. During an observation on 4/20/26 at 12: 29 p.m. with CNA 4, in Resident 30's room, CNA 4 delivered and set up Resident 30 's lunch tray by cutting up meat on lunch plate. During an observation and interview on 4/20/26 at 12:36 p.m. with Resident 30 in Resident 30's room, Resident 30 had a lunch tray in front of him and was eating. Resident 30 stated he did not get anything to clean his hands prior to getting his lunch tray. During an observation and interview on 4/20/26 at 12:39 p.m. with Resided 26 in Resident 26's room, Resident 26 had a lunch tray she was using a knife and fork. Resident 26 stated the staff did not give him something to clean his hands before lunch today. During an interview on 4/20/26 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the process was to provide hand hygiene to the residents prior to the meal. During an interview on 4/20/26 at 12:47 p.m. with Registered Nurse (RN) 1, RN 1 stated the staff were to provide hand hygiene to residents prior to meals. During a concurrent observation and interview on 4/20/26 at 12:50 p.m. with Resident 15, in Resident 15's room. Resident 15 was eating her chocolate pudding with her fingers. Resident 15 was asked if the staff had offered her hand hygiene. Resident 15 stated they did not. During a concurrent observation and interview on 4/20/26 at 12:54 p.m. with CNA 3, in Resident 15's room. CNA 3 was seen giving Resident 15 her lunch tray. CNA 3 was asked if she had provided or offered Resident 15 hand hygiene. CNA 3 stated she did not and she should have. During a review of Resident 15's Brief Interview for Mental Status (BIMS, a screening tool used in long term care to evaluate cognitive function.13-15 points: cognitively intact; 8-12 points: moderate cognitive impairment; 0-7 points: severe cognitive impairment), dated 4/3/26, the BIMS score was 4. During a review of the facility's policy and procedure (P&P) titled, Infection Control-Resident Care Hand Hygiene by Residents, dated 2016, the P&P indicated, Residents are informed and encouraged to perform hand hygiene to prevent transmission of potentially infectious organisms to others.In the case of the non-ambulatory resident, facility staff will assure the resident has access to methods of performing hand hygiene. 2. During an observation on 4/22/26 at 9:49 a.m. outside of Resident 6's room, a sign on the wall indicated Resident 6 was on EBP. Housekeeper (HK) 1 entered Resident 6's room wearing only gloves and cleaned Resident 6's overbed table, top of dresser, handles of drawers, and shutters covering the window. During a concurrent observation and interview on 4/22/26 at 9:56 a.m. with Infection Preventionist (IP), outside of Resident 6's room, HK 1 was mopping the floor wearing only gloves. IP stated Resident 6 was on EBP due to having a urinary catheter (tube inserted into the bladder to drain urine). IP stated HK 1 needed to wear a gown in addition to gloves, while cleaning Resident 6's room. During an interview on 4/22/26 at 9:58 a.m. with HK 1, HK 1 stated the EBP sign indicated that she was to wear a gown and gloves when entering the room, but was not sure which resident was on EBP or why. HK 1 stated she did not wear a gown while cleaning Resident 6's room. During a review of the facility's P&P titled, Infection Control – Transmission-based Precautions, dated 6/13/24, the P&P indicated, C. Enhanced Barrier Precaution is used for residents with medical devices and chronic wounds. 6 moments of care:. cleaning the environment. Enhanced Barrier Precautions include: . a. Personal Protective Equipment (PPE) [gloves and gown] are made available. 1) All personnel and visitors are to make use of the PPE necessary for protection before going into the room when the anticipated 6 moments of care are provided. 3) Gloves: Must be worn by staff upon entering the room and removed upon leaving when providing 6 moments of care is anticipated. 4) Gowns: Will be worn when providing 6 moments of care and anytime there is an anticipation of contamination from the resident and or the environment.

Based on interview and record review the facility failed to follow its policies and procedures (P&P) titled, Staffing, Sufficient and Competent Nursing, for all residents when a Registered Nurse (RN) was not present in the facility for eight working hours. This failure had the potential for residents needs to go unmet.Findings:During a concurrent interview and record review on 4/22/26 at 10:59 a.m. with Director of Nursing (DON), the facility's Total Skilled Nursing Hours (TSNH), dated October 2025 and December 2025 was reviewed. The following dates indicated:On 10/26/25 Census 52 residents, and 0 RN hours.On 10/30/25 Census 52 residents, and 0 RN hours.On 12/29/25 Census 55 residents, and 0 RN hours.On 12/30/25 Census 55 residents, and 0 RN hours.DON stated the facility did not have a RN covering the floor on those dates.During an interview on 4/22/26 at 11:10 a.m. with Assistant Director of Nursing (ADON), ADON stated in October they did not have a RN on 10/26/25 or 10/30/25.During a review of the facility's P&P titled, Staffing, Sufficient and Competent Nursing, dated 7/28/25, the P&P indicated, A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) day a week.

Based on observation, interview, and record review, the facility failed to follow its Policy and Procedure (P&P) tiled, Medication Storage, for one of one medication cart when Licensed Vocational Nurse (LVN) 1, left the medication cart unlocked in the hallway. This failure had the potential for accidental ingestion of medication by a wondering resident.Findings:During an observation on 4/21/26 at 11:39 a.m. with LVN 1 in the hallway during medication pass, there was unattended blood sugar supplies (including lancets [small needle], diabetic test strips, testing solutions and glucometer) on top of a medication cart that was left unlocked.During an observation on 4/21/26 at 11:51 a.m. with LVN 1 in hallway outside Resident 6's room during medication pass. there were unattended blood sugar supplies and the medication cart was left unlocked. During an interview on 4/21/26 at 11:53 a.m. with LVN 1, LVN 1 stated normally when he walked away, he would lock the medication cart.During an interview on 4/21/26 at 11:55 a.m. with LVN 2, LVN 2 stated yes, she did see LVN 1 did not lock the medication cart twice when he walked away. LVN 2 stated yes, the blood sugar supplies needed to be locked on top of the cart.During a review of the facility's P&P titled, Medication Storage, dated 5/26/15, the P&P indicated, Medications shall be locked and attended by persons with authorized access.

During an observation, interview, and record review, the facility failed to ensure one of two cooks (Cook 2) followed the Hair and beard Restraint policy and procedures (P&P), when [NAME] 2 did not have a beard cover. This failure had the potential for food contamination.Findings: During an observation on 4/21/26 at 10:45 a.m. in the kitchen, [NAME] 2 had a full beard on his face. [NAME] 2 was cutting up strawberries and was not wearing a beard cover. During an interview on 4/21/26 at 10:47 a.m. with [NAME] 2, [NAME] 2 stated he should use a beard cover while in the kitchen. During an interview on 4/21/26 at 10:51 a.m. with Certified Dietary Manager (CDM) in the kitchen, CDM stated she did not know why [NAME] 2 was not wearing a beard cover and stated he should have been. During a review of the facility's P&P titled, Hair and [NAME] Restraint' dated 2020, the P&P indicated, Hair and beard restraints are designed and worn to effectively keep hair from contacting food, clean equipment and utensils. Staff entering and working in the kitchen must wear a hair and beard restraint.

Based on observation, interview and record review, the facility failed to ensure two of two sampled housekeeping carts (Cart 1 and Cart 2) were secured and cleaning chemicals were not accessible by residents. These failures had the potential to result in residents accessing the cleaning chemicals causing injury or death.Findings: During a concurrent observation and interview on 4/22/26 at 9:43 a.m. with Housekeeper (HK) 1 by Cart 1, Cart 1 had an open bucket on the outside of the cart that was half full of clear liquid. HK 1 used a measuring container to dip the liquid from the bucket and poured it into the mop handle, then placed the container back into the bucket. A small bucket was on top of the cart half full of clear liquid. A pocket on the side of the cart contained two containers, one labeled Super Sani Cloth [cleaning chemical], and one labeled Sani Cloth Bleach [cleaning chemical]. HK 1 stated the smaller bucket contained a cleaning chemical used to wipe down the resident rooms. During a concurrent observation and interview on 4/22/26 at 10:03 a.m. with HK 2 by Cart 2, Cart 2 had an open bucket on the outside of the cart that was half full of clear liquid, with mop heads a measuring container. A small bucket on top of the cart contained clear liquid. A pocket on the side of the cart contained two containers, one labeled Super Sani Cloth, and one labeled Sani Cloth Bleach. HK 2 stated the mop bucket and small bucket (on top of cart) contained microkill 3 [cleaning chemical]. HK 2 stated the container in the mop bucket was used to pour cleaning chemical into the mop handle. HK 2 stated the cart was not to be left unattended while in the facility because there were some confused residents who would take things off the cart. HK 2 stated she was unable to stay with the cart at all times, while she was in the resident rooms cleaning, the cart was left unattended. During an interview on 4/23/26 at 12:04 p.m. with Director of Nursing (DON), DON stated housekeeping staff were to keep cleaning chemicals locked and secured at all times while in the facility due to confused residents who liked to wander the hallways. DON stated the confused residents could pick something up and be injured. During a review of the facility's policy and procedure (P&P) titled, Cleaning Skilled Nursing Resident Room, dated 3/2/11, the P&P indicated, E. Housekeeping personnel will keep the cleaning cart in view at all times in the Skilled Nursing Unit. F. No dangerous items will be kept on the cart.

Based on observation, interview, and record review, the facility failed to ensure physician orders (PO) to monitor oxygen saturation (O2 Sat- a measurement of how much oxygen your blood is carrying as a percentage of the maximum it could carry) was followed for one of eight sampled residents (Resident 1). This failure had the potential for Resident 1 not to receive the appropriate oxygenation that is required to maintain the parameters the physician ordered. Findings:During an observation on 4/20/26 at 10:50 a.m. in Resident 1's room. Resident 1 was not receiving oxygen (a colorless and odorless gas that is essential for life) while lying in her bed.During a concurrent observation and interview on 4/20/26 at 3:11 p.m. with Resident 1 in Resident 1's room, an oxygen concentrator (a medical device that delivers oxygen in short bursts upon inhalation) was seen in Resident 1's room. Resident 1 was not using her nasal cannula (a flexible tube put in the nostrils to deliver supplemental oxygen to a patient). Resident 1 stated she did not need the oxygen machine in her room.During a concurrent observation and interview on 4/20/26 at 3:19 p.m. with Registered Nurse (RN) 9 in Resident 1's room, Resident 1 was not using her nasal cannula. RN 9 stated Resident 1's PO for oxygen is PRN (as needed) and at medication pass they check her O2 Sat's.During a review of Resident 1's Brief Interview for Mental Status (BIMS- a screening tool used in long term care to evaluate cognitive function.13-15 points: cognitively intact; 8-12 points: moderate cognitive impairment; 0-7 points: severe cognitive impairment), dated 3/3/26, the BIMS score was 9.During a concurrent interview and record review on 4/22/26 at 1:45 p.m. with Assistant Director of Nurses (ADON), Resident 1's Order Summary (OS), dated 2/24/26 was reviewed. The OS indicated, Verify O2 saturation is at or above 92% [percent] if outside parameters notify RN to titrate as indicated to achieve O2 saturation at or above 92% two times a day.During a concurrent interview and record review on 4/22/26 at 1:49 p.m. with ADON, Resident 1's Medication Administration Record (MAR), O2 Sat results dated April 2026, were as follows:4/21/26 O2 Sat was 91%, ADON stated there was no documentation that an RN was notified and no O2 was administered to Resident 1.4/18/26 O2 Sat was 90%, ADON stated there was no documentation that an RN was notified and no O2 was administered.4/17/26 O2 Sat was 90%, ADON stated there was no documentation that an RN was notified and no O2 was administered.4/16/26 O2 Sat was 91%, ADON stated there was no documentation that an RN was notified and no O2 was administered.4/15/26 O2 Sat was 83%, ADON stated there was no documentation that an RN was notified and no O2 was administered.4/4/26 O2 Sat was 89%, ADON stated there was no documentation that an RN was notified and no O2 was administered.During an interview on 4/22/26 at 2:09 p.m. with ADON, ADON stated the Licensed Vocational Nurses (LVN's) did not follow the PO for O2 management and stated they should have. During a review of the facility's policy and procedure (P&P) titled, Oxygen Delivery, dated 2014, the P&P indicated, Oxygen therapy shall be initiated with an appropriate physician order.Acknowledge order. Check the physician order noting the indications, contraindications, and hazards of the type of therapy ordered.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Foods Brought in by Family or Visitors, when a designated refrigerator was not provided for resident's food that is brought in by family. This failure had the potential to place residents at risk of foodborne illness due to unmonitored food brought in by the family and could limit food choices and options for residents. Findings: During an interview on 4/23/26 at 8:42 a.m. in the staff breakroom with Certified Nursing Assistant (CNA) 1, CNA 1 was asked if residents were allowed or able to have food brought in to the facility from their family. CNA 1 stated she was new and stated she believed residents were able to receive food from visitors or family. CNA 1 stated she was not aware of the process or where to store the residents food brought in from family. During an interview on 4/23/26 at 8:46 a.m. in the activities room with CNA 2, CNA 2 was asked if residents were allowed or able to have food brought in to the facility from their family. CNA 2 stated she believed residents were able to keep food bought in from family in the activities refrigerator. CNA 2 stated I guess I don't know where the residents would put their food.During an interview on 4/23/26 at 8:55 a.m. with Activities Assistant (AA), AA stated she was not aware that the residents food could be stored in the activities refrigerator. During an interview on 04/23/2026 8:57 a.m. with the Director of Nurses (DON), DON was asked if the facility had a refrigerator where the residents may store food brought in from family or visitors. DON stated we do not have a designated refrigerator for the residents food.During a concurrent interview and record review on 04/23/2026 8:58 a.m. with DON, P&P titled Food Brought in by Family or Visitors dated 4/10/2026 was reviewed. The P&P indicated Storage of Outside Food:Perishable food brought in from outside sources may be stored in designated unit refrigerators. DON stated they no longer have a designated refrigerator for food brought into for the residents from the outside.

Based on observation, interview and record review, the facility failed to develop and implement a policy and procedure (P&P) for smoking for one of one resident (Resident 45). This failure had the potential to result in Resident 45 being unsafe while smoking and injury of Resident 45 and other residents.Findings: During an observation on 4/21/26 at 11:06 a.m. in the courtyard outside the door of the activities room, Resident 45 used a lighter to light a cigarette with procedure mask pulled down around her chin (still hooked over each ear). No facility staff was present, no ashtrays were within reach and there was a no smoking sign on the door to the activities room. During an observation on 4/21/26 at 11:20 am in the courtyard outside the door of the activities room, Resident 45 extinguished her cigarette on the side of a cup hanging on the side of her wheelchair, and placed the cigarette butt in the cup. Resident 45 then lit another cigarette, while her procedure mask was still pulled down around her chin (still hooked over each ear). There was no facility staff present. During an observation on 4/23/26 at 9:25 a.m. Resident 45 was lying in bed, with eyes closed and did not respond when greeted. Resident 45's wheelchair had a cup attached to the side with a cigarette case in the cup. The cigarette case contained a lighter. During a concurrent observation and interview on 4/23/26 at 9:29 a.m. with Certified Nursing Assistant (CNA) 5, in Resident 45's room, a lighter was in a cigarette case on Resident 45's wheelchair. CNA 5 stated Resident 45 was not allowed to have the lighter and was to give the lighter back to staff when she finished smoking each time. During an interview on 4/23/26 at 9:34 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 45 does not return her lighter sometimes and staff have to go look for it. RN 1 stated Resident 45 sometimes uses the cup on the side of her wheelchair to dispose of cigarette butts, but needed to use the facility provided ashtrays. RN 1 stated the facility had multiple confused residents who liked to wander and were at risk of injury due to having access to the lighter. During an interview on 4/23/26 at 12:15 p.m. with Director of Nursing (DON), DON stated there was no policy outlining the expectations for those residents who are allowed to smoke. DON stated Resident 45 was expected to smoke in the designated smoking area, use the facility provided ashtrays and return the lighter to the charge nurse to be locked up until needed again.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was able to exercise the right to refuse physician ordered meal consistency. This failure resulted in Resident 2's rights to make decisions on her care to be violated and had the potential for not meeting Resident 2's nutritional needs .Findings: During a review of Resident 2's Order Summary Report, (OSR) dated 10/15/25, the OSR indicated Resident 2's diet order was NAS (No Added Salt) diet pureed texture (foods are smooth, lump-free, and uniformly blended, resembling pudding or paste, used for people with chewing/swallowing difficulties), regular/thin consistency, no straws . During a review of Resident 2's care plan with the focus on non compliance with following recommendations related to diet/drinking fluids, initiated 10/16/25. The care plan indicated a few of the interventions were to Educate risk and benefits and possible outcomes of recommendations as needed .Observe for s/s of aspiration during routine care . residents right to refused recommendations to be respected. During a review of Resident 2's Minimum Data Set, (MDS - an assessment tool) dated 10/22/25, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status with a range of 0-15) score was 15 (a score of 13 to 15 suggests the resident is cognitively intact). During a review of Resident 2's Video Swallow Evaluation, (VSE) dated 12/11/25, the VSE indicated, Your Recommended Diet Texture Food texture: Minced & Moist (ground / minced, can smash with a fork, 1/4 inch pieces, moist and sticks together) Liquid Texture thin liquid by cup only, in chin tuck position (position involves gently gliding your chin straight back, as if making a double chin, without tilting your head up or down, to align your head over your shoulders, to assist with swallowing) or nectar thick (mildly thick like fruit syrup, coats the back of a spoon) During a review of Resident 2's OSR, dated 10/15/25, the OSR dated 12/11/25, indicated, NAS . diet Pureed Texture, Nectar/Mildly thick consistency . During a review of Resident 2's IDT Notes, dated 12/12/25, the IDT indicated, NP [nurse practitioner] discussed current diet order for Puree texture and nectar thickened liquids. Resident is noncompliant with these orders; she often eats food that family brings her, that is not within ordered diet and she always refuses thickened liquids, she will only drink thin liquids. NP clearly stated all possible risks associated with non-compliance of diet; up to and including death. NP states current dx [diagnosis] of pneumonia is likely caused by aspiration. NP states that res [Resident 2] chances of aspirating are very probable, if she continues to be non-compliant with diet. NP states that [Resident 2] stated, I don't care if this is what kills me. During a review of Resident 2's NN, dated 12/16/25, the NN indicated, [Resident 2] wanted to participate in Christmas hot chocolate bar and treats. Resident is on an ordered Pureed diet with nectar thick liquids per provider after video swallow evaluation. [DON] verified via phone with provider to see if resident could participate. It was stated that, she can participate but her hot chocolate and treats must meet the order dietary requirements of texture. [DON] and [Charge Nurse] went to activity room and explained what provider said. [Resident 2] stated I am going back to my room. I don't want any if I can't have it the way I want it. During a concurrent observation and interview, on 12/17/25 at 12:37 p.m. with Resident 2, in Resident 2's room. Resident 2's untouched lunch tray was sitting on her bedside table, there were seven types of pureed meats, potatoes, soups and desserts. Resident 2 stated I was in the hospital for Pneumonia and that is why the facility wants me to eat the mashed food, she stated I do not eat it, she stated she will eat the deserts. Resident 2 stated she told PN that she has gotten pneumonia almost every year but he did not change the diet. Resident 2 stated she has asked to speak to her previous medical doctor in hopes that he will change her diet order. Resident 2 stated she does not ask for alternate meal or textures she stated, I am stubborn and want it my way I will probably end up leaving, I love it here every everyone is nice, but if I die from eat food I like I am ok with that. Resident 2 stated the facility must bring the food, but they know I won't eat it. During an interview on 12/17/25 at 3:23 p.m. with Director of Nursing (DON), DON stated the facility does not have waivers for residents who refuse therapeutic diets. DON stated the facility does not offer minced moist texture. During a review of the facility's policy and procedure (P&P) titled, Patient Rights and Responsibilities, approval date 11/03, the P&P indicated, As a patient of [facility name], you have the right to: .5. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedures as you may need in order to give informed consent to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment, or non-treatment and the risk involved in each . 3. The patient is responsible for his actions if he/she refuses treatment or does not follow the physician's instructions.

Based on interview and record review, the facility failed to notify one of three sampled residents (Resident 4) family members when Resident 4 had a fall incident. This failure had the potential for Resident 4's family member to be unaware of Resident 4's fall. Findings:During a review of Resident 4's admission Record, (AR) dated 12/22/25, the AR indicated Resident 4's first emergency contact was his daughter and second emergency contact was his son. During a review of Resident 4's Minimum Data Set, (MDS - an assessment tool) dated 10/21/25, the MDS indicated, Resident 4's BIMS (Brief Interview for Mental Status-standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 4 (a score of 0-7 suggests the resident has severely impaired cognition).During a concurrent interview and record review, on 12/17/25 at 3:08 p.m. with the Director of Nursing (DON), Resident 4's Nursing Note, (NN) dated 12/1/25 at 6:04 a.m. was reviewed. The NN indicated Resident 4 was found on bathroom floor, nurse practitioner and DON were notified. DON reviewed Resident 4's progress notes and there was no documentation of Resident 4's family was notified of the fall incident.During a concurrent interview and record review, on 12/17/25 at 3:23 p.m. with DON, Resident 4's TRIPS Form Forms (Tracking Record for Improving Patient Safety - facility developed fall protocol packet), dated 12/1/25 was reviewed. DON stated there was no documentation on TRIPS Form Resident 4's family was notified, the section where family notification indicated, NA (not applicable) is documented. DON stated she does not know what NA means.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, approval date 9/2/15, the P&P indicated, Licensed staff shall promptly notify the resident, his or her attending physician, and family/ representative of changes in the resident's medical/mental condition and/or status . A. The Care Manager/Charge Nurse will notify the residents' Attending Physician or On-Call Physician and Director of Nursing Services when there has been: 1. An accident or incident involving the resident; . B. Unless otherwise instructed by the resident , the Care Manager/Charge Nurser will notify the resident's family or representative . when: 1. The resident is involved in any accident .

Based on interview and record review, the facility failed to provide care and services for one of three sampled residents (Resident 1) when Charge Nurse intentionally neglected to document, report, and assess Resident 1 after a fall incident. This failure had the potential for delay in care, Resident 1 feeling neglected, and injury.Findings:During a review of Resident 1's Minimum Data Set, (MDS - an assessment tool) dated 10/1/25, the MDS indicated Resident 1's BIMS (Brief Interview for Mental Status) score was 11 (a score of 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 had impairments to both upper extremities (shoulders, elbows, wrists, hands) and lower extremities (hips, knees, ankles, feet) of her body and Resident 1 was dependent (helper does all the effort) for chair/bed to chair transfers (the ability to transfer to and from bed to a chair or wheelchair).During a review of Resident 1's Behavior Note, (BN) dated 12/2/25 at 2:08 p.m. the BN indicated, Charge RN [Registered Nurse] found resident attempting to get out of bed to go play a game with her boys. She also stated, I have to get that doggie. Resident placed back in bed; Charge RN sat with resident for 30 min and was able to calm resident. signed by Charge Nurse.During a review of Resident 1's BN, dated 12/2/25 at 3:11 p.m. the BN indicated, Resident found on the floor sitting and naked and playing a game with my boys. RN attempted to reorient resident to surroundings and she stated, I am going to eat your toes!. Resident was not aggressive or agitated but very confused and remains hallucinations of people and objects. Resident was dressed and place in Geri-Chair (a specialized, reclining, mobile chair on wheels designed for mobility-impaired individuals) and Placed out by the nursing station to keep observing signed by Charge Nurse.During a review of Resident 1's Nursing Note, (NN) dated 12/2/25 at 7:08 p.m. the NN indicated, Late Entry . CNAs approached me this evening to let me know that resident was found on the floor, naked and hallucinating earlier in the day. Resident was dressed and assisted into the Geri Chair. I notified [Director of Nursing (DON)] via phone call, [Resident 1's physician] . and left a message for resident 's son, . I completed the unwitnessed fall documentation, skin assessment, and vitals. A new bruise was noted on resident's right forearm. No other injuries noted. Signed by Licensed Vocational Nurse (LVN) 2.During a review of Resident 1's Neuro (neurological checks- is a group of questions and tests to check for disorders of the spinal cord and brain) /Vital Sign Flow Sheet, (NVSFS) dated 12/2/25, the NVSFS indicated the first set of neuro checks were completed at 6:30 p.m. on 12/2/25 (approximately 3 hours and 15 minutes after first fall).During a review of Resident 1's NN, dated 12/5/25 at 6:45 p.m. the NN indicated, On 12/4/25 at 1300 I was called into meeting with [CNO Chief Nursing Officer] and [CEO -Chief Executive Officer] regarding resident being found sitting on floor next to bed. Charge RN did not report this as a fall to supervisor due to resident denied falling out of bed 2 times. Resident was assessed at time of incident and found to have no injury and denied any pain or discomfort and neuro status unchanged. During meeting I was instructed to fill out full fall report following protocol. When I arrived, this am [sic] . I finished all required paperwork and documentation per protocol. Signed by Charge Nurse.During a review of Resident 1's care plan (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on Potential for neglect related to unwitnessed falls, initiated 12/5/25. The care plan indicated a few of the interventions were All Necessary documents will be filled out. and Staff will report any unwitnessed falls.During a review of Resident 1's NN, dated 12/2/25 at 3:11 p.m. the NN indicated, Late Entry: regarding fall of resident. Charge RN came into room and found resident calmly sitting on floor next to bed unclothed and playing a game with my boys, I asked resident if she fell from bed 2 times and resident denied falling both times. Resident was assessed and no injury noted. Resident was lifted into Geri-Chair and placed out by the nursing station for better observance. Resident was also asked if she had pain or discomfort anywhere and she denied both. Charge nurse did not report this as a fall to supervisor, nor was a fall form completed at the time due to Charge RN did not believe resident had actually fallen.During an interview on 12/17/25 at 11:56 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 12/2/25 she was walking down the hall when she saw Charge Nurse, CNA 2 and CNA 3 in Resident 1's room. Resident 1 was on the floor. CNA 1 stated the Charge Nurse told us to help her lift Resident 1 up and put Resident 1 into the Geri- chair. CNA 1 stated Charge RN did not assess Resident 1 before or after moving Resident 1 to the chair. CNA 1 stated Charge Nurse did not ask Resident 1 any questions. CNA 1 stated Resident 1 is totally dependent for care she could not climb to the floor and sit down. CNA 1 stated the Charge Nurse told her, CNA 2, and CNA 3 Not to say anything. CNA 1 stated she felt uncomfortable with Charge Nurse telling her not to say anything. CNA 1 stated, I think [Charge Nurse] was just trying to avoid the charting but what if something happened. I think because [Charge Nurse] failed to assess [Resident 1] afterward it was a form of neglect.During an interview on 12/17/25 at 3:10 p.m. with CNA 2, CNA 2 stated she was walking down the hall and saw the Charge Nurse CNA 1, and CNA 3 in Resident 1's room. CNA 2 stated Charge Nurse asked us to help put Resident 1 into the Geri-chair. CNA 1 stated Charge Nurse stated that this was the second time she found Resident 1 on the ground. CNA 2 stated she did not witness Charge Nurse conduct an assessment or ask Resident 1 any questions. CNA 1 stated Resident 1 could not bear weight and would not have been able to get out of bed and sit Indian style on her own. CNA 2 stated, [Charge Nurse] looked at all three of us and said don't say a word about this to anyone. CNA 2 stated she had given Resident 1 a shower earlier that day and Resident 1 did not have any skin issues. CNA 2 stated she believed the Charge Nurse did not want to do the paperwork. CNA 2 stated she reported to Social Services (SS) because it felt like it was medical neglect.During an interview on 1/13/26 at 3:50 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was made aware of Resident 1's fall by SS approximately 5:30 p.m. on 12/2/25. LVN 2 stated SS informed her that a few CNAs came to her and reported Resident 1 had a fall and it was not reported. LVN 2 stated the CNAs reported they were walking by and saw the Charge Nurse picking up Resident 1 and trying to put her back in bed, the CNAs helped put Resident I back in bed. LVN 2 stated the Charge Nurse told the CNAs Don't say anything this is the second time it has happened. LVN 2 stated she called the DON and was instructed to treat the fall like it had just happened. LVN 2 stated Resident 1 cannot bear weight and would not be able to get out of bed on her own. LVN 2 stated when she assessed Resident 1, Resident 1 did have a new bruise to her right arm below her elbow.During an interview on 1/14/26 at 3:01p.m. with CNA 3, CNA 3 stated on 12/2/25 she was the one who found Resident 1 on the ground at bedside, she stated Resident 1 was on floor without her nightgown on. CNA 3 stated she reported the fall to the Charge Nurse. CNA 2 stated the Charge Nurse came into Resident 1's room and two other CNAs were walking by and came into help. CNA 3 stated we put Resident 1's gown back on her and assisted her to the Geri-Chair. CNA 3 stated she did not witness Chare Nurse asking Resident 1 any questions or take any vital signs. CNA 3 stated the Charge Nurse did say to us (CNA 1, CNA 2, and CNA 3) not to say anything about the fall.During an interview on 1/15/26 at 3:12 p.m. with Charge Nurse, Charge nurse stated she has worked full time at the facility since January of 2025. Charge Nurses stated Resident 1 has dementia (memory loss) and was restless that day. Charge Nurse stated CNA 3 informed her Resident 1 was on the floor sitting crossed legged and without a gown on. Charge Nurse stated she and CNA 3 went into the room. Charge Nurse stated CNA 1 and CNA 2 came into Resident 1's room and assisted Resident 1 up into Geri-Chair. Charge Nurse stated she did not complete vital signs or neurological checks for Resident 1's fall. Charge Nurse confirmed the BN dated 12/2/25 at 3:11 p.m. documentation did not indicate an assessment was completed. Charge Nurse stated she did not document the Resident 1's NN, dated 12/2/25 at 3:11 p.m. late entry until a couple of days after Resident 1's fall. Charge Nurse stated she received training on the facility's TRIPS Forms (Tracking Record for Improving Patient Safety - facility developed fall protocol packet), for falls, make progress notes, care plan, notifying provider and family, DON, initiate neuro-check (neurological check-tests that a healthcare provider uses to see how well your nervous system is working) for unwitnessed falls. Charge Nurse stated, I did say to them I am not reporting this as a fall, but you guys can do whatever you want.During a review of the facility's P&P titled, Abuse Prevention Program, approval date 12/7/16, the P&P indicated, Each resident will be free from abuse, neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) . Components Of The Resident Protection Program . B. Training . D. Identification.

Based on observation, interview, and record review, the facility failed to implement a care plan for one of three sampled residents' (Resident 1) fall precaution. This failure had the potential to result injury for Resident 1.Findings:During a review of Resident 1's care plan (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) with the focus on The Resident has had an actual fall, initiated 12/13/25. The care plan indicated one of the interventions was Fall mats to both sides of bed when resident is in bed.During a concurrent observation, interview, and record review, on 12/17/25 at 1:52 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room. Resident 1 was in her bed with one fall mat at bedside. Resident 1's care plan with the focus on The Resident has had an actual fall, initiated 12/13/25, was reviewed. LVN 1 confirmed Resident 1 was care planned to have fall mats on both sides of the bed. LVN 1 stated Resident 1 had one fall mat at bedside.During a review of the facility's policy and procedure (P&P) titled, Fall Prevention, approval date 11/4/09, the P&P indicated, All patients/residents admitted to [facility name] are considered at risk for falls due to acuity of illness, medication, and unfamiliar environment. Therefore, the patients/resident will be assessed and the care plan will incorporate goals and interventions to provide the optimal safe environment for the patient /resident.

Based on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Neurological Evaluation [Neuro check- is a group of questions and tests to check for disorder of the spinal cord and brain], for one of three sampled residents (Resident 1) when Resident 1 had an unwitnessed fall. This failure had the potential for a delay in treatment and care for Resident 1, and had the potential for Resident 1 to suffer adverse health outcomes.Findings:During a review of Resident 1's Behavior Note, (BN) dated 12/2/25 at 3:11 p.m. the BN indicated, Resident [1] found on the floor sitting and naked and playing a game with my boys. RN [Registered Nurse] attempted to reorient resident to surroundings and she stated, I am going to eat your toes!. Resident was not aggressive or agitated but very confused and remains hallucinations of people and objects. Resident was dressed and place in Geri-Chair [a specialized, reclining, mobile chair on wheels designed for elderly or mobility-impaired] and Placed out by the nursing station to keep observing signed by Charge Nurse. During a review of Resident 1's Nursing Note, (NN) dated 12/2/25 at 7:08 p.m. the NN indicated, Late Entry . CNAs approached me this evening to let me know that resident was found on the floor, naked and hallucinating earlier in the day. Resident was dressed and assisted into the Geri Chair. I notified [Director of Nursing (DON)] via phone call, [Resident 1's physician] . and left a message for resident 's son, . I completed the unwitnessed fall documentation, skin assessment, and vitals. A new bruise was noted on resident's right forearm. No other injuries noted. Signed by Licensed Vocational Nurse (LVN) 2. During a review of Resident 1's Neuro/Vital Sign Flow Sheet, (NVSFS) dated 12/2/25, the NVSFS indicated the first set of neuro-checks were completed at 6:30 p.m. on 12/2/25 (approximately 3 hours and 15 minutes after first fall). During a review of Resident 1's NN, dated 12/5/25 at 6:45 p.m. the NN indicated, On 12/4/25 at 1300 I was called into meeting with [CNO Chief Nursing Officer] and [CEO -Chief Executive Officer] regarding resident being found sitting on floor next to bed. Charge RN did not report this as a fall to supervisor due to resident denied falling out of bed 2 times. Resident was assessed at time of incident and found to have no injury and denied any pain or discomfort and neuro status unchanged. During meeting I was instructed to fill out full fall report following protocol. When I arrived, this am [sic] . I finished all required paperwork and documentation per protocol. Signed by Charge Nurse. During a review of Resident 1's NN, dated 12/2/25 at 3:11 p.m. the NN indicated, Late Entry: regarding fall of resident. Charge RN came into room and found resident calmly sitting on floor next to bed unclothed and playing a game with my boys, I asked resident if she fell from bed 2 times and resident denied falling both times. Resident was assessed and no injury noted. Resident was lifted into Geri-Chair and placed out by the nursing station for better observance. Resident was also asked if she had pain or discomfort anywhere and she denied both. Charge nurse did not report this as a fall to supervisor, nor was a fall form completed at the time due to Charge RN did not believe resident had actually fallen. During an interview on 1/13/26 at 3:50 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was made aware of Resident 1's fall by SS approximately 5:30 p.m. on 12/2/25. LVN 2 stated SS informed her that a few CNAs came to her and reported Resident 1 had a fall and it was not reported. LVN 2 stated the CNAs reported they were walking by and saw the Charge Nurse picking up Resident 1 and trying to put her back in bed, the CNAs helped put Resident I back in bed. LVN 2 stated the Charge Nurse told the CNAs, Don't say anything this is the second time it has happened. LVN 2 stated she called the DON and was instructed to treat the fall like it had just happened. LVN 2 stated Resident first set of Neurological checks were completed at 6:30 p.m. on 12/2/25 (approximately 3 hours and 15 minutes after Resident 1's unwitnessed fall). LVN 2 stated when she assessed Resident 1, Resident 1 did have a new bruise to her right arm below her elbow. During an interview on 1/15/26 at 3:12 p.m. with Charge Nurse, Charge Nurse stated she did not complete vital signs or neurological checks or do a full assessment for Resident 1's fall. Charge Nurse confirmed the BN dated 12/2/25 at 3:11 p.m. documentation did not indicate an assessment was completed. Charge Nurse stated she did not document Resident 1's NN, dated 12/2/25 at 3:11 p.m. Late entry until a couple of days after Resident 1's fall. During a review of the facility's policy and procedure (P&P) titled, Neurological Evaluation, approved 2/22/16, the P&P indicated, A. In the event that a resident has a witnessed or unwitnessed fall and it is suspected/known or unwitnessed that the resident has bumped/hit his/her head, neurological evaluations are initiated and continued for 72 hours . B. Assure resident safety and complete a full assessment . Do not move resident until assessment has been completed and resident is found safe to move. Obtain a full set of vital signs. Assess pain location, intensity (pain scale), duration and type of pain felt. Document findings. C. Once resident safety has been assured notify resident's physician, family member or legal representative and fall coordinator. D. Place resident on alert charting for 72 hours. Document fall assessment, . and created and/or update fall . care plan . Complete an IDT meeting for appropriate interventions specific to resident and document meeting findings. E. The nurse completes the Neurological Evaluation Log according to the following time frames: 1. Every 15 minutes for the first hour. 2. Every 30 minutes for the 2nd hour after fall. 3. Every 1 hour for the next 3rd and 4th hour after fall.

Based on observation, interview, and record review, the facility failed to assess, recognize, escalate and properly respond to an emergency involving one of seven sampled residents (Resident 7) who experienced a physical change of condition (a significant change in a person's health, caregiver support, or functional status that will not usually resolve without further intervention). This failure resulted in a delay in transferring Resident 7 to the hospital for a higher level of care, resulted in a delay in treatment for a Cerebral Infarction (also known as a stroke, it is when blood flow to the brain is stopped, which can result in slurred speech, movement difficulties to one or both sides of the body, numbness, confusion, headache), and an intracranial hemorrhage (type of stroke that causes bleeding in the head), which resulted in Resident 7's functional decline in mobility, decline in ability to feed self, decline in ability to provide self with oral care, decline in ability to toilet self, decline in ability to shower and/or bathe self, decline in ability to dress upper and lower body, decline in ability to put on footwear, decline in ability to provide self with personal hygiene, and decline in ability to walk.Findings:During a review of Resident 7's MDS Assessment, dated [DATE], under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 - 15 with the higher the score the more intact their cognition is), the BIMS score was 15 (cognition intact).During a concurrent observation and interview on [DATE] at 1:21 p.m. with Resident 7 in the resident room, Resident 7 was observed in her wheelchair with her right side of face drooping. Resident 7 stated on the evening (no specific time provided) of [DATE] she started to experience slurred speech and right sided body weakness (change from her normal baseline status). She informed staff (no specific staff identified) that she was having a stroke. Resident 7 stated staff (no specific staff identified) called the Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) who instructed the staff to place Resident 7 back in bed and just monitor. Resident 7 stated, I had cried and yelled for help telling them I'm having a stroke, and they (no specific staff identified) said okay and put me in bed. I don't think that was right because [NP] said he was not going to do anything about it because I am a DNR (Do not resuscitate - a medical order written by a health care provider which instructs providers not to perform CPR [cardiopulmonary resuscitation- an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped] if a patient's breathing stops or if the patient's heart stops beating).During an interview on [DATE] at 9:05 a.m. with LVN 2, LVN 2 stated she was assigned to Resident 7 on [DATE] during the night shift ([DATE] 7 p.m. to [DATE] 7 a.m.) when Resident 7 complained of right sided weakness and difficulty speaking. LVN 2 stated Resident 7 was stating she was having a stroke, and the right side of her body was having spasms (painful cramps from the tightening of muscles). LVN 2 stated she observed Resident 7 with difficulty speaking and new onset right sided weakness. LVN 2 stated she called the NP regarding Resident 7's worsening condition and he instructed her to place Resident 7 back in bed and make her comfortable because Resident 7 had these types of issues (stroke) in the past. LVN 2 stated she was told by NP, there was nothing that could be done about Resident 7's change in condition because she had a DNR order. LVN 2 stated, I wish I can [sic] take her [Resident 7] to ED [Emergency Department] but that was his [NP] orders. He [NP] never came to see her after I [LVN 2] called. She [Resident 7] is a DNR, but she was not needing resuscitation, she [Resident 7] was needing advanced level of care and assessment. LVN 2 stated she did not pursue any further action after notifying NP of Resident 7's physical change of condition including not calling the Medical Doctor (MD).During an interview on [DATE] at 2:16 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to care for Resident 7 on [DATE] during the night shift (CNA shift is from 6:30 p.m. to 7 a.m.). CNA 1 stated at the beginning of her shift (6:30 p.m.) Resident 7 was smiling and happy, and able to move about the facility as well as her room using both legs and left arm in her wheelchair. CNA stated at approximately 9:30 p.m. she heard what sounded like a loud cry for help from Resident 7's room. CNA 1 stated she entered Resident 7's room and noticed immediately Resident 7's right side of face and body were noticeably drooping more than her normal. CNA 1 stated, [Resident 7's] face looked like it was hanging, her mouth was hanging, and she was drooling (not her normal status), CNA 1 stated she immediately notified LVN 2 about Resident 7's condition and LVN 2 called NP. CNA 1 stated she was instructed to place Resident 7 back in bed. CNA 1 stated it took three staff members (not identified) to place Resident 7 back into bed. CNA 1 stated prior to this incident Resident 7 was able to place herself back to bed without assistance. CNA 1 stated LVN 2 had told her the NP would be in later in the night to assess Resident 7. CNA 1 stated NP never came by to assess Resident 7. CNA 1 stated she was upset that the NP never came to see Resident 7 and that nothing was done for Resident 7's change in condition other than placing her in bed.During an interview on [DATE] at 10 p.m. with NP, NP stated he was working in the facility on [DATE] (date of Resident 7's change of condition) in a different department. NP stated LVN 2 called him regarding Resident 7's change of condition. NP stated from previous discussions he had with Resident 7, Resident 7 did not want any advanced type of care and that she was a DNR, so he instructed LVN 2 to monitor Resident 7. NP stated he was unaware Resident 7 could receive medical treatment without restrictions. NP stated he did not recall if he told LVN 2 he would see Resident 7 on [DATE]. NP stated he was not aware nor made aware by the facility staff that Resident 7 was willing to go to the ED. NP stated had he been made aware of this, he would have instructed staff to ask Resident 7 if she wanted to be transferred to the ED and proceeded with care based on the resident's decision.During an interview on [DATE] at 1:02 p.m. with Director of Nursing (DON), DON stated a resident with a DNR order does not prohibit the facility from assessing and treating the resident for medical conditions. DON stated a resident with a DNR order does not prevent them from being transferred to the Emergency Department for further care and/or treatment/assessment.During an interview on [DATE] at 12:48 p.m. with MD, MD stated he did not receive a call regarding Resident 7's change of condition on the night of [DATE]. MD stated staff are aware he is available for calls or text messages regarding residents twenty-four hours a day, seven days a week. MD stated if had received a call concerning Resident 7's change of condition he would have asked the staff to review her POLST (Physician Orders for Life-Sustaining Treatment is a written order which outlines the specific treatment the resident wants or does not want during a medical emergency) and ask Resident 7 what type of further care she would allow to happen, then make decisions based on the resident's responses. If Resident 7 stated she wanted further care when questioned, then he would have pursued the appropriate treatment per her request. MD stated if staff were concerned about NP's response to Resident 7's condition, the staff were aware they could have called him for further instructions/clarification.During a review of Resident 7's TRANSFER/DISCHARGE REPORT (TDR), dated [DATE], the TDR indicated, Resident 7 admitted to the facility on [DATE] with a diagnosis of personal history of Transient Ischemic attack (TIA - a temporary blockage of blood flow to the brain) and Cerebral Infarction (also known as a stroke, it is when blood flow to the brain is stopped, which can result in slurred speech, movement difficulties to one or both sides of the body, numbness, confusion, headache). The TDR indicated Resident 7 was taking amlodipine (medication for high blood pressure [BP -the pressure of blood as your heart pumps blood through the body. A normal blood pressure is 120/80 millimeter of Mercury [mmHG - a unit of measurement]) 5 milligrams (mg - a unit of measurement) for hypertension (high BP - which can cause a heart attack, stroke and other medical complications), Lasix (medication for high BP) 40 mg, and carvedilol (medication for high BP) 3.125 mg.During a review of Resident 7's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated [DATE], under the section titled, GG (assesses functional abilities and goals), the GG section indicated Resident 7 required the following:a. Set up or clean up assistance with eatingb. Set up or clean up assistance with oral hygienec. Set up or clean up assistance with toiletingd. Independently able to shower and/or bathe herselfe. Independently able to dress her upper and lower bodyf. Independently able to put on/take off footwearg. Set up or clean up assistance with personal hygieneh. Independently able to turn left and right, move from sitting to lying position, move from lying to sitting position in bed, move from a sitting to standing position, move from bed to chair or chair to bed, move herself on and off the toilet, move self in and out of shower and/or tub, walk 50 feet (ft - a unit of measurement) with two turns, and walk 150 feet.During a review of Resident 7's Physician Orders for Life-Sustaining Treatment, dated [DATE], the POLST indicated, Resident 7 signed the POLST on [DATE] and NP signed the POLST on [DATE] acknowledging Resident 7 did not want to be resuscitated (the act of reviving someone from unconsciousness or apparent death, typically by restoring breathing or heartbeat) but did want selective treatment with a goal of treating medical conditions while avoiding burdensome measures (not defined or specified). The medical treatments Resident 7 agreed to included: medical treatment, Intravenous (IV - into or within the vein) antibiotics (medication for infections), IV fluids, use of non-invasive airway pressure (delivery of oxygen into the lungs), and artificial nutrition (a method of providing nutrition).During a review of Resident 7's Care Plan Report (CP), dated [DATE], the CP indicated, Resident 7 had a history of stroke with right sided weakness. The CP indicated the goal was for Resident 1 to be independent with most ADLs (activities of daily living - Basic routine tasks that most healthy individuals can perform without assistance, these activities include bathing, dressing, walking, eating, using the toilet and transferring positions). Interventions for Resident 7's stroke with right sided weakness included calling the MD as needed.During a review of Resident 7's Progress Notes (PN), dated 10/2025, the PN indicated:a. [DATE] at 2:36 a.m. - Licensed Vocational Nurse (LVN) 2 documented, (Resident 7) c/o (complained of) right sided weakness, speech difficult to understand . Called in [NP], no new order. Resident [7] back to bed . will continue to monitor. The PN indicated Resident 7 had an oxygen saturation (a measurement of how much oxygen your blood is carrying. Normal levels are 90 to 100 % [% - a unit of measurement].) of 86 %. The PN indicated Resident 7 was placed on three liters (a unit of measurement) of oxygen.b. [DATE] at 7:28 a.m. - LVN 2 documented on [DATE] at 9:59 p.m., Blood pressure warning . [Resident 7's BP was 143/68 mmHG] . High of 130 exceeded .c. [DATE] at 7:37 a.m. - LVN 2 documented, [Oxygen saturation warning] low of 90 [%] . The PN indicated Resident 7 was placed on three liters (a unit of measurement) of oxygen.d. [DATE] at 10:08 a.m. - Registered Nurse (RN) 1 documented, Resident [7] inquired [questioned] 'Do you think I had a stroke?' Speech is slurred and mumbled, ability to be understood is decreased from baseline . Left hand grasp is WNL (within normal limits) minimal right hand flexion (grasp) upon request.e. [DATE] at 10:30 a.m. - RN 1 documented, Resident 7 had, facial droop [weakness to one side of the face] is increasingly pronounced with smile, and slight tongue deviation [departure from normal] is observed. [NP] notified. Resident [7] will be sent to [emergency department] per family request.f. [DATE] at 1:03 p.m. - LVN 3 documented, resident [7] is being transferred ER [emergency room] to ER via ambulance [related to] left side brain bleed.During a review of Resident 7's ED Physician Notes (EDPN), dated [DATE], the EDPN indicated, Patient (Resident 7) presented at 11:52 AM today at outside (hospital). She (Resident 7) was complaining of difficulty speaking and some right facial droop (when your face muscles are not working properly) (sic) And (sic) increased right-sided weakness. Patient (Resident 7) apparently has had a stroke in the past with right sided weakness apparently symptoms started several days earlier. CT (computed tomography - an imaging procedure) of the head is showing a left thalamic (a portion of the brain that deals with movement and sensation) intracranial hemorrhage (type of stroke that causes bleeding in the head) with possible mass effect (surrounding areas of brain tissue or brain structures that is compressed and injured due to the degree of space from leaking blood). Critical Care Statement . Due to a probability of clinically significant, life threatening deterioration of their clinical condition, the patient (Resident 7) required my (ED doctor) highest level of preparedness to intervene emergently in case of deterioration of their condition. I (ED doctor) personally spent 32 minutes of critical care time directly and personally managing the patient (Resident 7). critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in the loss of life or limb. Condition (of Resident 7) . guarded (there's not enough information yet to make a judgment about likely outcomes) and critical (needs immediate medical care due to life-threatening injuries or a serious illness). The EDPN indicated Resident 7 was to be placed in the Intensive Care Unit (a department of a hospital in which patients who are dangerously ill are kept under constant observation).During a review of Resident 7's acute hospital neurology (branch of medicine that specializes in issues and diseases of the brain) Consultation (NC), dated [DATE], the NC indicated, Resident 7 had, Increased symptoms of right facial droop and right hemiparesis (weakness to one side of the body). She did notice that she had a facial droop and increased right upper extremity [arm] weakness compared to her baseline (her normal condition).During a review of Resident 7's acute hospital Discharge Summary (DS), dated [DATE], the DS indicated, Resident 7 was discharged from the acute hospital on [DATE] back to the facility. The DS indicated Resident 7's discharge diagnosis was:a. Left thalamic intercranial hemorrhageb. Right sided weakness and facial droop with dysarthria (difficulty speaking because the muscles you use for speech are weak)c. CVA (cerebral vascular accident - also known as a stroke)d. Atrial fibrillation (an irregular heartbeat which causes the heart to beat faster than normal).During a review of Resident 7's MDS Assessment, dated [DATE], under the section titled, GG, the GG section indicated Resident 7 required the following:a. Supervision and/or touching assistance for eating (a decline from previous MDS assessment)b. Substantial (large amount) and/or maximal assistance with oral hygiene a (decline from previous MDS assessment)c. Substantial and/or maximal assistance with toileting (decline from previous MDS assessment)d. Dependent on staff to shower or bathe (decline from previous MDS assessment)e. Substantial and/or maximal assistance with upper body dressing (decline from previous MDS assessment)f. Substantial and/or maximal assistance with lower body dressing (decline from previous MDS assessment)g. Substantial and/or maximal assistance with putting on/taking off footwear (decline from previous MDS assessment)h. Substantial and/or maximal assistance with personal hygiene (decline from previous MDS assessment)i. Substantial and/or maximal assistance with turning left and right, moving from sit to lying position, moving from lying to sitting position in bed, moving from sitting to standing position, moving from bed to chair of chair to bed, and moving herself on and off the toilet (decline from previous MDS assessment)j. Was not able to be assessed with walking 50 feet with two turns and 150 feet due to medical condition and/or safety concerns (decline from previous MDS assessment).During a review of the facility's policy and procedure (P&P) titled, Do Not Resuscitate (DNR), dated [DATE], the P&P indicated, In addition to the advance directive and DNR forms, state specific forms include: Physician Orders for Life-Sustaining Treatment (POLST) .The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. Inquiries concerning DNR orders/request should be referred to the Administrator, Director of Nursing, or the Social Services Director.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated [DATE], the P&P indicated, Licensed staff shall promptly notify the resident, his or her attending physician, and family/representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The Care Manager/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the Director of Nursing Services when there has been . A significant change in the resident's physical/emotional/mental condition . A need to alter the resident's medical treatment significantly . A need to transfer the resident to a hospital/treatment center . Regardless of the resident's current mental or physical condition, the Care Manager/Charge Nurse will inform the resident of any changes in his/her medical care or nursing treatments.

Based on interview and record review, the facility failed to conduct Medical Doctor (MD) and/or Nurse Practitioner (NP - a registered nurse with a graduate degree who provides advanced healthcare, including diagnosing and treating illnesses, ordering and interpreting tests, and prescribing medication) resident assessments per the facility policy and procedure for seven out of seven residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7). This failure had the potential for residents' medical conditions to change without appropriate interventions by the MD or NP. Findings: During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 9/19/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns] with scores ranging from 0 to 15 with the higher the score the more intact the cognitive status is), the BIMS score was 10 (moderately impaired cognition). During an interview on 10/27/25 at 12:11 p.m. with Resident 1, Resident 1 stated MD or NP had not seen the resident for over a year. During a review of Resident 1's PROGRESS NOTE (PN), the PN indicated NP had documented assessing Resident 1 on 12/31/24 (electronically signed by NP on 1/12/25), 1/31/25 (electronically signed by NP on 3/1/25), 2/27/25 (electronically signed by NP on 3/19/25), 3/28/25 (Electronically signed by NP on 5/12/25), 4/30/25 (electronically signed by NP on 5/13/25), 5/26/25 (electronically signed NP on 6/24/25), 6/4/25 (electronically signed by NP on 7/12/25), 7/23/25 (electronically signed by NP on 8/10/25), and 8/24/25 (electronically signed by NP on 9/22/25). During a review of Resident 2's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15 (cognition intact). During an interview on 10/27/25 at 12:16 p.m. with Resident 2, Resident 2 stated MD or NP had not seen the resident in months (not able to give exact amount of time). During a review of Resident 2's PN, the PN indicated NP had documented assessing Resident 2 on 1/8/25 (electronically signed by NP on 2/24/25), 2/27/25 (electronically signed on 3/6/25), 3/6/25 (electronically signed on 3/6/25), 4/30/25 (electronically signed on 5/3/25), 5/25/25 (electronically signed 5/26/25), 6/19/25 (electronically signed 7/6/25), 7/25/25 (electronically signed on 8/9/25), 8/20/25 (electronically signed on 9/22/25), and 9/21/25 (electronically signed on 10/26/25). During a review of Resident 3's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15. During an interview on 10/27/25 at 12:25 p.m. with Resident 3, Resident 3 stated she has not seen her MD or NP in the facility for over three months. During a review of Resident 3's PN, the PN indicated NP had documented assessing Resident 3 on 12/31/24 (electronically signed by NP on 1/19/25), 1/31/25 (electronically signed by NP on 2/15/25), 2/27/25 (electronically signed by NP on 3/19/25), 4/30/25 (electronically signed by NP on 5/4/25) 5/25/25 (electronically signed by NP on 6/24/25), 6/24/25 (electronically signed NP on 7/8/25), 7/23/25 (electronically signed by NP on 8/9/25), 8/24/25 (electronically signed by NP on 9/17/25), and 9/20/25 (electronically signed by NP on 10/26/25).During a review of Resident 4's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 12:36 p.m. with Resident 4, Resident 4 stated she has been in the facility for two years this coming May (2026). Resident 4 stated she saw an MD when she first arrived to the facility almost two years ago and has not seen the MD or NP in a very long time (could not specify how much time has passed but stated it has been a few months).During a review of Resident 4's PN, the PN indicated NP had documented assessing Resident 4 on 12/31/24 (electronically signed by NP on 1/22/25), on 1/31/25 (electronically signed on 2/15/25), 2/27/25 (electronically signed by NP on 3/19/25), 3/8/25 (electronically signed by NP on 5/12/25), 4/30/25 (electronically signed by NP on 5/13/25), 5/25/25 (electronically signed by NP on 6/30/25), 6/24/25 (electronically signed by NP on 7/12/25), 7/24/25 (electronically signed by NP on 8/28/25), 8/28/25 (electronically signed by NP on 9/17/25), and 9/19/25 (electronically signed by NP on 10/26/25).During a review of Resident 5's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 12:49 p.m. with Resident 5, Resident 5 stated she has seen the NP two or three times since she admitted to the facility (2/2024) and the MD maybe once. Resident 5 stated, I don't think they (NP and MD) come as they should be and they don't follow up.During a review of Resident 5's PN, the PN indicated NP had documented assessing Resident 5 on 12/31/24 (electronically signed by NP on 1/19/25), 1/31/25 (electronically signed by NP on 2/15/25), 2/27/25 (electronically signed by NP on 3/19/25), 3/28/25 (electronically signed by NP on 5/14/25), 4/30/25 (electronically signed by NP 5/4/25), 5/25/25 (electronically signed by NP on 5/26/25), 6/19/25 (electronically signed by NP on 7/6/25), 7/12/25 (electronically signed by NP on 8/6/25), 8/20/25 (electronically signed by NP on 9/21/25), and 9/20/25 (electronically signed by NP on 10/26/25).During a review of Resident 6's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 12:51 p.m. with Resident 6, Resident 6 stated he could not recall the last time he saw MD because it had been a long time. Resident 6 stated he saw NP the prior month due to having to get clearance for surgery but prior to that it had been a very long time (greater than 8 months) since he saw the NP.During a review of Resident 6's PN, the PN indicated NP had documented assessing Resident 6 on 1/31/25 (electronically signed by NP on 2/15/25), 2/27/25 (electronically signed by NP on 3/3/25), 3/28/25 (electronically signed by NP on 5/2/25), 4/30/25 (electronically signed by NP on 5/4/25), 5/25/25 (electronically signed by NP on 5/26/25), 6/19/25 (electronically signed by NP on 7/8/25), 7/12/25 (electronically signed by NP on 8/6/25), and 9/21/25 (electronically signed by NP on 10/23/25).During a review of Resident 7's MDS assessment dated [DATE], under the section titled BIMS, the BIMS score was 15.During an interview on 10/27/25 at 1:21 p.m. with Resident 7, Resident 7 stated she had never seen MD or NP prior to seeing them on Friday (10/24/25). During a review of Resident 7's PN, the PN indicated NP had documented assessing Resident 7 on 12/31/24 (electronically signed by NP on 1/11/25), 1/31/25 (electronically signed by NP on 2/15/25), 2/27/25 (electronically signed by NP on 3/19/25), 3/28/25 (electronically signed by NP on 4/28/25),4/23/25 (electronically signed by NP on 4/23/25), 5/25/25 (electronically signed by NP on 5/26/25), 6/19/25 (electronically signed by NP on 7/6/25), 7/23/25 (electronically signed by NP on 8/6/25), 8/24/25 (electronically signed by NP on 9/22/25), and 9/20/25 (electronically signed by NP on 10/26/25).During an interview on 12/1/25 at 12:34 p.m. with Assistant Director of Nursing (ADON), ADON stated she had heard staff members (cannot recall who) complain the NP and/or MD had not been seeing the residents. During an interview on 12/1/25 at 12:55 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she cannot recall who but over the last year there had been complaints from residents and staff that the MD and/or the NP have not been in to see the residents to conduct assessments and/or address a medical concern. LVN 1 stated residents (cannot recall who) will state they have never met the MD or NP. LVN 1 stated staff (cannot recall who) have mentioned residents complaining of not seeing there MD and/or NP. During an interview on 12/1/25 at 1:02 p.m. with Director of Nursing (DON), DON stated she had not heard from staff or residents regarding concerns of not being seen by the MD and/or NP. DON stated her expectation is for residents to be seen for their assessments. During a review of the facility's policy and procedure (P&P) titled, HEALTH INFORMATION MANAGEMENT, dated 1/26/15, the P&P indicated, The medical record should contain complete information about the resident's illness and his treatment. Events should be recorded in the order in which they occur. Such complete chronological recording justifies the diagnosis and proves that the condition warrants the treatment and the end result. All medical records shall be completed and filed within 30 days after discharge date . Residents shall be visited by their physician a minimum of every 30 days. Each visit must be documented with a progress note by the attending physician.

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) on Abuse Prevention Program - Reporting for two of three sampled residents (Resident 1 and Resident 2) when: 1. The facility did not report an allegation of sexual abuse to the California Department of Public Health (CDPH), the Ombudsman (representatives advocating residents in long-term care facilities) and the local law enforcement (LLE) within 24 hours. 2. The facility did not complete a follow-up investigative report (FIR) within five working days. These failures had the potential to result in continuous sexual abuse and emotional distress for Resident 1 and Resident 2. Findings: 1. During a review of the SOC-341 (Report of Suspected Dependent Adult/Elder Abuse), dated 6/14/25, the SOC-341 indicated, (Activities Assistant [AA]) reported that (Resident 2) stated that (Resident 1) grabbed her breast. During a concurrent interview and record review on 6/26/25 at 1:39 p.m. with Director of Nursing (DON), the FAX Transmission Status (FTS), dated 6/16/25 was reviewed, the FTS indicated the SOC-341 was submitted to CDPH on 6/16/25 (two days after the allegation of sexual abuse on 6/14/25). DON stated there was no documentation to verify the SOC-341 was submitted to the Ombudsman and the LLE. DON stated the SOC-341 should have been submitted to CDPH, the Ombudsman and the LLE within 24 hours of the allegation of sexual abuse on 6/14/25. During a review of the facility's P&P titled, Abuse Prevention Program - Reporting, dated 2016, the P&P indicated, All reports of suspected and/or alleged sexual abuse must be immediately reported to the identified local law enforcement agency to be investigated as well as the immediate State Agency Report. Initial reporting of allegations: If an incident or allegation is considered reportable, the licensed nurse will make a report to California Department of Public Health and the Ombudsman within 24 hours. 2. During an interview on 6/26/25 at 1:39 p.m. with DON, DON stated she has not completed the FIR after the allegation of sexual abuse on 6/14/25. DON stated the FIR should have been submitted within five working days from 6/14/25 (by 6/20/25). During a review of the facility's P&P titled, Abuse Prevention Program - Reporting, dated 2016, the P&P indicated, After the report of the incident, a complete written report of the conclusion the investigation, including steps the facility has taken in response to the allegation, will be sent to California Department of Public Health within 5 business days.

Based on interview and record review, the facility failed to follow their policy and procedure on narcotic (pain medication) count, narcotic dispensing, and storage for one of three sampled residents (Resident 1). This failure resulted in missing narcotic medications and had the potential to affect Resident 1's pain control.During a review of the facility email (FEM), dated 6/24/25, the FEM indicated Resident 1's narcotic medications (morphine - a narcotic pain medication) were placed into the medication room on 6/11/25 but were not double locked in the narcotics drawer. Licensed Vocational Nurse (LVN) 1 accessed Resident 1's home medications during her evening shift (7 p.m. to 7:30 a.m.) to administer one morphine ER (extended release - medication that is released into the body over a period of time) 15 mg (milligram - a unit of measurement) pill to Resident 1. The FEM indicated, The (Resident 1's morphine) should not have been used, and the staff should have notified the provider (medical doctor) to see if an alternative pain medication . could be used to control (Resident 1's) pain. The FEM indicated, (The facility) received a new (admission) from Acute (hospital) on 6/11/25 (at 1:05 p.m.) . Resident (1) came over with a large bag of ‘at home' Narcotics . (Resident 1's) at home medications sheet (a sheet that keeps count of medications) was folded and placed in the (Resident 1's) bag. The bag was placed in the (medication) room by (Registered Nurse - RN 1). (RN 1's) name is printed as the (receiving) Nurse. However (sic) no signature was on the sheet. When I (unknown person) came on shift today I noticed the bag sitting on the med room counter and (unknown person) mentioned that (LVN 1) used (Resident 1's) at home (medications) instead of pulling from the Ekit (a container that holds different medications in case of emergency). The (medications) were counted and it was noted that the Morphine 15mg tabs were 67 in one bottle 1 used on (LVN 1's) shift (totaling 68) and the count on acute (hospital) care sheet stated 44 + 39 (83). That would make a discrepancy of 15 (pills) short. The (Acute Care Nurse - ACN) and (Facility Pharmacist - FP) from acute (hospital) should have counted before (Resident 1) left acute (hospital) and then counted with the (facility) receiving (RN 1).During an interview on 6/25/25 at 11:47 with Director of Nursing (DON), DON stated Resident 1 was admitted to the facility from the acute hospital (the facility and acute hospital share the same building) on 6/11/25. Resident 1's home medications including morphine were brought in by family and counted by the acute hospital staff. DON stated when Resident 1 was discharged from the acute hospital portion of the facility, RN 1 (facility RN) picked up Resident 1 from the acute hospital (via gurney) and was given Resident 1's home narcotic medications (morphine) from ACN. DON stated a count of Resident 1's narcotics medications was not done during the exchange from acute care to the facility. DON stated RN 1 placed Resident 1's narcotic medications (morphine) into the facility medication room but not stored in a locked area as it should have been. DON stated a count of Resident 1's narcotic medication (morphine) was not done until the next day (6/12/25). DON stated when Resident 1's narcotic medications were counted on 6/12/25 by Assistant Director of Nursing (ADON), 15 morphine ER 15 mg pills were found to be missing from the 83 pills she had brought in from home. During an interview on 6/25/25 at 12:15 p.m. with ADON, ADON stated on 6/12/25 she counted Resident 1's narcotic medications (morphine) in the facility medication room. ADON stated Resident 1's narcotic medications were on the counter and not double locked as they should have been. ADON stated she counted the medications and found 15 morphine ER 15 mg pills were missing. ADON stated she called FP, and FP verified 15 morphine ER 15 mg pills were missing. During a review of Resident 1's admission RECORD (AR), dated 6/25/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung conditions that make it hard to breathe), major depressive disorder (a serious mental health condition characterized by feelings of sadness, loneliness, and hopelessness), wedge compression fracture (a type of spinal break in bone of unspecified where part of the bone collapses or [NAME] in) of lumbar vertebra (lower back), and cachexia (condition characterized by the loss of muscle and fat mass). During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 6/19/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 15 (cognition intact).During an interview on 6/25/25 at 12:32 p.m. with Resident 1, Resident 1 stated she was taking narcotic medication to control pain from COPD and a fracture (broken bone) in her spine. During an interview on 6/25/25 at 1:16 p.m. with Risk Manager (RM), RM stated during Resident 1's transfer from the acute hospital to the facility ACN and RN 1 did not conduct a narcotic count of Resident 1's morphine. RM stated Licensed Vocational Nurse (LVN) 1 had taken over care for Resident 1 in the evening and a narcotic count of Resident 1's morphine was not done. RM stated LVN 1 used one of Resident 1's home morphine ER 15 mg to treat a complaint of pain (During the night of 6/11/25 and 6/12/25, no time specified). RM stated LVN 1 should not have used Resident 1's morphine medication from home. RM stated a count of narcotics to ensure accuracy should have been done per policy, the narcotic medications should have been double locked and Resident 1's home medication of morphine ER 15 mg should not have been used. During an interview on 7/2/25 at 11:05 a.m. with RN 1, RN 1 stated on 6/11/25 she went to the acute hospital to pick up Resident 1 from ACN. RN 1 stated she did not conduct a count of Resident 1's narcotic medications with ACN. RN 1 stated when she brought Resident 1 to the facility, she had placed Resident 1's narcotic medications in the facility medication room but did not lock the medication in a secure area. RN 1 stated that night (6/11/25) Resident 1's care was transferred to LVN 1, but a narcotic count was not done. During an interview on 7/21/25 at 2:29 with LVN 1, LVN 1 stated she could not recall doing a narcotic count of Resident 1's home medications when she took over her care on 6/11/25. LVN 1 stated she did give Resident 1 morphine ER 15 mg from Resident 1's home medication (During the night of 6/11/25 and 6/12/25, no time specified) due to a complaint of pain but should not have done that. During a review of Resident 1's Patient Home Medications (PHM), dated 5/25/25, the PHM indicated Resident 1 had 83 morphine ER 15 mg pills brought in from home. During a review of the facility's policy and procedure (P&P) titled, Controlled Substance Distribution and Security, dated 4/27/15, the P&P indicated, The storage, distribution and accounting of controlled substances will be done in accordance with all federal and state laws and standards of professional practice. Any controlled substance prescription dispensed to a patient within the SNF shall be issued a count sheet capable of recording each administration of all the doses dispensed. When an actual/physical controlled substance count does not match a perpetual count on a count sheet through routine use of the count sheet or random audit and the discrepancy cannot be explained on investigation, the event will be reported to the Director of Nursing as well as the facility risk management department. Lost or missing controlled substances shall be reported to the California State Board within 30 days of discovery. The product, strength and quantity shall be reported. All controlled substances will be stored utilizing double locked security. Only licensed personnel or authorized personnel under the direct supervision of licensed personnel shall have access to controlled substances stored within the (facility).On 7/18/25 at 3:52 p.m. a request for the facility's P&P on narcotic count during change of shifts was made and had not been made available and/or found at the time of this write up.

Based on observation, interview, and record review, the facility failed to label and store food in a sanitary manner when: 1. Food items were not closed and sealed appropriately in one of one dry storage room. 2. Food items did not have a received by date label in one of one dry storage room. These failures had the potential for Residents eating in the facility to be at risk of acquiring a foodborne illness. Findings: 1. During a concurrent observation and interview on 6/9/25 at 9:52 a.m. with [NAME] 1 in the kitchen's dry storage room, one bag of powdered Cocoa was on the shelf. The bag of Cocoa was not closed or sealed properly, it was open and exposed to room air. [NAME] 1 stated the bag should have been closed and sealed when it was opened. 2. During a concurrent observation and interview on 6/9/25 at 9:57 a.m. with [NAME] 1 in the kitchen's dry storage room, five bottles of [NAME] Brand Chocolate syrup were on the shelf of the dry storage room. All five bottles did not have a received by date. [NAME] 1 stated all food items must have a received by date label on them. During a concurrent observation and interview on 6/9/25 at 10:03 a.m. with [NAME] 1 in the kitchen's dry storage room, 11 cans of Star Kiss tuna were on the shelf of the dry storage room. All 11 cans of tuna did not have a received by date. [NAME] 1 stated all food items must have a received by date label on them. During a review of the facility's policy and procedure (P&P) titled, Food Storage, Labeling & Dating undated, the P&P indicated, It is the policy of Nutrition Services to wrap, cover, label, date, and store all foods in a safe, appropriate manner. To prevent foodborne illness. On each package, either write the expiration date, when item was received.

Based on interview and record review the facility failed to ensure they staffed a Registered Nursed (RN) eight hours a day for seven days a week from 9/2024 to 12/2024. This failure had the potential to affect the quality of care of the residents and put the residents at risk for injury. Findings: During a review of the Payroll Staffing Data Report (PBJ) (an electronic system for facilities to submit staffing information) dated 10/1/24 to 12/31/24, the PBJ indicated, no RN hours dated 10/6,10/9,10/13,10/16,10/18,10/19,10/20,10/23/24,11/3,11/9,11/10,11/17,11/23, 11/24,11/28,11/29,11/30/24, 12/1,12/7,12/8,12/13,12/14,12/15,12/16,12/21,12/22, 12/24,12/25,12/26,12/27,12/28,12/29/24. During a concurrent interview and record review on 6/12/25 at 10:50 a.m. with Staffing Coordinator (SC) the facility's Staffing Log dated 9/2024 to 12/2024 was reviewed. The Staffing log indicated on the following dates there was no RN for the regulated eight hours per day: On 9/6/24, 6.28 RN hours worked. On 9/7/24, 0 RN hours worked. On 9/15/24, 3.68 RN hours worked. On 9/16/24, 0 RN hours worked. On 9/18/24, 7.97 RN hours worked. On 9/22/24, 0, RN hours worked. On 10/6/24,0 RN hours worked. On 10/7/24,7.92 RN hours worked. On 10/12/24,7.56 RN hours worked. On 10/13/24,0 RN hours worked. On 10/15/24,7.32 RN hours worked. On 10/16/24,0 RN hours worked. On 10/19/24,0 RN hours worked. On 10/20/24,0 RN hours worked. On 10/27/24,5.92 RN hours worked. On 11/3/24,0 RN hours worked. On 11/4/24, blank RN hours worked. On 11/9/24,0 RN hours worked. On 11/10/24,0 RN hours worked. On 11/15/24,3.97 RN hours worked. On 11/16/24,2.5 RN hours worked. On 11/17/24,0 RN hours worked. On 11/19/24,6.68 RN hours worked. On 11/22/24,6.03 RN hours worked. On 11/23/24,0 RN hours worked. On 11/24/24,0 RN hours worked. On 11/27/24,7.13 RN hours worked. On 11/28/24,0 RN hours worked. On 11/29/24,0 RN hours worked. On 11/30/ 24,0 RN hours worked. On 12/1/24, 0 RN hours worked. On 12/4/24, 5.33 RN hours worked. On 12/6/24, 7.97 RN hours worked. On 12/7/24, 0 RN hours worked. On 12/8, 0 RN hours worked. On 12/12/24, 4.8 RN hours worked. On 12/14/24, 0 RN hours worked. On 12/15/24, 0 RN hours worked. On 12/16/24, 0 RN hours worked. On 12/19/24, 6.55 RN hours worked. On 12/21/24, 0 RN hours worked. On 12/22/24, 0 RN hours worked. On 12/24/24, 0 RN hours worked. On 12/25/24, 0 RN hours worked. On 12/26/24, 0 RN hours worked. On 12/28/24, 0 RN hours worked. On 12/29/24, 0 RN hours worked. On 12/30/24, 7.57 RN hours worked. SC stated we are not getting staff. SC stated when we get applications, a requirement is they have previous skilled nursing facility experience. SC stated I reach out to registries when we do not have any applications.

The facility failed to ensure tab alarm orders and informed consents were obtained for two of nine Residents (Resident 45 and Resident 14). 1. Resident 45 had no order and no informed consent for tab alarm. 2. Reisdent 14 had no informed consent for tab alarm. This failure had the potential for staff to be untrained in the proper use of alarms. Findings: During an observation on 06/10/25 at 11:57 a.m. in Resident 45's room, Resident 45 had a tab alarm (safety monitor to prevent falls or wandering) attached from the back of the wheelchair to the back of Resident 45's T-shirt. During a review of Resident 45's Minimum Data Set (MDS-a standardized assessment tool to evaluate residents' health status and functional abilities), dated 3/19/25, the MDS indicated, Restraints and Alarms Resident chair alarm not used. During a concurrent interview and record review on 06/11/25 at 10:56 a.m. with Assistant Director of Nursing (ADON), Resident 45's Orders [undated], were reviewed. The orders indicated there was no order for a tab alarm. ADON stated there is no order for a tab alarm for Resident 45, but there should be one. During a concurrent interview and record review on 06/11/25 at 11:10 a.m. with ADON, Resident 45's Informed Consent Form (ICF), dated 1/23/25 was reviewed. The ICF indicated, Proposed Treatment: Tag transmitter to w/c [wheelchair] Reason for Treatment: Safety/Wandering in wheelchair. Resident's Signature/ Resident's Responsible Party was blank. ADON stated Resident 45's consent for the tab alarm is not signed by Resident 45's representative, and it should be. During a review of Resident 45's Care Plan (CP), dated 11/12/24 the CP indicated, Resident 45 transfers self without assistance. Interventions: bed alarm and tab arm while in W/C [wheelchair]. During an observation on 06/09/25 at 10:36 a.m. in Resident 14's room, Resident 14 was sitting in a wheelchair with a tab alarm attached from the back of the wheelchair to the back of Resident 14's T-shirt. During a review of Resident 14's MDS, dated 3/19/25, the MDS indicated, Restraints and Alarms Resident chair alarm daily. During a review of Resident 14's Orders, dated 9/4/2020, the orders indicated tab alarm while in the chair. During a concurrent interview and record review on 6/11/25 at 2:24 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 14's Medical Record (MR) was reviewed. The MR indicated there was no informed consent for the tab alarm. LVN 1 stated there is no consent for the tab alarm in Resident 14's MR. During a concurrent interview and record review on 6/12/25 at 12:13 p.m. with ADON, Resident 14's MR was reviewed. The MR indicated no care plans for the tab alarm. ADON stated there are no care plans initiated for Resident 14's tab alarm. During an interview on 6/11/25 at 2:44 p.m. with ADON, ADON stated there is no alarm policy or process. During an interview on 6/11/25 at 2:56 p.m. with ADON, ADON stated when a resident has any kind of alarm the requirement is to have an order, create a care plan, obtain informed consent and place the alarm documentation in the resident's MDS.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) on ELOPEMENT (when a resident leaves the facility without the knowledge of the staff)/WANDERING (moving from place to place without a fixed plan) to evaluate for elopement, initiate a care plan (document that outlines the specific needs, goals, and interventions for a resident) and notify the physician for one of three sampled residents (Resident 1) who expressed and attempted to leave the facility. These failures resulted in Resident 1 eloping and sustaining a fall outside of the facility which resulted in a fracture (a partial or complete break of the bone) to the left hip requiring surgical intervention. Findings: During a review of Resident 1's ADMISSION RECORD (AR), dated 11/7/24, the AR indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 diagnoses including muscle weakness, anxiety (feeling of fear, dread, and uneasiness) and bipolar disorder (mental disorder where the person was having extreme mood changes). During a review of Resident 1's admission Minimum Data Set (MDS- an assessment tool) under the section Brief Interview for Mental Status (BIMS- an assessment of cognition [how well a person thinks, remembers, and learns]), dated 11/14/24, the BIMS indicated, Resident 1 had a score of 12 (cognition [how well a person thinks, remembers, and learns] moderately impaired). During a review of Resident 1's admission Elopement Risk Evaluation (ERE), dated 11/7/24, the ERE indicated, not applicable (no score- not indicated if Resident 1 was a low risk or high risk for elopement). During a review of Resident 1's Progress Notes (PN), dated 11/2024, the PN indicated the following: a. 11/9/24 - At 3:12 a.m. Resident 1 told a nurse (not specific who) I want to go home, my Son (sic) is going to pick me up .Resident (1) did tried (sic) to open double door (toward outside street), but unable to push open. b. 11/9/24 - At 6:04 p.m. Resident (1) was very angry, stating ' you are keeping me prisoner here.' Resident (1) attempted to enter other residents' room, (staff) redirected her to her room and In (sic) the processes (sic) . Resident (1) has been attempting to walk around (without) any assistance, disrespecting staff, and other resident. She (Resident 1) also attempted to enter (other area of facility), her son works in (other area of facility), screaming and cursing at him as well. c. 11/10/24 - At 4:33 p.m. (Resident 1) attempting to leave facility, with no shoes or socks on and was being physically aggressive towards staff when staff was trying to redirect (Resident 1). Staff was finally able to get (Resident 1) to sit in chair and bring her back to the hallway by (her room). d. 11/10/24 - At 8:01 p.m. Resident (1) . [was] Exit seek[ing]. Told me to call the cops. Continued to exit seek and cuss staff out. Resident educated again and she continued to cuss and yell at staff. e. 11/11/24 - At 11:29 p.m. (Resident 1) attempted to elope. (Director of Nursing) and (Certified Nursing Assistant- not identified) and cart nurses (not identified) were able to redirect (Resident 1) after several minutes of (encouragement). f. 11/15/24 - At 2:35 a.m. Resident (1) up out of her bed trying (to) leave (facility), when staff trying to redirect (Resident 1) began hitting and kicking the double doors on hall . screaming ' Help, somebody help me their holding me prisoner.' (Resident 1) was helped to nurses (sic) station. g. 11/15/24 - At 8:05 a.m. Resident (1) is showing small signs of getting use to staff and being on unit, then mood changes and resident (1) wants to elope from facility. h. 11/16/24 - At 7:30 p.m. at (6:25 p.m.), a (CNA- not identified) informed me (that the) resident (1) was not in her room. I searched the unit. At (6:29 p.m.) .all available staff was looking for (Resident 1). i. 11/17/24 - At 7:35 a.m. report from day cart nurse 11/16/24 regarding an elopement from (Resident 1). At approximately (8:00 p.m.) 11/16/24 resident (1) was returned to our facility. Resident was assessed and found two small abrasions (wearing off the skin, usually caused by a scrape or a brush burn). One to left shoulder and one to right knee. Resident (1) is alert and oriented. Resident (1) refused treatment and Is (sic) comfortable in her bed. j. 11/17/24 - At 2:04 p.m. Resident (1) having left hip pain and requesting Tylenol. Having a hard time moving around. k. 11/17/24 - At 5:49 p.m. While In the radiologist (someone that specializes in x-rays [medical imaging]) room (Resident 1) told the radiologist that she jumped a fence last night. Radiologist informed this nurse that (Resident 1) had a (left hip fracture). During an interview on 11/25/24 at 11:25 a.m. with Director of Nursing (DON), DON stated on 11/16/24 at approximately 6:30 p.m. she received a phone call from Licensed Vocational Nurse (LVN) 1, Resident 1 had eloped from the facility. DON stated on 11/16/24 at approximately 8 p.m. (approximately one and a half hours after elopement) Resident 1 was found across the street from the facility at a church in front of the glass doors lying on the grass. DON stated Resident 1 was brought back (by staff) to the facility and started complaining of left hip pain on 11/17/24 (2:04 PM). DON stated Resident 1 sustained a left hip fracture and had a surgery. During a review of Resident 1's acute hospital, Emergency Documentation (ED), dated 11/17/24, the ED indicated, Resident 1 here due to (hip) fracture. Patient ran away from her (facility) and as she jumped over a fence, landed incorrectly. Complaining of left hip pain. Admit to trauma center (a hospital unit that specializes in treating patients with life- threatening injuries) with Ortho (Orthopedic- a bone specialist). The Surgical Documentation (SD), dated 11/18/24, indicated, Resident 1 is a female who resides in (facility). She (Resident 1) attempted to ' escape', apparently by jumping a fence and fell and broke her left hip. recommended (hip surgery). The Progress Notes (HPN), dated 11/19/24, indicated, Resident 1 had a left hip hemiarthroplasty (a surgical procedure where half of the joint was replaced). During an observation and interview on 11/25/24 at 11:50 p.m. with Resident 1, in Resident 1's room, Resident 1 was noted lying in her bed and stated she left the facility without telling anyone on 11/16/24, because she felt better and wanted to go to her son's home. Resident 1 stated she climbed a fence where the church was located (across from the facility) and hurt herself (left hip). During a concurrent interview and record review on 11/25/24 at 1:31 p.m. with Assistant Director of Nursing (ADON), Resident 1's Electronic Medical Record (EMR), dated 11/2024 was reviewed. There was no care plan initiated and documented evidence the physician was notified after Resident 1 attempted to elope on 11/9/24. ADON confirmed the findings there was no care plan initiated and documented evidence the physician was notified after Resident 1 attempted to elope on 11/9/24. ADON confirmed the ERE dated 11/7/24, did not indicate a score or if Resident 1 was a low risk or high risk for elopement. ADON stated the ERE should indicate if Resident 1 was a low risk or high risk for elopement. ADON stated there was no risk for elopement assessment or evaluation noted after Resident 1 attempted to elope from the facility on 11/9/24. ADON stated Resident 1 should have been re-assessed for risk of elopement when she attempted to elope from the facility on 11/9/24. ADON stated a re-assessment for elopement would have triggered the staff to call the physician for appropriate interventions such as a wander guard (safety monitoring device). During an interview on 11/25/24 at 1:38 p.m. with DON, DON stated an elopement risk assessment should be done upon admission, every quarter, and after any attempts to elope from the facility. DON stated she does not believe the staff [not specified] knew to implement the policy. During a review of the facility's policy and procedure (P&P) titled, ELOPEMENT/WANDERING dated 2/21/17, the P&P indicated, The facility evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process. Based on results of the Wandering Risk Scale, care plan interventions to manage wandering and/or exit seeking behaviors are initiated/implemented. Residents deemed at risk to elope or have.poor safety awareness . are accompanied by family, responsible party, or a facility staff member when leaving the facility for appointments and/or outings. a change in wandering/exit seeking behavior, or after an actual elopement attempt, the resident who is deemed at risk to elope is evaluated by a licensed nurse using the Wandering Risk Scale. Resident Monitoring System .The facility obtains a physicians order for the use of the device (wander guard) prior to application and after consent is received.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) received one-to-one (also written as 1:1) supervision from staff as ordered by her physician. This failure resulted in actual harm to Resident 1 when the one-to-one staff assigned to her (Monitor 1) left Resident 1 unsupervised, resulting in a fall with multiple fractures to her face, lacerations (tears in the skin) to her forehead which required sutures (also known as stitches), subdural hematoma (a dangerous, potentially life-threatening bleed into brain tissue) decreased mobility, and pain. Findings: During a review of the Physician's Orders for Resident 1, an order dated 12/14/21, indicated Resident 1 was to have 1:1 resident monitoring daily as needed. During a review of a statement written and signed by Monitor 1, dated, 7/24/22, the statement indicated, I was monitoring [Resident 1] when the lunch meals arrived. I left her eating her lunch, while sitting on her bed. I volunteered to feed another patient while she was eating, because she typically stays seated for a long time, until she finishes her meals. I checked on her twice before heading into room [ROOM NUMBER] to assist another patient. Less than 5 minutes later I heard another female patient yell [Resident 1] fell , three times. I headed out and saw [Resident 1] laying on the floor on her left side, immobile. I went to see her, but the nurse, [LVN 9] was able to arrive to her first. [Resident 1] was bleeding from the left side of the head thus another nurse, [LVN 8] applied a towel and pressure to the wound. Someone called for the Gurney to be brought. Then several people assisted [Resident 1] on to the Gurney. She was then transported to the ER where she was treated. I then stayed with [Resident 1] in the ER until she was released back into the [Skilled Nursing Facility]. During a review of the Progress Notes, for Resident 1, dated 7/24/22, at 6:42 PM, the Progress Notes indicated, resident was found on floor in hall three, when nurse approached resident she was lying on her left side bleeding from her eyebrow area. Large laceration to her left eyebrow area was observed, pressure applied to area. Resident was conscious and moaning upon arrival of nurse. It was determined that resident needed to go to ER right away. The Progress Note was written by LVN 9. During a review of the Progress Notes, for Resident 1, undated, the Progress Notes indicated, Resident returned from ER [after] fall with injury at 7:20 PM, via wheelchair, accompanied by [Monitor 1/ one-to-one staff]. Resident had blood on her forehead and to the left of her left eye, and some blood also in her hair and left ear Resident has bruising to the left of her eye wrapping down under the eye across the top of the cheek bone, it is a dark blue in color. Resident has 11 sutures to the forehead and left of her eye that must be removed in 8 days. Resident states her eye only hurts when she blinks. Resident came back with new order for Norco [Norco is a combination of two medicines (acetaminophen and hydrocodone bitartrate) used to treat moderate to severe pain. Hydrocodone is an opioid pain medication, commonly referred to as a narcotic. Acetaminophen is a less potent pain reliever that increases the effect of hydrocodone. Hydrocodone has a high potential for abuse, and is a controlled substance and is a dangerous drug as defined in Business and Professions Code section 4022]. The Progress Note was written by LVN 7. During a review of the Care Plan, for Resident 1, dated 7/25/22, the Care Plan indicated, Resident 1 was at risk for increased pain due to multiple facial fractures. During a review of Physician Orders, for Resident 1, a physician order dated 7/24/22, indicated, Resident 1 was prescribed Norco with the purpose of controlling acute pain for 12 doses. During a review of the CT Scan [a type of advanced x-ray] of Head for Resident 1, dated 7/26/22, it indicated Resident 1 had a 2 - 3 millimeter subdural hematoma. During a review of Physician Orders, for Resident 1, a physician order dated 7/29/22, indicated, Resident 1 received a new order for Norco, to be given for facial [fracture] pain. During a review of the Progress Notes for Resident 1, dated 7/30/22, at 6:11 PM, the Progress Notes indicated, Nursing will continue to monitor sutures and bruises. The resident monitor stated that [Resident 1] started holding the right side of head during dinner and lost her appetite saying her head hurt. Norco was given with good results. The Progress Note was written by Registered Nurse (RN) 1. During an interview on 8/3/22, at 2 PM, with Monitor 2, Monitor 2 stated, their role as a Monitor is to supervise Resident 1 because she is a wanderer and a fall risk. Monitor 2 stated, they have been supervising Resident 1 since April 2022 and is very familiar with Resident 1's needs. Monitor 2 stated, Resident 1 has memory issues and can easily get confused and needs to be reminded to use her cane before she tries to walk. Monitor 2 stated, Resident 1 can walk on her own if she used her own cane and had someone to supervise her, because she is unsteady. Monitor 2 stated, Resident 1 now requires a wheelchair for mobility after the fall on 7/24/22 due to weakness. During an interview on 8/3/22, at 2:30 PM, with LVN 9, LVN 9 stated, that after lunch on 7/24/22, LVN 9 was notified by a staff member that Resident 1 had fallen onto the floor in hallway 3. LVN 9 stated, that she observed Resident 1 bleeding from a facial wound while on the floor. LVN 9 stated, that Resident 1 was transferred to a local emergency department for treatment. LVN 9 stated, a CT scan was performed and Resident 1 had multiple facial fractures and required stitches to close the open wound. During a review of video surveillance of Hallway 3, on 8/3/22, of surveillance video occurring on 7/24/22, indicated, Resident 1 ambulating in hallway 3 at 12:16 PM. The surveillance video indicated, Resident 1 walked down hallway 3 without her cane, with an unsteady step, shuffling from side to side. Resident 1 turned around and fell on to the floor. No staff were observed in hallway 3 at time of fall. The video was viewed with the DON, who identified Resident 1. During an interview on 8/3/22, at 1:40 PM, with Director of Nursing (DON), DON stated, on 7/24/22, Monitor 1 was assigned as the one-to-one staff for Resident 1 at the time of the fall. DON stated Monitor 1 should have been monitoring Resident 1 continuously, but Monitor 1 voluntarily left Resident 1 alone in their room during lunch. DON stated, Resident 1 then wandered into the hall, without her cane, unsupervised, and fell on to the floor in hallway 3. During an interview on 8/3/22, at 2:40 PM, with DON, DON stated, Resident 1 was placed on monitoring due to wandering and confusion. DON stated, the role of the monitor is to redirect the patient and make sure she is using her cane when attempting to walk. DON stated, I think the fall could have been prevented if the Monitor was there, they could have helped [Resident 1] eat her lunch and coax her into using their cane. DON stated, with 100% certainty the fall was preventable had the one-to-one Monitor not left Resident 1 alone. During an interview with LVN 6, on 9/14/22, at 11:34 AM, LVN 6 stated, Resident 1 is not ambulating the same as before [the fall on 7/24/22] and becomes short of breath and fatigued easily, often requiring use of a wheelchair. Since the resident's fall, she now complains of headaches and back pain for which she has been prescribed Norco.

Based on interview and record review, the facility failed to implement the ABUSE PREVENTION PROGRAM - DEFINITIONS AND INDICATORS policy and procedure (P & P) for 10 (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10) of 15 sampled residents. This failure resulted in the facility neglecting personal hygiene care needs of Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10, which negatively impacted their quality of life and had the potential to negatively impact their emotional wellbeing. Findings: During a review of the facility record (FR), dated 12/24/21, the FR indicated, On December 19, 2021 at approximately [7:30 PM], I [Director of Nursing - DON] was performing a yearly evaluation with one of my [night shift] nurses. During the process of this evaluation, [Licensed Vocational Nurse - LVN 1] had stated 'there was a problem with [Certified Nursing Assistant - CNA 1] leaving her residents in bed soaked with urine'. [sic] I [DON] asked her to write me a report on the incidence. December 20, 2021 - When I [DON] came to work, I read the report in which [LVN 1] wrote. It stated 'During night shift on 12/19/2021, it was brought to my attention that [Resident 8], bedding was soaked through the linens. This complaint has come from CNAs on my shift at different times over the last few weeks. The same CNA [CNA 1] has been the one they followed'. [sic] . One of the CNA's that works [LVN 1's] shift is [CNA 2]. I called [CNA 2], and asked her if she knew of any issues happening with day shift CNA's daily care. She verbally gave me a report on the phone regarding [CNA 1] care especially with [Resident 8]. After the conversation, I then asked her to write up a statement. I [DON] then assessed ALL residents for rashes, redness or any other skin issues who were incontinent of bowel and bladder. I [DON] found six total in which I immediately placed on a [every] 2 hour check and change related to mild redness. [Resident 1] . Redness noted placed on [every] 2 hours checks and changes. [Resident 2] . Redness and excoriation [wearing off of skin] of scrotum area. [Resident 3] . Redness to peri/anal area. During an interview on 1/6/22, at 10:40 AM, with LVN 1, LVN 1 stated, she noticed issues with CNA 1 neglecting her residents a few weeks prior to 12/19/21, around the end of November or beginning of December 2021. LVN 1 stated she noticed other CNAs complaining that CNA 1's assigned residents would be soaked and wet with urine. LVN 1 stated the incidents were occurring more often and increasing in frequency until reported on 12/19/21. LVN 1 stated some residents under CNA 1's care would have soaked briefs through the linens and through their mattress. LVN 1 stated, For weeks I would have CNAs state she's [CNA 1] the worst CNA to follow. LVN 1 stated, I should have reported it to [DON] because it was neglect on [CNA 1's] part for not taking care of residents properly. During a follow up interview on 6/16/22, at 2:36 PM, with LVN 1, LVN 1 stated, she was getting verbal reports from CNA 2 and CNA 3 that CNA 1 was the worst staff member to take over care for residents. CNA 2 and CNA 3 would report many job duties were not getting done by CNA 1. These job duties included stocking of resident rooms, removing of old resident meal trays, basic care needs (answering call lights, ensuring fluids are within reach, incontinent care) for residents, throwing out resident trash and changing residents when soiled. LVN 1 stated she followed up on CNA 2 and CNA 3's complaints and noted: Resident 8 soaked through his briefs, bed pads, bedding, and mattress; Resident 1 soaked with urine; Resident 5 soaked with urine through her brief and bedding; Resident 2 soaked with urine through his briefs, bed pads, and bedding. LVN 1 stated CNA 1 left the residents soaked in urine on several occasions but could not recall the exact dates. LVN 1 stated these issues became more prominent starting in November of 2021. LVN stated the issues came to the point of being resident neglect around a week and a half prior to 12/19/21. LVN 1 stated it reached the level of neglect when CNA 1 continued to leave her residents unattended and soaked with urine continuously. LVN stated the skin irritation and redness were a direct cause from CNA 1's lack of provision of care. LVN 1 stated she should have reported the neglect but did not, it was an error on my part. During an interview on 1/6/22, at 11:50 AM, with Resident 1, Resident 1 stated, he would be left in poop by a female CNAs but could not remember who it was. During an interview on 6/16/22, at 3:20 PM, with CNA 3, CNA 3 stated, she noticed issues with CNA 1 neglecting residents at the beginning of December 2021. CNA 3 stated on 12/19/21, she had taken over CNA 1's residents to begin her shift at 6:30 PM. CNA 3 stated she immediately noticed Resident 8 was soaked with urine from head to toe. CNA 3 stated she had to completely change Resident 8's bedding, provide a bed bath, wash his hair from urine, and clean up the room. CNA 3 stated Resident 8's skin was inflamed from sitting in the urine soaked bed. CNA 3 stated she also noted on 12/19/21 that Resident 7's bathroom door was locked. CNA 3 stated CNA 1 reported she locked Resident 7's bathroom door because Resident 7 was trying to get up and use the bathroom. CNA 3 stated on 12/19/21 she considered lack of provision of care to residents by CNA 1 to have reached the level of neglect but did not immediately report it as abuse. During an interview on 7/18/22, at 10:40 AM, with CNA 2, CNA 2 stated, she would take over care for CNA 1's residents when her shift was over and also give report to CNA 1 when CNA 2's shift ended. CNA 2's shift was from 6:30 PM to 7 AM. CNA 2 stated when CNA 1 would clock in to begin her shift (about 6:30 AM) she would immediately take a 30 minute smoke break rather than begin working. CNA 2 stated she noted the following resident issues associated with CNA 1's lack of care starting in the late summer, early fall of 2021: 1. Resident 10's brief was left with dry feces and/or she would have her brief soaked with urine all the way through the bedding. Resident 7 had wet feces all the way up to her bra line, covering her head and back. Also noted her bathroom door was locked so she could not use the restroom. CNA 2 stated the condition Resident 7 was left in and the locking of her bathroom door was very worrisome. CNA 2 stated she noticed these issues starting in October of 2021 with CNA 1 not providing adequate care for Resident 7. 3. Resident 8's Foley catheter bag (a bag that collects urine via a tube inserted into the resident) was full secondary to not being emptied throughout CNA 1's shift (12 hours). CNA 2 stated she would also observe dry feces on Resident 8's brief. CNA 2 stated she placed a time and date on Resident 8's brief when she left him in CNA 1's care. When CNA 2 returned 12 hours later to take over CNA 1's care she noted Resident 8's brief had dry feces and he still had the timed and dated brief she had placed on him earlier. CNA 2 stated she could not recall the exact date she placed the timed brief on Resident 8. 4. Resident 6 left with his Foley catheter bag full of urine from not being emptied throughout CNA 1's shift. 5. Resident 1 left with his Foley catheter bag full of urine from not being emptied throughout CNA 1's shift. 6. Resident 5 was observed trying to get to the restroom (cannot recall exact date). Resident 5 was very distressed. She was crying and could not talk or get any words out. CNA 2 found Resident 5 soaked in urine. CNA 2 stated if Resident 5 is taken to the bathroom, she will use the toilet and not have incontinent episodes. CNA 2 stated these incidents with resident neglect by CNA 1 went on for about three to four months. CNA 2 stated she spoke with CNA 1 about the care issues, but CNA 1 would state she knew how to do her job. CNA 2 stated the neglect resulted in Resident 10 having severe redness to her buttocks and resulted in distress for Resident 5 because of the crying from being left in urine. CNA 2 stated she is a mandated reporter and she should have reported the neglect, but did not out of fear of retaliation from the coworkers that worked with CNA 1. CNA 2 stated she noticed only CNA 1's residents that were not alert or able to verbalize issues were left uncared for. CNA 2 stated, When you walk in and see a resident [Resident 5] crying because she was not taken to the restroom it breaks your heart and makes you angry. During an interview on 6/15/22, at 11:16 AM, with CNAs 7, CNAs 7 stated, she has worked with CNAs 1. CNAs 7 stated she would get complaints from residents regarding CNAs 1's lack of care. CNAs 7 stated Resident 1, Resident 10, Resident 5, and about three other residents (she could not recall) would complain that CNAs 1 was rough and inappropriate when providing care (no specifics given). CNAs 7 stated these complaints from the residents about CNAs 1 would occur sporadically throughout the time CNAs 1 worked at the facility. CNAs 7 stated she could not recall exact dates. CNAs 7 stated she did not report these allegations. CNAs 7 stated what the residents told her should have been reported as an alleged abuse. CNAs 7 stated the resident complaints were only about CNAs 1 and no other staff member. During an interview on 6/15/22, at 11:42 AM, with CNAs 8, CNAs 8 stated, residents would complain about not wanting CNAs 1 caring for them. CNAs 8 stated the residents would not go into specifics regarding the reason they did not want CNAs 1 assigned to care for them. CNAs 8 stated the resident she recalled stating this was Resident 6. CNAs 8 stated she could not recall the names of the other residents. During an interview on 6/15/22, at 12:27 PM, with LVN 6, LVN 6 stated, she would get reports (does not recall from who) that CNAs 1 was not changing Resident 7. LVN 6 stated these complaints started happening in November 2021. LVN 6 stated CNAs 1's coworkers who no longer worked at the facility would complain about not being able to find CNAs 1 and having to answer resident call lights. During an interview on 6/15/22, at 12:59 PM, with LVN 7, LVN 7 stated when she worked with CNAs 1, the staff on the shift would be like, oh god because CNAs 1 would consistently smoke and be on her phone. LVN 7 stated CNAs 1 would take about 10 breaks during her shift not including her regularly scheduled two breaks and lunch. LVN 7 stated when not on break CNAs 1 would be on her phone. LVN 7 stated CNAs 1 told her she was not happy and had stated if they [facility] fire me they fire me and LVN 7 would tell CNAs 1 to just put in her two week notice instead. LVN 7 stated you could tell CNAs 1 was over it (working at facility) and was taking more and more breaks. During an interview on 6/15/22, at 1:28 PM, with Infection Preventionist (IP), IP stated, she would get reports from CNAs' that total bed changes for residents saturated with urine would have to be done after taking over CNAs 1's assigned incontinent residents. IP stated she recalled CNAs 2 and CNAs 3 mentioning this but could not recall who were the other CNAs that complained about CNAs 1. IP stated she encouraged the CNAs to report these issues to the DON. IP stated she remembered CNAs 2 had placed a date and time on a resident in November and/or December of 2021 to show that CNAs 1 was not changing her residents during the whole 12 hour shift. IP stated CNAs 1 would take a lot of breaks and go smoke a lot throughout her shift. During an interview on 6/15/22, at 2:15 PM, with DON, DON stated, she was able to link CNAs 1's care as meeting the level of neglect once she concluded her investigation. DON stated she came to this conclusion via the written and verbal statements she obtained from staff. DON stated she was first made aware of CNAs 1's neglecting her residents when she spoke with LVN 1 on 12/19/21 around 7:30 PM. During an interview on 7/9/22, at 10:05 AM, with LVN 2, LVN 2 stated, she worked with CNAs 1 during her shift (7 AM to 7:30 PM) about twice a week. LVN 2 stated CNAs 1 was hard to find, always outside on breaks, staff would need to track her down to get her to change her assigned residents. LVN 2 stated staff on the shift would try to find CNAs 1 because they would have to answer her resident call lights and CNAs 1 could not be found. LVN 2 stated she would receive report from LVN 1 that CNAs 1 would leave her residents saturated in urine. LVN 2 stated she recalled CNAs 1 left Resident 8 saturated in urine. LVN stated she did not know other nursing staff had issues with CNAs 1's provision of care to her residents until after CNAs 1 was gone. LVN 2 stated it was various staff members that came forth and said CNAs 1 was a problem and not caring for her residents. LVN 2 stated the lack of care provided by CNAs 1 to her residents came about as something bigger then she was first aware of. LVN 2 stated around December 2021, it appeared CNAs 1 was no longer caring for her residents and was more concerned with taking her breaks or smoking. LVN 2 stated in a 12-hour shift CNAs 1 would take at minimum one break every hour. LVN 2 stated CNAs 1's alert and verbal residents had no issues, but toward the end of December 2021, CNAs 1 was neglectful with her time management in regards to her nonverbal bedbound residents. During a review of LVN 1's written statement (WS), dated 12/20/21, the WS indicated, During night shift on 12/19/21, it was brought to my attention that [Resident 8], bedding was soaked through the [linens]. This complaint has come from CNAs' on my shift at different times over the last few weeks. The same CNAs [CNAs 1] has been then [sic] one they have followed. During a review of CNA 2's WS, dated 12/21/21, the WS indicated, [CNA 1] didn't empty Foley [A bag that collects urine from a tube inserted directly into the resident's bladder] for [Resident 6] a nor [sic] [Resident 8 or Resident 1] these were full . [Resident 5] had to go to bathroom so bad she was crying . [Resident 4] was in the same boat as soon as I [CNA 2] walked in door at [6:10 PM] they started hollering . [Resident 6] was soaking and had b/m [bowel movement - feces] every where [sic] what was so bad about situation is it wasn't the only time we have talked to her [CNA 1] . one morning she [CNA 1] came in didn't get report yet and went outside to smoke . [Resident 9] was on the [call light] for a full 30 minutes that was at [6:45 AM] . she [CNA 1] told [Resident 8] that night would get his water for him he didn't have any . She [CNA 1] told [Resident 7] that they would have to wait until nightshift [sic] to go to restroom. During a review of LVN 2's WS, dated 12/21/21, the WS indicated, I [LVN 2] have received in report from night shift nurses that Night [sic] CNAs' reported that residents are soaked with urine when following this employee [CNAs 1]. She takes multiple breaks during the day and is hard to find at times during shift. During a review of LVN 3's WS, dated 12/21/21, the WS indicated, This e-mail is to inform you of multiple times when [Resident 8] was left entirely soaked completely through his brief, pad, and bed linens at change of shift. At one time residents brief was timed by [night shift] CNAs at 4 am and upon returning to work that night [CNAs 1 worked the day shift after] residents still had the same timed brief on. [Resident 10] also had the same experience with soaked brief, pad and bed linens. [Resident 7] had watery stool all the way up to her shoulders while sitting in her [wheelchair] for several hours. All of this is a result of the same CNAs, [CNAs 1]. Just to let you also know, [CNAs 1] . come to work at 6:30 am only to sit around for at least 45 min [minutes] before even get started [sic]. I [LVN 3] usually go home around 7:15 to 7:30 [AM] and [CNAs 1 is] either [NAME] [missing in action], smoking, in the bathroom or doing nothing. During a review of CNAs 4's WS, dated 12/23/21, the WS indicated, On Sunday, December 19, 2021, I [CNAs 4] observed the bathroom door to [Resident 7's room] locked from the inside as I tried to assist [Resident 7] in using the restroom. I had to go through the bathroom on [another residents adjacent room] to unlock it. I mentioned that I thought it was odd that the bathroom door was locked. [CNAs 3] replied she had done so because [CNAs 1] had done it previously in an attempt to keep [Resident 7] from using the bathroom unassisted and potentially falling, as there had been prior incidents. I [CNAs 4] acknowledged her [CNAs 3's] concerns about the resident's risk of falling, but reiterated that it was unethical for the residents to be locked out of their bathrooms . I [CNAs 4] had observed the same resident's bathroom being locked on a separate occasion, but could not confirm that it was done on purpose. During a review of the facility's P&P titled, ABUSE PREVENTION PROGRAM - DEFINITIONS AND INDICATORS, dated 12/7/16, the P&P indicated, The Director of Nursing, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat or harmfully neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect or misappropriation shall immediately report to the Director of nursing or designee. ABUSE MEANS ANY OF THE FOLLOWING IF DONE INTENTIONALLY . Substantially disregards a resident's right or a caregiver's duties and obligations to a resident. NEGLECT . Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Substantially disregards a resident's rights or a caregiver's duties and obligations to a resident. DEFINITION OF ABUSE AND NEGLECT . Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Medical Neglect . Failure to provide care for existing medical problems. Not taking action on medical problems, prescribed treatment, or therapies.

Based on interview and record review, the facility failed to report alleged abuse and neglect for 10 (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6, Resident 7, Resident 8, Resident 9, Resident 10) of 15 sampled residents. This failure resulted in alleged abuse to continue with no facility intervention. Findings: During a review of the facility record (FR), dated 12/24/21, the FR indicated, On December 19, 2021 at approximately [7:30 PM], I [Director of Nursing - DON] was performing a yearly evaluation with one of my [night shift] nurses. During the process of this evaluation, [Licensed Vocational Nurse - LVN 1] had stated 'there was a problem with [CNAs 1] leaving her residents in bed soaked with urine'. [sic] I [DON] asked her to write me a report on the incidence. December 20, 2021 - When I [DON] came to work, I read the report in which [LVN 1] wrote. It stated 'During night shift on 12/19/2021, it was brought to my attention that [Resident 8], bedding was soaked through the linens. This complaint has come from CNAs on my shift at different times over the last few weeks. The same CNAs [CNAs 1] has been the one they followed'. [sic] . One of the CNAs that works [LVN 1's] shift is [CNAs 2]. I called [CNAs 2], and asked her if she knew of any issues happening with day shift CNAs' daily care. She verbally gave me a report on the phone regarding [CNAs 1] care especially with [Resident 8]. After the conversation, I then asked her to write up a statement. I [DON] then assessed ALL residents for rashes, redness or any other skin issues who were incontinent of bowel and bladder. I [DON] found six total in which I immediately placed on a [every] 2 hour check and change related to mild redness. [Resident 1] . Redness noted placed on [every] 2 hours checks and changes. [Resident 2] . Redness and excoriation [wearing off of skin] of scrotum area. [Resident 3] . Redness to peri/anal area. During an interview on 1/6/22, at 10:15 AM, with DON, DON stated, she first became aware of CNAs 1's abuse and neglect of residents on 12/19/21. DON stated despite being informed on 12/19/21, her investigation uncovered abuse and neglect by CNAs 1 had been going on for weeks and that staff were aware. Although the DON was not informed. During an interview on 1/6/22, at 10:40 AM, with LVN 1, LVN 1 stated, she noticed issues with CNAs 1 neglecting her residents a few weeks prior to 12/19/21, around the end of November or beginning of December 2021. LVN 1 stated she noticed other CNAs complaining that CNAs 1's assigned residents would be soaked and wet with urine. LVN 1 stated the incidents were occurring more often and increasing in frequency until reported on 12/19/21. LVN 1 stated some residents under CNAs 1's care would have soaked briefs through the linens and through their mattress. LVN 1 stated, For weeks I would have CNAs state she's [CNAs 1] the worst CNAs to follow. LVN 1 stated, I should have reported it to [DON] because it was neglect on [CNAs 1's] part for not taking care of residents properly. During a follow up interview on 6/16/22, at 2:36 PM, with LVN 1, LVN 1 stated, she was getting verbal reports from CNAs 2 and CNAs 3 that CNAs 1 was the worst staff member to take over care of residents. CNAs 2 and CNAs 3 would report many job duties were not getting done by CNAs 1. These job duties included stocking of resident rooms, removing of old resident meal trays, basic care needs (answering call lights, ensuring fluids are within reach, incontinent care) for residents, throwing out resident trash and changing residents when soiled. LVN 1 stated she followed up on CNAs 2 and CNAs 3's complaints and noted: Resident 8 soaked through his briefs, bed pads, bedding, and mattress; Resident 1 soaked with urine; Resident 5 soaked with urine through her brief and bedding; Resident 2 soaked with urine through his briefs, bed pads, and bedding. LVN 1 stated CNAs 1 left the residents soaked in urine on several occasions but could not recall the exact dates. LVN 1 stated these issues became more prominent starting in November of 2021. LVN stated the issues came to the point of being resident neglect around a week and a half prior to 12/19/21. LVN 1 stated it reached the level of neglect when CNAs 1 continued to leave her residents unattended and soaked with urine continuously. LVN stated the skin irritation and redness were a direct cause from CNAs 1's lack of provision of care. LVN 1 stated she should have reported the neglect but did not, it was an error on my part. During an interview on 6/16/22, at 3:20 PM, with CNAs 3, CNAs 3 stated, she noticed CNAs 1 neglecting residents at the beginning of December 2021. CNAs 3 stated on 12/19/21, she had taken over CNAs 1's residents to begin her shift at 6:30 PM. CNAs 3 stated she immediately noticed Resident 8 was soaked in urine from head to toe. CNAs 3 stated she had to completely change Resident 8's bedding, provide a bed bath, wash his hair from urine, and clean up the room. CNAs 3 stated Resident 8's skin was inflamed from sitting in the urine soaked bed. CNAs 3 stated she had also noted on 12/19/21 that Resident 7's bathroom door was locked. CNAs 3 stated CNAs 1 reported she locked Resident 7's bathroom door because Resident 7 was trying to get up and use the restroom. CNAs 3 stated as of 12/19/21 she considered lack of provision of care to residents by CNAs 1 had reached the level of neglect but did not immediately report it as abuse. During a review of CNAs 2's written statement (WS), dated 12/21/21, the WS indicated, [CNAs 1] didn't empty Foley [A bag that collects urine from a tube inserted directly into the resident bladder] for [Resident 6] a nor [sic] [ Resident 8 or Resident 1] these [Foley] were full . [Resident 5] had to go to bathroom so bad she was crying . [Resident 4] was in the same boat as soon as I [CNAs 2] walked in door at [6:10 PM] they [Resident 4, Resident 5] started hollering . [Resident 6] was soaking and had b/m [bowel movement - feces] every where [sic] what was so bad about situation is it wasn't the only time we have talked to her [CNAs 1] . one morning she [CNAs 1] came in didn't get report yet and went outside to smoke . [Resident 9] was on the [call light] for a full 30 minutes that was at [6:45 AM] . she [CNAs 1] told [Resident 8] that night would get his water for him he didn't have any . She [CNAs 1] told [Resident 7] that they would have to wait until nightshift [sic] to go to restroom. During an interview on 7/18/22, at 10:40 AM, with CNAs 2, CNAs 2 stated, she would take over care for CNAs 1's residents when her shift was over and also give report to CNAs 1 when CNAs 2's shift ended. CNAs 2's shift was from 6:30 PM to 7 AM. CNAs 2 stated when CNAs 1 would clock in to begin her shift (about 6:30 AM) she would immediately take a 30 minute smoke break rather than begin working. CNAs 2 stated she noted the following resident issues associated with CNAs 1's lack of care starting in the late summer early fall of 2021: 1. Resident 10's brief was left with dry feces and/or she would have her brief soaked with urine all the way through the bedding. 2. Resident 7 had wet feces all the way up to her bra line, covering her head and back. Also noted her bathroom door was locked so she could not use the restroom. CNAs 2 stated the condition Resident 7 was left in and the locking of her bathroom door was very worrisome. CNAs 2 stated she noticed these issues starting in October of 2021 with Resident 7's lack of care. 3. Resident 8's Foley catheter bag was full. CNAs 2 stated she also observed dry feces on Resident 8's brief. CNAs 2 stated she placed a time and date on Resident 8's brief when she left him in CNAs 1's care. When CNAs 2 returned 12 hours later to take over CNAs 1's care she noted his brief had dry feces and he still had the timed and dated brief she had placed on him earlier. CNAs 2 stated she could not recall the exact date she placed the timed brief on Resident 8. 4. Resident 6 left with his Foley catheter bag full of urine from not being emptied throughout CNAs 1's shift. 5. Resident 1 left with his Foley catheter bag full of urine from not being emptied throughout CNAs 1's shift. 6. Resident 5 was observed trying to get to the restroom (cannot recall exact date). Resident 5 was very distressed. She was crying and couldn't talk or get any words out. She was soaking wet when CNAs 2 found her. She is a resident if you take her to the restroom she will use the toilet and not have incontinent episodes as much. CNAs 2 stated these incidents with resident neglect by CNAs 1 went on for about three to four months. CNAs 2 stated she spoke with CNAs 1 about the care issues, but CNAs 1 would state she knew how to do her job. CNAs 2 stated the neglect resulted in Resident 10 having severe redness to her buttocks and resulted in distress for Resident 5 because of the crying from being left wet with urine. CNAs 2 stated she is a mandated reported and should have reported the neglect, but did not out of fear of retaliation from co-workers that worked with CNAs 1. CNAs 2 stated she would notice only CNAs 1's residents that were not alert or able to verbalize issues were affected with neglect. CNAs 2 stated, When you walk in and see a resident [Resident 5] crying because she was not taken to the restroom it breaks your heart and makes you angry. During an interview on 1/6/22, at 10:57 AM, with LVN 2, LVN 2 stated, she would get reports from staff that when CNAs 1 would provide care to Resident 8, he would be found left saturated in urine by the oncoming shift. LVN 2 stated she would get these reports starting in early December. LVN 2 stated she did not report these incidents to leadership (DON). During a review of LVN 2's WS, dated 12/21/21, the WS indicated, I [LVN 2] have received in report from night shift nurses that Night [sic] CNAs' reported that residents are soaked with urine when following this employee [CNAs 1]. She takes multiple breaks during the day and is hard to find at times during shift. During an interview on 7/9/22, at 10:05 AM, with LVN 2, LVN 2 stated, she worked with CNAs 1 during her shift (7 AM to 7:30 PM) about twice a week. LVN 2 stated CNAs 1 was hard to find, always outside on breaks, and would need to track her down to get her to change her assigned residents. LVN 2 stated staff on the shift would try to find CNAs 1 because they would have to answer her resident call lights and the staff could not find CNAs 1. LVN 2 stated she would get report from LVN 1 that CNAs 1 would leave her residents saturated with urine. LVN 2 stated she recalled Resident 8 was left saturated. LVN stated she did not know other nursing staff had issues with CNAs 1's care of her residents until CNAs 1 was longer employed. LVN 2 stated it was different staff members that came forward and said CNAs 1 was not caring for her residents. LVN 2 stated the CNAs 1's lack of care provided to her residents became bigger than she was first aware of. LVN 2 stated around December 2021, it appeared CNAs 1 was no longer caring for her residents and was more concerned with taking her breaks or smoking. LVN 2 stated in a 12-hour shift CNAs 1 would take at a minimum, one break every hour. LVN 2 stated CNAs 1's alert and verbal residents had no issues but toward the end of December 2021, CNAs 1 was neglectful with her time management in regards to her nonverbal, bedbound residents. During a review of LVN 3's WS, dated 12/21/21, the WS indicated, This e-mail is to inform you of multiple times when [Resident 8] was left entirely soaked completely through his brief, pad, and bed linens at change of shift. At one time residents brief was timed by [night shift] CNAs at 4 am and upon returning to work that night [CNAs 1 worked the day shift after] residents still had the same timed brief on. [Resident 10] also had the same experience with soaked brief, pad and bed linens. [Resident 7] had watery stool all the way up to her shoulders while sitting in her [wheelchair] for several hours. All of this is a result of the same CNAs, [CNAs 1]. Just to let you also know, [CNAs 1] . come to work at 6:30 am only to sit around for at least 45 min [minutes] before even get started [sic]. I [LVN 3] usually go home around 7:15 to 7:30 [am] and they are either [NAME] [missing in action], smoking, in the bathroom or doing nothing. During an interview on 6/15/22, at 11:16 AM, with CNAs 7, CNAs 7 stated, she had worked with CNAs 1. CNAs 7 stated she would get complaints from residents regarding CNAs 1's lack of care. CNAs 7 stated Resident 1, Resident 10, Resident 5, and about three other residents (she could not recall) would complain CNAs 1 was rough and inappropriate when providing care (no specifics details given). CNAs 7 stated these complaints from the residents about CNAs 1 would occur sporadically throughout the time CNAs 1 worked at the facility. CNAs 7 stated she could not recall exact dates. CNAs 7 stated she did not report these allegations. CNAs 7 stated what the residents told her should have been reported as allegations of abuse. CNAs 7 stated the resident complaints were only about CNAs 1 and no other staff member. During an interview on 6/15/22, at 1:28 PM, with Infection Preventionist (IP), IP stated, she would get reports from CNAs that total bed changes for residents saturated with urine would have to be done after taking over CNAs 1's assigned incontinent residents. IP stated she recalled CNAs 2 and CNAs 3 mentioning this but could not recall who were the other CNAs that complained about CNAs 1. IP stated she encouraged the CNAs to report these issues to the DON. IP stated she remembered CNAs 2 placing a date and time on a resident in November and/or December of 2021 to show that CNAs 1 was not changing her residents during the whole 12 hour shift. IP stated CNAs 1 would take a lot of breaks and go smoke a lot throughout her shift. During a review of the facility's policy and procedure (P&P) titled, ABUSE PREVENTION PROGRAM - DEFINITIONS AND INDICATORS [trend or fact that indicates the state or level of something], dated 12/7/16, the P&P indicated, The Director of Nursing, Administrator, Licensed Nurse, employee, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat or harmfully neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect or misappropriation shall immediately report to the Director of nursing or designee [nurse in charge of shift]. ABUSE MEANS ANY OF THE FOLLOWING IF DONE INTENTIONALLY . Substantially disregards a resident's right or a caregiver's duties and obligations to a resident. NEGLECT . Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Substantially disregards a resident's rights or a caregiver's duties and obligations to a resident. DEFINITION OF ABUSE AND NEGLECT . Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental.

Based on observation, interview, and record review, the facility failed to protect two of three sampled residents (1 and 2) from verbal abuse from a physician (Physician 1). This occurred when Physician 1 entered both of their rooms and verbally abused them both by reprimand and intimidation. This failure resulted in Resident 1, who was cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), becoming anxious, upset, distraught, tearful, and required an anti-anxiety medication to calm down; and resulted in Resident 2 becoming upset, agitated, distraught, short of breath, and feeling beaten up emotionally after the incident. Findings: During a review of the clinical record for Resident 2, the Patient Progress Notes, dated 8/30/17, at 5:33 PM, indicated under Social Service Notes, Met with (Resident 2) to discuss incident that happened this past weekend. (Resident 2) reported she had referred to a (Certified Nursing Assistant or CNA) to another CNA as the new colored CNA and that was told to the CNA who became upset. (Resident 2) reported that CNA told the emergency room doctor (Physician 1) and emergency room doctor came and confronted (Resident 2) in her room (located in the Skilled Nursing Facility, or SNF, which is a distinct part of the same facility that also contains an emergency room , or ER). (Resident 2) reported she did not know doctor and was upset that doctor came in her room to confront her about incident without knowing the details and accused her of being racist. (Resident 2) reported that snf nurses heard incident and came to room to assist (Resident 2). The Daily Progress Nurse's Notes, dated 8/26/17, at 11:30 PM, written by Licensed Vocational Nurse, (LVN) 2, indicated, At approximately 8:10 PM, Registry CNA (RCNA, a CNA from an outside agency hired by the facility to help with staffing) was wheeled in a wheelchair by our ER RN (emergency room Registered Nurse, or RN 1), and accompanied by (Physician 1) from our ER. They headed to (Resident 2's room). At the moment, (Treatment Nurse, TN), stated, Where are they going? headed to (Resident 2's room). Before the (LVN 1) was able to go down to the room, they all three were heading back out of room. When (Physician 1) came, asked if there was a problem and she stated, No. Both (TN) and (LVN 1) went to the resident's room to speak to the resident (2) involved. Resident (2) told us that the reason they came down to tell something about a conversation said a day ago. It was about what the resident said to the (RCNA). The resident (2) had also stated that she wanted to just let it go and not talk about it. During a review of the clinical record for Resident 1, the document titled Daily Progress Nurse's Notes, dated 8/26/17, at 8:05 PM, written by LVN 3, indicated (Physician 1, RN 1) wheeled (RCNA) being seen in ER to SNF entering (Resident 1)s room to talk with resident. (Resident 1) sat on (her roommate's bed) while being talked with about how she was talking with (RCNA). After conversation resident came to nurses station with increased anxiety and stated that grandma (how Resident refers to her roommate in the next bed) is upset because she had to hear the conversation that took place in the room. Resident stated I'm not crazy, staff members around resident talked with residents about her feelings decreasing the anxiety a little. This nurse took resident back to her room to give [MEDICATION NAME] 0.25 milligrams, (a controlled anti-anxiety medication) to help with the anxiety that she was having prior to the conversation that is now increased. Resident states that she was told that she was being aggressive. Resident . placed on alert charting to monitor emotional concerns and anxiety. During an interview with RN 1, on 9/12/17, at 10:01 AM, she stated Physician 1, who she had been working with in theER on [DATE], told her to wheel the (RCNA) to the Skilled Nursing Facility to educate people. RN 1 stated, I did not know the doctor (Physician 1) wanted to 'educate' the residents in the SNF. (Physician 1) told the resident (1) not to discriminate and not to call people 'colored' or 'redneck,' but the first resident (1) was confused, but apologized. RN 1 stated, The (RCNA) said there was another resident (2) who discriminated against her, so (Physician 1) said to go check this second resident (2) and we went to the resident's (2) room. RN 1 stated, (Physician 1) told her the same thing, not to discriminate. (Resident 2) got upset and (Physician 1) tried to calm her down. RN 1 stated, I was scared because she (Physician 1) gets people fired. She (Physician 1) reports a lot. I just followed what she asked me to do. I have no one to turn to. I knew it was wrong to go to the SNF to educate residents. I am uncomfortable working with (Physician 1). During an interview with the Director of Nursing (DON), on 9/12/17, at 10:20 AM, she stated Physician 1 was not suspended from employment at the facility after the incident. The DON stated, I talked to the (Administrator) and CNO (Chief Nursing Officer) and it's under their hands. The way (Physician 1) handled the situation was wrong. During an interview with the CNO, on 9/12/17, at 10:47 AM, he stated Physician 1 was not suspended, but was informed not to enter the SNF anymore unless invited. The CNO stated, She had no right to go there (to the SNF). If she's on duty (in the ER) and when a resident is sent to the ER, we might have a separate ER for them. The CNO did not indicate how a resident sent to a separate ER while Physician 1 is on duty, would not still be seen and treated by Physician 1, thereby potentially exposing residents to verbal abuse from her. During an interview with Physician 1, on 9/13/17, at 12:53 PM, she stated, First of all, I have a degree in law and currently a physician. Physician 1 stated discrimination and profiling is illegal, and her patient (RCNA) had told her in the ER that she was called a 'colored girl' by Residents 1 and 2 while she was on duty in the SNF. Physician 1 stated, So we wheeled the patient (RCNA) over to the unit (SNF) and I talked to (Resident 1) in private. I told (Resident 1) we cannot call people colored girl or nigger. Physician 1 stated that she also told (Resident 2) that she cannot call people a colored girl. She got a little upset. The (Administrator) called me and he was very angry and told me I cannot go to the SNF anymore. This is an eye opening for me. But they (facility) cannot use the State and Federal government money for discrimination. Profiling is illegal. (RCNA) was discriminated and they (facility) did not do anything about it. The SNF was wide open, nobody was there, not a single employee came to us. During a concurrent observation and review of the clinical record for Resident 1, on 9/12/17, at 9:05 AM, in the hallway of the SNF, Resident 1 was very confused and unable to be interviewed. Resident 1 had no recollection of the incident with Physician 1. The Minimum Data Set (a standardized, comprehensive assessment tool), dated 9/12/17, indicated Resident 1 had a Brief Interview of Mental Status score of 3 (score of 0-7 indicated severe cognitive impairment). During a review of the clinical record for Resident 2, the Minimum Data Set, dated dated [DATE], indicated Resident 2 had a Brief Interview of Mental Status score of 15 (score of 13-15 indicated she was cognitively intact). During an interview with Resident 2, on 9/19/17, at 2:30 PM, she stated she recalled the incident, occurring over three weeks earlier, with Physician 1 and stated she had accused her of name calling. Something like the (RCNA) was black or colored. I can't get over that, it hurt me. I am very confused who was spreading the rumors. She's (Physician 1) very mean, she came stormed at me and finger point in my face. She's rude, how dare her treat me that way? I feel like I have been beaten up emotionally. I don't understand why that doctor came to me and said she had a degree in law and she is Italian and Spanish. It was a lot to endure, my husband just passed away. Resident 2 stated, (RCNA) was my CNA that day, she did not say anything to me. I did not call her 'a colored girl.' It was terrible. My nurse was trying to ask the doctor what's going on. She tried to protect me. She's nice. Only that doctor, I carry the grudge. During an interview with the TN, on 9/21/17, at 12:31 PM, she stated she saw Physician 1 with the RCNA in a wheelchair being pushed by RN 1 walk into the SNF. The TN stated, They went to talk to (Resident 1) and then later, (Resident 1) came out of her room upset and very confused. Then, (Physician 1) was looking for the other resident (2). I saw (LVN 1) asking questions to (Physician 1), but (Physician 1) was not answering her. The TN stated, (Physician 1, RCNA, and RN 1) all went down the hall together. I alerted (LVN 1) something is going on. By the time we got there, (Resident 2) was disturbed and did not want to talk about what (Physician 1, RCNA, and RN 1) did in her room. I don't think (Physician 1) did the right thing, this is the residents' home and both residents (1 and 2) have mental issues. (Physician 1) did not ask the Staff any questions before going to see the residents. It was totally inappropriate. It was shocking. We were appalled because of her position as a doctor. She should be advocating for the residents but she was advocating for the Registry CNA. The TN was asked if there were SNF staff available for Physician 1 to talk to while she was in the SNF. The TN stated, Yes, (LVN 1) was at the desk and actually (LVN 1) kept on questioning (Physician 1) what was going on, but (Physician 1) did not give an answer. (Resident 2) later said the doctor told her not to call a colored girl and something against the law and she knew the law because she had a degree in law. The TN stated, Recently, (Resident 1) is having severe depression, her husband passed away. (Resident 1) is the one who can't let go. During an interview with LVN 1 on 10/16/17, at 9:30 PM, she stated she recalled the incident with Physician on 8/26/17. LVN 1 stated she had never seen Physician 1 prior to that evening, and did not know who she was. LVN 1 stated upon (Physician 1)'s arrival on the SNF, she asked her if she needed assistance with anything, and Physician 1 Absolutely 100 percent ignored me, and was very rude. LVN 1 stated Physician 1 eventually gave her name, and that she had spoken to the DON. LVN 1 stated after Physician 1's encounter with Residents 1 and 2, that they were both upset and distraught. LVN 1 stated she does not believe anyone should be treated the way Physician 1 treated them. LVN 1 stated, I felt so bad for (Resident 1). She has dementia. (Physician 1) should have explained herself. She didn't do that. I called the DON, she was shocked (by Physician 1's behavior). (Resident 1) was definitely distraught, she was upset after (Physician 1)'s visit. I also saw (Resident 2) after (Physician 1) spoke with her. (Resident 2) is more alert, and she was absolutely upset and distraught. (Resident 2) was saying she could not believe a doctor would behave this way, could do that. I was upset for both of them (Residents 1 and 2). Their rights had been violated. I feel they were harassed and bullied, violated by that doctor. I feel like I protect my residents, but I never thought I'd have to protect them from a doctor. During an interview with the DON on 10/18/17, at 1 PM, she stated Physician 1 had telephoned her at home from the ER during the evening of 8/26/17 about RCNA, but gave no indication she was intending to come to the SNF to reprimand residents. The DON stated had she known that, she would have come to the SNF immediately to stop her. The DON stated, How dare she do that. How dare her. The document titled Incident Report, written by the DON and addressed to the Department, indicated On or about August 26, 2017 at approximately 8:11 PM, I received a call from (LVN 1) regarding (Physician 1) walking over to our skilled nursing center with (RN 1), (RCNA). I arrived at the skilled nursing center approximately 15 minutes later and spoke to (Resident 2). I asked her What did the doctor want? (Resident 2)'s reply she said I shouldn't say things like 'Colored Girl' because she's involved in a civil case litigation against discrimination and that's against the law, I'm a wop spic are you going to call me that? I noticed (Resident 2) appeared a little anxious and short of breath so I left the room to let her calm down. I then proceeded to (Resident 1's room), as I knocked and went in I seen that (she) was sleeping on her bed. I asked (LVN 1) is she was ok, (LVN 1) replied, Yeah she has an [MEDICATION NAME] on board that's why she's asleep. During an interview with LVN 3, on 10/20/17, at 10:20 PM, she stated she was Resident 1's nurse during the evening of 8/26/17. LVN 3 stated after Physician 1 left her room, (Resident 1) was extremely upset. She was upset this conversation took place in front of her roommate. (Resident 1) was crying, tears coming out of her eyes, nose draining. She was very anxious, this made her existing anxiety worse. It increased her behaviors very much so. (Resident 1) told me, immediately after (Physician 1) left her room, that the Doctor had come to see her and said she had been aggressive. (Resident 1) has no idea what she was talking about. The Doctor had brought a CNA into the room with her to show her. After this, (Resident 1) was clearly in distress, upset. I thought it was inappropriate to enter (Resident 1)'s room like that. She should have grabbed me or another nurse to go in with her. I work with (Resident 1) all the time, she can't remember my name from one night to the next. It was really inappropriate to take another employee and confront her. If I'd have known this was her plan, I wouldn't let it happen. Unfortunately, it happened. LVN 3 stated, If a resident had to go to the ER, I'd want a staff person to go with them, one-on-one, if (Physician 1) was on duty. For any resident. As shook up and uncomfortable as (Resident 1) was after this event, I think it was a form of abuse. LVN 3 stated she personally gave Resident 1 the anti-anxiety medication for anxiety. The facility policy and procedure titled, Abuse Prevention Program, dated 12/7/16, indicated, Each resident will be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse can include but is not limited to physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse, or involuntary seclusion from any source. Additionally all residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated and all residents will be monitored for protection. The facility will strive to educate all participants in techniques to protect all parties. The facility policy and procedure titled, Abuse Prevention Program - Definitions and Indicators, dated 12/7/16, indicated, Abuse means any of the following if done intentionally: Causes or could reasonably be expected to cause mental or emotional damage to the resident, including harm to the resident's psychological or intellectual functioning that is exhibited by anxiety, depression, withdrawal, regression, outward aggressive behavior, agitation, or fear of harm or death, or combination of these behaviors. A course of conduct or repeated acts by caregiver which serve no legitimate purpose and which, when done with intent to harass, intimidate, humiliate, threaten or frighten a resident, causes or could reasonably be expected to cause the resident to be harassed, intimidated, humiliated, threatened or frightened. Emotional or Psychological Abuse: The verbal or nonverbal infliction of anguish, pain, or distress that results in mental or emotional suffering. Demeaning statements, harassment, threats, insults, humiliation, or intimidation.

Based on observation, interview, and record review, the facility failed to ensure a controlled medication, Norco (a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication and is called a narcotic. Acetaminophen is a less potent pain reliever that increases the effects of hydrocodone. Norco is used to relieve moderate to moderately severe pain) was securely stored. This failure resulted in one of two sampled residents (1), who was wandering in the facility, obtaining access to a medication card containing Norco tablets from the nurse's station. Resident 1 experienced a change of condition after ingesting a portion of the Norco, and required an emergent transfer to an acute hospital. Findings: During a review of the clinical record for Resident 1, the admission record dated 5/19/16, indicated Resident 1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a comprehensive assessment tool) dated 6/9/16, indicated Resident 1 had a short term memory problem and was able to walk independently. The Wandering Risk Scale dated 6/15/16, indicated a score of 11 (meaning Resident 1 was high risk to wander). The care plan for Resident 1 titled Dementia with behavioral disturbance dated 1/8/16, indicated Resident 1 wandered in the facility and became agitated when redirected by staff. The facility document titled Possible Diversion undated, indicated Medication was delivered by retail pharmacy on 8/1/16 at approximately 1800 (6 PM) and signed in by (Licensed Vocational Nurse 1-LVN 1). Norco 10/325 mg (milligrams) was amongst the medication that was delivered. (LVN 1) reported that he left the medications on the table in front of him at the nurse's station while he continued charting. (LVN 1) reported that he did leave the medication out on the table unattended to speak with the CNA (Certified Nursing Assistant) Instructor in the medication room (MR) .A short time later resident (Resident 1) came into the nurse's station and picked up a medication card .CNA # 1 found a bubble pack (a large card with plastic bubbles containing individual pills) of Norco 10/325 mg tabs dated 8/1/16 at 2303 (11:03 PM) that evening, on the dresser, in the resident's room . It was noticed that 14 of the 30 tablets were missing .On 8/2/16 .Resident drug screen was negative .On 8/3/16 resident was evaluated in the emergency room (ER/Acute Hospital (AH 1)) for hypertension (a condition in which the force of the blood against the artery walls is too high), fever and an altered mental status (is a disruption in how your brain works that causes a change in behavior). The resident's room was searched again and two half tablets consistent with Norco 10/325 identification markings were found under the resident's bed. It was determined with the ER work-up that he was now opiate (a drug with morphine like effects) positive on UDS (Urine Drug Screen). Resident was treated and returned to the unit a few hours later .On 8/4/16 at 8:00 PM RN (Registered Nurse) # 1 reported . and noted that the residents gait became unsteady and was hypotensive (abnormally low blood pressure) with lethargy (lack of energy). Resident was sent to and evaluated in the emergency room (AH 1) .Resident was stabilized and transferred to another acute hospital (AH 2) .RN # 1 searched residents room and found 1 white tablet that is oblong inside a goldfish box .when an open package of zoo animal crackers was poured out there were 8 white medication tabs mixed with the animal crackers . During an interview with the Director of Nursing (DON), on 8/16/16, at 10:10 AM, she stated Resident 1 was confused, able to ambulate independently around the facility and had a history of [REDACTED]. During a concurrent observation and interview with Resident 1 at the nurse's station on 8/16/16, at 10:36 AM, Resident 1 walked into the nurse's station. Resident 1 was ambulating by himself. Upon interview, he stated he was Okay but continued his walking. Resident 1 was noted ambulating back and forth in front of the nurse's station. Then Resident 1 went inside the nurse's station and was grabbing papers. During an interview with LVN 1, on 8/17/16, at 9:25 AM, he stated on 8/1/16, at approximately 6 PM, he received the pharmacy delivery. LVN 1 stated he received all the medications delivered including the residents' medications which was assigned to the other two nurses working on the floor. After receiving the medications, he placed the medications on top of the table in the middle of the nurse's station. LVN 1 stated he went to the facility's parking lot and stayed in the parking lot for approximately ten minutes. He then returned to the nurse's station and he noted the medications were still on top of the table. LVN 1 then went to the MR and talked to the CNA Instructor and stayed inside the MR for approximately 10 to 15 minutes. LVN 1 went back to the nurse's station and completed his nursing documentation. After his nursing documentation he grabbed the medications on the table and secured them away. LVN 1 stated he did not recheck the amount of medications before securing them. LVN 1 stated the facility informed him regarding the missing narcotic medications and that the staff found some tablets in Resident 1's room. The AH 2 clinical record for Resident 1 titled History and Physical dated 8/5/16, indicated Resident 1 was admitted to the hospital with [REDACTED]. The facility policy and procedure titled NARCOTIC COUNT dated 7/1/15, indicated under PROCEDURE: Controlled substances are not available to other than nurses, pharmacist, and medical personnel designated by the facility. Indicated under NOTE: THE NARCOTICS SUPPLY IS TO BE KEPT UNDER TWO LOCKS AT ALL TIMES. THE LOCK ON THE MEDICATION CART AND THE LOCK ON THE NARCOTICS DRAWER ARE TO BE LOCKED AT ALL TIMES. IF THE CART IS KEPT IN A MEDICATION ROOM, THE MEDICATION ROOM IS TO BE LOCKED AT ALL TIMES.

Based on interview and record review, the facility failed to ensure a controlled medication (Norco a combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication and is called a narcotic. Acetaminophen is a less potent pain reliever that increases the effects of hydrocodone. Norco is used to relieve moderate to moderately severe pain) was securely stored to prevent unauthorized access to the medication. This failure resulted in one (1) of two sampled residents, obtaining access to a medication card containing Norco tablets. Resident 1 experienced a change of condition after ingesting a portion of the Norco, and required an emergent transfer to an acute hospital. Findings: The clinical record for Resident 1 was reviewed. Resident 1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a comprehensive assessment tool) dated 6/9/16, indicated Resident 1 had a short term memory problem and was able to ambulate without assistance. The Wandering Risk Scale for Resident 1 indicated a score of 11 (meaning Resident 1 was high risk to wander). The facility document Possible Diversion undated indicated Medication was delivered by retail pharmacy on 8/1/16 at approximately 1800 (6 PM) and signed in by LVN (Licensed Vocational Nurse) # 1. Norco (narcotic medication) 10/325 mg (milligrams) was amongst the medication that was delivered. LVN # 1 reported that he left the medications on the table in front of him at the nurse's station while he continued charting. LVN # 1 reported that he did leave the medication out on the table unattended to speak with the CNA (Certified Nursing Assistant) Instructor in the medication room (MR) .A short time later resident (Resident 1) came into the nurse's station and picked up a medication card .CNA # 1 found a bubble pack of Norco 10/325 mg tabs dated 8/1/16 at 2303 (11:03 PM) that evening, on the dresser, in the resident's room . It was noticed that 14 of the 30 tablets were missing .On 8/2/16 .Resident drug screen was negative .On 8/3/16 resident was evaluated in the emergency room (ER/Acute Hospital (AH 1)) for hypertension (a condition in which the force of the blood against the artery walls is too high), fever and an altered mental status (is a disruption in how your brain works that causes a change in behavior). The resident's room was searched again and two half tablets consistent with Norco 10/325 identification markings were found under the resident's bed. It was determined with the ER workup that he was now opiate (a drug with morphine like effects) positive on UDS (Urine Drug Screen). Resident was treated and returned to the unit a few hours later .On 8/4/16 at 8:00 PM RN (Registered Nurse) # 1 reported . and noted that the residents gait became unsteady and was hypotensive (abnormally low blood pressure) with lethargy (lack of energy). Resident was sent to and evaluated in the emergency room (AH 1) .Resident was stabilized and transferred to another acute hospital (AH 2) .RN # 1 searched residents room and found 1 white tablet that is oblong inside a goldfish box .when an open package of zoo animal crackers was poured out there were 8 white medication tabs mixed with the animal crackers . A review of the physician's orders [REDACTED].>During an interview with LVN 1, on 8/17/16, at 9:25 AM, he stated on 8/1/16, at approximately 6 PM, he received the pharmacy delivery. LVN 1 stated he received all the medications delivered including the residents' medications which was assigned to the other two nurses working on the floor. After receiving the medications he placed the medications on top of the table in the middle of the nurse's station. LVN 1 went in the facility parking lot and attended to another resident's concerns. LVN 1 stayed in the parking lot for approximately ten minutes. He then returned to the nurse's station and he noted the medications were still on top of the table. LVN 1 then went to the MR and talked to the CNA Instructor and stayed inside the MR for approximately 10 to 15 minutes. LVN 1 went back to the nurse's station and completed his nursing documentation. After his nursing documentation he grabbed the medications on the table and put them away. LVN 1 stated he did not recheck the medications anymore. LVN 1 stated the facility informed him regarding the missing narcotic medications and the staff found some tablets in Resident 1's room. Another staff found the narcotic sheet in the shredding box in the nurse's station. AH 2's clinical record for Resident 1 titled History and Physical dated 8/5/16, indicated Resident 1 was admitted to the hospital with [REDACTED]. required a four day hospital admission to recover from his Norco overdose (8/5/16-8/9/16). The facility policy and procedure titled NARCOTIC COUNT dated 7/1/15, indicated under PROCEDURE: Controlled substances are not available to other than nurses, pharmacist, and medical personnel designated by the facility. Indicated under NOTE: THE NARCOTICS SUPPLY IS TO BE KEPT UNDER TWO LOCKS AT ALL TIMES. THE LOCK ON THE MEDICATION CART AND THE LOCK ON THE NARCOTICS DRAWER ARE TO BE LOCKED AT ALL TIMES. IF THE CART IS KEPT IN A MEDICATION ROOM, THE MEDICATION ROOM IS TO BE LOCKED AT ALL TIMES.

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (2) from sexual abuse when Resident 1 touched Resident 2 under her skirt. This failure resulted in Resident 1 sexually assaulting Resident 2 two times. Findings: The clinical record for Resident 1 was reviewed. The patient progress note dated 7/18/15 at 2 PM, indicated Resident 1 was found in Resident 2's room and was touching her breast (first incident). The plan of care for Resident 1 dated 7/18/15, indicated Resident 1 had inappropriate sexual behavior. The interventions for this behavior included Resident (Resident 1) is to have line of sight from staff while out of bed. This care plan was updated 6/3/16 with no change to the above intervention. The Patient Progress Notes, dated 6/15/16, at 3:04 PM, indicated at approximately 1:45 PM, Resident 1 was found in Resident 2's room by Certified Nursing Assistant 1 (CNA 1) with his hand up Resident 2's dress and Resident 2 screamed which alerted staff (second incident). During a review of the clinical record for Resident 1, the Cognitive Patterns, dated 6/2/16, indicated a Summary Score of 13 (score of 13-15 means cognitively intact). During a review of the clinical record for Resident 2, the admission record indicated Resident 2 had a [DIAGNOSES REDACTED]. During an observation on 7/7/16, at 9:49 AM, in the Activity Day Room, Resident 1 was sitting beside a private sitter, Resident 2 was approximately 2 meters away from Resident 1 with an Activity Staff sitting in between them. Resident 1 and 2 were playing kick ball with 6 other residents. During an interview with CNA 2, on 7/7/16, at 11:34 AM, she stated right before the incident, Resident 1 was wandering in hall 2 (where Resident 2 was) and removed Resident 1 and placed him in his room. CNA 2 stated, After few minutes, (Resident 1) was found in (Resident 2's) room. During an interview with the Mental Health Coordinator (MHC), on 7/7/16, at 11:46 AM, she stated, We are aware (Resident 1) is such a predator, he will target the confused residents. He can't be trusted. The MHC stated Resident 1 was on every 15 minute checks before the incident. The MHC stated, (Resident 1) had history of previous attempts of touching other residents. During an interview with CNA 1, on 7/11/16, at 9:35 AM, she stated she heard Resident 2 screaming for help and was saying 'Get out of my room'. CNA 1 stated, When I walked in (Resident's 2's) room, I saw (Resident 1) facing (Resident 2), both in their wheelchairs, with his (Resident 1's) hand inside (Resident 2's) skirt moving back and forth. CNA 1 stated she had seen Resident 1 try to look under other resident's clothing. CNA 1 stated the facility was aware Resident 1 wanders in the hall and goes into other residents' rooms. The facility policy and procedure titled Abuse Prevention Program, dated 3/2016, indicated, In the event of suspected maltreatment, the needs of the resident will be immediately assessed and the safety of the resident will be ensured. The safety and health of the resident(s) will be attended to before any other action is taken. Immediate steps should be taken to ensure that no resident remains in danger of maltreatment, including medical intervention as needed. Sexual Assault: Sexual contact that results from threats, force, or the inability of the person to give consent, and involving a range of activities, including, but not limited to, assault, rape, or sexual harassment. Any sexual activity that occurs when an individual cannot or does not consent.

Based on observation, interview, and record review, the facility failed to assess six of 13 sampled residents' (10, 1, 6, 3, 7, and 13) and three random residents' (15, 14, and 16) skin condition when changes occurred. This failure resulted in a delay in treatment, continued discomfort, and worsening of skin conditions. An immediate jeopardy was called on 5/22/13, at 11 AM by survey team. The Director of Nursing (DON) was informed of the immediate jeopardy situation. A Plan of Correction presented by the DON was accepted on 5/23/13 by the District Manager. The condition of Immediate Jeopardy was abated at 2:40 PM with the DON. Findings: 1. During a review of the clinical record for Resident 10, on 5/22/13, Resident 10's admission skin assessment dated [DATE] was blank. Six days later, on 1/8/13, a skin assessment indicated Resident 10 had a Stage II pressure ulcer (presenting as a shallow open ulcer with a red pink wound bed) to coccyx (tailbone) area. Resident 10's physician was notified and treatment orders were obtained. More than one month later, on 2/15/13, Resident 10's physician documented Resident 10 had a Stage IV pressure ulcer (full tissue loss with exposed bone, tendon or muscle) to left buttock measuring 6.8 centimeters round and 1/2 centimeters deep crater to the glutei (buttock muscles). Resident 10 was discharged from the facility to an acute hospital on [DATE]. On the discharge not, dated 2/24/13, Resident 10's physician documented, "The patient was stable in our facility over the first few weeks, however over the course of the last month he developed a large pressure ulceration to his left buttock which became infected... The patient's condition was further complicated by the fact that orders per (physician's name) about wound care were not followed... The resident had not received treatment for [REDACTED]. During a concurrent interview with the Registered Nurse Care Manager (RNCM) on 5/23/13, at 8:35 AM, she reviewed the clinical record and was unable to find admission skin assessment for Resident 10. She stated, "She was unable to do his skin assessment on admission because he (the resident) had a lot of visitors." The RNCM stated she did not do his skin assessment until 1/8/13. It was then she noted a Stage II pressure ulcer and a pimple-like hair follicle to left buttock. The RNCM stated she notified the physician and obtained treatment orders. The RNCM explained, "I'm not really used to doing skin treatments I'm learning." The RNCM added the certified nursing assistants should have notified the licensed nurses when a resident had skin breakdown. The RNCM agreed the admission skin assessment should have been completed on admission. The facility policy and procedure titled "Prevention of Pressure Ulcers and Pressure Ulcer Risk Assessment" dated March 2005, indicated the facility should have a system/procedure to assure assessments are timely and appropriate ..." 2. During a review of Resident 1's admission record dated 5/16/13, Resident 1 had a pressure ulcer (injuries to the skin and/or underlying tissue that usually occur over a bony area as a result of pressure) to the right upper buttock, one to the right lower buttock, one at the left middle buttock, and one on her right heel. There was no documentation of the appearance, size, or the stages of these pressure ulcers. During an interview with Resident 1's license vocational nurse (LVN) 1, on 5/21/13, at 11:45 AM, she stated, "She (Resident 1) does not have any wounds or skin treatment orders." During a concurrent interview and clinical record review with the DON, on 5/21/13, at 11:47 AM, she was unable to find any assessment on these pressure ulcers. The DON asked LVN 1 at this time if she had done any treatments to Resident 1's wounds. LVN 1 stated, "No. I haven't. I didn't know she had any wounds." The DON stated the licensed staff who was responsible for the admission assessment worked only casually and she did not do the skin assessment on admission. The DON stated the certified nurse assistants were to document and report to the licensed nurses when there was a concern with a resident's skin and the licensed nurses were to assess the skin. The DON was unable to find certified nurse assistant's documentation of Resident 1's skin. During an interview with the RNCM, on 5/21/13, at 5 PM, she stated she had just completed Resident 1's skin assessment and identified Resident 1 had four Stage II pressure ulcers. Resident 1's four pressure ulcers had not been accurately assessed for five days. The facility was unable to determine if these pressure ulcers had improved or worsened. The facility policy and procedure titled "Prevention of Pressure Ulcers and Pressure Ulcer Risk Assessment," dated March 2005, read, "the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated." 3. During a concurrent observation and interview with the Activities Director, also a licensed staff (AD), on 5/21/13, at 4:30 PM, the AD completed a body check on Resident 15. The AD identified Resident 15 had excoriation and redness to bilateral buttocks and her right heel was soft and mushy. Her lower extremities were dry and itching. During a concurrent interview and record review with the RNCM on 5/21/13, at 5:10 PM, she was unable to find any assessment documented regarding the above skin issues for Resident 15. The RNCM stated the licensed nurses should document any skin concerns and the certified nursing assistants should document and notify licensed nurses of any changes in a resident's skin. 4. During a concurrent observation and interview with the the AD, on 5/21/13, at 4:50 PM, Resident 3's skin was checked. The AD stated the resident had a skin tear to her left inner arm with dried blood. The area was covered with a clear dressing. She had a Band-Aid on her right forearm, steri-strips on her left elbow and bruising to her left lower leg. During a concurrent interview and clinical record review with the RNCM on 5/21/13, at 5:10 PM, she was unable to find any skin assessment for Resident 3. The RNCM stated the nurses should assess and document any skin concerns. 5. During a concurrent observation and interview with the AD, on 5/21/13, at 4:40 PM, Resident 14 agreed to a body-check by the AD. The AD identified redness to the resident's left lower chin, and right elbow. Resident 14 also complained of itching in these two areas. Resident 14 stated the nurses put cream on sometimes but is does not help. During a concurrent interview and clinical record review with the RNCM on 5/21/13, at 5:10 PM, she was unable to find documentation that licensed staff had assessed Resident 14's skin problems. The RNCM stated the nurses should have re-evaluated her since she continued to experience itching and redness to her chin. 6. During an interview with Resident 16, on 5/21/13, at 10 AM, Resident 16 stated he had notified a nurse concerning his skin irritation and itching. Resident 16 thought the itching was caused by the laundry detergent. Resident 16 stated, "The nurse gave him a pill awhile back for my itching but it did not help." During a concurrent interview and clinical record review with the RNCM, on 5/21/13 at 5 PM, she was unable to find any skin assessment related to the irritation. The RNCM states licensed staff should have assessed Resident 16's skin irritation and itching. 7. During a review of the clinical record for Resident 6 on 5/21/13, at 9:45 AM, the initial physical assessment, dated 11/14/12, at 3:50 PM, indicated Resident 6 had a Stage II pressure ulcer to the left coccyx (tailbone) measuring 1.8 x 1.5 centimeters (cm) and a Stage II on the right coccyx measuring 0.5 x 0.5 cm. During a concurrent interview and record review with the DON on 5/21/13, at 3:10 PM, she stated she was unable to locate any other skin assessments done on the documented pressure sores. The facility policy and procedure titled "Pressure Ulcer Risk Assessment," dated 3/05, read, "Assessment: 3. Monitoring: ...c. Nurses will conduct skin assessments at least weekly to identify changes." 8. During an interview with a LVN 2 on 5/22/13, at 9:45 AM, Resident 6 stated she had a rash under her left breast. Resident 6 stated she had told a nurse who worked on 5/21/13 about the rash and was told by the nurse to put a washcloth under her breast. LVN 2 asked Resident 6 if she could look at the rash. Resident 6 agreed. LVN 2 stated there was redness and excoriation noted under Resident 6's left breast. During a review of the clinical record for Resident 6 with LVN 2, she stated she could not locate any documentation of the rash or excoriation under Resident 6's left breast. During an interview with the DON on 5/22/13, at 11 AM, she stated the rash should have been assessed and charted. 9. During a review of the clinical record for Resident 7, the Nurse's Notes dated 5/20/13, at 6:36 PM, did not reveal a complete assessment of the resident's right heel [MEDICAL CONDITION]. During an interview with the Unit Secretary (US) on 5/22/13, at 1:30 PM, she stated she asked the DON where the complete assessment for 5/20/13, at 6:36 PM was for Resident 7, but the complete assessment could not be found. During a review of the clinical record for Resident 7, the wound nurse notes dated 5/21/13, at 7:02 PM, read "Extremely fragile skin covering heel at this time..." During a body check on 5/22/13, at 9:35 AM with the AD, it was observed Resident 7 had two Stage II pressure ulcers on the right heel. During a review of the clinical record for Resident 7, the bath/skin check on the nursing assistant care record, dated 5/22/13, at 11:23 AM, specified a skin check was completed, including the resident's heels. No documentation of the open areas was noted. During an interview with Certified Nurses' Assistant 5 on 5/22/13, at 2:15 PM, she stated regarding Resident 7's heel, "I didn't see it open this morning." 10. During an observation on 5/23/13, at 9:20 AM, Resident 13 had a dime-sized, dark-purple lesion on his hand. The lesion was later identified by a registered nurse (minimum data set nurse) to be a blood blister. During a review of Resident 13's clinical record, an assessment of the lesion could not be located. During interviews with a LVN 5 and the DON on 5/23/13, at 9:20 AM, no mitigating information was given regarding the lack of evidence of assessing the lesion.

Based on observation, interview, and record review, the facility failed to have a current assessment that accurately reflected one resident's (31) orientation and functional ability to participate in her ADL's (activities of daily living, such as hygiene, eating, and positioning self in bed). This had the potential for Resident 31's current care needs to go un-noted and unmet. Findings: During an observation of Resident 31 on 7/30/13, at 9:08 AM. She did not respond to her name or to knocking on the over-bed table. Resident 31 appeared not to be aware of her surroundings. When spoken to she blinked her eyes but made no eye contact. During an interview with Registered Nurse (RN) 4 at 7/31/13, at 11:25 AM, she stated, "Resident 31 has really gotten worse in the last few weeks. She's not talking and has diminished orientation." During an interview with Certified Nursing Assistant (CNA) 7 on 7/31/13 at 11:30 AM, she indicated Resident 31 was no longer able to do her own ADL's (such as hygiene, eating, and positioning self in bed). CNA 7 stated while caring for Resident 31 today she fed her breakfast and just completed her morning hygiene. CNA 7 repositioned her, supported her back with pillows and placed a pillow between her legs for comfort. CNA 7 was asked if Resident 31 spoke with her and if she felt Resident 31 was oriented. CNA 7 stated, "Not really." During a concurrent interview and record review with the Director of Nurses (DON) on 7/31/2013, at 2 PM, the DON stated Resident 31 had been re-admitted on [DATE] after being diagnosed "with a stroke". The re-admission history and physical dated 6/4/13 documented Resident 31 was alert and conversant. The Minimum Data Set (MDS, a thorough physical and mental assessment tool) documented she was independent with positioning herself in bed, dressing and eating and needed limited assistance with personal hygiene. The DON was informed that on this surveyor's two days of observation, Resident 31 was not conversant and did not seem oriented. The DON stated, "Her condition has changed since she came from the hospital. It is a marked decline." The DON was asked if she viewed Resident 31's condition change as "significant", and would that trigger another MDS assessment to identify care needs. The DON stated, "It should have."

Based on observation, interview, and record review, the facility failed to ensure a pressure blister was identified for one (R 30) of nine sampled residents, which resulted in a pressure sore going un-noted and un-treated. Findings: The facility policy titled "Pressure Ulcer Prevention Program" indicated in part that "The CNA/Charge Nurse will observe the resident for any skin breakdown daily during routine care. Any identified problem will be reported to the CM (care manager) for further evaluation." The policy identified "Suspected Deep Tissue Injury: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue." During an observation on 7/30/13 at 9:25 AM with Activities Director/Licensed Psychiatric Technician (AD/LPT) of the skin of Resident 30, the side of the left heel contained a dime-sized darkened area surrounded by a quarter-sized area of blister-like swelling. Manipulation of the heel by the AD/LPT caused pain. The resident became agitated and the skin check had to end before completion. During review of the clinical record for Resident 30, documentation by the CNA on 7/30/13 at 6:55 PM (after the two-person observation above) specified the resident's skin was intact, with no evidence the above skin issue was noted. During an interview with the Director of Nurses (DON) on 7/31/13 at 10 AM, she was asked whether she expected the CNA to notify staff of Resident 30's skin problem. The DON replied, "If (the CNA) saw it. (The CNAs) don't go over every inch ...You were searching for it. "

Based on observation, interview, and record review, the facility failed to complete skin checks and assessments, and/or develop and implement a plan of care, and physician notification for four (10, 1, 7, and 6) of 13 sampled residents. These failures resulted in Resident 10's pressure ulcer progressing and becoming infected. Resident 1 and 6's pressure ulcers went untreated, and Resident 7's wounds went unidentified. These failures resulted in delays in treatment, continued discomfort, wound infections and worsening of skin conditions. Findings: 1. During a review of the clinical record for Resident 10, on 5/22/13, Resident 10 was a healthy male who sustained a fall from trimming a tree. He was admitted to the facility on [DATE], after hip surgery, for rehabilitation. The admitting nurse left Resident 10's admission skin assessment blank. The admission assessment was finally completed on 1/8/13 (six days after he was admitted to the facility). On this day, a licensed staff identified a Stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer...caused by pressure) to coccyx area ( bone at the base of the spine tailbone) and a pimple-like hair follicle to left buttock. Resident 10's physician was notified and treatment orders were obtained. On 1/17/13, another skin assessment indicated an open area to left buttock with drainage. One month later Resident 10's physician progress notes [REDACTED]..slough or eschar may be present...) measuring 6.8 centimeters round and 1/2 centimeters with deep crater (bowl-shaped opening) to the buttock muscles. Resident 10 was discharged on [DATE] to an acute hospital for further treatment to the pressure wound. Resident 10 Physician discharge note, dated 2/24/13, read: "The patient was stable in our facility over the first few weeks, however over the course of the last month he developed a large pressure ulceration to his Left buttock which became infected... The patient's condition was further complicated by the fact that orders per Physician (PHY 1) about wound care were not followed... The resident had not received treatment for [REDACTED]." During a concurrent interview with Registered Nurse Care Manager (RNCM) on 5/23/13, at 8:35 AM, she reviewed the clinical record and was unable to find an admission skin assessment for Resident 10 until 1/8/13. She explained, "She was unable to do his skin assessment on admission because he had a lot of visitors." The RNCM stated when this licensed staff did his skin assessment on 1/8/13, she identified a Stage II decubitus ulcer to his coccyx area and hair follicle to left buttock. The hair follicle got worse and turned to a Stage IV. The RNCM was unable to provide any information how Resident 10's wounds worsened from Stage II to Stage IV. 2. On 5/21/13, Resident 1's clinical record was reviewed. Resident 1 returned to the facility after a hip surgery on 5/16/13. On admission, a licensed staff assessed her to have four pressure ulcers; one on right upper buttock, one on right lower buttock, one on left middle buttock, and one on the right heel. During a record review of the clinical record for Resident 1, the clinical record indicated [DIAGNOSES REDACTED]. Resident 1's admission physician orders did not include any treatment to her pressure ulcers. There was no documentation Resident 1's physician was notified or a care plan in place to initiate appropriate interventions. During an interview with Resident 1's charge nurse (License Vocational Nurse, LVN 1), on 5/21/13, at 11:45 AM, she stated, "She (Resident 1) does not have any wounds or skin treatment orders." During a concurrent interview and clinical record review with Director of Nursing (DON), on 5/21/13, at 11:47 AM, after reviewing the records, she confirmed the above findings. At this time, the DON questioned LVN 1 if she had done any treatments to Resident 1's wounds. LVN 1 stated, "No I haven't. I didn't know she had any wounds." The DON stated the licensed nurse that did Resident 1's skin assessment on admission only worked casually and the skin assessment was incomplete. During a concurrent interview and record review with the RNCM, on 5/21/13, at 5 PM, she stated she had just completed Resident 1's skin assessment and identified the same four pressure ulcers that were identified on admission. During an interview with the RNCM, on 5/22/13, at 8:40 AM, she stated, "The resident does not have treatment orders for her decubitus ulcers (same as pressure ulcers). I'm waiting on her physician's respond to the e-mail I sent yesterday." The facility staff had not notified Resident 1's physician of the pressure ulcers for six days, had not treated her pressure ulcer for seven days since her admission, and had not planned for her care to promote wound healing. 3. During a review of Resident 6's clinical record on 5/21/13, at 9:45 AM, the initial physical assessment, dated 11/14/12, indicated Resident 6 had a Stage II pressure ulcer to the left coccyx (tailbone) measuring 1.8 x 1.5 centimeters (cm) and a Stage II on the right coccyx measuring .5 x .5 centimeter. Another skin assessment, dated 11/14/12, read, " ...Skin is in fair condition with 2 small Stage II on the right side of buttocks and one Stage II on the left side of buttocks apprx. (approximately) 1.5 x 1.0 cm (centimeters) ... " There was no documentation on the pressure ulcers to her left and right coccyx area identified on admission. During further review, there was no plan of care initiated on all pressure ulcers identified above. During a concurrent interview and record review with the DON on 5/21/13, at 3:10 PM, she stated she was unable to locate any other skin assessments of the documented pressure sores, physician notification of the worsening ulcers, or initiation of any care plans. During an interview with LVN 3 on 5/21/13, at 2:30 PM, she stated, "If someone comes in with a Stage II pressure sore we get orders for treatment from the doctor." When questioned if any treatment was ever done for Resident 6, LVN 3 stated she had never done any treatments on Resident 6 and was not sure the doctor was ever notified. 4. During a review of the clinical record for Resident 7, the wound nurse notes dated 5/21/13, at 7:02 PM read, "Extremely fragile skin covering heel at this time..." The treatment documented in the notes was "Open to air." During an observation on 5/22/13, at 9:35 AM, with Activity Director (AD) who was also a licensed nurse, the AD identified Resident 7 had two Stage II pressure ulcers found on the right heel. During a review of the clinical record for Resident 7, the bath/skin check on the nurses assistant care record, dated 5/22/13, at 11:23 AM, specified a skin check was completed, including the resident's heels. No documentation of the open areas was noted. During an interview with Certified Nurses' Assistant 5 on 5/22/13, at 2:15 PM, she stated, "I didn't see it open this morning." The facility policy and procedure titled "Prevention of Pressure Ulcers and Pressure Ulcer Risk Assessment" dated March 2005, indicated the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Routinely assess and document the condition of the resident's skin per facility wound skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of developing pressure ulcers to the supervisor....under Assessment: 3. Monitoring: a. Staff will maintain a "skin alert," performing routine skin inspections daily or every other day as needed. and chart. Nurses will conduct skin assessments at least weekly to identify changes."

Based on interview and record review, the facility failed to accurately assess and prevent the decline in urinary elimination for three of 13 sampled residents (1, 2, and 3). This failure resulted in the actual decline in Resident 1, 2 and 3's ability to maintain urinary continence. Findings: During a review of the clinical record for Resident 1, the Minimum Data Set assessments (MDS is a core set of screening, clinical and functional status screening tool which form the foundation of a comprehensive assessment for the residents in the nursing home) were reviewed. The MDS dated [DATE] and 11/9/12 indicated the resident was occasionally incontinent of urine elimination. The MDS assessment completed on 2/6/13 indicated she was frequently incontinent of urine. During a review of the clinical record for Resident 2, the MDS was reviewed. The MDS dated [DATE] and 12/20/12 indicated the resident was occasionally incontinent of urine elimination. The MDS assessment dated [DATE] indicated the resident's urinary continence had further declined as she was assessed to be frequently incontinent of urine. During a review of the clinical record for Resident 3, the MDS was reviewed. The MDS dated [DATE] and 12/5/12 indicated the resident was always continent of urine. The MDS assessment on 3/4/13 indicated the resident continence status had declined as she was assessed to be frequently incontinent of urine. Resident 3's care plan dated 4/22/13 indicated urinary incontinent...place incontinence products to protect clothing and bedding...no toileting resident on bedrest due to status [REDACTED]. During an interview with the MDS nurse regarding the decline of Resident 1, 2, and 3's continence abilities on 5/23/13, at 1:35 PM, she stated the facility did not have a system in-place to evaluate a resident's continence status nor did it have a bladder or toileting program (a resident could be placed on to assist them in maintaining or gaining bladder control).

Based on observation, interview, and record review, the facility failed to perform daily routine testing of their alarm system (an alarm that sounds when a resident wearing the transmitter passed through certain doors) as recommended by the manufacturer for six (1, 2, 3, 4, 5, and 6) of six sampled residents and two random sampled residents (7 and 8). For Resident 1, the alarm system did not sound when she wheeled herself, passed two doors and out of the facility. While unattended outside, Resident 1 fell off the stairs and broke her right leg. She had a long leg cast and became immobile due to the cast. Consequently, Resident 1 suffered pneumonia (infection of lungs) and developed a pressure ulcer to her left heel. For Resident 2, 3, 4, 5, 6, and Random Sampled Resident 7 and 8, the facility failed to ensure their transmitters were in working condition. This failure placed the residents at risk of bodily injury when going outside the facility without being supervised by staff. Findings: During an interview with the Licensed Vocational Nurse Care Manager (LVNCM) on 3/6/12, at 1:25 PM, she stated Resident 1 sustained fractures to her lower right leg and required a full length (leg) cast. After the injury, Resident 1 developed an infection in her lungs, and a Stage II pressure sore (an open wound over a bony point may appear as a shallow, pinkish-red, basin-like wound) to her left heel. She also required a urinary catheter (a tube inserted into the bladder to drain urine) due to her wearing a full-length leg cast. LVNCM further stated that prior to the fall, Resident 1 was able to get up and could bear some weight on her leg. LVNCM attributed these changes to the resident's fracture. On 3/6/12, the facility's investigative report was reviewed. It indicated Resident 1 had an alarm transmitter attached to her wheelchair to prevent her from attempting to leave the facility. However, on 2/7/12, at 6:30 PM, the alarm system did not alarm and Resident 1 exited the facility. During an interview with the LVNCM on 3/6/12, at 1:15 PM, she was asked if any facility staff had checked the transmitters of the other residents to ensure their effectiveness after Resident 1's transmitter did not alarm. LVNCM replied, "Yes, maintenance staff checked them the day of the occurrence." During an interview with the Maintenance Staff on 3/28/12, at 9:12 AM, he stated he was not called to check the alarms until 2/8/12. He tested the sensors by the doors and "They worked fine but just to be safe I widened the alarm area. I do not check the individual (transmitters)." During an interview with the Director of Nursing (DON) on 3/26/12, at 11:23 AM, she was asked when the maintenance staff was called to check the alarm system after the incident. The DON replied, "They (Nursing staff) didn't call the maintenance (staff)." At 12:31 PM, after the surveyor requested to have a copy of the manufacturer's recommendations on policies and procedures in use of the transmitters. The DON stated she was not aware when the alarm system was installed and the facility did not have the manufacturer's recommendations. On request, the DON contacted the manufacturer and acquired a copy of recommended policies and procedures. The manufacturers recommended policy for transmitter use, dated 11/30/01, was reviewed on 3/26/12. The policy included the following: "It is imperative that the Secure Care systems be checked periodically and that documentation of such check-ups be made... Each transmitter should be tested daily to ensure the transmitter is working properly... The procedure involves using the #707 Transmitter Tester and the Exit Panel on the wall by the exit, and documenting the performance of the transmitter... This product must be installed, set-up, tested , supported, operated, maintained, repaired and used only in accordance with all manuals and instructions issued...." During an interview with the LVNCM on 3/6/12, at 2:10 PM, she was asked regarding checking of the transmitters. LVNCM stated, "We don't have a system to check them (transmitters). We wait until the device expires and toss it." During a concurrent observation and interview on 4/2/12, at 1 PM, the DON took Resident 1's transmitter off her wheelchair and walked it through four doors equipped with Secure Care systems in the facility, one of the doors did not alarm. The DON stated the transmitter worked intermittently and she needed to request the manufacturer to check the system and transmitters. At 4:20 PM, the DON was asked to provide a copy of the facility's policy and procedure on testing of transmitters, she stated a system to check the individual transmitters had not been implemented, and the facility did not have a transmitter tester. At this time, the DON was asked to identify the number of other residents who may be affected and were placed at risk for fall related injury by such deficient practice. She identified a total of seven other residents: Resident 2, 3, 4, 5, 6, Random Resident 7, and Random Resident 8.