Every finding on record at Lassen Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to ensure the residents' right to be free from verbal abuse for four of four sampled residents when the Activities Assistant (AA), yelled at Residents during a smoke break activity. (Residents 1, 2, 3 and 4)This resulted in embarrassment, fear, humiliation and made the Residents felt like children. This caused Resident 1 emotional distress and had the potential to negatively impact the other Resident's emotional and psychosocial well-being.During a review of the facility's policy and procedure titled, Abuse Prevention Program indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone, including, but not necessarily limited to: facility staff, other residents, family members.During a review of the facility's policy and procedure titled, Resident Rights indicated, employees shall treat all residents with kindness, respect, and dignity.A review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with diagnoses that included, left leg fracture, obesity, and a fast heart rate. A review of Resident 1's Minimum Data Set (MDS, an assessment and care screening tool), dated 6/8/2026, indicated Resident 1's Brief Interview for Mental Status (BIMS, a test of memory and decision making skills scored from 0-15) score was 15, no memory or decision making problems. During an interview on 7/2/26 at 10:00 a.m., with Resident 1, Resident 1 stated, I was sitting out in the smoking area with [Resident's 2, 3, and 4]. [Resident 3] asked [AA] for another cigarette and [AA] gave him one. I then asked him for another one too, [AA] took a deep breath and launched into a lecture about smoking. [AA] became unglued and started yelling at me about how he hates the smell of cigarettes, he hates lighting the cigarettes for us, and he hates coming out here with us on our smoke breaks. It made me feel like I was a child getting a lecture. I have Post traumatic Stress Disorder (PTSD) and it brought all that up again. I avoided going to any room that I thought he would be in. I stayed in my room for a couple days until the Administrator told me he had been suspended and later that he quit.A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included, heart attack, difficulty in walking, and generalized weakness. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score was 15.During an interview on 7/2/26 at 10:46 a.m., with Resident 2, Resident 2 stated, We were outside on our smoke break and [Resident 1] asked for another cigarette. [AA] became unglued and started yelling at [Resident 1]. [AA] said I hate coming out here with you guys to smoke, I hate the smell of cigarettes, and I hate lighting them for you. [AA] looked very angry when he was yelling at her [Resident 1]. I finished my cigarette and went back inside.A review of Resident 3's admission Record indicated Resident 3 was admitted on [DATE] with diagnoses that included, congestive heart failure (the heart does not beat as well as it should), generalized weakness, and low blood pressure.A review of Resident 3's MDS, dated [DATE], indicated Resident 3's BIMS score was 15.During an interview on 7/2/26 at 11:26 a.m., with Resident 3, Resident 3 stated, We were outside taking our smoke break when I asked for another cigarette and [AA] handed me one. Then [Resident 1] asked [AA] for another cigarette, and he just started yelling at her. [AA] was yelling about how much he hates cigarettes. He hates the smell of them, hates coming outside on our smoke break with us, and lighting them for us. [AA] made me feel like I was a child.A review of Resident 4's admission Record indicated Resident 4 was admitted on [DATE] with diagnoses that included, left leg fracture, weakness, difficulty walking and anxiety (fear of the unknown).A review of Resident 4's MDS, dated [DATE], indicated Resident 4's BIMS score was 9 (moderately impaired).During an interview on 7/2/26 at 12:30 p.m., with Resident 4, Resident 4 stated, We were out taking our smoke break with [AA] that works in activities. [AA] all of a sudden starts yelling at us. AA yelled about having to be out here with us and how much he hated the smell of smoke. It made me feel nervous and I quickly finished my cigarette and went back inside.During a concurrent interview and record review on 7/2/26 at 12:46 p.m., with Social Services (SS), Resident 1's, Interview Record, dated 6/23/26, was reviewed. The Interview Record indicated, Resident 1 said AA was very rude, yelling, cussing. Resident 1 asked AA for a second cigarette and he said no and if that was a problem she could take it up with the Activity Director. Resident 1 said AA yelled he hated taking smokers out and made her feel embarrassed. Resident 1 said she did not feel safe and every time AA takes them out, she couldn't talk and that when this happened the environment felt hostile. AA stated to Resident 1, I'm not giving you another one. I don't even like being freaking out here with you guys. Resident 1 felt scared and felt she had a PTSD moment and couldn't handle it, so she rolled herself away to do a lap around the building. Resident 1 said she doesn't feel safe around him and doesn't think her PTSD can handle it. Resident 1 stated she has not participated in activities when AA is present because of the way AA speaks to her. Resident 1 said it is a hostile environment when smoking and he is there.

The facility failed to store, prepare, and serve food in a safe and sanitary manner when:1.Meat was not thawed appropriately.2.Water from thawing meat splashed onto ready to eat vegetables causing possible cross contamination (transfer of harmful bacteria, viruses, or allergens from one surface, food, or object to another between raw meat thawing and cooked vegetables).3.Staff did not wash hands after handing dirty items on the dirty side of the dish machine and before touching clean items such as eating utensils, water pitchers, and food storage tubs.Staff did not wash hands upon entering the kitchen and before starting kitchen tasks.4.Cooking pans were in poor condition.5.The can opener blade and holder was not clean.6.Cutting boards were in poor condition.7.The standing mixer was not clean.8.The knife holder was not clean.9.Thickener (a powder used to thicken liquids) was not covered, labeled, or dated.10.Dry food located in the food storage room was not stored appropriately.11.A scoop was stored directly on top of a bin of dried rice.12.Sugar was contaminated.13.Water cups were not covered.14.Cold food was not stored appropriately.15.Range (stove) hood filters were not clean.16.Swamp cooler ceiling vents and surrounding surfaces were not clean.17.Two kitchen fans were not clean.18.One floor tile was not intact.19.Kitchen walls were not clean.20.Hairnets and beard covers were not worn in the kitchen.These findings placed the 89 residents who receive food from the kitchen at risk for receiving contaminated food and/or contaminated eating utensils, out of a census of 90.Findings: 1.A review of the facility's Food Preparation and Service policy, dated 10/2017, under Thawing Frozen Food, Line 1 indicated, Thawing procedures include: b. Submerging the item in cold running water (70 degrees Fahrenheit or below). Line 4 indicated, Potentially hazardous foods, including raw meats which might contaminate other foods or the food preparation area, will be prepared in specified areas using appropriate measure to prevent cross contamination. During an observation in the kitchen on 6/22/26 at 11:05 AM, two slabs of pork shoulder were in a clear bucket in the food preparation sink. Half of both pork shoulders were not submerged in water, and water was running to the side of the meat. An observation on 6/22/26 at 12:02 PM, showed the pork shoulder continued to be half submerged in the two-compartment preparation sink, under running water. During an interview on 6/22/26 at 2:42 PM, with the Dietary Manager (DM), DM stated running water should be flowing right over the meat. DM stated, No wonder it was taking so long to thaw the meat because the water wasn't running over the meat. During a concurrent observation and interview on 6/23/26 at 8:41 AM, with DM, Surveyor observed a white bag in a container with water running into the container on the right side on the two-compartment preparation sink. The white bag had at least 3 inches of the bag sticking up above the water and water was running onto the bag. DM stated the white bag contained ground turkey that was being thawed for tonight's supper. 2. During an observation on 6/23/26 at 11:43 AM, with [NAME] A, [NAME] A removed a pan of vegetables from the steamer and poured the vegetables into a large colander in the left side of the two-compartment sink (compartment 1). The adjacent sink compartment had packaged ground turkey thawing in a container with water running over the package. Water splashed from the ground turkey package into the cooked vegetables draining in the colander. During a concurrent observation and interview on 6/23/26 at 11:45 AM, with the DM, Surveyor asked DM regarding the thawing meat and cooked vegetables being close to each other and if it was a concern. DM confirmed water splashed from the thawed meat into the cooked vegetables in the colander and stated that they should be placed further apart. DM removed the thawed meat package and placed it in a pan. Surveyor observed red fluid accumulated in the bottom of the pan from the meat package. When the surveyor asked DM their thoughts on the safety of the vegetables, DM confirmed the vegetables were not safe to eat. 3.A review of the facility's, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, dated 10/2017, indicated on Line 6, Employees must wash their hands: Line C indicated, Whenever entering or re-entering the kitchen. Line D indicated, Before coming in contact with any food surfaces. Line F indicated, After handling soiled equipment or utensils. During an observation on 6/23/26 at 11:37 AM, Dietary Aide (DA) B washed dishes and organized silverware from a dish machine crate and placed them in the silverware holder on the dirty side of the dishwashing area. DA B handled the water sprayer at the dirty side of the dish machine. DA B put the silverware holder in the dish machine, then grabbed the handle on the dirty side of the dish machine to pull the door down to start the cleaning cycle. Then DA B went to the clean side of the dish machine, where clean utensils and equipment were stored and touched pitchers, tubs, utensils including a whisk, tongs, and a large potato masher. Next, DA B proceeded to handle clean silverware and placed the silverware in a clean storage area next to the tray line. DA B did not wash their hands between handling items on the dirty side of the dish machine and touching the clean items used for food preparation, food storage, and food service. During an interview on 6/23/26 at 11:42 AM, with the DM, DM confirmed hand hygiene should be done between handling dirty items and moving on to clean items when washing items in the dish machine. During an observation on 06/23/26 at 11:56 AM, [NAME] B entered the kitchen, did not wash their hands, and walked across the kitchen to the food preparation area near the mixer and microwave where he placed a hair net on his head. [NAME] B then touched the food preparation table and handled the recipe binder. 4.A review of the facility's, Sanitization policy revised 10/2008, Line 2 indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Line 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. During an observation in the kitchen on 6/22/26 at 11:02 AM, nine cooking pans were hung above a two-compartment preparation sink and ready for use. Each of the nine pans had dark black buildup on the cooking surfaces with a significant amount of pitting and scratches. During a concurrent observation and interview on 6/23/26 at 9:40 AM, with the DM, DM confirmed that pitting scratches were on multiple hanging pans. DM confirmed that two fry pans had lost their protective coating on the cooking surface. DM stated the pans were not usable. DM stated, It has been on the back of my mind to replace the pans but hadn't ordered them yet. 5. During an observation on 6/22/26 at 10:54 AM, in the kitchen, the industrial can opener attached to the food preparation table had brown residue on the cutting blade and on the surface. During a concurrent observation and interview on 6/23/26 at 9:40 AM, with the DM, DM stated the can opener should be cleaned after each use. DM stated the can opener, Was definitely not cleaned after each use. DM stated that when food residue is left on food equipment there is a risk of cross contamination to food. DM stated the can opener holder should be cleaned off every night and that it did not look like it was being cleaned every night. 6.During an observation on 6/22/26 at 10:57 AM, three large plastic cutting boards and five small plastic cutting boards had significant scratch marks, a coating of white flakes, chipped surfaces, and black discolorations. During a concurrent observation and interview on 6/23/26 at 9:40 AM, with the DM, DM confirmed the above observations of the cutting boards and stated the cutting boards needed to be replaced. 7.During an observation on 6/22/26 at 10:55 AM, a standing mixer was not covered. The metal guard and metal plate shield had yellowish residue that appeared to be food residue on the surface. During a concurrent observation and interview on 6/23/26 at 9:40 AM, with DM, the standing mixer was covered with plastic. DM stated the standing mixer was not covered yesterday and it should be covered when it is clean. DM confirmed the standing mixer was not cleaned after it was used to mix cake batter yesterday. The plastic cover was removed from over the mixer and there was still yellowish residue splatters on the surface of the mixer, the metal guard, and metal plate shield. DM confirmed there was what appeared to be food residue on the mixer and it was not clean. DM stated the residue on the mixer could attract bugs. 8.During an observation on 6/22/26 at 10:53 AM, a knife holder above the food preparation table held multiple knives. The knife holder had white particles covering the surface where the knives entered the holder. During an interview on 6/23/26 at 9:40 AM, with the DM, DM confirmed the outside surface of the knife holder was sticky and had a rough surface. 9.A review of the facility's, Food Receiving and Storage policy, dated 7/2014, indicated on Line 7, Dry food that are stored in bins will be removed from original packaging, labeled and dated ( use by date). Such food will be rotated using a first in-first out system (organizational system where the oldest items are the first ones to be used or removed). According to the 2022 Federal Food Code for food that is not time/temperature control for safety food, such as bins of sugar, flour, or cinnamon, during pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored with their handles above the top of the food. In addition, a food that is adulterated (something that has been made impure by adding a foreign substance, this can be intentional or unintentional contamination), or not honestly presented shall be discarded. During an observation on 6/22/26 at 11:01 AM, in the preparation area of the kitchen, a tall clear pitcher was stored on top of a microwave with a white granular substance in it. The pitcher was uncovered and unlabeled. During an observation and interview on 6/23/26 at 9:10 AM, with the DM, DM confirmed that the granulated substance in the pitcher in the preparation area was food thickener. DM confirmed that the pitcher should have been labeled and covered. 10.During an observation on 6/22/26 starting at 11:24 AM, in the dry food storage room, an open bag of white cake mix sealed in a separate plastic bag had an open date of 1/8/26, but had no use-by date. Two open bags of yellow cake mix were sealed in a plastic bag and not labeled with manufacturer recommended expiration dates. A label on a container of wheat flour read, Expired 6/13/25. A large container of a white granulated substance was unlabeled. Two bags of ziti pasta had been opened and the bag tied in a knot and lying on a wire shelf. One of the pasta bags had sticky grease on the outside. The Pasta bags had no open or expiration dates labeled. One opened package of angel hair pasta was not sealed in a separate plastic bag and had no open or expiration dates labeled. During an observation and interview on 6/23/26 at 9:10 AM, with the DM, DM confirmed the white granulated substance in the large container was sugar and was not labeled but should have been. DM confirmed the container of wheat flour in the food storage room expired 6/13/25. DM confirmed that opened ziti and angel hair pasta bags should be sealed in a separate plastic bags and labeled with their opened and used by or expiration dates. DM confirmed one ziti pasta bag was greasy on the outside and stated it was not okay because grease can attract bugs and can foster bacterial growth leading to cross contamination. DM stated when items in the dry food storage room are opened, they should be sealed in a separate plastic bag with an open date and use by date label. DM stated cake, pancake mix, and buttermilk biscuit mix generally can be used after opening for six months to one year. DM could not verify manufacturer recommended expiration or use-by dates on the dry mixes. DM stated most items have expiration dates on the box, however if the products are opened and removed from the box, some products might lose the information of the expiration date. DM provided a list of Food Labeling Reference Guide for Opened Items dated 12/2024. DM confirmed that tortillas were not on the list and that two boxes of the tortillas found without dates. 11.During an observation in the kitchen dry storage room on 6/22/26 at 11:36 AM, a scoop (large deep spoon-like utensil) was observed stored inside a container of rice. The scoop handle was touching the rice. 12.During an observation in the kitchen dry food storage room on 6/22/26 at 11:35 AM, a large plastic container holding a white granulated substance had black bits of a substance in it. There was no label on the container to indicate what the container held. During an interview and observation in the kitchen dry storage room on 6/23/26 at 9:10 AM, DM confirmed the white granulated substance in the unlabeled container was sugar and confirmed the sugar had black things in it which the DM could not identify. 13.A review of the facility's, Refrigerators and Freezers policy, dated 12/2014, indicated under, Policy Statement, the facility will observe food expiration guidelines. Line 7 indicated, All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dated (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dated indicated once food is opened. A review of the facility's, Food Receiving and Storage policy, dated 7/2014, showed all foods in the refrigerator or freezer will be covered, labeled, and dated by use-by date. During an observation in the kitchen on 6/22/26 at 10:43 AM, the Nourishment refrigerator had a tray of uncovered cups filled with water. During an observation and interview on 6/22/26 at 9:01 AM, with the DM, surveyor discussed observation of water cups being stored in the nourishment refrigerator uncovered. DM stated they ran out of lids for the cups that day but the cups should have been covered to prevent air germs from getting into the water. 14.During an observation in the kitchen on 6/22/26 at 11:12 AM, of a freezer located in the dry food storage room, two opened packages of what appeared to be cookie dough were sealed in a plastic bag with no open or expiration dates on the bag and no label to indicate what the food was. The freezer contained frozen angel food cake with an expiration date of 5/24/26. A large box of pizza dough was labeled 12/18/25. During an observation and interview on 6/23/26 at 9:01 AM, with the DM, DM confirmed the opened package of cookie dough was not labeled and they were not able to determine the open and expiration dates from the original box. DM stated they would not feel safe serving them to residents because the cookie dough was susceptible to frost bite. DM confirmed pizza dough and the angel food cake in the freezer had expired. 15.Review of the facility's, Sanitization policy and procedure, dated 2008, showed the food service area shall be maintained in a clean and sanitary manner. All kitchens and kitchen areas shall be kept clean. Kitchen surfaces not in contact with food shall be cleaned on a regular schedule frequently enough to prevent an accumulation of grime. According to the 2022 Federal Food Code, indoor floors under conditions of normal use are to be smooth and easily cleanable for areas where food establishment operations are conducted. During an observation on 06/22/26 at 12:01 PM, the range hood filters had gray fuzzy build-up on them and the light fixture under the hood had gray fuzzy residue on the surface. During an observation and interview on 6/23/26 at 9:10 AM, with the DM, DM confirmed the range hood filters appeared fuzzy. DM stated they were in need of cleaning. DM stated, They could use a wipe down, but they are not terrible when discussing the condition of the lights inside the range hood. 16.During an observation on 6/22/26 at 10:51 AM, the swamp cooler vents above two refrigerators had dark gray fuzzy build-up present in between the slats and there was dark gray fuzzy build-up on the ceiling around the vents and on the wall below toward the refrigerators. During an observation and interview on 6/23/26 at 9:10 AM, with the DM, DM acknowledged the swamp cooler vents on the ceiling in the kitchen had fuzzy dust and black residue. DM acknowledged that the swamp cooler above two refrigerators had fuzzy dust and black residue on the cooler vent slats and black residue was on the wall toward the refrigerators. DM acknowledged the swamp coolers need to be cleaned and stated maintenance services these coolers but was unsure of when they are cleaned or if this service is on a schedule. DM stated they needed to be wiped down. During an observation and interview on 6/24/26 at 9:32 AM, with the Maintenance Technician (MT), MT confirmed that they cleaned the swamp cooler vents last month and they are supposed to be cleaned monthly or every other month. MT stated they were behind with cleaning the vents. MT did not know what the dark material was on and around the swamp cooler vents but confirmed it was there. 17.During an observation on 6/23/26 at 8:53 AM, in the kitchen, a large, black fan next to ice machine had black fuzzy particles on the blades and blade guards. A grey fan near the tray line had a grey fuzzy substance on the blade and blade guards. During an observation and interview on 6/23/26 at 10:02 AM, with the DM, DM confirmed that the grey standing floor fan near the tray line had gray fuzzy substances on the wire blade guards and on fan blades. DM confirmed the large black fan by the ice machine was dusty. DM stated they had recently started using the fans in the kitchen. 18.During an observation and interview in the kitchen on 6/24/26 at 9:10 AM, a tile adjacent to a floor sink drain behind the ice machine, was cracked and missing a large chunk creating a rough floor surface. Water was leaking onto the floor around the floor sink creating pooling water on the tiles. DM stated they were not aware of the broken tile and had not reported it to maintenance. During an observation and interview on 6/24/26 at 10:40 AM, with the DM, DM acknowledged that the floor sink drain was leaking onto the floor and a tile was broken that needed repair. He acknowledged the presence of black residue around the plastic pipe entering the floor sink drain. 19.During an observation on 6/23/26 at 9:59 AM, two walls above the work desk in the kitchen had orange residue that looked like food had splattered on them. During an observation and interview on 6/23/26 at 9:40 AM, with the DM, DM stated they had not noticed this discoloration on the wall before. DM stated, It looks like soup. Like something exploded but wasn't sure. 20.A review of the facility's policy, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 10/2017, Line 12 indicated, Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. During an observation on 6/22/26 at 10:57 AM, DM was not wearing a hairnet to cover the hair on their head. During an observation on 6/22/26 at 2:45 PM, DM had no hairnet on, and their beard net did not cover their beard completely. During an observation on 6/23/26 at 8:43 AM, DM was not wearing a hairnet. MT was on a ladder placing a light cover on a ceiling light above the refrigerators in the back of the kitchen. MT had mustache and beard and was not wearing a beard net. During a concurrent observation and interview on 6/23/26 at 9:10 AM, with the DM, DM 's beard net was not covering their mustache and beard completely. Surveyor asked what the expectations for maintenance workers was when entering the kitchen. DM confirmed that all hair must be covered. Surveyor discussed an observation of a MT not wearing a beard net on 6/22/26. DM stated he had not noticed this yesterday and had not communicated to the MT that hair covers are required. During an interview on 6/23/26 at 10:02 AM, with the DM, DM stated in the kitchen it is the expectation that all employees wear hair coverings for their hair and beards when going beyond the red line (tape boundary) on the kitchen floor. DM confirmed that they forgot to wear a hair net yesterday. DM stated their beard cover keeps falling down and it was hard to fully cover their mustache and beard because it had grown.

Based on interview and facility policy and procedure (P&P) review, the facility failed to ensure call lights were answered timely for 8 of 19 sampled residents (Residents 73, 98, 3, 85, 74, 57, 6, 93) and four of seven confidentially interviewed residents.This failure resulted in dependent residents (residents not able to help themselves to the bathroom, out of bed, or out of their wheelchairs) not receiving the assistance they needed. Findings: Review of a facility procedure titled, Answering the Call Light revised October 2023 indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs.1. Answer the resident call system immediately. Review of Resident 73's medical record indicated that she was admitted to the facility on [DATE] with diagnoses which included muscle weakness, and need for assistance with personal care. During an interview on 6/22/26 at 11:00 AM, Resident 73 indicated staff were slow to answer call lights at night. Review of Resident 98's medical record indicated that she was admitted to the facility on [DATE] with diagnoses which included a wound on her left leg, an abscess (a localized, enclosed pocket of pus that forms in the body's tissues in response to an infection) of her right foot, and weakness. During an interview on 6/22/26 at 11:28 AM, Resident 98 indicated that call lights take too long and it would take a long time to get help. During an interview on 6/22/26 at 3:30 PM, the Director of Nursing (DON) confirmed that her expectation was that call lights be answered by staff and resident needs be met within a reasonable timeframe. A review of Resident 3's medical record indicated that Resident 3 was admitted on [DATE] with diagnoses that included Acute Congestive Heart Failure (CHF, Heart does not pump blood adequately), Atrial Fibrillation (A-fib, Irregular heart beat), and Acute Respiratory Failure with Hypoxia (Inadequate oxygenation of the blood). During an interview on 06/22/2026 11:30 AM, with Resident 3, in their wheelchair in the resident's room, Resident 3 stated, Call lights can take a very long time. I have waited for an hour. I think nights are a problem, weekends are a problem, and holidays are a problem. Staffing definitely seems to be an issue. It takes way too long to get pain medications. I can have my light on and just have to wait for the medication to be administered. It can be a very long wait. It isn't every time but it does happen frequently. Night shift is the longest, I know I have waited an hour. My roommate has actually had an accident because it took so long. There have been times in the day, especially on weekends or holidays that it has taken a very long time to get around to the call lights. A review of Resident 85's medical record indicated that Resident 85 was admitted on [DATE] with diagnoses that included Cerebral Infarction (Stroke), Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side (Paralysis and weakness that affects one side of the body), and Abdominal Pain. During an interview on 06/22/26 11:46 AM, with Resident 85 in their bed while in the resident's room, Resident 85 stated, The call light takes an hour, pain meds take a long time to get. It seems like there is not enough staff. It takes a long time to get help when I use the call light. During an interview on 6/23/26 at 3:00 PM, with Certified Nursing Assistant (CNA) F in the hall outside room [ROOM NUMBER], CNA F stated the residents in room [ROOM NUMBER] (Resident 3 and Resident 85) use the call light a lot, we do our best to answer it timely even when we are short staffed. During an interview with 6/25/26 at 1:15 PM, with CNA G on the back patio entering the building, CNA G stated we could use another CNA position, it would help with things like call lights. During a review of Resident 93's admission record indicated that Resident 93 was admitted on [DATE] with diagnoses that included aftercare following surgery on the digestive system, atrial fibrillation (a cardiac condition), high blood pressure, diabetes, heart failure and sleep apnea (disrupted breathing during sleep). During an interview on 6/22/26 at 10:56 AM, resident 93 stated that staff take a long time to respond to call lights and that the wait time is often well over 30 minutes. Resident 93 stated they have had to wait for assistance with bed changes and to use the bathroom. Resident 93 stated they have come to accept that this is just the way it is but that the delays are embarrassing and make them feel that they are being a bother. During a review of Resident 74's record indicated that Resident 74 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), retention of urine, heart failure, anxiety disorder, and muscle weakness. During an interview on 6/22/26 at 11:30 AM, Resident 74 stated they regularly wait more than 30 minutes after activating the call light. Resident 74 stated the call light is usually used to request assistance to the restroom and that staff have taken so long to respond that they have experienced episodes of incontinence (lost control of bowels or bladder) before assistance arrived. Resident 74 stated the delays occurred during both the day and the night shifts and made them feel upset, angry, and undignified when waiting for assistance to use the restroom. During a review of Resident 6's admission record indicated that Resident 6 was admitted on [DATE] with diagnoses that chronic obstructive pulmonary disease (COPD), colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body), diabetes, obesity, artificial openings of urinary tract, and muscle weakness. During an interview on 6/22/26 at 12 PM, Resident 6 stated that they often wait a long time for staff to respond after activating the call light, especially during the night. Resident 6 stated they have a urinary drainage bag that requires routine emptying at night. Resident 6 stated that on a couple of occasions during the previous two weeks, they woke up in the morning to find the bag full, which the resident stated only happens if it was not emptied during the night. Resident 6 stated they typically wait more than one hour after activating the call light and that, at times during the night, the call light is not answered at all. Resident 6 stated these delays make them feel forgotten. During a review of Resident 57's admission record indicated that Resident 57 was admitted on [DATE] with diagnoses that included metabolic encephalopathy (brain disfunction caused by a problem in the body rather than an injury), epilepsy (a brain disorder that causes recurring seizures), high blood pressure, diabetes, and muscle weakness. During an interview on 6/22/26 at 3:24 PM, Resident 57 stated there are times when the call light is not answered during the night and that they have often waited more than an hour for assistance. Resident 57 recalled a recent night when they had a bowel movement in the middle of the night, activated the call light, and did not receive assistance until the morning staff arrived and cleaned them up. Resident 57 stated they informed the morning staff that they had waited all night. Resident 57 stated the delays are worse at night, make them feel uncomfortable, and have caused them to think about leaving the facility. Resident 57 further stated they try to avoid using the call light during busy times because they know it will take longer to receive assistance, which sometimes results in waiting longer to be changed. During a confidential interviews on 7/24/26 at 10:10 AM, four of seven confidentially interviewed residents it takes staff 45 minutes or longer to answer their call lights. One of one confidentially interviewed resident stated they don't get their pain medication on time. They put their call light on at 11:00 AM and at 11:30 AM, no one answered the call light so they had to get out of bed and go find someone, only to be told the nurse was at lunch and they had to wait until she got back to get the pain medication. One of one confidentially interviewed resident stated they had an accident (peed the bed) because her call light was not answered in time. During a review of the, Resident Council Minutes (RCM), dated January 2, February 6, March 6, April 3, May 1, and June 5, 2026, the RCM indicated that call lights are being turned off and no one comes back to assist the resident with what they need. Residents are having to wait 20 to 30 minutes for their call light to be answered.

Based on observation, interview, and facility document review, the facility failed to ensure Food and Nutrition Services (FNS) staff had the appropriate competencies and skills sets to carry out the functions of the FNS department when:1.Two staff did not know manual dishwashing procedures;2.One staff did not follow the recipe for pureed food;3.One staff used expired test strips for testing sanitizer strength; and4.Two staff did not follow proper hand hygiene procedures (Cross Reference F812).The failure to ensure FNS staff competency and skills sets resulted in 4 of 10 FNS staff not appropriately carrying out tasks related to their jog duties which had the potential to lead to contamination of food and food service equipment, and decreased quality of food for a census of 90.Findings: 1.Review of the policy and procedure titled, Food and Nutrition Services Staff dated 2001, showed the food and nutrition services staff, under the supervision of the Dietitian and/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department.During an interview on 6/22/26 at 11:50 AM, the Dietary Manager (DM) stated he was the DM for about a year.During an interview on 6/23/26 at 9:01 AM, DM explained he had nine kitchen staff and six of those staff were new, less than a month.During an interview on 6/24/26 at 9:02 AM, when DM was asked for documentation of inservice training for kitchen staff regarding their job duties and performed tasks, DM stated he did not have any documented inservices. DM explained a Dietary Assistant who was experienced, trained the dietary aides on their job duties and he (the DM) trained cooks on their job duties. DM stated he did on-the-job training because he was too busy trying to keep up. DM stated due to staff turnover, he did not have enough time to provide documented training or competency assessments. DM stated he also did not have any records of kitchen staff training from the previous kitchen manager.During an interview on 6/24/26 at 11:15 AM, the Director of Staff Development (DSD) B stated she provided onboarding training for all staff, but DSDs did not provide kitchen specific training. Review of the Personal File Checklist dated 6/1/24 provided by DSD B as the checklist used for newly hired employees included competency check-off list for items applicable to all staff at the facility, and some nursing specific competencies, but did not include competencies for kitchen specific job duties and tasks.During an interview on 6/23/26 at 11:26 AM, Dietary Aide (DA) B stated her position was a dishwasher.During an observation in the kitchen and interview on 6/23/26 at 12:45 PM, DA B stated she had to manually (wash by hand) wash dishes sometime last year because the dish machine (dishwasher) was not working. DA B described and demonstrated how she would use the two-compartment manual sink to wash dishes by hand, if the dish machine was out-of-order. DA B stated the first step was to sanitize the items in the first sink, the second step was to rinse the items well in the second sink, the last step was to place the items on the counter to air dry. DA B stated she would not use soap to wash the dishes on any of the steps.During an observation in the kitchen, interview, and document review on 6/24/26 at 9:02 AM, the DM described manual dish washing procedures using the two-compartment manual dish washing sink. DM stated the first sink was for washing items (dishes, utensils, etc.), the second sink was for sanitizing the items, then they were rinsed with a sprayer adjacent to the two-compartment sink. Then DM stated he needed to look at the posted directions if he needed to manual dishwash. DM confirmed the undated laminated poster titled Dishwashing 2 sink method for pots, pans and cooking utensils showed first to wash, then to rinse, then sanitize. DM stated according to the directions on the poster for the two-compartment sink, the first step was to fill the first sink with to wash items with detergent, then empty the first sink to rinse items, then fill the second sink with sanitizer to sanitize. DM stated the directions were normally posted on the wall above the two-compartment sink, but the directions were removed at some point. 2.Review of the policy and procedure titled, 'Kitchen Weights and Measures dated 2001, showed Food Services staff will be trained in proper use of cooking and serving measurements.Review of the policy and procedure titled, Food and Nutrition Services dated 2001, showed each resident is provided with a palatable diet.Review of the menu spreadsheet titled, [Facility Name] Spring 2026 Therapeutic Spreadsheets dated week 3 Tuesday, showed Pork Roast with gravy as the main entree for Regular diets and pureed (liquified) pork roast with gravy for the pureed diets.During an observation and interview on 6/23/26 at 10:25 AM, [NAME] A blended pork in a food processor. [NAME] A stated he was making the pureed pork for the upcoming lunch meal. [NAME] A stated he was making enough portions for four residents who were on pureed diets. After [NAME] A added pork to the food processor, [NAME] A poured in water from a plastic pitcher. [NAME] A confirmed he did not measure the water poured in with the pork and he did not know exactly the amount but stated it was more than one cup. [NAME] A proceeded to blend the pork and water, then added more pork, then poured in a powdered thickening agent without measuring the thickening agent.During an observation and document review of lunch tray line food service on 6/23/26 starting at 12:05 PM, showed four pureed diets were served to residents with a tray ticket dated, Noon Meal - Tuesday, June 23, 2026 and indicated, Pureed/Level 4 Texture as part of the diet order.During an observation and interview on 6/23/26 at 1:59 PM, a test tray for pureed and regular textured food was conducted in the presence of DM as soon as the last lunch tray was passed to a resident in the dining room. When the food was tasted, the regular textured pork was very flavorful. However, the pureed pork did not have much flavor. DM tasted the pureed pork and stated it was bland. During an interview and document review on 6/24/26 starting at 12:35 PM, the recipe titled, Pot Roast/Grvy [Gravy] dated Spring 2026 for the pork pot roast served for lunch on 6/23/26 was reviewed with DM. The recipe showed for puree, to place portions needed from the regular prepared pot roast into a food processor and process to a fine texture. Add thickener and process until smooth. If the product is too thick, add one tablespoon of hot liquid at a time, and re-process. DM stated [NAME] A did not follow the recipe for the pureed pot roast if he added over a cup of water without measuring. DM stated he guessed the pureed pork was bland for lunch on 6/23/26 because the recipe was not followed and too much water was added. 3. During an observation on 6/23/26 at 11:00 AM, DA B demonstrated how to check the sanitizer strength of the chemical sanitizing/low temperature dish machine. DA B removed a test strip from a test strip container and dipped the strip in the dish machine sanitizer solution after the dish machine completed the cycle. DA B compared the test strip to the test strip color chart on the container to assess the strength of the sanitizer. Review of the sanitizer test strip container titled, [Manufacturer Name] Chlorine Test Papers showed an expiration date of 10/1/25. During a concurrent interview and observation on 6/23/26 at 11:00 AM, the test Chlorine Test Paper container was shown to DM. DM stated he did not know there was an expiration date for the test strips and no wonder they were getting unexplainable test strip readings when they tested the sanitizer strength. An observation and interview on 6/24/26 at 8:57 AM, showed [NAME] A demonstrated how to test the sanitizer in the red bucket used for sanitizing food contact surfaces in the kitchen. [NAME] A showed the container of sanitizer from which the sanitizer was from and showed it was a, [Brand Name] Multi-Quat Sanitizer (also known as Quaternary Ammonium, or Quat). Review of the test strip container titled, QAC QR Test Strips which [NAME] A stated were the test strips used to test the Quat sanitizer had an expiration date of 5/2026. In a concurrent interview and observation on 6/24/26 at 8:57 AM, DM confirmed the Quat test strips were expired and again stated he was unaware the test strips expired. 4.An observation on 6/23/26 at 11:37 AM, showed DA B touched dirty items then clean food service and food preparation items without washing her hands in between. During an observation on 06/23/26 at 11:56 AM, [NAME] B did not wash his hands upon entering the kitchen, touched his hair to put on a hair net, touched a food preparation surface and a recipe binder without washing his hands. Review of the Facility's, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, dated 10/2017, showed employees must wash their hands: Line C indicated, Whenever entering or re-entering the kitchen, before coming in contact with any food surfaces, and after handling soiled equipment or utensils. During an interview on 6/24/26 at 9:46 AM, with the DM, DM stated there was no documentation regarding cross contamination, dishwashing, or hand hygiene.

Based on observation and interview, the facility failed to provide alternate entrees of equal nutritive value to the entree served. This failure had the potential to result in decreased nutrient intake leading to food related medical issues for 11 out of 11 residents who requested an egg salad sandwich alternate entree for a lunch meal out of a census of 90. Findings: Review of the policy and procedure titled, Menus dated 2001, showed menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet, the resident is provided an alternate means of meeting his or her nutritional needs. Review of the menu spreadsheet titled, [Facility Name] Spring 2026 Therapeutic Spreadsheets dated week 3 Tuesday, showed Pork Roast with gravy as the main entree. Other items on the menu included mashed potatoes, Italian blend vegetables, and a roll with margarine.An observation of tray line food service and concurrent interview on 6/23/26 starting at 12:05 PM, showed 11 residents who requested an egg salad sandwich, versus what was served on the menu, received an egg salad sandwich and potato chips. These residents did not receive any of the other menu items on their tray, such as vegetables. The Dietary Manager (DM) explained residents could choose an alternate entree if they wanted. DM explained that residents are given menus once a week for the entire week, and the residents circle or write in on the menu, what they want to eat off the menu for the week and only receive what they mark on the menus. During an observation and interview on 6/23/26 at 1:08 PM, [NAME] A prepared an egg salad sandwich to serve as an alternative during the tray line lunch service. [NAME] A removed egg salad from a pan with a metal spatula and placed the egg salad between two pieces of bread. When asked how much egg salad he placed on the sandwich, [NAME] A stated he prepared enough to give each residents two eggs per sandwich, but he did not measure the amount he placed on the sandwich. During an interview on 6/24/26 at 12:35 PM, DM stated he or the Registered Dietitian (RD) did not look into the nutritional value of alternate entrees provided to residents, to ensure the alternate was of equal nutritive value to what the alternate was substituted for. DM confirmed the egg salad sandwich was the alternate just for the entree. DM stated in the past, he offered food items such as salads, but the residents did not want the salad, so he stopped asking. DM stated the other menu items should be served in addition to the alternate entree and stated, for example, the residents should still receive vegetables or a salad as a substitute for the vegetables. DM stated he did not know the protein content of the egg salad sandwich and he did not know if the egg salad sandwich was of equal nutritive value to what was served. When the egg salad sandwich recipe was requested, DM stated there was not an egg salad sandwich recipe. DM stated he thought staff must be Googling the recipe. [NAME] A stated he looked at YouTube videos to learn how to make the egg salad sandwiches. [NAME] A showed a variety of YouTube videos on his phone but did not specify which video he watched to make egg salad sandwiches. During an interview on 6/25/26 at 8:27 AM, when RD was asked the process for determining the nutritive value of alternates for menu items, RD stated she was not 100 percent sure. RD stated she relayed resident preferences, but she did not compare nutritive values when meal planning. When asked if she observed resident dining, RD stated she observes dining when she visits the facility by sitting at the nurse's station across the hall from the entry to the dining room. RD stated she did not observe alternate meals. When asked about residents being served alternate meals but not receiving all of the food that is not the entree, she stated the residents should be receiving the rest of the meal.

Based on interview and record review, the facility failed to comprehensively assess and implement appropriate interventions to restore bladder continence following indwelling urinary catheter (a tube inserted into the bladder to remove urine), removal for one of 19 sampled residents (Resident 74).This failure placed Resident 74 at risk for missed opportunities to restore or improve bladder continence, avoidable complications associated with prolonged incontinence (loss of bladder control), and reduced quality of life.Findings: A review of Resident 74's admission record indicated that Resident 74 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), retention of urine (unable to fully empty the bladder), heart failure, anxiety disorder, and muscle weakness.During a review of Resident 74's Minimum Data Set (MDS-assessment tool) section C, dated 4/20/26, indicated Resident 74 had mild cognitive (memory and decision making ability) impairment. Section GG, dated 4/20/26, indicated Resident 74 required extensive assistance (one or two staff need to provide help) with Activities of Daily Living (ADLs) including bed mobility, transfers, and toileting.During a review of Resident 74's MDS section H, dated 4/24/26, indicated Resident 74 arrived to the facility with an indwelling urinary catheter.During a review of the facility's policy and procedure (P&P) titled, Behavioral Programs and Toileting Plans for Urinary Incontinence, dated 10/2010, indicated, the purpose of the policy was to provide guidelines for initiating and monitoring behavioral interventions for residents with urinary incontinence. The policy directed staff to conduct a comprehensive assessment to identify factors contributing to a decline in urinary incontinence, including changes in medical condition or medications. The assessment included evaluating the resident's comprehension and ability to recognize the urge to void. The policy further directed staff to monitor and document voiding patterns, including voiding times, type in frequency of incontinence, and the resident's response to interventions. Once the resident is assessed appropriate interventions such as pelvic floor rehabilitation (a strengthening exercise), toileting plans, prompting, and habit training, can be implemented. The policy indicated that bladder training is appropriate for residents with urge (sudden need to void) or mixed incontinence (both continent (able to control bladder) and incontinent episodes), who are cognitively intact.During an interview on 6/24/26 at 9 AM, in the resident's room, Resident 74 stated they sometimes have difficulty reaching the restroom in time and required staff assistance to transfer them on and off the toilet. Resident 74 stated they have had trouble controlling their bladder since removal of their indwelling urinary catheter, which was about three days after they were admitted . Resident 74 stated, at times staff took so long to respond to the call light that they had episodes of incontinence before assistance arrived. Residents 74 further stated nursing staff had not asked about their bladder control and reported that prior to hospitalization, they were continent and used the restroom normally. Resident 74 expressed concern that they may not regain continence and felt their bladder control had continued to worsen over time.During an interview on 6/24/26 at 3:00 PM, Certified Nursing Assistant (CNA) B stated the point-of-care information (electronic CNA documentation), indicated Resident 74 required one person assistance with toileting, had at least one episode of incontinence during the previous shift, and was not on any scheduled toileting program. CNA B stated that because they had not previously cared for Resident 74, they would need to ask the resident what type of toileting assistance was needed and would not otherwise know whether the resident was continent or incontinent.During an interview on 6/24/26 at 3:10 PM, Licensed Vocational Nurse (LVN) C stated that Resident 74 was admitted with an indwelling urinary catheter, which was removed three days after admission. LVN C stated a voiding (urinating) trial was completed following catheter removal, but that Resident 74 had not been evaluated for a specific individualized toileting program. LVN C further stated they were not sure who at the facility initiates bladder training programs. LVN C stated resident 74 would be a good candidate for bladder training because the resident has intact cognition and continues to have episodes of incontinence.During a concurrent record review and interview on 6/24/26 at 3:19 PM, with the facility Director of Nursing (DON), Resident 74's medical record titled, POC Response History Bladder Continence, for April, May, and June of 2026 were reviewed. The DON confirmed documentation showed that in April Resident 74 had 15 episodes of incontinence and 38 episodes of continence, in May 46 episodes of incontinence and 146 episodes of continence, and in June 48 episodes of incontinence and 37 episodes of continence. The DON confirmed that documentation was not reflective of an individualized bladder training program for Resident 74. The DON stated bladder training is initiated by the interdisciplinary team (IDT) (a group of healthcare professionals who work together to manage a resident's needs) and nursing following an individualized assessment that considers the resident's medical history, cognition, medications, and physical abilities. The DON stated Resident 74 had been screened on two occasions with documentation reflecting both continent and incontinent episodes. The DON stated resident 74 was not considered for a bladder training program due to episodes of incontinence and the use of diuretic (a water pill) medication. The DON acknowledged that Resident 74 has had an increase in incontinent episodes and could have benefited from an individualized bladder training program.During an interview on 6/24/26 at 3:25 PM, Registered Nurse (RN) D stated that resident 74 was not considered for bladder training because Resident 74 was physically capable of using the toilet and episodes of incontinence were behavioral or by choice. RN D further stated that Resident 74's history of COPD, as well as the residents age, contributed to the incontinence. RN D then confirmed that urinary incontinence is not a normal part of the aging process.During an interview on 6/25/26 at 8:15 AM, RN A stated that bladder training consists of scheduled toileting, assisting the resident to the toilet, and monitoring voiding patterns. RN A stated that residents are assessed for bladder training upon admission and upon return from hospital stays, but not after the removal of an indwelling urinary catheter. RN A confirmed that Resident 74 was not assessed for bladder training following the removal of the indwelling urinary catheter, or at any point assessed for the type of incontinence they were experiencing. RN A stated that Resident 74 was not considered a good candidate for bladder training due to fluid restriction (physician ordered limited amounts of fluids), non-compliance with fluid restrictions, and having more episodes of incontinence than continence. RN A further stated that Resident 74 would now be considered a good candidate for bladder training because they have had increased episodes of incontinence and required more assistance with mobility to reach the toilet. RN A acknowledged that Resident 74 would have benefited from bladder training when the indwelling urinary catheter was first removed, on 4/21/26, but stated Resident 74, slipped through the cracks.During a review of Resident 74's medical record, dated 4/20/26, the Bowel and Bladder Screener indicated Resident 74 was having episodes of incontinence, was alert and oriented, showed willingness for bladder training, and was at risk for incontinence. During a review of Resident 74's Physician's Order, dated 4/21/26, indicated Resident 74's indwelling urinary catheter was to be removed.Record review did not show any evidence of a bladder assessment for the type or cause of Resident 74's incontinence or an individualized toileting training program.

Based on interview and facility document review, the facility failed to ensure professional standards of quality were met when one of the Registered Dietitians (RD) was not onsite to complete timely and comprehensive nutrition assessments. This failure had the potential to result in delayed nutrition care for residents leading to an increased risk for nutritionally related clinical decline.Findings:Nutrition-focused physical findings are a fundamental part of a comprehensive nutrition assessment. Registered dietitian nutritionists are uniquely trained to evaluate physical examination data to correctly evaluate nutrient-specific physical findings and analyze the role of nutritional status in health maintenance as well as recovery from injury or disease. The physical assessment is used to evaluate for malnutrition and other nutritional related factors. Physical examination techniques include gathering data via observation and touch. (Academy of Nutrition and Dietetics. Nutrition Care Manual. Nutrition Focused Physical Findings. https://www.nutritioncaremanual.org. Accessed July 5, 2026.)Review of the policy and procedure titled Nutritional Assessment dated 2001, showed as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian shall, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition. Review of the job description titled Dietitian dated 2001, showed the dietitian may be full time or part time depending on the current requirements of the facility. These requirements are based on assessments and care plans of resident nutritional needs and the overall facility assessment of the number, acuity and diagnosis of the resident population.Review of the document titled Consultant Agreement and signed by RD and Admin on 10/20/25, showed the consultant shall provide consulting services to the Facility weekly, both in house and remotely. Consultant and Facility may increase Consultants visits as needed per agreement of both Consultant and Facility. Consultant shall provide the following services within the scope of the dietitians professional credentials, in accordance with Federal, State, and County laws, rules, regulations and current professional standards of practice. The Consultant shall actively participate in Facilities overall patient care evaluation programs. Review of the Document titled Requirements of Participation [Facility name and address] with a completion date of 1/12/26, showed the facility must employ sufficient staff with appropriate competencies and sills sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The facility assessment showed the average daily census was approximately 86-92 residents. Average admissions were 1 per weekend and 2-4 average weekday weekly. It was noted the facility assessment did not include the staffing needs for Food and Nutrition services or Registered Dietitians. During an interview on 6/25/26 at 8:27 a.m., the Registered Dietitian (RD) stated she started working for the facility as their Registered Dietitian nine to twelve months ago. RD described her role as providing clinical nutrition services. RD stated she worked remotely about one day a week and worked on site about once every three to four weeks. RD stated she did her resident assessments remotely unless she was at the facility, then she did the assessments when she was on site. When asked if there was a physical component to her assessments, RD stated yes. When asked how she did the physical portion of her assessments remotely, RD stated she did not do the physical portion of the assessment remotely. RD stated she guessed she would do the physical part later when she was on site. RD stated initial assessments are done within a week of a resident's admission.During an interview on 6/25/26 at 10:49 a.m., the Administrator (Admin) confirmed RD worked remotely and was on site about once a month.

Based on observation, interview and record review, the facility failed to ensure two Residents (26, 30) received assistance with their meal in a timely manner. This failure had the potential to result in decreased quality food and/or decreased intake of food leading to weight loss for 2 of 13 residents who received their lunch during the assisted dining.Findings:A review of Resident 26's admission Report, dated 6/24/26, indicated Resident 26 was admitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), seizures (a sudden, temporary burst of uncontrolled electrical activity in the brain), and dementia (a decline in mental ability affecting daily life).A review of Resident 26's Annual Minimum Data Set (MDS) (yearly comprehensive assessment), dated 9/8/25, indicated under the Swallowing and Nutrition Status Assessment that resident had significant weight loss.Review of Resident 26's Quarterly MDS, dated [DATE], indicated partial/moderate assistance was required with eating.A review of Resident 26's Care Plan Report showed Resident 26 has potential nutritional problems related to underweight/unintended weight loss, dementia, increased depression. Interventions included assist with meals dated 2/5/26.Review of Resident 30's admission Report, showed Resident 30 was admitted on [DATE] with diagnoses including Alzheimer's Disease (a form of dementia, slowly destroying memory, thinking skills, and eventually the ability to perform simple daily tasks), unspecified dementia with mild agitation, lack of coordination, cognitive communication deficit (occurs when brain disruptions make it difficult it understand, express or process information), and adult failure to thrive (a syndrome of progressive physical and mental decline. It is characterized by unexplained weight loss, poor appetite, malnutrition, fatigue, and reduced ability to perform daily tasks).Review of Resident 30's Care Plan Report showed Resident 30 had and had the potential for nutritional problems, including unintended weight loss, food intake fluctuations. Interventions included assist with meals as needed dated 9/3/25.Review of Resident 30's Quarterly MDS, dated [DATE], indicated Partial/moderate assistance with eating was required.During an observation on 6/22/2026 at 12:59 PM, the second dining group for residents who needed assistance with meals started being brought into dining room. Three staff were in the dining room helping residents to their table. There were eight tables in the room and Residents were sat at each table.During an observation on 6/22/26 at 1:03 PM,, thirteen residents were sitting in the dining room ready for lunch. A cart containing lunch meal trays arrived at the dining room. During an observation on 6/22/26 from 1:10 PM to 1:15 PM, staff passed resident food trays from the food cart to residents sitting at tables. When the trays were passed, staff set up the meal in front of the resident. Part of the set up included removing the residents' hot food from an insulated cover, so the plate of hot food was uncovered on the table in front of the resident.An observation on 6/22/26 at 1:16 PM, showed Resident 26 in a wheelchair, slumped over, with her eyes closed (at table 5 according to the posted Assisted Dining seating chart). A couple times Resident 26 vocalized, oh, oh, oh. A staff member in the dining room asked Resident 26 how she was doing. Resident 26, continued to sit at the table with her food in front of her, but was not eating. Resident 26's plate of hot food was untouched and not covered. An observation on 6/22/26 from 1:16 PM to 1:31 PM, showed Resident 30 sat in her wheelchair at the same table as Resident 26. Resident 30 had her eyes closed and her hot food was on the table in front of her, untouched, and not covered. It was noted another resident (there were three residents total at this table) who was seated at this table with Resident 26 and Resident 30 was eating and was able to eat independently.An observation on 6/22/26 at 1:25 PM, showed Certified Nursing Assistant (CNA) K feeding a resident at a table adjacent from the table for Resident 26. CNA K stood up and walked over to Resident 26's table, sat down and assisted Resident 26 with several bites of food. Then CNA K walked back to the adjacent table to continue feeding the resident she was originally feeding. When CNA K left Resident 26, Resident 26 did not eat anymore. Five minutes later CNA K went back to Resident 26 to assist her with her meal again and Resident 26 began eating with assistance.An observation on 6/22/26 at 1:31 PM, showed CNA H entered the dining room and sat next to Resident 30 to begin assisting Resident 30 with her lunch. Resident 30 began to eat with assistance.During an interview on 6/24/26 10:20 AM, when CNA J was asked what the process was for assisting residents with feeding in the dining room, CNA J stated there was a list at the nurse's station that showed CNA assignments. She stated the facility usually assigned one CNA per table in the dining room. When CNA J was asked why there were not 8 CNAs in the dining room on 6/22/26 for lunch service, (8 tables in dining room, 1 CNA per table=8 CNAs total), she stated there were call offs. CNA J stated that Administration helped out if asked, but she did not think to ask on Monday. Then CNA J stated she did not want to get up to leave the resident she was assisting, to go ask for help. During an interview on 6/24/26 at 1:02 PM, CNA K stated there was supposed to be one staff per table to assist residents with eating during dependent dining. However, lately there were usually 4 CNAs or less to assist dependent eating residents in the dining room, and that was how it usually was lately. CNA K stated there were call-offs on Monday 6/22/26 which is why there were not enough CNAs to attend to each dining table. CNA K explained for lunch on 6/22/26, she assisted her assigned resident with eating but noticed Resident 26 was not eating and felt bad for her, so she left her assigned resident to give Resident 26 a couple bites of food before going back to her assigned resident. CNA K stated she wants to feed residents at other tables when she sees them sitting there with food in front of them and the food would probably get cold. During an interview on 6/25/26 at 10:08 AM, when CNA H was asked about entering the dining room at 1:31 PM, on 6/22/26 to assist Resident 30 with her lunch meal, CNA H stated he got pulled away for something but could not recall what it was. CNA H stated sometimes he was pulled away to answer call lights or for resident care. CNA H acknowledged he was assigned to the dining room for lunch on 6/22/26 and he was late getting to the dining room to assist Resident 30. CNA H stated there were usually about four staff assisting in the dining room and it was dependent on how many residents had to be assisted with feeding. CNA H stated it was supposed to be one staff assisting one resident. CNA H stated even if two residents needed assistance with eating at one table, it was still one staff per resident. Review of the Nursing Daily Assignment and Sign-in Sheet dated 6/22/26 A.M. shift, showed five CNAs were assigned to the assisted dining for lunch on 6/22/26. (It was noted there were five CNAs in the dining room for assisted dining including another who showed up later). During an interview on 6/25/26 at 10:17 AM, Director of Staff Development (DSD) B stated there should be one staff to one to two residents for resident feeding assistance. DSD B stated at least eight CNAs should be in the dining room on a good day, depending on staffing. DSD B stated licensed staff were also encouraged to help with assisting residents with feeding after completing their medication pass. DSD B stated CNAs were supposed to let administrative staff know when they needed assistance in the dining room. DSD B stated if CNAs needed assistance, they should have gone to the nursing station to ask for help before starting to assist residents or use their personal cell phone to call for assistance. DSD B stated multiple administrative roles are cross-trained as CNAs to help with feeding residents. DSD B stated for lunch on 6/22/26, staff should have asked for help when they knew there were not enough assistants. DSD B also stated hot food should remain covered if CNAs cannot assist with feeding right away. DSD B stated there was not a list of residents who required assistance with feeding. DSD B stated she thought there were eight residents who required assistance with feeding. Review of the facility's policy and procedure titled Assistance with Meals revised March 2022, showed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays and will help residents who require assistance with eating.

Based on interview and document review, the facility failed to ensure:1.One of one Dietary Managers received frequently scheduled consultations from a qualified dietitian; and2.One of one Dietary Managers was qualified for his position when DM did not meet a State requirement for a Dietary Manager.Failure to ensure one of one Dietary Managers received frequent consultation from the dietitian and training qualifications were met for the Dietary Manager, had the potential to result in substandard Food and Nutrition Services operations serving a census of 90. Findings:According to the California Code, Health and Safety Code - HSC S 1265.4 current as of January 01, 2025, a licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. One of five educational requirements to qualify for a dietetic services supervisor is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility.Review of the job description titled, Dietitian dated 2001, showed a qualified, competent, and skilled Dietitian will help oversee the food and nutrition services in the facility. A Food and Nutrition Services Manager will oversee the production, storage, and delivery of food. The Dietitian will work closely with the Food and Nutrition Services Manager and clinical staff. If a dietitian is not employed full time (35 or more hours per week) a director of food service management will be designated. This individual will have at least one of five qualifications, on of which being a Certified Dietary Manager, and receive frequently scheduled consultations from a qualified dietitian. Review of the job description titled, Dietary Manager signed by DM on 6/22/2025, showed the position summary included to organize, plan and supervise the dietary department functions in accordance with applicable federal, state and local standards that govern the facility.1.During an observation and interview on 6/22/26 at 11:50 AM, DM was in the kitchen helping Food and Nutrition staff with job duties. DM introduced himself and stated he was the Dietary Manager and was a Certified Dietary Manager. DM stated he was in the position for about one year. During an interview on 6/24/26 at 9:02 AM, DM stated the Registered Dietitian (RD) worked remotely and came on site every few weeks. DM stated the RD rarely entered the kitchen.During an interview on 6/25/26 at 8:27 AM, the RD stated she started working for the facility as their Registered Dietitian from nine months to a year ago. RD described her role as mainly providing clinical nutrition services and did not provide any consultation to kitchen staff. RD stated she did not do anything in the kitchen in regard to looking at kitchen sanitation. RD also described her hours working for the facility as less than full time when she worked remotely about one day per week and was physically in the facility once every three to four weeks.During an interview on 6/25/26 at 10:49 AM, the Administrator (Admin) stated the RD oversees the kitchen manager. Admin stated RD should be doing a kitchen inspection/checklist however she did not receive any reports from RD. Admin stated the RD was supposed to check in with DM and answer his questions as needed. Admin stated she was unaware the RD and DM were not collaborating. 2.Review of the document titled, CDM/CFPP Certified Dietary Manager Certified Food Protection Professional showed that DM was a CDM CFPP and was certified through 8/31/26. During an interview on 6/24/26 at 12:35 PM, DM stated he did not have Title 22 training and he did not know what Title 22 was. During an interview on 6/25/26 at 10:49 AM, Admin stated she was unaware the CDM/Dietary manager position required Title 22 training.

Based on observation, interview and record review, the facility failed to ensure two of four Residents (27 and 35) received their prescribed nutritional supplements.This failure placed Residents 27 and 35 at increased risk for malnutrition and weight loss.Findings: A review of Magic Cup definition per the manufacturer of Magic Cup; it can be eaten frozen like an ice cream or thawed like a pudding. Magic cups are a supplement option for adding nutrition, calories, and protein for those experiencing involuntary weight loss. Magic cups contain 290 calories and 9 grams of protein for a 4 ounce serving. (Magic Kitchen, Magic Cup, magickitchen.com, accessed 3/7/26)A review of the facility's, Therapeutic Diet policy, dated 10/2017, indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.A review of the facility's, Food and Nutrition Services policy, dated 10/2017, indicated, Each resident is provided with nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs.A review of Resident 27's, admission Report, dated 6/24/26, indicated Resident 27 was admitted on [DATE] with diagnoses including gastritis (inflammation of the gastrointestinal system), dysphagia (difficulty swallowing), and respiratory failure.A review of Resident 27's, Minimum Data Set (MDS, comprehensive assessment), Swallowing and Nutritional Status section, dated 4/15/26, indicated Resident 27 had unanticipated weight loss and was on a mechanically altered (chopped food) therapeutic diet.A review of Resident 27's care plan dated 5/21/26, indicated Resident 27 had weight loss, malnourishment, and the potential risk for pressure ulcers (bed sores). Care plan interventions included providing nutritional supplements as ordered by the physician.A review of Resident 27's, Physician's Order Report undated, indicated Resident 27 was prescribed Magic Cups to be given twice a day for risk of malnutrition starting 1/10/26.A review of Resident 35's, admission Report, dated 6/24/26, indicated Resident 35 was admitted on [DATE] with diagnoses including heart failure, low blood pressure, and muscle weakness.A review of Resident 35's care plan indicated Resident 35 had a history of weight loss. Care plan indicated on 5/13/26 Resident 35's weight was 132 pounds, a 13-pound weight loss from 4/30/26. Interventions on care plan included increasing Magic cup to three times a day.A review of Resident 35's, Physician's Order Report indicated Resident 35 was prescribed Magic cups with meals for malnutrition starting on 5/14/26.A review of Resident 35's, Quarterly Nutrition Assessment dated 6/17/26, indicated Resident 35 weighed 133 pounds and their ideal body weight was 178 pounds. Assessment indicated Magic Cup to be given three times a day.During a dining observation on 06/22/26 at 12:35 PM, Resident 27 and Resident 35's lunch meal ticket instructions indicated to give a Magic Cup with the meal.During a tray line observation on 6/23/26 starting at 12:00 PM, Resident 27 and 35's meal trays had no Magic Cup. During an interview on 6/23/26 at 12:45 PM, with the Dietary Manager (DM), DM stated, We are out of Magic Cups and indicated he had not known they were out. During a concurrent observation, interview, and meal ticket review on 6/23/26 at 12:50 PM, with Dietary Aide (DA) A, Resident 27 and 35's lunch meal ticket Tray Instructions, read Magic Cup with meals. A Magic Cup was not placed on either Resident's meal tray. DA A stated they were out of Magic Cups. DA A stated we substituted the Magic Cup with ice cream. During an interview on 6/24/26 at 12:30 PM, with DA A, DA A stated there were still no Magic Cups available. During an interview on 6/24/26 at 12:37 PM, with the DM, when DM was asked about the reason the facility did not have Magic Cups, DM stated they ran out yesterday. When DM was informed Magic Cups were not provided on 6/22/26, DM stated Magic Cups must have run out over the weekend. DM stated they ran out because nursing asked the DAs to give them extra Magic Cups, that were not physician ordered, and that should not have happened. DM stated the nutritional values and protein content of ice cream was not equal to a Magic Cup. During an interview on 6/25/26 at 8:25 AM, with the Registered Dietitian (RD), RD stated they make a recommendation to resident's physicians for Magic Cups to be ordered as a nutritional intervention for residents who had orders for thickened liquids, or who had weight loss, unhealed wounds, and low protein status. RD stated Magic Cups were supposed to be given to residents who had physician's order for them and should not have been given to nursing staff to give to residents who did not have a physician's order. RD confirmed ice cream was provided in place of Magic Cups and confirmed ice cream was not of the same nutritive value as the Magic Cups.

Based on observation and interview, the facility failed to maintain equipment located in the kitchen when there was not a system to track maintenance requests, and:1.One of seven food storage coolers was leaking;2.There was a leak from plumbing in relation to the ice machine;The failure to have a system for tracking maintenance requests and maintain leaks from two of over 13 pieces of equipment had the potential to result in delayed maintenance of equipment; attract and provide harborage for pests leading to contamination of food and equipment; and pose an electrical safety risk for a census of 90. Findings:During an interview on 6/23/26 at 9:01 AM, the Dietary Manager (DM) stated he was responsible for reporting maintenance issues for the kitchen. DM stated maintenance issues were mostly reported to maintenance verbally because maintenance was very quick to fix things, and there was not even time to put in a work order before something was fixed. It was noted there was not a way to track most maintenance requests from DM due to requests were mostly verbal. 1.An observation on 6/22/2026 at 11:56 AM, showed refrigerator number six, a tall roll-in food cart refrigerator, had water pooling under the refrigerator, and black, wet residue build-up on the floor at the edges of the refrigerator. There was also a puddle of water inside the refrigerator. During an observation and interview on 6/23/2026 at 9:35 AM, a cart holding food was inside refrigerator number 6. The Dietary Manager (DM) stated the refrigerator was used to hold desserts. The cart holding desserts was removed so the inside could be observed. There was orange residue on the bottom inside surface. DM stated the refrigerator leaked sometimes. DM stated he tried to monitor the refrigerator, but he did not put in a work order or notify maintenance about the leak. DM looked at the refrigerator and verified there was water pooled underneath and stated he thought it was worse and now it was rusty inside. During an observation and interview on 6/23/26 at 9:35 AM, Maintenance Technician (MT), confirmed there was water under refrigerator number six and stated he was unaware of the issue. 2. During an observation on 6/23/26 at 8:59 AM, water leaked onto the tile floor, from what appeared to a pipe plumbed into the wall behind the ice machine. The water leak created pooled water on the floor, and the leak was close to an electrical outlet. DM stated he was aware of the leak, but it looked worse now. DM stated he did not put in a work order but reported the water leak to maintenance verbally, so there was no way to verify the maintenance request. During an observation and interview on 6/24/26 at 9:32 AM, with MT and DM, the plumbing behind the ice machine continued to leak onto the tile floor, creating a pool of water. MT stated the leak seemed to be from the actuator (a device attached to a valve to automate opening and closing, allowing water flow to be controlled automatically). MT, who was the only maintenance staff on site on 6/24/26, stated he was not aware of the leak. DM stated an outside company was contacted yesterday (6/23/26) but the company said they were not responsible for fixing the leak, and now he needed to work with the facility maintenance to get it fixed. DM confirmed the maintenance staff he reported the issue to was not at the facility today (6/24/2026). During an interview on 6/24/26 at 12:35 PM, DM stated he was aware of the leak behind the ice machine since, last week on Friday.

Based on observation, interview, and record review the facility failed to provide basic safety measures for three of 19 residents (Resident 1, 64, and 93) when call lights were not easily accessible as they were not placed within the resident's reach.This failure placed residents at risk for avoidable complications, including incontinent issues and falls, associated with the inability to urgently communicate with staff for needs and safety issues, which could result in physical and emotional decline and reduced quality of life. Findings: During a review of the facility's policy and procedure titled, Answering the Call Light, dated October 2023, the policy indicated, The purpose is to ensure timely responses to the resident's requests and needs.Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. During a review of a facility document titled, New Employee Orientation Checklist, First 8 Hours, undated, indicated, Employees are oriented and trained to manage resident care through the following subject matter: Orientation Topic.Use of Equipment.Resident's Unit/Call Lights. During a review of a facility document titled, Inservice Lesson Plan and Attendance Record, dated 6/10/26, indicated the Weekly CNA (Certified Nursing Assistant), RNA (Restorative Nursing Assistant) .Meeting topics included, Gentle Reminder.Call light is in reach. A review of Resident 1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included, Acute Respiratory Failure with Hypoxia (Lungs cannot supply enough oxygen to bloodstream), Anxiety Disorder (Excessive, uncontrollable worry), and Heart Failure (Heart cannot pump enough blood). During a concurrent observation and interview on 6/22/26 at 2:05 PM, with Resident 1, who was sitting in their wheelchair by their bedside closest to the door, the call light is observed hanging from the far-side of the bed onto the floor. Resident 1 stated I want to go back to bed, I have been sitting here for 30 minutes, I don't have the call light. Surveyor turned on Resident 1's call light for her. During a concurrent observation and interview on 6/22/26 at 2:20 PM, with Certified Nursing Assistant (CNA) E outside Resident 1's room, CNA E was observed to go in and out of Resident 1's room three different times following the call light being initiated by surveyor, each time CNA E interacted with Resident 1. The first two interactions the call light was left out of the resident's reach, on the third interaction CNA E placed the call light in Resident 1's hand. CNA E stated, I always check that the call light is within the residents' reach when I go into rooms.I just missed it. During an interview on 6/22/26 at 3:30 PM, with Director of Nursing (DON), in the DON office, DON stated, the expectation is that call lights are placed within residents' reach. A review of Resident 64's medical record indicated that Resident 64 was admitted on [DATE] with diagnoses that included, Cancer, Coronary Artery Disease (heart disease), high blood pressure, diabetes (high blood sugar), and Alzheimer's (loss of memory). During a concurrent observation and interview on 6/22/26 at 3:05 PM, with Resident 64 in their room, Resident 64 was up in the wheelchair on the left side of the bed facing the wall and the call light was at the bottom of her bed out of reach. Resident 64 stated, I can not reach my call bell. During a review of Resident 93's admission record indicated that Resident 93 was admitted on [DATE] with diagnoses that included aftercare following surgery on the digestive system, atrial fibrillation (a cardiac condition), high blood pressure, diabetes, heart failure and sleep apnea (disrupted breathing during sleep). During a concurrent observation and interview on 6/22/26 at 8:56 AM, with Resident 93, the call light was observed stretched from the wall to the bed rail, extending to approximately knee level on the bed. The call light obstructed the walkway between the bed and the nightstand and would become detached if the bed rail was lowered. Resident 93 stated the call light had been in this condition for three days and frequently became detached from the bed rail. Resident 93 stated that on one occasion, after the call light became detached from the bed rail while he was in bed, he attempted to use dishes from the bedside table to reach the call light but was unsuccessful. Resident 93 stated he had to wait for assistance to use the bathroom and for a bed change, which he described as embarrassing and made him feel like he was being a bother.

Based on interview and record review, the facility failed to prevent verbal and physical abuse for three of five sampled residents (Residents 1, 2, and 5) when:Resident 2 hit Resident 1 in the arm twiceResident 3 pulled Resident 2's hair and spit on Resident 4Nursing Assistant (NA 2) sprayed Resident 5 in the face with the shower nozzle, tossed her in bed and verbally threatened her. These failures had the potential to result in psychological, behavioral, and psychosocial outcomes causing fear, anxiety, and adverse outcomes.During a review of the facility's policy and procedure titled, Abuse Prevention Program indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility is committed to protecting our residents from abuse by anyone, including, but not necessarily limited to: facility staff, other residents, family members.During a review of the facility's policy and procedure titled, Resident Rights indicated, Employees shall treat all residents with kindness, respect, and dignity.1.Resident 1 was admitted to the facility on [DATE] with a diagnosis that included, dementia (memory loss, confusion, and poor judgement), and muscle weakness.A review of Resident 1's Minimum Data Set (an assessment and care screening tool) (MDS) , dated 9/5/2025, indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 3 out of 15 (severe cognitive impairment). Resident 2 was admitted to the facility on [DATE] with a diagnosis that included, diabetes, substance abuse, bipolar (a condition that causes mood swings), and chronic pain.A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score was 15, cognitively intact.During an interview on 5/14/26 at 8:15 a.m., with Resident 2, Resident 2 stated, I feel bad for hitting [Resident 1]. I know I shouldn't hit other people. But I was taught to fight back if I needed to. I will try not to do it again, but I can't make any promises.During an interview on 5/27/26 at 1:30 p.m., with Certified Occupational Assistant (COTA), COTA stated, I was walking into the dining room. The residents were watching a movie and [Resident 2] was in the middle of the room. [Resident 1] was rolling toward her, and [Resident 2] said don't come over here. I heard [Resident 2] yell at [Resident 1], and I tried to get to them before something happened. I saw that [Resident 1] was reaching for the back of [Resident 2's] wheelchair handle and then [Resident 2] turned and open-handedly hit [Resident 1] a few times. [Resident 2] said keep him away or we will see what happens. During a review of Resident 2's, Social Service Note (SSN), dated 5/8/26 at 7:41 p.m., the SSN indicated, Resident 2 stated, [Resident 1] was rolling towards me, and he would not listen to me, I thought he was going to hurt me, he got what he deserved for being in my way.During a record review of the facility document titled, Witness statement, dated 5/7/26, the Witness statement indicated, Resident 1 reached toward the back handle of Resident 2's wheelchair, Resident 2 turned and began to punch out at Resident 1. Resident 1 began to roll backward with his fists raised. Resident 2 yelled, try to swing at me you son of a bitch. Resident 1 had been struck on his arm by Resident 2 twice.2.Resident 2 was admitted to the facility on [DATE] with a diagnosis that included, diabetes, substance abuse, bipolar (a condition that causes mood swings), and chronic pain.A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score was 15, cognitively intact.During an interview on 5/14/26 at 9:13 a.m., with Resident 2, Resident 2 stated, [Resident 3] came up to [Resident 4] and spit on her then turned toward me and grabbed a big chunk of my hair and pulled really hard and pulled a chunk out. So, I grabbed her hair and I pulled her to the ground. [Resident 3] yelled at me and told me she was going to get me. During a review of Resident 2's SSN, dated 3/22/26 at 5:10 p.m., the SSN indicated, Resident 2 stated, [Resident 3] was being crazy, she spit on [Resident 4] and then grabbed hold of my hair so then I grabbed [Resident 3's] hair back and pulled her to the ground.During a review of Resident 2's SSN, dated 3/23/26 at 4:15 p.m., the SSN indicated Resident 2 stated, [Resident 3] got what she got.During a record review of the facility document titled, Witness statement, dated 2/23/26, the Witness statement indicated, Resident 2 was noted to have some of her hair pulled out during the altercation. Resident 3 was admitted to the facility on [DATE] with a diagnosis that included, bipolar, dementia, and muscle weakness.A review of Resident 3's MDS, dated [DATE], indicated Resident 3's BIMS score was 3.During a review of the Resident 3's SSN, dated 3/14/26 at 8:46 p.m., the SSN indicated, Resident 3 entered another residents room and became verbally aggressive towards the resident with her fists clenched. As staff began to escort Resident 3 back to her room she became aggressive toward staff and threw the liquids from her cup into staff's face.During a review of Resident 3's SSN dated 3/15/26 at 12:19 a.m., the SSN indicated, Resident 3 approached a resident standing at the medication cart and tried to grab them by the back of the head. When stopped Resident 3 became enraged put her fists up and stated, F.U. bitch, get the F. out of this place. Then Resident 3 spit in the nurses face.During a review of Resident 3's SSN, dated 3/1/26 at 7:01 a.m., the SSN indicated Resident 3 had been having multiple behaviors of physical and verbal aggression towards staff. Resident 3 walked up to nurse and pulled her hair and threatened to hit her.During a review of Resident 3's Care Plan, revised on 3/25/26, the Care Plan indicated, Resident 3 continues to have aggressive behaviors towards others, spitting, wandering and agitation.Resident 4 was admitted to the facility on [DATE] with a diagnosis that included, chronic respiratory failure, adult failure to thrive, and difficulty walking.A review of Resident 4's MDS, dated [DATE], indicated Resident 1's BIMS score was 15.During an interview on 5/14/26 at 11:48 a.m., with Resident 4, Resident 4 stated, I remember [Resident 3] was mad and walked right up to where I was sitting and spit.During an interview on 5/27/26 at 1:00 p.m., with Director of Nursing (DON), DON said, Resident 3 had aggression towards staff upon admission.During a review of Resident 4's SSN, dated 3/12/26 at 5:02 p.m., the SSN indicated Resident 4 said Resident 3 had spit on her.3.Resident 5 was admitted to the facility on [DATE] with a diagnosis that included, weakness, bipolar, and diabetes. A review of Resident 5's MDS, dated [DATE], indicated Resident 5's BIMS score was 9, moderate cognitive impairment.During an interview on 5/14/26 at 10:00 a.m., with Resident 5, Resident 5 said, she remembered a girl that worked here was mean to her in the shower.During an interview on 5/27/26 at 3:39 p.m., with NA 1, NA 1 said she witnessed NA 2 grabbed the shower head and say to Resident 5, if you hit me, I'm going to spray you with cold water and sprayed Resident 5 in the face. Then when we got back to Resident 5's room NA 2 tossed Resident 5 on her bed. NA 2 then turned to NA 1 and said she [Resident 5] is going to learn to not talk back to me. During a review of Resident 5's SSN dated 12/22/25 at 5:20 p.m., the SSN indicated Resident 5 stated, she [NA 2] hit me and sprayed my face.

Based on interviews and record reviews, the facility failed to report to the California Department of Public Health (CDPH), the Ombudsman (State advocacy program for residents), and to local Law Enforcement a verbal and physical abuse allegation for two of three sampled residents when Resident 3 told the facility Administrator (FA) that Certified Nursing Assistant (CNA) A was harsh, brutal and mean to her roommates (Residents 1 and 2). This failure to report an abuse allegation prevented local and state agencies from providing prompt oversight to ensure the residents in the facility were safe and protected from abuse.Findings: A review of the facility's policy and procedure titled, Abuse Investigating and Reporting revised July 2017, indicated that, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 2. a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse . During a record review of Resident 1's, admission Record dated 3/23/26, Resident 1 had diagnoses that included dementia (loss of memory) and bipolar disorder (a type of depression mixed with anxiety). Resident 1 had a Brief Interview for Mental Status (BIMS-a standardized cognitive screening tool scored on a scale from 0 to 15 where higher numbers indicate better cognitive function) score of 10 out of 15, indicating moderate cognitive (ability to understand and make decisions) impairment. During a record review of Resident 2's, admission Record dated 3/23/26, Resident 2 had diagnoses that included mild dementia and bipolar disorder. Resident 2 had a BIMS score of 0 out of 10, indicating severe cognitive impairment. During a record review of Resident 3's BIMS Assessment dated 5/12/26, Resident 3 had a BIMS score of 15, indicating no cognitive impairments. During an interview on 5/20/26 at 12:05 pm, the Director of Nursing (DON) confirmed Resident 3 had reported that CNA A was abusive to Residents 1 and 2. The DON stated, There was [an abuse allegation] and we did investigate it. When asked whether the allegation was reported to CDPH, Ombudsman and Law Enforcement as indicated in the facility's Abuse Policy, the DON stated, I didn't think it rose to that kind of an event. During a concurrent interview and facility Abuse Policy review on 5/20/26 at 12:10 pm, the FA confirmed that there was an allegation made by Resident 3 that CNA A was verbally and physically abusive toward Residents 1 and 2, approximately around 5/5/26. FA stated, The concern was not physical and believed [CNA A] was sounding burned out. FA confirmed CNA A was suspended on 5/10/26. When asked whether the allegation was reported to CDPH, Ombudsman and Law Enforcement FA stated, No. I didn't report it. During an interview on 5/20/26 at 12:50 pm, in Resident 1's room, Resident 1 was not able to respond to interview questions. During an interview on 5/20/26 at 12:55 pm, in Resident 2's room, Resident 2 was not able to respond to interview questions. During an interview on 5/20/26 at 1:05 pm, in Resident 3's room, Resident 3 stated, I have a problem with a CNA [CNA A] here. He [CNA A] is harsh and brutal to my room mates. He [CNA A] ripped [Resident 1's] shirt off of her and when I looked over at her she was crying. [Resident 2] is scared of him [CNA A] and he is mean and disrespectful to her and says things like 'In your dreams.' I told [FA] about this and he [CNA A] was off for a few days and now he is back.he is so brutal and mean.

Based on interview and record review the facility failed to ensure that significant medication error was avoided for one of three sampled residents (Resident 1) when, an order written by the Family Nurse Practitioner (FNP) to restart Resident 1's Eliquis (a blood thinner) was not carried out and went unrecognized by the FNP and Licensed Nurses (LN), for 42 days.This failure contributed to Resident 1 developing a Deep Vein Thrombosis (DVT, blood clot) in his right leg which required a surgical procedure and hospitalization to remove the blood clot and had the potential to cause serious pain, emotional distress, prolonged health declines, and life-threatening conditions.Findings:During a review of the facility's policy and procedure (P&P) titled, Attending Physician Responsibilities, dated Revised August 2014,indicated, Each Attending Physician will be responsible for.initial and subsequent resident care.The physician's documentation should indicate review and acknowledgement of a resident's program of care. The review should be extensive enough to ensure that the current approach overall is consistent with the individual's medical condition.The attending physician will perform accurate, timely, and relevant medical assessments.The physician will periodically review all medications prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions. During a review of the facility's P&P titled, Medication Orders, dated Revision January 2025, indicated, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. (including) nurse practitioners if they comply with the requirements.The prescriber is contacted to verify or clarify an order (.(if) the directions are confusing).During a review of the facility's P&P titled, Reconciliation of Medications on Admission, dated Revised July 2017, indicated, Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes.During review of Resident 1's medical record, Resident 1 was admitted [DATE] with diagnoses that included Atrial Fibrillation (heart rhythm disorder), Peripheral Vascular Disease (PVD, circulatory blood vessel disorder causing narrowing, blockage, or spasming of vessels which results in clotting of blood), and Chronic Respiratory Failure with Hypoxia (Lungs can no longer transfer oxygen into the blood stream, resulting in low blood oxygen levels).During an interview on 2/26/26 at 10:30 am, with FNP 1 via telephone, FNP 1 stated Resident 1 was sent to the hospital for respiratory complications and hemoptysis (coughing with blood in the sputum) on 12/17/2025, and FNP 1 put Resident 1's Eliquis (a blood thinner) 5 milligrams (mg, unit of measurement) by mouth (PO) that he had been taking twice a day on hold. Resident 1 was then discharged from the hospital back to the facility on [DATE]. On 12/28/25, FNP 1 wrote orders to restart Resident 1's Eliquis 5 mg PO two times daily. FNP 1 stated LN 1 had discontinued (stopped) Resident 1's Eliquis instead of restarting it on 12/28/25, but this was not realized until Resident 1 complained of right leg pain on 2/8/26. FNP 1 confirmed she had made two monthly visits to assess Resident 1 and review his medical record at the facility on 1/1/26 and 2/1/26, but had not realized Resident 1 had not been taking his Eliquis. During an interview on 3/11/26 at 2:00 pm, with Resident 1 in the hallway, Resident 1 stated he had experienced a very painful blood clot in his right lower leg, and he had been sent to the hospital for surgery to remove it. Resident 1 confirmed he was doing much better since returning to the facility.During a record review of Resident 1's medical record documents titled, MARs for December 2025, January 2026, and February 2026 were reviewed. Eliquis 5 mg PO two times daily was administered until 12/17/25, when Resident 1 was sent to the hospital. Eliquis was then not administered for the remainder of December 2025 and all of January 2026. Resident 1's Eliquis was not restarted until 2/17/26.During a record review of Resident 1's medical record document titled, Discharge Summary from the hospital, dated 12/22/25, indicated the anticoagulant (Eliquis) was discontinued and would be restarted at the discretion of Resident 1's primary care provider (Physician or FNP 1).During a record review of Resident 1's medical record document titled, Order Details, dated 12/28/25, Order Details indicated that an order was written by FNP 1 to restart Eliquis 5 mg PO two times daily.During a record review of Resident 1's medical record document titled, Order Audit Report, dated 12/28/25, indicated the order placed for Eliquis 5 mg PO two times daily was discontinued by LN 1.During a record review of Resident 1's medical record document titled, Monthly Visit - Progress Notes by FNP 1, dated 1/1/2026 and 2/1/26, indicated Resident 1's medications currently being administered included Eliquis 5 mg BID (two times daily), and the plan of care indicated restart Eliquis 12/28/25. These monthly visit progress notes written by FNP 1 indicated Resident 1 was currently taking Eliquis in January and February 2026. FNP 1 had not recognized that Resident 1's Eliquis had been discontinued by LN 1, in December 2025. During a record review of Resident 1's hospital medical record document titled, Internal Medicine Discharge summary, dated [DATE], indicated Resident 1 presented with right leg pain, diagnostic testing was performed, Computed Tomography Angiography (CTA, non-invasive specialized x-ray diagnostic), results diagnosed Resident 1 with a right distal superficial femoral artery and popliteal artery occlusion (DVT, blood clot in vascular system) requiring vascular surgery of thrombectomy/embolectomy.During a concurrent interview and record review on 2/26/26 at 1:30 pm, with Administrator (Admin) and Director of Nursing (DON) in the administrator's office, Resident 1's Medication Administration Records (MAR, record or medications prescribed to resident with administration indications) dated December 2025, January 2026, and February 2026, as well as Discharge Summary from the local hospital dated 12/22/25, Physician Order Details for 12/28/25, and Hospital Medicine and History and Physical Note (H & P, documentation regarding patient information and plan for care) dated 2/8/26, and Internal Medicine Discharge summary dated [DATE], from the acute regional medical center were reviewed. Admin and DON confirmed that Resident 1 was transferred to the local acute hospital on [DATE] for respiratory problems and hemoptysis. The local acute hospital discharged Resident 1 back to the facility on [DATE] and had discontinued Resident 1's Eliquis 5 mg, PO two times a day. FNP 1 wrote an order to restart Resident 1's Eliquis on 12/28/25, but LN 1 had incorrectly transcribed FNP 1's order as discontinued. This medication error was not identified or recognized by nursing staff or FNP 1, until 2/8/26 when Resident 1 began complaining of right leg pain. Resident 1 was then transferred to the hospital which diagnosed Resident 1 with a Deep Vein Thrombosis (DVT, blood clot in his leg vessel) and then the hospital transferred Resident 1 to a larger medical center for surgery to remove the blood clot (Thrombectomy). Admin and DON confirmed a significant medication error was made by the facility and confirmed the medication error went unrecognized 42 days.

Based on interview, record review, and policy review, the facility failed to ensure that one of three residents sampled (Resident 1) received care consistent with professional standards when the physician's order to change her urostomy bag (a waterproof pouch worn on the outside of the abdomen to collect urine) was not followed.This failure had the potential to cause infection.Findings:Review of a facility policy titled Administering Medications revised December 2012, indicated .must be administered in accordance with the orders, including any required time frames.Review of Resident 1's medical record indicated that she was admitted to the facility on [DATE] and had diagnoses which included history of urinary tract infections (infection of any part of the urinary tract such as the kidneys, ureters, and/or bladder), and artificial opening of urinary tract (urostomy - a surgical opening in the abdomen to create a way for urine to exit the body when the bladder is damaged or removed).During an interview on 2/4/26 at 12:22 pm with Licensed Nurse (LN A), LN A indicated that in the past the urostomy bags were stored in the medication room (a locked room in a healthcare facility used to store, organize, and prepare medications), then an unknown staff person took them out of the medication room and put them in Resident 1's drawer in her room, and then they were moved to central supply (the department in a healthcare facility responsible for ordering, and storing medical equipment and supplies) and that central supply was where they were currently stored. LN A indicated that when the urostomy supplies were stored in Resident 1's drawer nursing staff thought they were out of urostomy bags but later they found them in Resident 1's drawer.During an interview on 2/4/26 at 12:50 pm with the Central Supply Lead (CSL), the CSL indicated that if they are out of urostomy bags one of the nurses can go to the local hospital and get them there. The CSL indicated that the urostomy bags were stored in central supply.During an interview on 2/4/26 at 1:09 pm with the Director of Nursing (DON), the DON indicated that the urostomy bags were kept in central supply or on the treatment cart (a locked cart used to store, transport, and organize supplies needed to perform resident care such as wound care or urostomy care) and that there was a time in the past when they kept them in the medication room.During a concurrent interview and record review on 2/4/26 at 2:20 pm with the DON, the DON confirmed that Resident 1's Treatment Administration Record (TAR) dated January 2026 indicated that Resident 1 had a physician's order (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) for her urostomy bag to be changed every Wednesday and Saturday and that the January 2026 TAR showed no documentation that Resident 1's urostomy bag was changed on Saturday 1/3/26. The DON indicated that Resident 1's urostomy bag should have been changed and that her expectation is that if nursing staff do not have supplies to change a urostomy bag they should have reached out to let her know and that they could have gotten supplies from the local hospital. The DON indicated that they could also have asked any nursing staff and they would be able to tell them where to find the supplies or what to do if the supplies were not available at the facility.

Based on interviews and record reviews, the facility did not notify the Pharmacy Consultant (PC) to complete medication reviews for three out of three sampled residents (Resident 1, 2, and 3) who experienced weight loss. This resulted in unmet pharmacy service needs and had the potential to contribute to further weight loss.Findings: A review of the facility's policies and procedures (P&P), titled, Weight Assessment and Interventions, revised 3/1/22, indicated, the facility would evaluate medication for possible side-effects that could cause weight loss. A review of the facility's (P&P) titled, Nutritional Assessment, revised 10/1/23, indicated, the PC would review the resident's current medication list and ensure the medication did not interfere with nutrition absorption or appetite. A review of the facility's P&P titled, Consultant Pharmacist Reports, dated 6/1/21, indicated, the consultant pharmacist performed a comprehensive medication regimen review (MRR) at least monthly. The P&P indicated the MRR included a resident evaluation to determine if the resident maintained their highest practicable level of functioning and prevent or minimize adverse consequences related to medication. The P&P indicated, an immediate MRR may be performed if there was a change in condition that medication might have contributed to. The P&P indicted, the Director of Nursing (DON) was responsible to notify the PC when an immediate MRR was required. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of major depression (a sad mood) and fatigue (extreme feeling of tiredness or a complete lack of energy that made it difficult to do everyday tasks). Resident 1 was not her own responsible party (RP, decision maker). A review of the Neuropsychological Assessment (a detailed evaluation that measured how the brain functioned and how it affected behavior and thinking), dated 12/1/23, indicated, Resident 1 had a major neurocognitive (how the brain processed information) disorder due to possible Alzheimer's Disease (memory loss, problems with thinking, and reasoning). A review of the Weight Summary, dated 8/10/25, indicated, Resident 1 weighed 76.4 pounds and triggered for an 11.6 percent (%) loss of body weight, over 180 days, which indicated severe weight loss. A review of the admission Record, dated 12/1/22, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (memory loss, doctors were unable to determine the type), unspecified severity (unknown if it is mild, moderate, or severe) and adult failure to thrive (a decline in health that included a slow loss of energy and appetite). Resident 2 was not his own RP. A review of the Weight Summary, dated 7/21/25, indicated, Resident 2 weighed 89 pounds and triggered for a 10.1 (%) loss of body weight, over 180 days, which indicated severe weight loss. A review of the admission Record, dated 10/28/24, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's, dementia, and type 2 diabetes (body was unable to regulate blood sugar levels) with diabetic neuropathy (high blood sugar levels over time caused nerve damage). Resident 3 was not his own RP. A review of the Weight Summary, dated 5/5/25, indicated, Resident 3 weighed 152 pounds and triggered for a 23.6 (%) loss of body weight, over 180 days, which indicated severe weight loss. During an interview on 9/5/25 at 11:35 am, PC stated, I perform the monthly medication review. The facility requests a change of condition for these special reports, we have a separate department with a different PC for residents with weight loss, and I look at the immediate MRR form also during my monthly MRR if one was completed. There is a fax record the facility should have, the protocol is for the facility to alert us [that] there is a change of condition for weight loss, then we will do a thorough medication review to assess medications and talk with facility. The PC was at a different facility and did not have access to the medical records. PC stated, I can look at the records in the office for these three residents later today and call back. During an interview on 9/5/25 at 12:02 pm, Director of Nursing (DON) stated, change of condition to PC was not done, I didn't know I needed to. DON confirmed, there was no documentation that supported the PC had performed an immediate MRR for Resident 1, 2, and 3's weight loss. During an interview on 9/5/25 at 7:21 pm, PC confirmed, there had been no pharmacy review regarding weight loss for Residents 1, 2, or 3 and there was no documentation that supported the facility notified the PC.

Based on observations, interviews, and reviews, the facility failed to consistently provide three out of three sampled residents (Residents 1, 2, and 3) with Physician ordered therapeutic (customized meal plan to manage a medical condition) diets when: 1. Residents 1 and 2 were not consistently provided with a meal that was fortified (added calories); and 2. Resident 3 was not consistently served a fortified meal that included double portions of protein (examples of protein are meats, eggs, and dairy). These failures had the potential to contribute to weight loss.Findings: 1. A review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised 10/1/17, indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of major depression (a sad mood), anemia (a condition where there was a lower-than-normal number of red blood cells in the blood, red blood cells carried oxygen throughout the body), and fatigue (extreme feeling of tiredness or a complete lack of energy that made it difficult to do everyday tasks). Resident 1 was not her own responsible party (RP, decision maker). A review of the Neuropsychological Assessment (a detailed evaluation that measured how the brain functioned and how it affected behavior and thinking), dated 12/1/23, indicated, Resident 1 had a major neurocognitive (how the brain processed information) disorder due to possible Alzheimer's Disease (memory loss, problems with thinking, and reasoning). A review of the admission Record, dated 12/1/22, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (memory loss, doctors were unable to determine the type), unspecified severity (unknown if it is mild, moderate, or severe) and adult failure to thrive (a decline in health that included a slow loss of energy and appetite). Resident 2 was not his own RP. During a concurrent observation and record review, on 9/3/25 at 12:10 pm, Resident 1 was observed in the RNA dining room (RNA, Restorative Nurse Assistants provided residents with additional verbal encouragement or physically fed the resident. The dining room utilized for meals was a small area and the common phrase for that setting was called RNA dining). On Resident 1's lunch tray was a cup of hot chocolate, a cup of grape juice, a cup of water, a bottle of chocolate Boost (a nutritional supplement drink), and a bowl of diced pears. The plate contained [NAME], mandarin chicken, and fried rice. The meal tray ticket indicated Resident 1's meal was fortified. During an observation on 9/3/25 at 4:29 pm, Resident 1's dinner tray was observed. There was a large baked potato covered with chili and cheese, and a bowl of coleslaw was present. A partially empty bowl that contained diced fruit was present. A cup of water, a cup of hot chocolate, and a bottle of chocolate Boost were observed along with a cup of red in color liquid. The meal tray ticket indicated that the meal was fortified. During a concurrent observation, interview, and record review on 9/4/25 at 7:16 am, with Certified Dietary Manager (CDM), Resident 1's Physician's Order (diet order), dated 7/2/24 was reviewed. CDM confirmed the diet order indicated, Resident 1 was on a fortified diet. CDM stated, we don't fortify every meal. For breakfast we fortify the cereal with butter and dry evaporated milk and for dinner we fortify the soup. CDM looked at the photograph taken on 9/3/25, of Resident 1's lunch tray and confirmed, the lunch was not fortified and restated, lunch wouldn't be fortified. CDM reviewed the photograph taken on 9/3/25 of Resident 1's dinner tray. The dinner consisted of a baked potato covered with chili and cheese, coleslaw, and a bowl of diced fruit. CDM stated, it did not appear fortified, there was no soup. CDM walked to the RNA dining room to observe Resident 1's breakfast. There was an uneaten bowl of oatmeal (hot cereal) on Resident 1's tray and CDM stated, the hot cereal was fortified. During a concurrent record review and interview on 9/4/25 at 9:07 am, with Registered Dietician (RD), Resident 1's Nutrition Assessment-V1.5 dated 7/14/25 was reviewed. RD confirmed the Nutrition Assessment, indicated that Resident 1 was on a fortified diet. RD reviewed the care plan (a detailed plan that outlined resident goals and interventions in place for staff to utilize to assist resident with achieving their goals) titled, Nutritional Problem, dated 4/12/22, and confirmed the care plan indicated, an intervention was in place for Resident 1's fortified diet. RD stated, you would fortify every meal and every meal is different.During a concurrent interview and record review on 9/5/25 at 9:40 am with CDM, Resident 2's Physician's Order, dated 5/28/25, was reviewed. CDM stated, the Physician's Order, indicated, Resident 2's diet was fortified. CDM confirmed that lunches were not fortified. 2. A review of the admission Record, dated 10/28/24, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's, dementia, and type 2 diabetes (body was unable to regulate blood sugar levels) with diabetic neuropathy (high blood sugar levels over time caused nerve damage). Resident 3 was not his own RP.During a concurrent observation and record review, on 9/3/25 at 12:16 pm, Resident 3 was observed in the RNA dining room. Resident 3 was provided with one grilled cheese sandwich. During an interview on 9/4/25 at 4:42 pm, Resident 3's RP stated, my concerns are the nutritionist ordered double portions, I'm here almost every single night for dinner, he isn't getting double portions, not even the double proteins. RP confirmed, facility staff were required to obtain additional food during dinner in order for Resident 3 to have double protein. During a concurrent interview and record review on 9/5/25 at 9:40 am with CDM, Resident 3's Physician's Order, dated 8/5/25 was reviewed. CDM stated the Physician's Order, indicated, Resident 3 was on a fortified diet that included double portions for protein/meat. There were issues with the PM (evening) cook and double portions were not being provided. It's been an ongoing battle with the cook. CDM confirmed, no resident lunches had been fortified.

Based on interview and record review the facility and the Registered Dietician (RD) did not maintain an adequate food and nutrition department for three out of three sampled residents (Resident 1, 2, and 3) with weight loss when: 1. A timely nutrition assessment was not performed for Residents 1, 2, and 3 after a weight loss triggered a change of condition. 2. The RD did not attend weight variance interdisciplinary team (IDT, a group of department heads and staff that provided resident care, to discuss resident care goals and identified concerns) meetings and did not document a progress note that indicated the IDT meeting notes had been reviewed. 3. RD did not communicate to the facility the recommendations made for residents with weight loss or collaborate with the dietary department. 4. The facility and RD were not familiar with the Agreement to Provide Dietetic Consultation Services contract that outlined the facility and RD responsibilities. This had the potential to contribute to further weight loss.Findings: 1. A review of the facility's P&P titled, Nutritional Assessment, revised 10/1/23, indicated, The dietician in conjunction [together] with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change of condition that places the resident at risk for impaired nutrition. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of major depression (a sad mood) and fatigue (extreme feeling of tiredness or a complete lack of energy that made it difficult to do everyday tasks). Resident 1 was not her own responsible party (RP, decision maker). A review of the Neuropsychological Assessment (a detailed evaluation that measured how the brain functioned and how it affected behavior and thinking), dated 12/1/23, indicated, Resident 1 had a major neurocognitive (how the brain processed information) disorder due to possible Alzheimer's Disease (memory loss, problems with thinking, and reasoning). A review of the admission Record, dated 12/1/22, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of unspecified dementia (memory loss, doctors were unable to determine the type), unspecified severity (unknown if it is mild, moderate, or severe) and adult failure to thrive (a decline in health that included a slow loss of energy and appetite). Resident 2 was not his own RP. A review of the admission Record, dated 10/28/24, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's, dementia, and type 2 diabetes (body was unable to regulate blood sugar levels) with diabetic neuropathy (high blood sugar levels over time caused nerve damage). Resident 3 was not his own RP. During a concurrent interview and record review on 9/4/25 at 9:07 am, with RD, Resident 1s Quarterly Nutrition Assessment-V1.5 (nutrition assessment), dated 7/14/25 was reviewed. RD stated, I started working [at this facility] remotely (worked in a different location that was not in the facility) mid-July, and the nutrition assessment was performed by a different RD. The last assessment [nutrition assessment dated [DATE]] indicated [Resident 1's] PO (by mouth) intake was not great. If she had severe weight loss, she would get another assessment. RD reviewed the Weight Summary, dated 8/10/25 and confirmed, Resident 1 weighed 76.4 pounds and triggered for an 11.6 percent (%) loss of body weight, over 180 days, which indicated severe weight loss. RD stated, I would be happy to assess her and take a harder look at this. A review of the Monthly Weight Report, dated 9/1/25, that included the monthly weights taken throughout the month of August, completed by RD, indicated, Resident 1 triggered an 11.4 % weight loss. A review of the nutrition assessment dated [DATE], indicated that RD performed a nutritional assessment that included recommendations, 26 days after Resident 1 triggered a severe weight loss. During an interview on 9/4/25 at 10:14 am, the facility's Administrator (ADMIN) stated, our regular RD was currently on a leave of absence and the remote RD started working at the facility 7/25/25. During an interview on 9/4/25 at 10:28 am, RD confirmed, the Monthly Weight Reports were performed by RD and the data collected regarding residents with weight loss was emailed to the facility. RD confirmed, the Monthly Weight Report, dated 9/1/25, was a review of weights from 8/1/25 through 8/31/25. During a concurrent interview and record review on 9/5/25 at 10:37 am, Resident 2's reentry nutritional assessment (a reentry assessment was performed when a resident was out of the facility for an inpatient stay at a different facility such as a hospital), dated 5/7/25 was reviewed. RD confirmed, the nutrition assessment was completed by a different RD. RD reviewed the Weight Summary, dated 7/21/25 and confirmed, Resident 1 triggered a severe weight loss. RD reviewed and confirmed, the Weight Summary, dated 7/21/25, indicated, Resident 2 weighed 89 pounds and triggered for a 10.1 (%) loss of body weight, over 180 days, which indicated severe weight loss. RD stated, I started the nutrition assessment on 8/31/25 and finished it yesterday. The nutrition assessment indicated an effective date of 8/31/25 at 3:52 am and was signed by RD on 9/5/25. A review of the nutrition assessment dated [DATE], indicated the nutritional assessment was completed 46 days after Resident 2 triggered a severe weight loss. During a concurrent interview and record review on 9/5/25 at 10:47 am, RD confirmed, the medical records indicated Resident 3 had a quarterly nutrition assessment completed on 4/22/25. Resident 3's Weight Summary, dated 5/5/25 was reviewed. RD confirmed, the Weight Summary, indicated, Resident 3 weighed 143 pounds, triggered a 23.6% weight loss and stated, the last nutrition assessment was performed 7/21/25 by a different RD. (77 days after the triggered weight loss). 2.A review of the facility's P&P titled, Nutritional Assessment, revised 10/1/23, indicated, the facility's IDT would work together to identify situations that placed residents at an increased risk for weight loss and develop personalized nutritional care plans (document described resident health concerns, goals, and care instructions for staff). A review of the Agreement to Provide Dietetic Consultation Services (RD contract), dated 7/25/25, indicated the RD would attend facility conferences and meetings. During an interview on 9/4/25 at 9:07 am, RD stated, I'm not involved in the weight variance or IDT meetings. They do their meetings on a date I'm already in other meetings, and I can't attend. During an interview on 9/4/25 at 10:14 am, with ADMIN and Director of Nursing (DON), the DON confirmed, every week the facility had a weekly weight variance meeting (also called the IDT weight meeting) to review residents that had experienced weight loss, and the weekly meeting also included residents that weighed less than 100 pounds. DON stated, the RD had not attended any weight meeting since starting at the facility [7/25/25] and wanted to move the meetings from Tuesday to Wednesday to accommodate RD's schedule. We declined due to it causing a delay in care. ADMIN confirmed DON's interview and stated that the RD had not attended any meetings. During an interview on 9/4/25 at 10:39 am, ADMIN stated, the RD was expected to document a weight progress note because she is not attending the meetings and confirmed there were no progress notes entered by the RD for missed meetings. During an interview on 9/5/25 at 10:26 am, RD stated, I wasn't aware that I was expected to enter a weekly progress note for weekly weight variance meetings. 3.A review of the RD contract, dated 7/25/25, indicated the RD would provide the nutritional service department with support and consult with the health care team concerning the nutritional care of the residents. During an interview on 9/4/25 at 7:16 am, the facility's Certified Dietary Manager (CDM) stated, we have a remote RD, but I personally have not spoke to the remote RD. CDM confirmed, there had been no communication or collaboration with RD regarding the dietary department or residents that experienced weight loss. During an interview on 9/4/25 at 9:07 am, RD stated, there was no communications with the CDM, every building is different, and asked, what's their protocol? During an interview on 9/5/25 at 9:13 am, ADMIN stated, we talked with the RD yesterday to get nutritional assessments completed, Resident 1's assessment is in there [electronical medical records], I have not seen it yet, and I am reviewing it now. The RD did not call, text, or email that the assessments for all three residents (Residents 1, 2, and 3) were completed or that there were recommendations. During an interview on 9/5/25 at 10:26 am, RD was asked how nutritional assessment information for the residents was obtained. RD stated, my assessments are performed by information [gathered] in the system, I didn't speak to anyone. RD stated, Resident 1's nutritional assessment was performed on 9/4/25 at 5:55 pm and confirmed, RD had not contacted the facility regarding recommendations that were made. RD stated, I wanted the CDM to review the food preferences and for the facility to obtain lab work (drawing blood). RD indicated the information obtained from the lab work would assist with looking for changes to protein levels and electrolyte imbalances. (Good protein levels were required for the body's constant need to repair and grow cells and electrolytes were essential minerals required for muscle contraction, nerve function, and heart function.) During an interview on 9/5/25 at 10:37 am, RD stated, I started [Resident 2's] assessment on 8/31/25 and completed it yesterday [the assessment was signed by RD on 9/5/25, five says after starting the assessment]. My recommendations were to clarify the med plus (liquid, nutritional supplement provided with medication) order, and I ordered labs. RD confirmed, RD had not called the facility to discuss RD recommendations and stated, when I call to discuss [Resident 2], we can discuss other interventions that we might do. During an interview on 9/5/25 at 10:47 am, RD stated, I did an assessment yesterday and I recommended Boost (liquid nutritional supplement) three times a day. RD confirmed, the facility had not been notified. 4. A review of the RD contract, dated 7/25/25, indicated the RD would provide RD services based on the facility's P&P and would periodically review with the facility P&Ps for the food and nutrition department. The RD contract indicated, the facility would orient the RD to the facility's P&Ps and would notify the RD in writing when there were residents that had significant weight losses. During a concurrent interview and record review on 9/5/25 at 10:39 am, with ADMIN, the RD contract was reviewed. ADMIN confirmed, the RD contract indicated, the RD would be provided orientation to the facility's P&P and was not. ADMIN confirmed that the RD contract indicated that when a resident had significant weight loss, the facility would notify the RD in writing. ADMIN stated, I didn't notify the RD about the weight loss in August. I had told her where to look for the information and told her there was a report with the residents that triggered. During an interview on 9/5/25 at 10:47 am, RD stated, I don't know their policies and the facility never notified me that there were residents with weight loss. A review of the Monthly Weight Report, dated 8/1/25, indicated, RD had performed an evaluation of resident weights taken during the month of July. Resident 2 weighed 86 pounds and lost 14.85% body weight. Resident 3 weighed 140.5 pounds and lost 17.8% body weight. Both residents had triggered severe weight loss. A review of the Monthly Weight Report, dated 9/1/25, indicated, RD had performed an evaluation of resident weights taken during the month of August. Resident 1 weighed 74.4 pounds and lost 11.4% body weight. Resident 2 weighed 83 pounds and lost 14.4% body weight. Resident 3 weighed 139.4 pounds and lost 12.79% body weight. All three residents triggered for severe body weight.

Based on observation, interview, and record review the facility failed to treat one out of three sampled residents (Resident 1) with dignity and respect when Resident 1 wanted to return to her room during lunch and the Licensed Nurse (LN) assessed (examined) Resident 1 at the lunch table in front of three other residents. This violated Resident 1's right to maintain the privacy of her medical conditions by allowing other residents to watch and listen as the LN examined her.Findings: A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 2/1/23, indicated, facility staff would treat residents with respect and dignity. The P&P indicated, residents had the right to a dignified existence (treated with self-respect), would be provided privacy and confidentiality, and the facility would support residents in exercising (using or acting on) their rights. A review of the admission Record, dated 3/29/22, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of major depression (a sad mood), anemia (a condition where there was a lower-than-normal number of red blood cells in the blood, red blood cells carried oxygen throughout the body), and fatigue (extreme feeling of tiredness or a complete lack of energy that made it difficult to do everyday tasks). Resident 1 was not her own responsible party (RP, decision maker). A review of the Neuropsychological Assessment (a detailed evaluation that measured how the brain functioned and how it affected behavior and thinking), dated 12/1/23, indicated, Resident 1 had a major neurocognitive (how the brain processed information) disorder due to possible Alzheimer's Disease (memory loss, problems with thinking, and reasoning). During an interview on 9/3/25 at 10:58 am, LN E stated, She [Resident 1] refuses RNA dining [RNAs are Restorative Certified Nursing Assistants who help residents in a designated area in the dining room for residents who need additional help and attention with eating and the RNA provides encouragement for those who have lost weight] a lot, she doesn't like to be around people and be watched while eating. During an observation on 9/3/25 at 11:54 am, Resident 1 was observed in bed, lying on her right side, with her eyes closed. RNA A was observed walking into the room with a wheelchair and stated, I have to get you up for lunch and take you to the dining room. Resident 1 replied I don't want to go, then asked why? RNA A stated, they said you have to go just today. Resident 1 agreed, and was taken to the RNA dining room. During an observation on 9/3/25, from 12:10 pm to 12:31 pm, Resident 1 was observed in the RNA dining room with three other residents at the dining table. Resident 1 appeared dissatisfied with her lunch, displaying signs of unhappiness such as frowning, a wrinkled forehead, and closer together eyebrows. Resident 1 verbally expressed a desire to leave by stating, I want out of here, six times, I want to go back to my room two times, and I don't want any of it two times. While RNA B made attempts to verbally encourage or physically feed Resident 1, she non-verbally indicated refusal by shaking her head side-to-side three times. Additionally, twice when RNA B offered food, Resident 1 physically moved away by placing her right arm on her chest and curling in her right shoulder. During the observation period, Resident 1 also stated, I'm not hungry, it's hard to eat just because I'm supposed to eat. I feel pressure down here, I don't know what it is, while pointing to her lower abdomen [lower belly/gut area]. During an observation on 9/3/25 at 12:31 pm, LN E entered the RNA dining room and squatted next to Resident 1's wheelchair to assess Resident 1's lower abdomen while three other residents were eating lunch at the same table. Resident 1 stated, I just don't want to eat. RNA B responded, We're just going to drink some more of this and be here for a few more minutes. LN E told RNA B, I don't want her to drink it if she's having pressure. LN E then informed Resident 1, After you're done eating, we can go to the bathroom to see if that pressure goes away. LN E then left the RNA dining room, and RNA B asked Resident 1, How about some hot chocolate? Resident 1 replied, I don't know what's happening, I don't want it, I have to go to the bathroom. Facility staff arrived and took Resident 1 to her room and then to the bathroom. During an interview on 9/3/25 at 12:35 pm, RNA B confirmed the observations made in the RNA dining room and stated Resident 1's, family member said she has to be in here. Sometimes I sit in her room and help her eat.During an interview on 9/3/25 at 1:56 pm, RNA B stated, I know she [Resident 1] is more comfortable eating in her room, she should have been taken out of the dining room long before she was, and should have been allowed to drink her Boost [nutritional, milkshake like drink] in her room.During an interview on 9/3/25 at 1:40 pm, Resident 1 confirmed the observations made in the RNA dining room and stated, I don't like eating in front of other people, I don't like going [to RNA dining]. Resident 1 stated, I would expect the conversation about using the bathroom to be private and confidential, I didn't like being asked in front of others.During an interview on 9/3/25 at 1:47 pm, LN E confirmed the observation from the RNA dining and stated, I normally take them out to assess, that wasn't how it was supposed to be. LN E confirmed talking to Resident 1 in front of other residents about using the bathroom and stated, that conversation should have been in private. LN E stated, from what I know, we offer three times to eat in RNA dining, after the third time we will take her to her room. We thought RNA dining would be a good idea for socialization, sometimes she wants to stay in her room and she has the right to refuse. During an interview on 9/3/25 at 1:56 pm, RNA B stated, Usually, on a normal day, she says I don't want to be here [RNA dining room], and she is taken back to her room. I know she is more comfortable eating in her room.During an interview on 9/4/25 at 8:46 am, RNA A confirmed the observation made on 9/3/25 at 11:54 am. RNA A stated, I was told by the Lead RNA that [Resident 1] had to be here [RNA dining room] yesterday. During an interview on 9/4/25 at 5:55 pm, Director of Staff Development (DSD), the observations of Resident 1, RNA A, and RNA B, that were made on 9/3/25, were described. DSD confirmed, Resident 1's rights were violated and stated, we ask three times, then let the nurse know.

Based on observation, interview, and record review, the facility failed to prevent accidents for two of 12 sampled residents (Residents 4 and Resident 10) when: 1. Certified Nursing Assistant (CNA) B rushed providing care and did not ensure that Resident 4's left arm was correctly and safely positioned before repositioning the resident in bed which resulted in a fracture (broken bone) and pain to the resident's left upper arm when the resident's arm was caught in the side rail of the bed. 2. Resident 10 sustained two falls, when her fall prevention interventions were not consistently implemented by facility staff. These failures caused severe injury to Resident 4, and the potential for severe injury to Resident 10. Findings: 1. Resident 4's clinical record was reviewed. Resident 4 was admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. Resident 4 was observed in his bed on 12/5/16 at 4:15 pm, awake and alert, covered with his sheet and a blanket. A complete left arm splint was observed in place wrapped by an elastic bandage. During an interview on 12/5/16 at 4:15 pm, Resident 4 stated that he made his own health care decisions. Resident 4 described that his left leg and arm were totally paralyzed, but that he had been able to transfer holding his weight on his right leg with staff assistance. Resident 4 stated that he was currently in the process of healing a broken left arm. Resident 4's clinical record was reviewed. A Health Status Note, documented in Progress Notes, dated 9/16/16 at 4:24 pm, was reviewed and read, While transferring to bed resident got left arm caught in the bed rails, arm was bent back, and resident is c/o (complaining of) 8/10 pain (assessment of pain level based on a 0 to 10 scale where 0 represents no pain and 10 represents excruciating pain). Slight swelling noted. Send to ER (Acute care emergency room ) for evaluation and treatment as needed via ambulance A Diagnostic Radiology (X-ray) report from the acute care hospital, dated 9/16/16 at 5:14 pm, was reviewed and read that Resident 4 had sustained a non-displaced acute fracture in the distal humerus (elbow area). Resident 4's clinical record was reviewed. A Health Status Note, documented in Progress Notes, dated 9/16/16 at 8:40 pm was reviewed and read, Resident returned from (acute care hospital) . with a distal humerus fracture (elbow) Needs to keep splint and sling on until appointment with ortho(pedic doctor) (a physician that specializes in the diseases and injuries of bones). Resident 4's clinical record was reviewed. A physician's orders [REDACTED]. every 4 hours as needed for severe pain related to . fracture of lower end of left humerus (Left elbow) During an interview on 12/5/16 at 5:30 pm, CNA B stated that when Resident 4's left arm was injured he and another aide were repositioning the resident just after transferring him to bed. CNA B stated that he felt a little hurried with Resident 4's transfer and repositioning, because his coworker was faster than him. CNA B stated he did not have Resident 4's left paralyzed arm in a safe position across the resident's stomach, as he usually did. CNA B stated It was my fault. CNA B stated that he did not notice Resident 4's arm/hand was caught in the rail until Resident 4 stated, My arm, My arm and complained of pain. During an interview on 12/6/16 at 9:50 am, the Director of Nurses (DON) stated that she was aware of Resident 4's left arm injury. The DON stated that staff required training on transfers and care for Resident 4. On 12/7/16 at 10:15 am, CNA C was interviewed and stated that she was the other staff involved with Resident 4's care when his left arm was injured. She stated that she was working overtime as someone had called off. CNA C stated that she assisted Resident 4 with a shower, then with the assistance of CNA B, the two of them placed Resident 4 from the shower chair to a sitting, then to a laying position on his bed. She stated that Resident 4's left side quarter bed rail was in the up position. She stated that, We were worried about his left leg that had been previously injured. CNA C stated that after Resident 4 was laid in his bed he needed to be centered. She stated that was when she and CNA B slid Resident 4 over, using a draw sheet beneath him, They heard him say Ow, my arm, my arm. We looked over and saw his hand was caught in the left side upper rail of the bed. CNA C stated, I tend to be speedier because I know we have things to do. CNA C denied that staff levels were any lower than usual, and stated that she felt rushed because they had other residents to get up for meals. 2. Resident 10's record was reviewed. Resident 10 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a standardized comprehensive assessment of each resident's functional capabilities that helps nursing staff identify health problems) dated 10/18/16, indicated Resident 10 had severe cognitive (ability to think and reason) impairment, did not walk, and required extensive assistance from staff for toileting needs. It also indicated Resident 10 was on a specific toileting program. Resident 10 was observed on 12/7/16, at 8 am, sitting in a wheelchair in the dining room. An alarm box was observed attached to the back of her wheelchair and noted to be turned to the off position. An observation and concurrent interview was conducted with Certified Nurse Assistant (CNA) D on 12/7/16, at 8:15 am. CNA D confirmed Resident 10's wheelchair alarm was turned off and turned it to the on position. CNA D stated the alarm is supposed to be turned on to alert staff if Resident 10 tries to get up unassisted from her wheelchair and explained the staff who get her into the wheelchair in the morning frequently forget to turn the alarm on. The assessment titled, Fall Risk Assessment, dated 4/20/16, indicated Resident 10 was at risk for falls. The Fall Risk assessment dated [DATE], indicated Resident 10 was at high risk for falls, was confined to a chair and exhibited a loss of balance while standing. The care plan for Resident 10 titled, High risk for falls initiated 7/16/14 was reviewed. It indicated the following interventions to minimize Resident 10's risks for fall and their implementation date; 12/21/15- Staff would anticipate and meet her needs throughout the day. 10/27/15-Alarm pressure pad on seat of wheelchair. 9/10/15-Appropriate footwear, non-skid socks or slippers/shoes would be worn. 9/10/15- A scheduled toileting plan would be utilized. The care plan titled, Scheduled toileting, dated 7/20/16, indicated staff would assist Resident 10 to toilet, before and after meals, naps, activities, upon rising, before bed and as needed in between those scheduled times. An interview was conducted with CNA E, on 12/7/16, at 2:10 pm. CNA E stated she was assigned to care for Resident 10 on that day and frequently was her aide. CNA E was asked to explain how Resident 10's toileting is accomplished. CNA E stated that Resident 10 Knows when she has to go (to the toilet) and when CNA E hears Resident 10's wheelchair alarm sounding she knows Resident 10 is trying to get up to the toilet and she then goes to assist her. CNA E stated other than that, she only toilets Resident 10 in the morning when she comes on shift. An interview was conducted on 12/7/16, at 4:20 pm, with Resident 10's caregiver, CNA F. CNA F stated Resident 10 is not toileted at any specific times, but is independent in toileting. CNA F clarified that when she hears Resident 10's wheelchair alarm sounding then she knows Resident 10 is attempting to toilet herself and she then goes to assist her. The document titled, Change Of Condition (COC), dated 6/23/16, was reviewed. It indicated Resident 10 had fallen and was found by staff sitting on the floor in the hallway, having prior been sitting in her wheelchair. The COC completed by a Registered Nurse indicated Resident 10's alarm pad in the wheelchair Was turned off. The COC document, dated 6/29/16, was reviewed and indicated Resident 10 had been found in the shower room attempting to self transfer in order to toilet herself. Resident 10 was found sitting on the shower room floor, having prior to the fall, been sitting in her wheelchair. The Licensed Nurse documentation indicated Resident 10's wheelchair pad alarm didn't sound. An observation of Resident 10 in the dining room and concurrent interview was conducted on 12/8/16 at 8:30 am CNA E. Resident 10 was observed to be wearing regular socks with smooth soles. CNA E confirmed Resident 10 was only to wear non-skid socks or slippers with tread as a fall prevention intervention. An interview and concurrent record review was conducted on 12/7/16 at 3:20 pm, with the DON. DON confirmed Resident 10 had fallen on 6/23 and 6/29/16, and care planned intervention of the alarm in her chair had not been implemented. DON stated one intention of a scheduled toileting plan was to assist Resident 10 to toilet with staff assistance in order to avoid potential falls. DON stated the specific toileting plan as outlined in the care plan was to be followed by the CNAs every shift.

Based on interview and record review, the facility failed to provide appropriate care and services for four of 20 sampled residents (Residents 6, 12, 24, and 25) when: Residents 12, 24, and 25 were candidates for, but were not provided, bowel/bladder training to restore as much normal bowel/bladder function as was possible. Resident 6 had an ongoing urinary tract infection and his catheter was not changed, per facility policy. These failures resulted in bowel/bladder function declines for Residents 12 and 25, placed Resident 24 and other residents at risk for bowel/bladder decline, and had the potential to result in or contribute to a urinary tract infection for Resident 6. Findings: The facility policy titled, "Bowel and Bladder Program," revised 11/20/13, indicated, "It is the facility's policy to assess and assist each resident to achieve and maintain the highest practicable level of independence and functioning. Residents who exhibit improvement or decline in bowel and bladder function will be assessed as indicated..."The Minimum Data Set (MDS) nurse will evaluate the most appropriate program for the resident... The MDS nurse will evaluate the 14 day Bowel & Bladder training program weekly and will make the decision to continue or stop...The MDS nurse will document weekly progress... the MDS nurse will update Bowel and Bladder assessment form and complete Post Evaluation of Re-Training program Form..." 1. Resident 12's record was reviewed. Resident 12 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's MDS' (MDS, a standardized resident assessment) for Resident 12 indicated the following: On 1/2/14, Resident 12 was continent of both bladder and bowel, and required staff assistance for her toileting; On 3/25/14, Resident 12 was frequently incontinent of urine, remained continent for her bowel functions, and was not being provided a toileting program at this time; On 6/23/14, Resident 12 had occasional bladder incontinence, remained continent for her bowel, and was not being provided a toileting program at this time; On 9/23/14, Resident 12 was occasionally incontinent of both bowel and bladder, required staff assistance for her toileting and incontinent care needs, and was not being provided a toileting program at this time. All reviewed assessments indicated that Resident 12 was dependent upon staff for toileting and incontinence care. During an interview and record review with LN (licensed nurse) G on 12/23/14 at 11:20 am, she was asked to clarify why Resident 12 was not considered a candidate for bowel and bladder training (a scheduled toileting program to help residents maintain as much bowel and bladder function as possible). LN G stated that Resident 12 was not combative with care and she was unaware of any issues with toileting for this resident. She was uncertain if the resident had been assessed upon admission, was unable to clarify if the resident had ever been considered for training, and was unaware of any residents currently on a bowel or bladder program. During an interview and record review with MDS O (the nurse responsible for completing MDS assessments), she was asked about the facility's bowel and bladder training program. MDS O stated that there were no residents currently receiving bowel or bladder training. After reviewing Resident 12's record, MDS O stated upon admission, Resident 12 was continent of both bowel and bladder with nocturia (excessive urination at night). Review of the nursing admission assessment for Resident 12, dated 12/16/13, MDS O confirmed the nurse who completed the assessment documented that Resident 12 was continent and incontinent of both bowel and bladder with nocturia and urgency. MDS O stated the admission assessment indicated Resident 12 required extensive staff assistance for toileting. Resident 12's bowel and bladder assessment and interventions, dated 12/26/13, indicated the resident was fully continent of both bowel and bladder, which led to no further assessments or interventions. Review of the MDS assessment, dated 3/25/14, indicated Resident 12 was not fully continent of bowel and bladder. The 3/25/14 assessment indicated Resident 12 showed initiative and willingness to participate and required staff assistance. MDS O was unable to locate any 72 hour bowel and bladder program assessments and evaluations that, according to the facility's policy, should have been done. MDS O stated that Resident 12 had declined in her level of ability to control her bladder and bowels, and had not been placed on a toileting program to address this decline in function. 2. A review of Resident 24's record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's nursing admission assessment for Resident 24, dated 4/18/14, indicated, Resident 24 had bladder retention, was incontinent of bowel, both continent and incontinent of bladder, and required extensive assistance from staff for toileting. A review of the facility's MDS'/bowel and bladder assessments for Resident 24 indicated the following: On 4/30/14, the admission MDS, Resident 24 was frequently, but not always, incontinent; On 10/15/14, Resident 24 was always incontinent of both bowel and bladder, and required staff assistance for toileting and incontinence care; and On 10/17/14, Resident 24 was determined to be a candidate for a scheduled voiding program (staff check and provide care on a timed schedule individualized to the resident's needs to assist in maintaining bowel/bladder function). During an interview with MDS O on 1/7/15 at 10:20 am, and a concurrent review of Resident 24's record, MDS O confirmed that the MDS assessment, dated 10/17/14, indicated Resident 24 should be placed on a scheduled voiding plan, which had not been initiated or indicated on his care plan. MDS O confirmed that there were multiple types of assessment forms used for bowel and bladder assessments and stated she "becomes confused by the conflicting information." MDS O stated she was unable to locate any documented 72 hour bowel and bladder assessments, required by the facility's policy. MDS O stated that the scheduled toileting program should be specific to the resident's needs, is designed upon reviewing the resident's patterns of incontinence over 72 hours, and staff should check the resident every two hours or more often. 3. Resident 25's record was reviewed. Resident 25 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment for Resident 25, dated 3/21/14, indicated Resident 25 had a history of [REDACTED]. Review of the facility's MDS'/bowel and bladder assessments for Resident 25 indicated the following: On 3/28/14, the admission bowel and bladder assessment for Resident 25 indicated the resident had functional bowel and bladder incontinence and was dependent on two or more staff for transfers and mobility; On 4/2/14, the initial admission MDS, Resident 25 was always incontinent of her bowel function, frequently incontinent of urine, and dependent on staff to assist her with her toileting; On 10/1/14, Resident 25's bowel function had improved since admission. Resident 25 was frequently incontinent of both bowel and bladder; On 10/3/14, a bowel and bladder assessment determined Resident 25 was a candidate for a scheduled toileting program; On 1/1/15, Resident 25 had lost function and was now always incontinent of both bowel and bladder function; and On 1/5/15, a bowel and bladder assessment determined Resident 25 was a candidate for a scheduled toileting program. Review of Resident 25's care plan, dated 10/4/14 and revised 1/5/15, indicated Resident 25 "has frequent incontinence of bowel and bladder. Usually wet when checked. Not a candidate for retraining or scheduled toileting." During a concurrent interview and record review with MDS O on 1/7/15 at 11 am, she confirmed that the assessments conducted on 10/3/14 and 1/5/15 indicated Resident 25 was a candidate for scheduled toileting. MDS O confirmed that Resident 25 had not been placed on a toileting program. MDS O stated there were multiple types of assessment forms used for bowel and bladder assessments and she "becomes confused by the conflicting information." MDS O stated she was unable to locate any documented 72 hour bowel and bladder assessments for Resident 25, as required by the facility's policy. 4. A review of Resident 6's record indicated Resident 6 with admitted to the facility with [DIAGNOSES REDACTED]. Resident 6's catheter was changed at a hospital emergency room (ER) on 12/2/14. The [DIAGNOSES REDACTED]. A record review of a facility's policy for "Catheter Care, Urinary," dated 2001, revised 2010, indicated, under "Changing Catheters": 1. Changing indwelling catheters or drainage bags...is suggested...based on clinical indications such as infection, obstruction, or when the system is compromised. A review of Resident 6's short term care plan titled, "Indwelling Catheter," dated 9/27/14, revised 12/27/14, indicated the care plan had not been updated to reflect the 12/2/14 catheter change at the hospital ER. when Resident 6 was diagnosed with [REDACTED]. During an interview conducted on 11/22/14 at 11:20 am, the Director of Nursing confirmed that Resident 6's care plan did not reflect a catheter change and that facility policy was not followed.

Based on observation, interview, and record review, the facility failed to provide supervision to minimize the risk of falls, for one of three residents when Resident 1 was left in a dining room without staff present. This failure resulted in Resident 1 having a fall and suffering an avoidable hip fracture (broken hip bone), surgery to repair the fracture, and a six day hospital stay. Findings: On 8/1/14 and 9/11/14 Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, an assessment), dated 7/17/14, indicated that Resident 1 had severely impaired cognition (ability to reason), and that she needed assistance to keep a steady balance when walking. A document titled, "Fall Risk Assessment," included assessments dated 7/16/14 and 7/23/14. The assessments considered factors related to Resident 1's mental and physical status that contributed to her risk of having a fall. On 7/16/14, the resulting score was 16, and on 7/23/14, the assessment resulted in a score of 18. The final instruction on the assessment form read, "Total score of 10 or above presents HIGH RISK." A care plan titled, "Falls, Safety, Restraint," was initiated for Resident 1 on the date of her first admission 1/8/14. The plan specified, "Problem/Need/Risk/Concern: At risk for falls/injury as evidenced by fall risk assessment, history of falls, gets out of bed without assistance, poor safety awareness, dementia, unsteady gait, medications (risk of side effects from medications)." Interventions were added to the care plan that included , "Alarm in bed and wheelchair," dated 1/28/14 and "1:1 supervision (one staff supervising the resident at all times)" dated 5/6/14. The most recent "Re-evaluation date" for the care plan was 7/10/14. An additional care plan for Resident 1 titled, "Falls, Rewritten/revised 5/7/14," dated 7/16/14, specified, "Approach/Intervention...Attempts to get out of chair often...Needs reminding on fastening seatbelt (a belt on the wheelchair that, once fastened, will subsequently sound an alarm on the chair if the resident unfastens it; thus warning staff that she is likely attempting to stand up and needs immediate assistance to avoid falling.)" A document title, "Fall Prevention Program, "presented to staff at educational inservices on 3/21 and 3/24/14, specified, "If the resident exhibits unsafe behavior, the resident should be placed in the supervised environment..." A nurse's "Report of...Actual or Suspected Fall," dated 7/23/14 at 3:30 pm, documented, "At around 12:35 pm I heard another resident yelling from the dining room, 'help, help, somebody fell ' ...I went into the dining room on Station 2 and found Resident (1) on the floor, laying on right side, holding her head, (chair) alarm was going off...large hematoma (swelling) on left side back of head...10 minutes after fall, Resident complained of severe hip pain...transferred to (hospital) for evaluation and treatment." An acute care hospital "Discharge summary," dated 7/30/14, documented that Resident 1 had been admitted to the hospital on [DATE] with a left hip fracture caused by a fall, and was being discharged after having had corrective surgery. During an observation on 8/1/14 at 1:40 am, Resident 1 was asleep in her bed. She was lying on here back with her left side slightly elevated with cushioning. During a concurrent interview, the Director of Staff Development (DSD) stated that it was Resident 1's left hip that was fractured by her most recent fall. During an interview on 8/1/14 at 1:05 pm, Licensed Nurse (LN) A stated that on the date of the fall, she had just finished coming come out to the hallway from a resident's room and could not hear Resident 1's chair alarm from the hallway. She stated that she heard another resident yelling from the dining room for help, that she heard the chair alarm after entering the dining room, and that there was no staff in the dining room. LN A further stated, "All the (Certified Nursing Assistants (CNAs)) know that (Resident 1) is not to be left unattended, and that there is always supposed to be someone (staff) in the dining room with residents." LN A stated that CNA C, "was assigned to monitor the dining hall and (Resident 1), and that(CNA C) had left (Resident 1) there, and (CNA C) had said she, 'went to get another resident'." During an interview on 8/1/14 at 1:20 pm, the Administrator (Admin) stated that she and the Regional Manager had interviewed CNA C and that CNA C had confirmed that she had left Resident 1 in the dining room prior to the fall. Admin stated that CNA C was suspended at that time and that, as of today 8/1/14, would be terminated. Admin further stated that CNA C had received a verbal warning in the past when a resident had fallen in the dining room after being left there unattended by CNA C. Admin stated that all staff understood that no residents were to be left unsupervised in the dining room. On 8/1/14 CNA C's personnel file was reviewed. A document dated 5/29/14, titled, "Counseling/Disciplinary Notice," specified, "Written warning...Carelessness/lack of safety ...Left resident alone in dining room resulting in fall with injury requiring transfer to acute hospital for evaluation and treatment...Corrective action: Will not leave residents alone in dining room..." The document was signed by a Registered Nurse and by CNA C. During an interview on 8/1/14 at 1:50 pm, Resident 4 was alert and oriented and recalled the incident when Resident 1 fell on [DATE]. She stated that she was in the dining room when Resident 1, "fell and couldn't get up and I called for someone to help. There is usually someone (staff) in the dining room. I don't know why (staff) wasn't in there then." During a telephone interview on 9/12/14 at 1:40 pm, CNA C stated that on 7/23/14 she had been bringing residents into the dining room for mealtime. She stated that there often was not enough staff to leave another CNA in the dining room, and that when she left Resident 1 there, she did not look up to see if another CNA was present. She further stated that she had received a verbal warning for doing the same previously. During a telephone interview on 9/12/15, Resident 1's husband and Responsible Party (RP, legally makes decisions for Resident 1) stated that at the time of his wife's fall there was not enough staff, that CNAs were poorly supervised, and that he had complained to the Ombudsman (County's advocate for residents). He stated that he was "impressed" with the ombudsman who "got it straightened out," as he had since seen more CNAs. During the interview on 8/1/14 at 1:50 pm, Admin concurred that that Resident 1's fall with a hip fracture on 7/23/14 should not have happened as it could have been avoided if Resident 1 had had the expected supervision.

Based on interview and record review, the facility failed to promptly notify physicians of the results from their resident's laboratory (lab) testing. (Residents 4, 5, and 6). These failures resulted in an untreated infection and subsequent death of Resident 4, two unplanned hospital transfers for infections that progressed [MEDICAL CONDITION] for Resident 5, with the potential to adversely affect all residents who require lab testing and resulted in a delay in the treatment of [REDACTED]. Findings: 1. Resident 4's record was reviewed. Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 11/7/12, Resident 4's physician ordered a urinalysis (UA). On 11/8/12, a urine specimen was collected and sent to the lab. On 11/9/12, the lab notified the facility that the specimen container was not properly labeled with Resident 4's identification, and the UA could not be completed and the physician was not notified. On 11/14/12, five days later, a second urine specimen was collected and sent to the lab and the physician was not notified of the delay. On 11/17/12, the lab notified the facility that Resident 4's urine specimen was contaminated and requested a clean specimen and the physician was not notified. On 11/19/12, a third urine specimen was collected and submitted to the lab and the physician was not notified of the delay. On 11/23/12, the lab notified the facility that Resident 4's urine specimen was contaminated and requested that a clean urine specimen be obtained and resubmitted and the physician was not notified. No further urine specimens were collected and Resident 4's physician was not notified. On 1/12/13, Resident 4's physician ordered a Complete Blood Count (CBC- requires a sample of blood which is drawn from the arm, and used to evaluate abnormal levels of blood cells. A high amount of white blood cells (WBCs) indicate an infection and a low amount of red blood cells are a sign of [MEDICAL CONDITION] or bleeding), and a Complete Metabolic Panel (CMP- requires a sample of blood drawn from the arm and used to evaluate fluid imbalances such as dehydration and kidney function). On 1/19/13, (one week later), nursing staff acknowledged the orders, but never carried them out. Blood specimens were never sent to the lab and the CBC/CMP was never done and the physician was not notified. On 1/24/13, Resident 4's physician ordered that a stool specimen be sent to the lab and tested for C&S, [MEDICATION NAME] pathogens (bacteria in the small intestines), and WBCs. There was no evidence that the stool specimen was collected or that the test had been done and Resident 4's physician was not notified. On 1/28/13, four days after ordered, the lab received Resident 4's stool specimen, but the incorrect test was requested and the stool was in the incorrect specimen container. There was no follow up or stool specimen submitted for retesting. Resident's physician was not notified. On 7/31/13 at 4 pm, an interview and concurrent record review was conducted with Licensed Vocational Nurse (LN) D. LN D confirmed that a UA, CBC/CMP, and stool for WBC's had all been ordered by Resident 4's physician, but not successfully completed, and the physician had not been notified. LN D stated that the facility had no lab policy or tracking system, and the nurses were not utilizing their "24 hour" nursing communication log between shifts, which would have alerted the next nurse on duty that a lab specimen needed to be collected. LN D confirmed that Resident 4 was never treated for [REDACTED]. On 8/1/13 at 1:45 pm, Resident 4's physician (PMD) was interviewed. PMD stated that he had no recall of the lab testing that he had ordered on Resident 4 and was not aware that he never received the results. 2. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/10/13 at 11:45 am, a nurse documented that Resident 5's physician had ordered a UA, to be done "tomorrow." On 2/15/13, four days later, nursing staff collected the urine specimen. On 2/25/13, Resident 5's physician ordered another UA. On 2/28/13, three days after ordered, the urine specimen was collected and sent to the lab, the physician was not notified of the delay in collecting the specimen. On 3/2/13 at 4 pm, while the results from the UA which should have already been available were still pending, Resident 5 was sent to the emergency room with [MEDICAL CONDITION] and a fever of 103.8F. On 7/31/13 at 4 pm, LN A confirmed that nursing staff delayed collecting Resident 5's urine specimens and his physician was not notified. 3. Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 6's record was reviewed. On 1/25/13, Resident 6's physician ordered that a stool specimen be tested for C.diff (a highly contagious intestinal infection that causes severe diarrhea). The stool sample was collected and submitted to the lab. On 1/26/13, the lab reported to the facility that Resident 6's stool was positive for C.diff. On 1/28/13, two days later, the facility faxed the lab report to Resident 6's physician and documented, "waiting for response." There was no documented evidence that nursing staff followed up on the fax or communicated with the physician. On 1/30/13, four days after the identification of the infection, Resident 6's physician called a telephone order to the facility, and treatment was initiated. On 7/31/13 at 9 am, an interview and concurrent record review was conducted with the Administrator (Admin). The Admin was unable to provide a dedicated policy and procedure for lab collection, documentation, and reporting. The Admin stated that there had been a lack of oversight regarding the management of resident laboratory specimens and that no tracking system had been in place. On 9/4/13 at 6:15 pm, during an interview and concurrent record review, LN F stated that the results of Resident 6's lab had been locked up over the weekend in an office which nursing staff had no access to from 1/26 to 1/28/13, and confirmed that her physician had not been notified promptly. LN F stated that on 1/28/13, the results were faxed to Resident 6's physician, but nursing had not followed up with a phone call to verify that the physician received the fax, then another two days lapsed before the physician responded.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for three residents (Residents 4, 5, and 6) by failing to timely obtain and report laboratory (lab) results, notify physicians of acute changes in resident conditions, and recognize and ensure timely treatment for [REDACTED]. 1. Resident 4 was at an increased risk for urinary tract infection [MEDICAL CONDITION] and urosepsis (blood poisoning from infected urine), due to the use of an indwelling catheter (a tube inserted into the bladder for the purpose of urine drainage from the bladder). Licensed nursing (LN) staff had either not collected or incorrectly collected urine, blood, and stool specimens that Resident 4's physician had ordered. LN staff, the primary care physician (PMD), another physician (MD), and a physician's assistant (PA) failed to recognize that the UAs had not been completed, ensure lab results were obtained, to ensure treatment for [REDACTED]. Licensed nursing staff had not recognized that promptly obtaining, evaluating, and reporting diagnostic lab testing was an important intervention in the early detection of infection, and diagnostic lab testing results that should have been available, were not. Resident 4's health status subsequently declined, and she was transferred emergently to the local hospital (Hospital A) where her infection and clinical condition could not be managed. Resident 4 was then transferred to a larger medical center (Hospital B) for a higher level of care, where she died from septic shock due to the untreated urinary tract infection (blood poisoning from infected urine). 2. Resident 5 had an increased risk for UTI [MEDICAL CONDITION], due to an atrophied (decreased in size) right kidney. LN staff had not promptly obtained diagnostic lab testing (UA) to ensure timely detection and treatment of [REDACTED]. On two separate occasions, Resident 5 had to be transferred to the hospital for a higher level of care when he became septic in the facility. 3. Resident 6 was identified to have C.diff (a highly contagious infection that causes severe diarrhea). Nursing staff had not promptly assessed, monitored, or implemented necessary interventions commonly used to control the spread of infection. Nursing staff delayed Resident 6's treatment by not promptly informing the physician of the results from her diagnostic lab testing. These failures resulted in an untreated infection and subsequently, the death of Resident 4, two unplanned hospital transfers [MEDICAL CONDITION] for Resident 5, a delay in the treatment of [REDACTED]. Refer to F279, F441, F490, F493, F501, F503, F505, F507, and F520 for additional information. Findings: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment tool), dated [DATE], reflected that Resident 4's cognition was intact and that she had an indwelling urinary catheter (Foley). Resident 4's record was reviewed. On [DATE], Licensed Vocational Nurse (LN) A documented in the Nursing notes that Resident 4's Foley was draining "cloudy sediment urine" and obtained and noted a telephone order from Resident 4's Primary Medical Physician (PMD) for a Urinalysis with a Culture and Sensitivity (UA- requires a sample of urine and tests for the presence of infection the urine, the C&S identifies the type of bacteria causing the infection and what antibiotics will best get rid of it). The results of the UA were not in Resident 4's record, and a request to locate the results was made to the Administrator. The results were not found in the facility, and had to be faxed directly by the laboratory. On [DATE], nursing staff collected a urine sample from Resident 4 and sent the specimen to the lab. On [DATE], the lab notified, who they identified as LN D, that the specimen container was not properly labeled with Resident 4's identification, and the UA could not be completed. On [DATE], five days later, a second urine sample was collected, (no evidence of who collected it), and sent to the lab. On [DATE], Physician A (not the PMD) saw Resident 4, but had not addressed that the UA results, which should have been available, were not and Resident 4's UTI remained untreated. On [DATE], the results from the UA reflected that Resident 4 had a UTI as evidenced by an abnormal amount of blood (2+, no blood is normal), a "few" bacteria, and more than 30,000 WBCs (white blood cells are a sign of infection-normal is 0 to 5000). The lab identified that the urine sample was contaminated with "more than three organisms" (a numerous variety of bacteria that come from other sources such as counter tops, hands, and other surfaces) and requested that a clean urine specimen be resubmitted. The C&S portion of the test could not be performed because there were too many bacteria to isolate and show which bacteria was causing the infection. There was no evidence that Resident 4's physician received the lab results and treatment was not initiated. On [DATE], a third urine specimen was collected by LN B and submitted to the lab. On [DATE], the results from that UA reflected that Resident 4 continued to have a UTI with blood (now 3+), "many" bacteria, and 6000 to 10,000 WBCs. The lab report added that the urine specimen was incorrectly submitted in a sterile cup, which had not been refrigerated (to prevent the overgrowth of bacteria), therefore contaminated, and the C&S could not be done. The lab requested that a clean urine specimen be resubmitted. There was no evidence that Resident 4's physician had been provided with the results of the UA collected on [DATE], and no evidence that another urine sample was collected. On [DATE], the Physician's Assistant (PA), (for Physician A and not the PMD), saw Resident 4, but had not addressed that the UA results, which should have been available over a month ago, were not and Resident 4's UTI remained untreated. On [DATE], the facility's Registered Dietitian requested a Complete Blood Count (CBC- requires a sample of blood which is drawn from the arm, and used to evaluate abnormal levels of blood cells. A high amount of white blood cells (WBCs) indicate an infection and a low amount of red blood cells are a sign of [MEDICAL CONDITION] or bleeding), and a Complete Metabolic Panel (CMP- requires a sample of blood drawn from the arm and used to evaluate fluid imbalances such as dehydration and kidney function). CBCs and CMPs are useful to the RD to evaluate if [MEDICAL CONDITION], dehydration, kidney failure, or nutrient deficiencies are present and Resident 4 had not had those tests done since admission. LN D faxed the request to Resident 4's physician on [DATE]. The fax was in Resident 4's physician's orders [REDACTED]. On [DATE], one week later, LN D documented in Resident 4's nursing notes that those orders had been obtained but they were never carried out and the CBC/CMP was not done. On [DATE] at 10 am, a student nurse documented in the nursing progress notes, that Resident 4's skin was "jaundice (yellow-can occur from the toxins that bacteria produce) appearing in color" and had "white sediment (WBCs)" in her urine collection bag. There was no evidence that Resident 4's physician was notified of her urinary status, but was notified by fax (no time) on [DATE], that Resident 4 had diarrhea. There was no nursing assessment, documentation, intervention, monitoring, or evaluation for that problem and despite Resident 4's symptoms, it continued to go unrecognized that the UA with a C&S (ordered over two months ago) and the CBC/CMP blood work tests (ordered nearly two weeks ago), were still not done. On [DATE], Resident 4's physician responded back by fax and ordered that a stool sample be tested for C&S,WBCs, and [MEDICATION NAME] pathogens (intestinal bacteria), LN F signed "done" on the fax (no date). The order for the C&S, WBCs, and [MEDICATION NAME] pathogens was entered on Resident 4's Treatment Administration Record (TAR), but dated [DATE], and never signed off as "done." There was no evidence that the test had been done. On [DATE], Physician A saw Resident 4 and documented in his History and Physical (H&P), "we will get stool studies," but failed to recognize that the stool should have already been sent for testing when the PMD ordered it on [DATE]. Physician A had not addressed that the UA C&S, which should have been done over two months ago, and the CBC/CMP, which should have been done nearly two weeks ago, were still not available (laboratory results are a vital piece of information when diagnosing problems). There was no evidence in Resident 4's physician orders, medication and treatment sheets, or nursing notes from the day of admission on [DATE], to the day of discharge to the hospital on [DATE], that she had received any antibiotic treatment for [REDACTED]. On [DATE] at 6:05 pm, LN G documented in the nursing notes that an "ambulance was contacted" and Resident 4 was sent to the local emergency room (ER). The nursing notes contained no detailed description or assessment of Resident 4's condition prior to the unplanned hospital transfer. LN G documented on the "Emergency Transfer Communication" form the reason Resident 4 had to be transferred was because, "Went into Res room at 1800 (6 pm) Res laying in bed ARP (Responsible party) requested mother go to the Hospital for evaluation. Took vitals Res responsive called (name of hospital)." Resident 4's blood pressure was ,[DATE] at the time of transfer (normal is ,[DATE]). On the "Change in Condition Assessment" form at 6:22 pm, (20 minutes later) LN G documented that Resident 4 was now "lethargic (not responsive)" and that Resident 4 had stated something was wrong with her, but that "she (Resident 4)" did not know what. The Change in Condition form specified that the nurse was to "Check resident lab and diagnostic testing...Describe any abnormal values." LN G wrote a zero (0) with a line (/) through it and failed to recognize that Resident 4 still had an untreated UTI, and a CBC/CMP and stool test for C&S, WBCs, and [MEDICATION NAME] pathogens that were still not done. The local ER (Hospital A) collected a urine specimen less than two hours later, which revealed 3+ blood, 2+ bacteria, bilirubin 1+ (causes jaundice and skin to yellow), and more than 60,000 WBCs. The local hospital (Hospital A) was not able to manage Resident 4's serious condition and she was transferred from there to the major medical center (Hospital B) 90 miles away for a higher level of care, where she died three days later. The physician's Discharge Summary from Hospital B, dated [DATE], listed the cause of death as, "Septic shock due to a urinary tract infection, C.diff (an intestinal bacteria), [MEDICAL CONDITION] (an abnormal heartbeat), leukocytosis (abnormal amounts of leukocytes in the bloodstream-normally found in severe infections such [MEDICAL CONDITION]), metabolic acidosis (occurs with severe dehydration and kidney failure), altered mental status, and acute (sudden onset)kidney failure." On [DATE] at 1:30 pm, an interview and concurrent record review was conducted with the Laboratory Manager (LM). The LM confirmed that three urine specimens for Resident 4 had been incorrectly submitted to the lab and the facility was notified each time. LM stated that the first specimen was not correctly labeled and was not processed and LN D was notified. The second urine specimen was contaminated as evidenced by "numerous bacteria that don't live in humans" and explained that the bacteria found in Resident 4's urine either came from dirty hands, counter tops or other surfaces such as floors, walls, or door knobs. The LM stated that the third specimen submitted was contaminated because it was put in a cup instead of the "specimen tubes with preservatives," that the lab provided to the facility. The LM confirmed that Resident 4 had a UTI and stated that the C&S portion of Resident 4's UA's had not been done because, "there were too many bacteria to isolate the one that was causing her infection, we needed a clean specimen." The LM stated that after the third specimen, "no more urine specimens were submitted" for testing. The LM confirmed that the lab never received a blood sample from Resident 4, to complete a CBC/CMP or a stool specimen to test for C&S, [MEDICATION NAME] pathogens, or WBCs. On [DATE] at 1:45 pm, Resident 4's PMD physician was interviewed. The PMD stated that he was not able to recall the circumstances of Resident 4's laboratory testing and was not aware that he had not received the results from those tests that he had ordered. On [DATE] at 2:40 pm and 6:15 pm, concurrent record reviews and interviews were conducted with LNs A, C, D, E, and F (LNs B and G no longer work at the facility). LNs A, C, D, and F, confirmed that they were all involved in Resident 4's care. All of the LNs stated that they were not aware that none of the physician ordered lab had been completed for Resident 4 or that a UTI had been left untreated for [REDACTED]. Resident 4's TAR on [DATE], only one nurse signed that the UA was done on [DATE]. LN A stated that resident lab results were received on a fax which nursing staff have no access to on weekends and holidays, because the office is locked, and stated that nursing never received Resident 4's UA results. LN A confirmed that the LN staff had not followed through and ensured that Resident 4's UA's were collected and reported or that she received treatment for [REDACTED]. LN D confirmed that she had faxed the CBC/CMP request to Resident 4's physician and stated, "I take care of all the Dietitians requests." LN D confirmed that when the order came back signed by the PMD, a nurse had not noted the order and could not explain how the order ended up in Resident 4's record when it had not been noted by a nurse. LN D stated, "our fax room is messy and unorganized and faxes are misplaced all the time." LNs A, C, D, E, and F, all stated that they had no lab policy and procedure to follow and no system for tracking which lab was collected or reported to the physicians. LNs A, C, D, E, and F all stated that nurses were to communicate in writing to the next shift any resident changes or new orders on the "24 hour log" (a log book that sits on the nurses desk), but LN A stated, "we don't all use it." LNs A, C, D, E, and F stated that they knew the way they collected and received resident lab reports, "was not working" and asked their Director of Nurses for help, but no new systems were developed. 2. Resident 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], reflected that Resident 5's cognition was intact and he was usually continent of his bladder. Resident 5's record was reviewed. On [DATE] at 6:35 am, a nursing student documented in the Nursing progress notes that Resident 5 had a fever of 100.3 degrees Fahrenheit (F) and, "nurse aware." There was no evidence of nursing assessment, monitoring, evaluation or intervention related to Resident 5's fever over the next 72 hours. There was no evidence that discussions regarding Resident 5's change in condition had been conducted with his physician and Resident 5's fever was left untreated. On [DATE] at 7:30 pm, LN H documented that Resident 5 had a fever of 102.3F, and chills, and was transferred to the ER. LN H completed an "Emergency Transfer Communication" form at 8 pm, and left the "reason for transfer" section blank. LN H documented on the form that Resident 5 had a fever "this morning at 6 am of 101.1" and that she had given him "Tylenol" and now his fever was "102.3." There was no evidence that Resident 5's physician had been notified and treatment sought for his fever which had been identified by LN H at 6 am. Less than two hours later in the ER, Resident 5's urine was tested and he had a UTI with more than 60,000 WBCs, 3+ blood, and 1+ bacteria. The ER physician documented in Resident 5's H&P, dated [DATE] at 10:22 pm, that Resident 5 was septic due to [MEDICAL CONDITION] (a kidney infection that developed from infected urine) and his temperature was 104.9F. Resident 5 returned to the facility on [DATE], on antibiotics for a UTI. On [DATE] at 11:45 am, LN F documented that Resident 5's physician had ordered a UA, to be done "tomorrow" and wrote the order on Resident 5' TAR. On [DATE], LN B circled her initials on the TAR and wrote "UA not obtained." On [DATE], four days later, a urine sample was collected (unknown by who) and submitted to the lab. On [DATE], the UA results revealed that Resident 5's urine was turbid (cloudy from bacteria), had a few bacteria, 3+ blood, and more than 60,000 WBCs. An antibiotic was ordered for Resident 5's UTI. Nursing notes over the next week documented that Resident 5 had no adverse reaction to the antibiotic therapy, but lacked a detailed description of his urine (i.e. color, clarity, odor, pain with urination) and assessment and evaluation of the effectiveness of the antibiotic treatment. On [DATE], LN A took an order for [REDACTED]. On [DATE], Resident 5 had completed the antibiotic therapy and LN A documented (no time) that Resident 5, "continues to complain of not feeling well" but had not described his symptoms or notified his physician and the UA was not done. There was no nursing assessment, intervention, or documentation over the next 72 hours related to how Resident 5 was feeling. On [DATE], three days after ordered, the urine sample was collected and sent to the lab. On [DATE] at 4 pm, LN F documented that she had obtained an order from Resident 5's physician to send him to the hospital for "evaluation and treatment" because he was "shaking." There was no description of Resident 5's condition prior to the unplanned hospital transfer and the UA results that should have been readily available, were still pending. There was no explanation of what was to be "evaluated" or what "treatment" Resident 5 needed at the hospital. On [DATE] at 6:43 pm, just over two hours later, the ER physician documented in an H&P that Resident 5's urine "appears grossly very dirty" and "The patient is very toxic... barely opening his eyes...appears very septic" and the [DIAGNOSES REDACTED]. On [DATE] at 2:40 pm and 6:15 pm, LNs A, C, D, E, and F were interviewed. LN A stated that she had not recalled that the student nurse reported Resident 5's change in condition to her. LN A stated, "we had problems with student nurses documenting things in the residents records without informing us" and stated that she had brought that to the DON's attention and he stated to her, "Oh well." LNs A and E stated that part of the problem with collecting specimens late was that nursing staff were not utilizing the 24 hour shift communication log and "we had no tracking system or policy and procedure for lab" and stated they had no way to know when or what lab was due, sent out, or expected back. LN A, C, D, E, and F confirmed that a "Change in Condition Assessment" should have been started on Resident 5 on [DATE], when he had a fever and on [DATE], when he complained of still not feeling well, despite being on antibiotics. None of the LNs were able to explain why there was no assessment and documentation on Resident 5, three days prior to both hospital transfers [MEDICAL CONDITION]. The facility's policy titled, "Change of Condition Management Guideline" dated [DATE], was reviewed. The procedure section directed the following: "Document change of condition assessment reporting, and interventions in nursing notes." "License Nurse reports at change of shift." "License Nurse will place resident on alert charting." "License Nurse will document resident response and progress to treatment interventions every shift until stabilized." "Attachment A" listed the following as resident changes in condition: "Abnormal lab & X-Ray" According to the "American Medical Directors Association (AMA)" Clinical Practice Guidelines for "Acute Change of Condition (ACOC) in the Long-Term Care Setting", Copyright 2003; "hospitalization of long term-care patients should be avoided for many reasons. Transfer to the ER or hospital is costly; is disruptive for patients; and can expose patients to many risks...Timely evaluation and intervention is necessary to address ACOCs effectively in the long-term care setting." The following guidelines are considered professional "standards of care;" Page 22: "A nurse should evaluate the patient with an ACOC at least once during every shift while the patient is unstable or significantly symptomatic and should document relevant findings in the patient's record. Nurses and other appropriate staff should provide practitioners with enough detailed information to allow them to determine the patient's progress and identify possible complications. At least one meaningful communication (by phone or fax) should occur between the nurse and the practitioner within 24 hours of the onset of ACOC or of identification of the fact that the patient's condition is not stable or improving as anticipated." Page 23. "Staff nurse: Recognize condition change early. Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms. Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame. Report patient's status to the practitioner as appropriate." 3. Resident 6's record was reviewed. Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE], a physician ordered stool specimen was collected and submitted to the lab. On [DATE], the lab reported to the facility that Resident 6 had C.diff. On [DATE], two days later, the facility faxed the lab report to Resident 6's physician and documented, "waiting for response." There was no documented evidence that nursing staff followed up on the fax or communicated with the physician. Resident 6 was not placed in contact isolation and assessment and care planning was not done. On [DATE], four days after the identification of the infection, Resident 6's physician ordered treatment, and Resident 6 was placed on contact isolation precautions. A review of the facility's policy titled, "Isolation Precautions" revised ,[DATE], was conducted. The policy directed the following: "1. In addition to standard precautions, use contact precautions for specified residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment." On [DATE] at 9 am, an interview and concurrent record review was conducted with the Administrator (Admin). The Admin was unable to provide a dedicated policy and procedure for lab management. The Admin stated that there had been a lack of oversight regarding the management of resident laboratory specimens and that no tracking system had been in place. The Admin confirmed that Residents 4, 5, and 6 had not received lab services according to professional standards of practice or as their physicians had ordered, which adversely affected their health and well-being. The Admin confirmed that nursing assessment, documentation, intervention, monitoring, and physician notification regarding resident changes in condition was not followed per policy. On [DATE] at 2:40 pm and 6:15 pm, during interviews, LNs A, C, D, E, and F stated that all laboratory results had been faxed to a locked office in a building outside of the main facility, which the nursing staff had no access to. LN D stated that if a resident's lab results were faxed back during a weekend or holiday, "we had to wait until Monday" to see the results and notify the physicians. LN F stated that she should have initiated change of condition charting and care planning on Resident 6, when the C.diff testing was ordered, instead of five days later when treatment was obtained. LNs A, C, D, E, and F stated that all faxes to physicians require a phone call to ensure the physician received the fax, by the end of the shift, if the physician had not responded and confirmed that was not done for Resident 6.

Based on observation, interview, and record review, the facility failed to ensure an environment that was free from accident hazards and that provided adequate supervision to prevent accidents for two residents (Residents 1 and 2) by failing to: 1. Provide adequate supervision of Resident 2 when she wandered into a therapy gym and had an unwitnessed, avoidable fall and was injured, then had a second unwitnessed, avoidable fall related to the same deficient practice; and Provide an environment that was free from accident hazards, when the therapy gym was left unlocked and Resident 2 was injured on a piece of equipment which lacerated her head and nose and abraised her wrist and; Have an effective system that ensured alarm devices were regularly checked for proper functioning, when Resident 2 sustained two avoidable falls eight days apart, and her wheelchair alarm was not operational, both times. These failures resulted in injuries to Resident 2 (the top right side of her head and the bridge of her nose lacerated and a skin tear to her right elbow). Resident 2 was sent to the emergency room where 11 staples were required to close the laceration on her head. 2. Provide adequate supervision and assistance, ensure that a call light was within reach, and that a pressure sensitive mat alarm was in place to prevent a fall with injury for Resident 1 that resulted in severe left hip and back pain, and transfer to a hospital where she was diagnosed with [REDACTED]. Findings: 1. Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS, an assessment tool), dated 6/25/13, reflected that Resident 2 had severely impaired cognitive skills and required moderate assistance of one person to transfer and ambulate. On 7/30/13 at 12:05 pm, Resident 2 was observed in her wheelchair wearing a self releasing seat belt (SRSB) which was connected to an alarm on the back of her chair. A CNA (Certified Nursing Assistant) demonstrated that when the seat belt was unbuckled the alarm sounded. Resident 2's record was reviewed. A "Change in Condition Assessment," dated 7/19/13 at 3 pm, revealed that Resident 2 had been found on the floor in the facility's therapy gym with the top right side of her head and the bridge of her nose lacerated and a skin tear to her right elbow. Resident 2 was then sent to the emergency room and 11 staples were required to close the laceration on her head. The Interdisciplinary Team Notes (IDT), dated 7/22/13, documented that on 7/19/13, when Resident 2 was alone in the therapy gym and the door was closed, she unbuckled her SRSB, but the "alarm wasn't going off." The IDT recommended that the "staff" monitor the light on the alarm to ensure that is was on and to keep the therapy gym door locked. A "Change in Condition Assessment," dated 7/27/13 at 5 pm, revealed that eight days later, Resident 2 again unbuckled her SRSB, and was found uninjured on the floor in a resident's room and the "alarm was not on." On 7/30/13 at 1:30 pm, an interview was conducted with the Administrator (Admin). The Admin stated the therapy gym was to be locked at all times when staff was not present and confirmed that on 7/19/13, staff had not followed that procedure and "had left the therapy door unlocked." The Admin stated staff had not adequately supervised Resident 2's whereabouts on 7/19/13, when she was found behind a closed door lying on the therapy gym floor bleeding, and again on 7/27/13, when she was found on the floor in a resident's room. The Admin stated staff that were responsible for the monitoring of alarm devices, had not been clearly assigned. The Admin stated both of Resident 2's falls and injury had been directly related to the SRSB alarm not properly functioning, and could have been avoided. 2. Resident 1's record was reviewed and admission documentation indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk evaluation, dated 9/9/12, identified that Resident 9 was a high risk for falls. A fall risk care plan, initiated on 9/9/12, included a goal that Resident 9 would have no falls with injury. The care planned interventions included quarterly, or as needed, fall risk assessments, a fall mat beside the bed, a mat alarm at bed side, to keep the bed in a low position, and keep the electrical bed controls out of reach of the resident. A self-care activities of daily living (ADL) care plan, dated 9/6/12, included an intervention to, "Have call light available and answer promptly." Resident 9's Minimum Data Set (MDS - an assessment tool), dated 9/13/12, identified Resident 9 had both short and long term memory problems and that she was dependant on staff for her toileting needs. The facility had Resident 1 on a toileting program that included night time awakenings several times through the night to assist her to the bathroom. A Change of Condition (COC) note, completed 4/12/13 at 8:30 am, read Resident 1 had a fall, complained of pain in her left hip and back with an intensity of 10/10 (On a scale of 1 to 10, 10 being highest level of pain, severe). The fall risk factors identified on the COC included history of fall, poor safety judgement, cardiac medications, requires assist for toileting and unsteady gait. The additional comments of the COC read, "found on floor next to her bed on left side complained of 10/10 left hip and back pain, stated she thinks her back bone is broke..." Resident 1 was transferred to an acute care facility and determined to have sustained two rib fractures. Resident 1 was interviewed, on 4/24/13 at 11:06 am, and stated, "I do not remember a fall out of my bed, I don't know what I was doing." Resident 1 was observed moving restlessly in her wheelchair and stated, "I want out of here." On 4/24/13 at 11:37 am, Licensed Nurse (LN) C stated she was on duty the day Resident 1 had fallen and was sent to the hospital. LN C stated she responded to the incident when called by a Certified Nursing Assistant (CNA). Resident 1's roommate (Resident 13) had come out to the hall to get a staff person to help. LN C stated she had never seen Resident 1 use her call bell, but the call bell was on when she responded. LN C stated Resident 13 witnessed the fall and told LN C that Resident 1 had to go to the bathroom, got up, tried to grab hold of a privacy curtain and fell into a bedside cabinet that belonged to another roommate. LN C stated Resident 1 did not have a pressure sensitive mat alarm beside her bed at the time, per the care plan. On 4/24/13 at 3:20 pm, Resident 13 stated, as she pointed to her wall calendar next to her bed, that on 4/12/13, Resident 1 woke up early, sometime around 6 am, and stated, "I want to go to the bathroom." Resident 13 stated she was encouraging Resident 1 to use her call bell but that Resident 1 said she could not find it. Resident 13 reported Resident 1's bed was left in a high position and the call bell was dangling down from a side rail out of the reach of Resident 1 (the facility investigation also noted that Resident 1's bed was in the high position). Resident 13 stated she handed Resident 1 the call light and assisted in ringing the bell. Resident 13 stated the call light seemed to be going for a while (about 20 minutes) before Resident 1 got up without assistance and fell . Resident 13 reported she covered Resident 1 with a robe and then needed to leave the room after Resident 1 fell to get staff to help. Resident 13 stated she walked to the nearby Nurse's Station One and four nurses were seated there.

Based on observation, interview, and record review, the facility failed to ensure that sexual abuse was reported and thoroughly investigated, and to ensure an effective system to prevent further abuse, in accordance with State and Federal law and facility policy for one of four sampled residents (Resident 1) when the facility's administrative and licensed/certified staff had knowledge of but failed to report two incidents of abuse, in accordance with State and Federal law and facility policy. Resident 1 was sexually abused by Resident 2 on two separate occasions. Resident 1 expressed ongoing fear and distress as a result of being the victim of two episodes of sexual abuse by Resident 2 on 6/29/13 and 7/1/13, and expressed being afraid that the abuse would happen again. Female residents were at current threat for abuse by Resident 2. These failures placed Resident 1 and female residents in immediate jeopardy for abuse by Resident 2. Due to the facility's failure to take action, report, and thoroughly investigate Resident 1's allegations of sexual abuse, to ensure that Resident 1 was not sexually abused and that all female residents were free from the threat of potential abuse, an Immediate Jeopardy situation was declared by the Department (CDPH). Refer to F223 and F226 for additional information. Findings: On 7/24/13, the CDPH investigated an anonymous complaint alleging that Resident 1 had been sexually assaulted by Resident 2, and the facility had not reported the incident, as required by State and Federal law and facility policy. The facility's "Abuse Reporting" policy, revised 10/1/02, required facility staff to abide by local, State, and Federal laws and regulations. All reports of alleged/suspected abuse are to be reported. The facility Administrator is responsible for timely completion and submission of these reports, which are to be reported to the Department of Health. A telephone report is to be made within 24 hours and a written report shall be prepared and sent within 5 working days. The facility's "Abuse Prevention" policy, revised 10/1/02, required the facility to protect its residents from abuse and prevent mistreatment, neglect and abuse of residents and assigned the Administrator as the person responsible for overseeing the policy implementation. Item 4, Reporting requirements included: "a. All facility staff and employees are considered mandated reporters... These individuals are required to report suspected or alleged incidents of abuse and neglect immediately to the appropriate supervisor. The facility administrator serving as the facility abuse prevention coordinator must be immediately notified of the alleged or suspected abuse." Item 5, Identification/Monitoring requirements included: a. Criteria have been established to help identify potential signs of abuse, refer to Abuse Investigation policy, Attachment 2." and "Refer to Abuse Investigation policy for procedures regarding protecting and care of resident." Resident 1's record was reviewed on 7/24/13. Resident 1, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In separate interviews on 7/24/13, at 2:15 pm and 4:45 pm, Resident 1 stated that several weeks ago, while she was in her room alone, Resident 2 entered her room, without permission, had touched her on her right breast, with his whole hand for about 5 seconds, and told her to get on her bed so he could f**k her. She stated that she yelled for help. Resident 1 stated that she continues to have fear of Resident 2. She stated that Resident 2 slaps nurses on the butt and has scary eyes. She stated that she was relocated to a different room at the opposite end of the facility from Resident 2 after the incident in her room. In an interview on 7/25/13 at 11 am, Resident 1 stated that Resident 2 had touched her breast outside the dining room, prior to what had happened in her room. Resident 2's record was reviewed. A licensed nurse's progress note, dated 6/7/13, read that Resident 2 had grabbed the nurse's breast and butt when she attempted to reposition him in his chair. When the nurse informed Resident 2 that he was being inappropriate, Resident 2 laughed and made a comment about the nurses "nice boobs." The note further documented that Resident 2 then took off his gown and said "suck it." A licensed nurse's progress note, dated 6/29/13 and timed 9 pm, documented that Resident 2 "has had numerous episodes of inappropriate sexually based comments toward staff and other residents, numerous episodes of inappropriate touching of female resident, touched another resident's breast, multiple episodes of touching of female staff. Multiple attempts made to redirect resident were unsuccessful." During an interview conducted on 7/24/13 at 6 pm, Licensed Nurse (LN) A stated that she was the charge nurse on duty on 6/29/13 when Resident 1 reported that she was touched on her breast by Resident 2, near the exit to the social dining room during a dinner meal. LN A stated that she was in the social dining room with her back to the two residents when it occurred, but that one of her Certified Nursing Assistants (CNA's) on duty did report that she witnessed the event and told her that it had occurred. LN A stated that Resident 1 said Resident 2 "touched my boob." LN A stated that on 6/29/13, she contacted the Director of Nursing (DON) and the physician about the event. She stated that she was instructed by the DON not to do an incident report on the event, but had completed one anyway for each resident and placed them in the Social Service Director's (SSD) box, and kept personal notes of the event. LN A stated that the facility SSD called her back that evening. LN A stated that she did not document the details (do a change of condition form) of the incident in the medical records of Residents 1 or 2, did not initiate new care plans, and did not make any other notifications of the incident on 6/29/13. Resident 1's record contained a Social Work Progress Note, dated 7/1/13, that documented that Resident 1 reported sexual abuse by Resident 2. There were no Nursing Progress Notes and no Change of Condition forms found in Resident 1's record to document the two incidents of abuse that occurred on 6/29/13 or 7/1/13. There was no documentation of an investigation of the incident. On 7/25/13 at 3:45 pm, SSD confirmed that she was not able to find the documentation in Resident 1's record. From 6/29/13, administrative and licensed/certified staff were aware that Resident 1 reported sexual abuse by Resident 2 on two separate occasions (6/29/13 and 7/1/13). These staff did not report or investigate the abuse, in accordance with facility policies and State/Federal law and regulations. On 7/24/13 at 3:45 pm, the facility abuse coordinator/Administrator (Admin) and SSD were interviewed. SSD stated that both Resident 1 and 2 should have had a Change of Condition form initiated/completed by nursing staff which should have been placed in the Residents' records for each of the incidents of abuse, further stating that it was not done. Admin stated, "Something happened, I don't recall, we talked about it as a team and decided not to report, as we did not feel there was harm." Admin was unable to provide evidence of an investigation of the two incidents. She stated that she had thought that her DON had taken care of everything. On 7/24/13 at 5:30 pm, the Interim DON (who started after the incidents of abuse had occurred) stated that she called the facility's DON, who was currently on leave. The Interim DON stated that the facility's DON stated that he had not done investigations of the two incidents. She stated that she was unable to find any evidence that the abuse allegations had been reported and investigated. On 7/25/13 at 10:15 am, the Administrator was notified that an Immediate Jeopardy (IJ) situation existed due to the facility's failure to take immediate action, report and thoroughly investigate Resident 1's allegations of sexual abuse to ensure that Resident 1 was not sexually abused, and that all female residents were free from the threat of potential abuse, and failure to implement an effective abuse prevention program including failure to identify, investigate, intervene to prevent, and report abuse, in accordance with State and Federal law and facility policy. On 7/25/13 at 2:07 pm, the immediate jeopardy was abated when the facility Administrator provided an acceptable plan of action that would prohibit Resident 2 from abusing Resident 1 and other female residents in the building and reeducate staff (including administrative staff) on the facility policy to identify, protect, document, and report abuse.

Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was free from actual abuse and the threat of further abuse, and that all female residents were protected from the potential threat of abuse when: Resident 1 was sexually abused by Resident 2 on two separate occasions. The facility did not identify Resident 2's actions as abuse and failed to take actions to protect Resident 1 and all female residents from further potential abuse by Resident 2. Resident 1 expressed ongoing fear and distress as a result of being the victim of two episodes of sexual abuse by Resident 2 on 6/29/13 and 7/1/13, and expressed being frightened that the abuse would happen again. Due to the facility's failure to take action to ensure that Resident 1 was not sexually abused and that all female residents were free from the threat of potential abuse, and failure to identify, intervene to prevent, investigate, and report abuse, an Immediate Jeopardy situation was declared by the Department (CDPH). Refer to F225 and F226 for additional information. Findings: On 7/24/13, the CDPH investigated an anonymous complaint alleging that Resident 1 had been sexually assaulted by Resident 2, and the facility had not reported the incident, as required by State and Federal law and facility policy. Resident 1's record was reviewed on 7/24/13. Resident 1, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS- a resident assessment) for Resident 1, dated 7/18/13, identified that Resident 1 needed extensive assistance with dressing, personal hygiene, and bathing, used a wheelchair and was able to move about the facility independently, and was able to transfer from her wheelchair with limited assistance. The facility's Brief Inventory of Mental Status (BIMS) for Resident 1, MDS assessments for measuring a resident's cognitive abilities (orientation, ability to make decisions and recall information), dated 4/18/13 and 7/18/13, gave Resident 1 a score of 15 out of 15, indicating her memory recall was intact. Review of a Depression care plan revealed that, on 7/1/13, the facility documented that Resident 1 had a new problem; "is very upset crying due to incident with male resident." The interventions included that the Social Services Director (SSD) was to monitor Resident 1 for emotional changes and all staff were to ensure that Resident 1 was not around other male residents. Review of a Social Work Progress note, dated 7/1/13, indicated that Resident 1 reported to the SSD that a male resident said inappropriate sexual things to her, but did not touch her. No details of the content of what was said or where the event occurred were documented by SSD. On 7/4/13, the SSD documented, "Nursing staff came to me stated that resident was upset, and was crying in hallway last night...male resident saying to her to lay on bed, I want to f**k you (expletive for intercourse). And she was upset about this." These incidents were not reported to the CDPH. The next documented by the SSD was dated 7/16/13, indicating that that Resident 1 had asked to move to another care facility. On 7/24/13 at 2:10 pm, the SSD was interviewed. SSD stated that Resident 1 had reported to her on 7/1/13 that Resident 2 "had gone into her room and told her to get on the bed so he could f**k her." SSD stated that she did not report this incident to CDPH because it was a sexual comment and did not see the harm. When asked if it was verbally abusive, SSD replied, "Yes." No nursing progress note or Change of Condition form were found in Resident 1's record to document what had happened to her on 6/29/13 or 7/1/13. Resident 1's record contained a licensed nurse's progress note, dated 7/4/13 and timed 6:30 am, that read, "late entry: last night (7/3/13) at approximately 8:30 pm, I saw resident sitting in hallway crying. When asked what was wrong, she said, "I don't feel safe." I asked her why and she said, "because of what happened." I asked what happened. She said, "(name of Resident 2) grabbed me." The nurse further documented that Resident 1 said that Resident 2 placed Resident 1's hand on her right breast and Resident 1 then called Resident 2 a "pervert!" Resident 2 told Resident 1 to "lay on the bed so I can f**k you." The nurse documented that she "texted" the Director of Nursing (DON) who said they were aware of what had happened (to Resident 1) and he would talk to social services. In separate interviews on 7/24/13, at 2:15 pm and 4:45 pm, Resident 1 stated that several weeks ago, while she was in her room alone, Resident 2 entered her room, without permission, had touched her on her right breast, with his whole hand for about 5 seconds, and told her to get on her bed so he could f**k her. She stated that she yelled for help. Resident 1 stated that she continues to have fear of Resident 2. She stated that Resident 2 slaps nurses on the butt and has scary eyes. She stated that she was relocated to a different room at the opposite end of the facility from Resident 2 after the incident in her room. In an interview on 7/25/13 at 11 am, Resident 1 stated that Resident 2 had touched her breast outside the dining room, prior to what had happened in her room. On 7/24/13 at 3:45 pm, the facility abuse coordinator, the Administrator (Admin), and the SSD were interviewed and asked about what had happened to Resident 1. SSD stated, "Nurses told me about it (Resident 1 being touched on the breast) on Monday" and "DON told me about it and said he (DON) had talked with her (Resident 1)." SSD stated that nursing both Residents 1 and 2 should have had a Change of Condition form initiated/completed by nursing staff in the record for the allegations of abuse. Admin stated, "Something happened, I don't recall, we talked about it as a team and decided not to report, as we did not feel there was harm." Admin further stated that she had thought that her DON had taken care of everything. SSD added, "She (Resident 1) told me she felt dirty," as a result of Resident 2's abuse. Admin was unable to provide evidence of an investigation for the two incidents of abuse toward Resident 1. On 7/24/13 at 5:30 pm, the Interim DON, who started work at the facility after the two incidents of abuse had occurred, stated that she called the facility's DON, who was on leave at the time, and he (the DON) stated that he had not done investigations of the two incidents. The Interim DON stated that she was unable to find any evidence that the abuse allegations had been reported or investigated. On 7/24/13 at 6 pm, Licensed Nurse (LN) A stated that she was the charge nurse on duty 6/29/13 when Resident 1 was touched on her breast by Resident 2, near the exit to the social dining room during a dinner meal. LN A stated that she was in the social dining room with her back to the two residents when it occurred, but that one of her Certified Nursing Assistants (CNA's) on duty did report that she witnessed the event and told her that it had occurred. LN A stated that Resident 1 said Resident 2 "touched my boob." LN A stated that on 6/29/13, she called the DON and the physician about the event. She stated that she was instructed by the DON not to complete an incident report on the event, but did one anyway for both Residents 1 and 2, placed them in the SSD's box, and kept personal notes of the event. LN A stated that the facility SSD called her that evening. She stated that she did not document the details (do a Change of Condition form) of the incident in the medical records of Resident 1 or 2, did not initiate new care plans, and did not make any other notifications of the incident that occurred on 6/29/13. At the time of the 6/29/13 incident, Resident 1's and Resident 2's bedrooms were in close proximity. The SSD did not address the first incident of sexual abuse (touching her breast) with Resident 1 until 7/1/13, the same day the second incident had occurred in her bedroom. The DON, Admin, SSD, and Activities Director (AD), who were members of the Interdisciplinary Team (IDT), documented in Resident 1's IDT notes, dated 7/1/13, "Resident flirts with male residents, holds their hands and places their hands on her thighs, then complains about the male residents being too friendly. Resident talked about her consequences of encouraging males." No details of the two incidents of sexual abuse were found in Resident 1's IDT notes that were signed on 7/1/13 by the Admin, DON, SSD, and AD. No further IDT notes were written to show that the IDT had acted appropriately to protect Resident 1 and other females from abuse, or about Resident 1's room change or her crying in the hall on 7/3/13. The facility was unable to provide evidence of reporting and investigation of these two allegations of abuse. No Change of Condition forms or investigations were documented in the record for Residents 1 or 2, for either incident. No room change was made until after the second abuse that occurred in Resident 1's room, toward Resident 1 by Resident 2 on 7/1/13 (two days later). On 7/25/13 at 8 am, Maintenance Director (MD) stated that he had intervened when Resident 2 had entered Resident 1's room when he heard her screaming for help, several weeks ago between breakfast and lunch. He stated that Resident 1 was upset and that Resident 2 was within reaching distance, about an inch away from Resident 1, when he was removed from the room. MD stated that he was told by Resident 1 that Resident 2 had told her to get on her bed so that he could have sex with her. MD stated that he had told the facility Admin of the event, and that the SSD was present at the time of the intervention and talked further with Resident 1. MD stated that the DON was on duty and aware of the incident. MD stated "I considered it abuse." The MD did not report the abuse to any outside agency, as per State and Federal law and facility policy. Resident 2's record was reviewed 7/24/13. Resident 2, an [AGE] year old male, was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's MDS , dated 6/13/13, identified that he had physical behavior symptoms directed toward others four to six days out of the seven day assessment period. Resident 2's BIMS score was six out of 15 possible, indicating severe cognitive impairment. Resident 2 had an extensive history of sexually inappropriate statements toward female staff, as well as, inappropriate touching of female staff. A licensed nurse's progress note, dated 6/7/13, read that Resident 2 had grabbed the nurse's breast and butt when she attempted to reposition him in his chair. When the nurse informed Resident 2 that he was being inappropriate, Resident 2 laughed and made a comment about the nurses "nice boobs." The note further documented that Resident 2 then took off his gown and said "suck it." A licensed nurse's progress note, dated 6/29/13 and timed 9 pm, documented that Resident 2 "has had numerous episodes of inappropriate sexually based comments toward staff and other residents, numerous episodes of inappropriate touching of female resident, touched another resident's breast, multiple episodes of touching of female staff. Multiple attempts made to redirect resident were unsuccessful." A Social Service Progress Note, dated 7/1/13, documented that Resident 2 was having increased behaviors, making inappropriate sexual remarks, and trying to touch staff and residents. Another Social Service Progress Note, dated 7/4/13, documented that Resident 2 had grabbed the SSD on her breast and was asked to stop. When SSD explained that it was inappropriate Resident 2 "just laughed." Resident 2 had a care plan, dated 3/13/13, for inappropriate sexual behavior toward females ("...looking down their shirts, try's to kiss them if they are close..."). The behavioral care plan identified Resident 2 "has been getting inappropriate with a female resident also, wanting to touch and kiss." An intervention added on 4/15/13 included 15 minute checks would be made on Resident 2. Resident 2 was transferred to an acute senior psychiatric center for stabilization of behavior on 4/30/13, prior to readmit back to the facility on [DATE]. The behavioral care plan was not in the current active record. No documentation of 1 on 1 supervision or 15 minute checks, since return to the facility, were provided when requested. On 7/24/13 at 3:30 pm, SSD stated that Resident 2's behavioral care plan should have been in the active record and could not find any other plan for sexually inappropriate behavior interventions. She stated that staff should have made 15 minute checks "when he was having increased behaviors." On 7/25/13 at 8:15 am, Resident 2 was observed in the back hall near his room in his wheelchair. No staff were observed to be monitoring or supervising his actions. He was asked if he had touched a female resident in a sexual way and stated, "I do not touch anyone who does not want to be touched." Resident 2 stated that he did not remember anything about touching Resident 1 or being in her room. Resident 2 stated that "some of the female residents are so ugly it hurts to look at them, and others are so nice and pretty." Resident 2 stated that his occupation was "chasing women and making love." On 7/25/10 at 10:10 am, LN B stated that she did not have direct responsibility for supervision of Resident 2, but that she had redirected him on 7/24/13 from going into two different female rooms (Rooms four and five) that were located in the back hall near his room. The back hall where Resident 2's room and the female rooms were located was not in the line of sight of the nursing station. The facility's Admin, DON, SSD, AD, MD, and other licensed and certified staff were were aware of the two incidents of alleged sexual abuse of Resident 1 by Resident 2. The staff did not protect Resident 1, or adequately document, investigate, or report the abuse. There was no plan in place to protect female residents from the threat of abuse by Resident 2. On 7/25/13 at 10:15 am, the Administrator was notified that an Immediate Jeopardy situation existed due to the facility's failure to effectively address Resident 2's sexually aggressive behavior towards others and take immediate action to ensure that Resident 1 was not sexually abused, and that all female residents were free from the threat of potential abuse, and failure to implement an effective abuse prevention program including failure to identify, investigate, intervene to prevent, and report abuse, in accordance with State and Federal law and facility policy. On 7/25/13 at 2:07 pm, the Immediate Jeopardy was abated when the facility Administrator provided an acceptable plan of action that would prohibit Resident 2 from abusing Resident 1 and other female residents in the building and reeducate staff (including administrative staff) on the facility policy to identify, protect, document, and report abuse.

Based on observation, interview, and record review, the facility failed to ensure that its written Abuse Prevention, Abuse Reporting, and Abuse Investigation policies and procedures were implemented to prevent to incidents of sexual abuse from occurring to one of four sampled residents (Resident 1) and to protect Resident 1 and other female residents from the threat of potential sexual abuse by Resident 2. (Resident 1) was not protected from abuse when the facility did not follow their abuse policy to identify the abuse, document the abuse, protect the resident, investigate the abuse, and report the abuse. These failures resulted in the Resident 1 expressing ongoing fear and distress when she was the victim of two episodes of sexual abuse from Resident 2 on 6/29/13 and 7/1/13, and placed Resident 1 and other female residents in Immediate Jeopardy from abuse by Resident 2. Refer to F223 and F225 for additional information. Findings: The facility's "Abuse Prevention" policy, revised 10/1/02, required the facility to protect its residents from abuse and prevent mistreatment, neglect and abuse of residents and assigned the Administrator as the person responsible for overseeing the policy implementation. The policy stipulated, under "Reporting" requirements, that all facility staff and employees are considered mandated reporters. Employees, volunteers, and visitors are required to report suspected or alleged incidents of abuse and neglect immediately to the appropriate supervisor. The facility administrator serving as the facility abuse prevention coordinator must be immediately notified of the alleged or suspected abuse. The "Abuse Prevention" policy referred to another "Abuse Reporting" policy, revised 10/1/02, which required facility staff to abide by local, State, and Federal laws and regulations, that all reports of alleged/suspected abuse were to be reported, and that the facility Administrator was responsible for timely completion and submission of reports, which are to be reported to the Department of Health via a telephone report made within 24 hours and a written report sent within 5 working days. The "Abuse Prevention" policy stipulated, under "Identification/Monitoring" requirements, that Criteria have been established to help identify potential signs of abuse, refer to Abuse Investigation policy, referring to the "Abuse Investigation" policy for procedures regarding protecting and care of resident. The facility's "Abuse Investigation" policy, revised 10/1/02, required that that alleged acts of abuse are reported immediately to the administrator and investigated thoroughly. The policy included the following Care and Safety procedures: -In cases where possible abuse to a resident is observed or reported, the facility provides a safe environment for resident(s), as indicated by the situation. If the suspected perpetrator is another resident, separate residents so that they do not interact with each other until circumstances of the reported incident can be determined. -Notify administrator or his/her designee of the incident as soon as possible and no later than 24 hours after receipt of the reported incident. Notify social services designee and begin intervention, if indicated. -Initiate a physical and mental assessment of the resident and document only objective findings in the clinical record. -Initiate a care plan to reflect the resident's condition and measure(s) to be taken to prevent recurrence. -Complete Incident Report form (CVLf-14) detailing alleged incident and assessment of resident condition. The policy included the following Investigation procedures: -The abuse investigation is to be documented on the "Investigation of Alleged Abuse" form. -The administrator or designee initiates an investigation of the alleged and/or suspected abuse immediately and may include interviews with the involved residents or other parties who have knowledge of the incident which is documented on the "Interview Record" form. -Refer to Signs and Symptoms of Potential Abuse for possible signs of abuse. -The administrator or designee makes reasonable attempt to discover the cause of the injury and takes corrective action(s) during the duration of the investigation to provide the resident with a safe environment. -A copy of the "Investigation of Alleged Abuse" form is kept in the facility for one year. The policy included the following Reporting procedures: -When the investigation demonstrates "reasonable suspicion" that an abuse incident did occur, or meets the "Mandated Reporter" definition, the administrator notifies the local Ombudsman or law enforcement agency by phone within 24 hours and in writing within 2 working days, using the form "SOC 341." -The administrator informs the Department of Health Services by phone within 24 hours of the allegation of or suspected abuse and in writing within 5 working days. The policy included the following Corrective Action procedure: -If the investigation confirms the alleged incident, corrective action is taken immediately, under the supervision of the Administrator. On 6/29/13 and 7/1/13, Resident 1 reported to facility staff that she was sexually abused by Resident 2 and fearful of Resident 2. These incidents of abuse were witnessed by staff. The facility's administrative and licensed/certified staff failed to implement its Abuse Prevention, Reporting and Investigation policies to prevent abuse and further protect residents. The facility was unable to provide evidence of reporting or investigating these two allegations of abuse. The facility's Interdisciplinary Team (IDT) met on 7/1/13, however, failed to take immediate action (identify, document, report, investigate, and protect residents) to prevent further abuse. No details of the two incidents of physical and verbal sexual abuse were found in Resident 1's IDT notes which were signed on 7/1/13 by the Admin, DON, SSD, and AD. No further IDT notes were written about Resident 1's room change or about Resident 1's crying in the hall on 7/3/13. No Change of Condition forms were completed for Residents 1 and 2. No physical and mental assessment or care plan updates/interventions or room changes were made to separate Residents 1 and 2 until after the second incident of abuse had occurred in Resident 1's room, between Resident 1 and Resident 2 on 7/1/13 (two days later). On 7/24/13 at 3:45 pm, the facility's abuse coordinator, the Administrator (Admin) and SSD confirmed that they were aware of Resident 1's allegations of abuse by Resident 2, but failed to report and investigate the abuse, per facility policy and State and Federal law. SSD stated that each resident should have had a Change of Condition form initiated/completed by nursing staff, but did not. On 7/24/13 at 6 pm, Licensed Nurse (LN) A, the charge nurse on duty on 6/29/13 when Resident 1 reported the first incident of abuse by Resident 2, stated that, on 6/29/13, she was instructed by the DON not to do an incident report on the event (but had completed one anyway for each resident and placed them in the Social Service Director's (SSD) box, and kept personal notes of the event). LN A stated that the facility SSD called her back that evening, indicating that the SSD was made aware of the abuse allegation on 6/29/13. LN A confirmed that she did not document the details of the abuse allegation or complete a Change of Condition form and initiate new care plans for Residents 1 or 2, and she did not make any other notifications of the incident on 6/29/13. On 7/24/13 at 5:30 pm, the Interim DON (who started after the incidents of abuse) stated that she called the facility's DON, who was on leave, and he confirmed that he had not done investigations of the two incidents of abuse. The Interim DON confirmed that she was unable to find any evidence that the abuse allegations had been reported or investigated, in accordance with State and Federal law and facility policy. On 7/25/13 at 10:15 am, the Administrator was notified that an Immediate Jeopardy situation existed due to the facility's failure to implement its abuse prevention policies and procedures to take immediate action, report, thoroughly investigate, and to protect residents from and to prevent abuse, to ensure that Resident 1 was not sexually abused, and that all female residents were free from the threat of potential abuse, and failure to implement an effective abuse prevention program including failure to identify, investigate, intervene to prevent, and report abuse, in accordance with State and Federal law and facility policy. On 7/25/13 at 2:07 pm, the Immediate Jeopardy was abated when the facility Administrator provided an acceptable plan of action that would prohibit Resident 2 from abusing Resident 1 and other female residents in the building and reeducate staff (including administrative staff) on the facility policy to identify, report, thoroughly investigate, and prevent abuse.

Based on observation, interview, and record review, the facility failed to ensure Activity Assistants (AA) were trained to connect the regulator (a device that regulates the amount of oxygen (O2) to be distributed) to be able to provide residents with proper care and treatment. This had the potential for residents to experience life threatening respiratory distress, while attending outside activities. Findings: On 6/18/13, the facility's Plan of Correction (POC) for F-328, dated 6/14/13, read, "...the facility inserviced all staff on the use of oxygen regulators on 11/12/12...To ensure the deficient practice does not recur, the facility will inservice all staff that of on outings and Licensed Nurses on the use of oxygen regulators at least quarterly." On 6/18/13, the facility's Inservice Meeting Minutes (training records), dated 5/7-12/13, were reviewed. The Topic was "set up and use of portable O2 tanks," and included, "The Brief Summary of Lecture" that read, "the steps to safely setting up a portable O2 tank, the importance of monitoring that the tank is full and working properly, and O2 regulator. F-328." AA F and AA G were listed and had signed that they had attended the inservice training. On 6/18/13 at 3 pm, AA F was asked to demonstrate how she would replace a resident's empty O2 tank attached to her wheelchair. AA F was observed as she grabbed an empty O2 tank as a replacement for the empty tank on the wheelchair. AA F was unable to distinguish the full O2 tanks from the empty O2 tanks. AA F was unable to close the empty tank and safely remove the regulator. At 3:05 pm (five minutes later), AA F was observed unable to correctly attach the regulator to a full tank. AA F stated she attended the training but did not independently demonstrate competence in changing O2 tanks and connecting the regulator. On 6/18/13 at 4:12 pm, AA G was asked to demonstrate the replacement of an empty O2 tank with a full tank and installation of the regulator onto the full tank. At 4:23 pm (eleven minutes later), AA G was unable to correctly attach the regulator to the full O2 tank. On 6/18/13 at 4:55 pm, the DSD confirmed that the facility's POC included training of all staff on the use and changing of O2 regulators and expected the staff to be competent. DSD confirmed that both AA F and AA G had demonstrated incompetence in changing the O2 regulators and had not been adequately trained. On 6/19/13 at 12:30 pm, the Administrator (ADM) was interviewed about the facility DSD's training methods and the lack of competence shown by staff following training. ADM stated that she had become aware that the DSD's and the facility's inservice trainings were not effective. ADM stated she had asked for and had received permission to hire a new DSD. ADM stated she had selected a new DSD to achieve effective, competent staff training.

Based on interview and record review, the facility failed to ensure Resident 3 received proper care and treatment when, during a field trip, Resident 3's oxygen tank ran low and the facility staff in attendance were unable to connect the regulator (a device that regulates the amount of oxygen delivered) to a new/full oxygen tank. Resident 3 experienced respiratory distress requiring emergency medical treatment from an ambulance crew and was transported to the hospital. Findings: Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 3's Minimum Data Set, (MDS - a resident assessment tool), dated 10/22/12, showed that she could make her needs known, that she was competent to make her own decisions, and as such, was her own responsible party. On 12/3/12 at 11:45 am, Resident 3 stated that in 10/2012, she and a group of about ten residents were taken on a field trip to the local casino for lunch and gambling. When it was time to go back to the facility, the transport van was summoned back to the facility. The van left with plans to return to the casino to transport the residents back to the facility. A few minutes after the van left, the Activities Director (AD) noticed that Resident 3's oxygen tank was running low of oxygen. The resident was receiving continuous oxygen at high rate of flow requiring frequent oxygen tank changes. A new tank was present, but none of the staff in the group knew how to attach the regulator onto the new oxygen tank. An off duty Licensed Vocational Nurse (LVN), who works at the facility, happened to be at the casino with her husband and assisted in putting the regulator on the new oxygen tank. Resident 3 stated that she told one of the staff that she did not feel well and the next thing she remembered was waking up in the ambulance. During an interview on 12/3/12 at 12:30 pm, AD stated that Resident 3 had just gotten over pneumonia and had taken her last antibiotic that morning. AD stated that Resident 3 had been hospitalized twice in 10/2012 with respiratory infections which were not uncommon for her, due to her [MEDICAL CONDITION]. AD stated that Resident 3 had severe respiratory disease and required the use of supplemental oxygen at 5-6 liters per minute, 24 hours a day. Due to the high flow rate, Resident 3 needed a new oxygen tank every few hours and used five to six tanks a day. AD stated that Resident 3 was one of 10 residents who attended a casino outing on 10/9/12. When it was time to leave the casino, the transport van was unexpectedly summoned back to the facility, prior to the residents boarding. Just after the van left, AD noticed that Resident 3's oxygen tank was running low. A new tank was available, however, no one present knew how to put the regulator on the new tank. Resident 3 complained that she did not feel well and an ambulance was called. AD stated that Resident 3 began shaking like she was having a [MEDICAL CONDITION], then lost consciousness just as the ambulance arrived. The ambulance report, dated 10/9/12, showed the ambulance crew arrived at the scene at 1:33 pm, and found Resident 3 sitting in her wheelchair, her skin color was blue (indicating a lack of oxygen), her breathing with angonal (life threatening pattern), and she was unable to open her eyes or make sounds and movements. The ambulance crew initiated emergency respiratory resuscitation (the use of oxygen and breathing equipment) and at 1:50 pm, transported Resident 3 to the emergency department at the local hospital. Resident 3's condition was initially treated at the local hospital and from there she was flown to a regional hospital for ongoing care. On 12/3/12 at 3:30 pm, a phone interview was conducted with Licensed Vocational Nurse (LVN) A. LVN A stated that she and her husband were having lunch at the casino on her day off. She heard a commotion and realized it was people from the facility where she worked. She went over to them to see if she could help and saw staff fumbling with the regulator, trying to get it on a new oxygen tank. LVN A noticed Resident 3's lips were turning purple and she was starting to loose consciousness. LVN A stated that she was able to get the regulator on the new oxygen tank just as the ambulance arrived. On 12/3/12 at 4 pm, interviews were held with all of the staff who attended the residents at the casino. When asked if they knew how to change the regulator on the oxygen tank at the time of the casino incident on 10/9/12, the Administrator stated "No," the Activities Director stated "No," Activities Assistants D and E stated "No," the Janitor stated "No," and Social Services Director stated "No."

Based on interview and record review, the facility failed to ensure all residents' environment was safe, when the Wanderguard (device that sets off alarm when wandering residents attempt to exit the building) sensors on the doors were not checked on the weekends. This had the potential for the residents that wore the Wanderguard to exit the building unsupervised, get lost, and/or be injured without staff being aware. Findings: The facility's Plan of Correction (POC) for F 323, dated 6/14/13, included corrective actions that "Door alarms will be checked daily to ensure the alarms are in working order..." Inservice Meeting Minutes, dated 6/5-10/13, for the Topic of "Wander Guard door alarms" included "BRIEF SUMMARY OF LECTURE, door alarms will be checked daily by Licensed nurses to ensure the alarms are in working order..." On 6/18/13 at 2:03 pm, the Director of Staff Development (DSD) confirmed she did the Wander Guard door alarm inservice the previous week (6/9 to 6/15/13). She stated that "Originally the nurses were going to do it...that the maintenance supervisor (MS) has to do it anyway..." DSD could not confirm who was checking the door alarms. On 6/18/13 at 11:15 am, the Social Services Director (SSD) stated that the MS checked the door alarms. The Wander Guard Daily Check List for 6/13, was obtained from the Maintenance Department and concurrently reviewed with SSD . There were no entries for 6/8, 6/9, 6/15, and 6/16/13 (weekends, Saturdays and Sundays) and the SSD confirmed those days were not checked. SSD stated that the MS was gone on the weekends. On 6/18/13 at 3:30 pm, the MS confirmed that he did not check the door alarms on the weekends and stated that the nurses were to do it then. MS stated that the facility's administration had decided that the door alarm checks would be done by the nurses on the weekends. On 6/18/13 at 3:45 pm, Licensed Nurses' (LN) A and B were concurrently interviewed and confirmed they did not check the door alarms. LN B confirmed that she worked weekends. On 6/19/13 at 2:55 pm, LN C stated the door alarms were not consistently checked on the weekends and that the checks were not documented. On 6/20/13 at 2:10 pm, LN D confirmed that the door alarms were checked randomly and the checks were not documented. On 6/19/13 at 12:30 pm, the Administrator (ADM) was interviewed about the facility DSD's training methods and the lack of competence shown by staff following training. ADM stated that she had become aware that the DSD's and the facility's inservice trainings were not effective. ADM stated she had asked for and had received permission to hire a new DSD. The ADM stated she had selected a new DSD to achieve effective, competent staff training.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an avoidable accident with injury and elopement from the facility when: Resident 5 was found on the floor in her room which resulted in head and facial injuries and a broken nose; and Resident 6 was found by police, outside during the night, down on the ground approximately 4 miles away from the facility, having eloped from the facility without staffs knowledge which resulted in broken bones and an acute care hospitalization . These failures caused the residents unnecessary injuries and an inability to maintain their highest practicable level of well-being. Findings: 1. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool), dated 3/8/12, reflected that Resident 5 was cognitively impaired and had difficulty making her needs known. Resident 5 was assessed and considered a fall risk due to impaired balance, an inablity to walk, requiring maximum physical assistance with transfers and toileting, medications, being wheechair bound, poor memory, mental health, diarrhea, and poor nutritional intake. Resident 5 lived in a four bed room, and three of the four beds were occupied by residents. During an interview at 11:30 am on 5/8/12, Certified Nurses Assistant (CNA) B stated that on the morning of 3/10/12, she had been informed that Resident 5 was very weak, would be up only for meals, and then returned to bed to rest. CNA B stated that on 3/10/12 at 1:30 pm, after assisting Resident 5 with her lunch meal, she left Resident 5 in the dining room with other residents and staff. CNA B stated that the next time she saw Resident 5 was a half an hour later, at 2 pm, when she went into Resident 5's room to get another resident ready for a shower. CNA B stated that while in the room, a visitor, who was visiting another resident in the room, told her that he "heard something" from Resident 5's area of the room. CNA B stated that she looked behind the curtain, that was drawn closed around Resident 5's bed, and saw Resident 5 "on the floor." CNA B stated that Resident 5 was "lying face down on the floor, in front of her wheelchair, and next to her bed, in a pool of blood." CNA B immediately called for help. During an interview conducted on 5/10/12 at 12:30 pm, Licensed Nurse (LN) C stated that on 3/10/12, CNA B called for help at 2 pm, when Resident 5 was found on the floor, face down in a large pool of blood. LN C stated that she saw a lot of blood from Resident 5's nose. LN C stated that emergency first-aid care was given to Resident 5 at the facility, then Resident 5 was taken by ambulance to the hospital. LN C stated that Resident 5 was weak, and after lunch Resident 5 should have been taken to the bathroom and then put in bed. LN C stated that Resident 5 should not have been left in her room unattended. LN C stated that, "for residents who are identified as a fall risk, the staff attempt to know the residents whereabouts, and visualize the residents when they're up." LN C stated that she immediately started the investigation into Resident 5's fall and learned that Resident 5 was in the dining room from 12:15 pm to 1:15 pm. After 1:15 pm, it was unknown how Resident 5 left the dining room, or how long she was in her room before she was found on the floor. LN C stated that none of the staff on duty at the time admitted to putting Resident 5 in her room, and closing the privacy curtains around her. On 5/8/12 at 10:30 am, LN D stated that she had also helped with Resident 5's care, after the resident had been found on the floor. LN D stated that Resident 5 had a disfigured nose, and lacerations on her forehead and under her left eye. LN D stated that residents who are at risk for falls are not to be left alone in their rooms, unless they are safe in their beds. Residents are kept by the nurses station, or out in the hallway by their room, where they can be seen." On 4/9/12 at 9 am, the Director of Nurses (DON) stated that Resident 5 was considered a fall risk, and that the facility practice was not to leave fall risk residents alone, unattended in their wheelchairs. He stated that "all staff are educated in this practice." DON stated that it was "unknown how or by whom Resident 5 was put in her room, how long Resident 5 was left unattended, and unknown how long Resident 5 had been lying on the floor in her room." On 4/9/12, Resident 5's hospital record was reviewed. The admission record, dated 3/10/12, showed that following the fall, Resident 5 was admitted to the hospital with [REDACTED]. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), a resident assessment tool, dated 9/7/12, assessed Resident 6 as having memory problems. He wandered throughout the facility without assistance. The facility identified that this wandering behavior placed Resident 6 at significant risk for elopement and injury. A nursing care plan, dated 4/23/12, identified that Resident 6 was at risk for elopement and that a wanderguard would be in place on Resident 6. On 10/30/12, the Department of Public Health received a notification that Resident 6 had eloped from the facility and was found by the Sheriff's Department at 4:08 am. On 10/31/12 at 12:30 pm, Administrative (Admin) Nurse B stated that he had received a phone call from staff on 10/30/12 at 3:40 am, informing him that Resident 6 was missing from the facility. He stated that Resident 6 wore a wanderguard (a device that activates an alarm when an unauthorized attempt is made to exit the building) and had attempted to get out of the building earlier that shift. He further stated that a police officer found Resident 6 rolling around on the ground, on the outskirts of town. "He had scrapes on his face and a broken hand." Admin Nurse B stated that Resident 6 was transported to another hospital for further treatment. On 10/31/12 at 4:50 pm, the local sheriff's department (SD) was contacted. The SD representative stated that there was no report, and that no one from the facility called the department to report Resident 6 missing. When law enforcement spotted Resident 6 he was down on the ground and a medical call was made for an ambulance. The SD representative stated that the dispatch log read, "Man down on side of Highway 36, one hundred yards west of Highway 36/395.....and requested medical assistance." On 10/31/12 at 5 pm, Certified Nursing Assistant (CNA) D was interviewed. She stated, when she went to take Resident 6's vital signs at 3:20 am he was gone. CNA D stated that she notified the charge nurse and continued to search for Resident 6 in all the areas he liked to go. She stated she looked outside, and walked to the local gas station, while the charge nurse was also looking for him. On 3/31/12 at 5:10 pm, CNA E stated that Resident 6 would become restless, pacing, and would go in and out of doors after talking to his wife on the telephone. She stated earlier that night, Resident 6 had activated the door alarm trying to go out of the facility. She stated that when she came back from lunch at 2:48 am, she was unable to find Resident 6. CNA E stated that the charge nurse left the faciity on foot to look for Resident 6, came back, and then went to go look for him in her car. CNA E stated she saw two police cars while she was out of the facility and described Resident 6 to one of the officers. One of the officers informed her that someone had been identified that matched Resident 6's description going out of town on the highway. On 3/31/12, an odometer (an instrument for measuring distance traveled) reading from the facility to where Resident 6 was stated to be found by law enforcement was assessed. The reading indicated that Resident 6 was found 4 miles away from the facility on the highway going out of town. On 11/1/13 at 3 pm, Licensed Nurse (LN) C was interviewed. She stated she was the charge nurse on the night that Resident 6 had eloped from the facility. She stated that Resident 6 had been restless all night, activating the door alarm, and wanting to go outside. LN C stated at 3 am, Resident 6 was discovered missing. LN C stated she got in her truck and drove down Main Street for about 15 minutes while another CNA went on foot in the opposite direction. She stated shortly afterwards, she received a call from another nurse at the facility stating that law enforcement had found Resident 6. She confirmed that she never called the police/sheriff, and that she did not check Resident 6's wanderguard every shift. She further stated that she was not sure what door Resident 6 had exited from the facility, but in the past, the kitchen door alarm did not work. Resident 6's medication administration and treatment records were reviewed. There was no documented evidence to show licensed nursing staff checked to ensure Resident 6 was wearing his wanderguard and that it was functioning properly. On 3/31/12 at 2:30 pm, Admin Nurse B reviewed Resident 6's record and confirmed that there was no documented evidence that Resident 6 was assessed every shift by either licensed nursing staff or CNAs to ensure he was wearing the wanderguard and that it was working. The facility's Elopement policy, revised 12/27/11, required that when a resident could not be located, the police would be notified timely and that additional off duty staff may be called in to assist in the search, if needed.

Based on interview and record review, the facility failed to ensure one of two residents, Resident 12, was free from abuse when Certified Nursing Assistant (CNA) C verbally abused Resident 12 during personal care. This failure resulted in verbal abuse to Resident 12 and emotional distress for her roommate, Resident 9, who witnessed the incident. Findings: During an interview on 12/3/12 at 11:50 am, Resident 9 stated that on 11/6/12 she was wakened, maybe around 3 am, by a loud voice in the night. She said that CNA C was speaking, in an angry sounding tone, to her roommate, Resident 12. Resident 9 said, "I believe she (Resident 12) pooped her pants." When CNA C was cleaning Resident 12 CNA C told the resident to "Stop acting like a baby." Resident 9 stated that it made her upset to hear that and the first thing the next morning she reported the incident to the Social Services Director (SSD). Resident 9's record showed that she was admitted to the facility on [DATE] for after care and physical rehabilitation following surgical repair of a [MEDICAL CONDITION]. Resident 9's Minimum Data Set, (a resident assessment tool) dated 11/6/12, showed that she was alert, oriented and had no problem with her memory. During an interview on 12/3/12 at 11:35 am, SSD stated that first thing in the morning, on 11/6/12, Resident 9 came and told her about an incident of verbal abuse that occurred during the night between CNA C and Resident 12. SSD stated that she interviewed Resident 12 that same morning and though Resident 12 was talkative, she could not recall the incident. The SSD's current statements correlated with her written statements dated 11/6/12 at 8:30 am and 11 am. A review of Resident 12's closed record, on 12/3/12, showed that Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her MDS, dated [DATE], identified Resident 12 required extensive assistance for personal care, and had moderate memory problems, but that she was able to make her needs known. Resident 12 was discharged from the facility on 11/30 12 and not available for interview. During an interview on 12/3/12 at 12:30 pm, the Administrator stated, on 11/6/12 CNA C was suspended for three days while the facility investigated the allegation of verbal abuse. The facility determined that CNA C had verbally abused Resident 12 and CNA C was terminated on 11/9/12.

Based on observation, interview, and record review, the facility failed to ensure that one of two residents was safe from potential injury, when they did not develop a plan for safe smoking that would ensure the resident would not smoke, while wearing oxygen (Resident 1). Oxygen is an invisible gas that causes fire to burn more rapidly. Because of this, warnings such as, "Do not smoke or let anyone else smoke around oxygen in transport, in use, or on standby" are issued when oxygen is in use. This failure had the potential to result in serious bodily harm, including death, and placed Resident 1 in immediate jeopardy. Findings: Resident 1's record was reviewed 1/16/13. Resident 1 was admitted to the facility 1/19/11, she has had two acute care hospitalization s, due to complications of her respiratory status, with her most recent readmission back to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS), an assessment tool, dated 9/27/12, read that Resident 1 was independent in her ability to transfer between surfaces and to use a wheelchair. She required staff assistance to walk because balance was not steady. The MDS also read that she had trouble breathing, used tobacco, and required oxygen therapy. Resident 1's Care Area Assessments (CAAs), used for care planning decisions, dated 9/28/12, read that Resident 1 fatigues with exertion, has a tobacco dependency, and refuses to give up smoking. She was dependent on supplemental oxygen that was delivered at six liters per minute; the highest amount of oxygen that can be given using nasal prongs. The CAAs also read that Resident 1 used an electric wheelchair and went outside of facility on her own in her chair. Resident 1's record contained a "Cigarette Smoking Contract," dated 4/10/12, signed by Resident 1 and the facility Administrator that included in its content that Resident 1 agrees "In the event that I choose to go off of the premises, I will sign myself out at the nurse's station and request my cigarettes and lighter. I may smoke cigarettes as I wish off the premises. I understand the risks and benefits of smoking with oxygen on." Resident 1's smoking assessment, signed by the facility Inter-Disciplinary Team (IDT) members on 10/15/12, read, "Smokes off premises several times daily in electric wheelchair, won't take off oxygen while smoking." The IDT smoking assessment recommendations read, "Must sign out to smoke and smoke off premises." Resident 1's care plan titled, "Smoking/Assistance Needed" dated 12/24/12, identified Resident 1's smoking problems as "Poor safety awareness, oxygen use, non-compliant, smokes oxygen on off premises and signed out as self while smoking." The facility approaches included "Must sign self out to smoke." On 1/16/13 at 4:05 pm, Resident 1 was observed in her room sitting on her bed. She was using an electric oxygen concentrator device ( a device that converts room air to provide concentrated oxygen) set at six liters per minute. Her electric wheelchair was parked outside her doorway and had a portable oxygen tank sitting in a rack that was secured to the back of the wheelchair. A sign just above the wheelchair on Resident 1's door frame read "Oxygen in use, No Smoking." On 1/16/13 at 4:05 pm, Resident 1 stated "I have to go out to the street to smoke because I have oxygen. I am not able to be off oxygen." Resident 1 continued to state that she had a signed agreement with the facility, to sign herself out, and go off the facility owned property, "to the corner of the street and curb" where she smokes with her oxygen on. On 1/16/13 at 4:30 pm, in a combined meeting with the Administrator and Director of Nurses (DON) the Administrator stated that she did have a "Smoking contract" with Resident 1 that if she was going to smoke, with her oxygen on, that she had to be off of the facility property. She stated that the facility could not deny Resident 1's right to smoke. The DON stated that Resident 1 is her own responsible party and signs herself out several times a day to go off the facility property and smoke. He stated that Resident 1 goes through several portable oxygen tanks a day. The DON stated that all interventions to help Resident 1 smoke safely had failed, that she was not compliant, and that was what had lead up to the agreed upon "Smoking contract." The DON and Administrator both stated that they have been aware of the problem of Resident 1 smoking off facility premises with oxygen running for several months. On 1/16/13 at 5:40 pm, the administrator and DON were notified that this situation was an Immediate Jeopardy. Facility staff were aware of the serious health and safety risks, including death, associated with smoking while using oxygen. The facility knowingly and willingly agreed to allow this life threatening practice by signing a contract allowing Resident 1 to smoke with a oxygen tank secured to her wheelchair and an oxygen administration rate of six liters per minute through prongs (a nasal cannula) that rested inside the resident's nostrils. The contract specified that Resident 1 had to smoke outside and off the facility property. Requiring the Resident 1 to leave the facility property did not negate the facility's responsibility to ensure the resident's safety. On 1/16/13 at 8:09 pm, the Immediate Jeopardy was abated when the facility Administrator provided an acceptable plan of action to prohibit Resident 1 from smoking while wearing oxygen.

Based on interview and record review, the facility failed to develop a care plan and provide care to prevent the worsening and further development of pressure ulcers when Resident 1 was admitted with reddened areas on her buttocks, bowel and bladder incontinence, and a decline in in her ability to care for herself. This failure resulted in the development of pressure ulcers on Resident 1's right and left buttocks and an unstageable pressure ulcer on her coccyx (tailbone). Findings: Resident 1 was admitted to the facility on [DATE] following a week stay (2/13/12 - 2/20/12) in the hospital for the treatment of [REDACTED]. The Nursing Admission Assessment, dated 2/22/13 at 2:30 pm, showed that Resident 1 was alert, orient, able to answer questions and make her needs known. She was experiencing diarrhea and urinary urgency with occasional incontinence. The skin assessment identified that Resident 1's skin was intact with an area of perirectal redness. A short term care plan, dated 2/22/12, noted as a problem Resident 1's area of perirectal redness, however the approaches of "Treatment per MD order and observe for signs and symptoms of infection..." were not sufficient approaches/interventions that would prevent the further development of skin breakdown, such as pressure relieving measures. A second care plan identified the problems of bowel and bladder incontinence and the predisposition to skin breakdown. Planned interventions included checking every two hours for incontinence and providing peri care, "monitoring for signs and symptoms of skin problems routinely, redness, etc." and monitoring skin integrity per facility protocols. The facility's "Pressure Ulcer Management" policy, revised 8/2007, read, " It is the policy of this facility to ensure that residents skin status is assessed and appropriate interventions are developed and implemented to maintain skin integrity, assist in wound healing and or prevent avoidable skin breakdown in order to attain or maintain the highest practicable physical, mental and psychosocial well-being." "Based on the assessment and identification of risk factors and through the assessment process the following interventions may be considered ... assist with or turn and reposition ... initiate positioning pillows or cushions ... apply pressure reducing devices to bed ... apply pressure reducing devices to chair or seat ...avoid friction and shearing." Nurse's notes for 2/23 and 2/24/12 described Resident 1 as needing the assistance of one to two persons to transfer and toilet, that she was both continent and incontinent of bowel and bladder, and that incontinence care was done on each shift, and as needed. Nurse's notes for 2/25/12 described Resident 1 as drowsy, incontinent of bowel and bladder, and unable to arouse enough to take her medication or eat meals. Resident 1 was "more awake" on 2/26/12, however, her respiratory status was declining and new orders for breathing treatments and medications were obtained and initiated. On 2/27/12 at 2:50 am, the nurse documented that Resident 1 was sleepy and slow to respond to verbal and physical stimulation. As such, the nurse held Resident 1's medications. The next nurse's note, dated 2/27/12 (no time), described Resident 1 as having increased confusion, that she was alert and oriented to person, but not time and place, her speech was unclear, and that she was incontinent of bowel and bladder. An untimed nurse's note and physician order, dated 2/27/12, both read, "Cleanse red area to right buttock...cleanse red area to left buttocks...cleanse black area to coccyx." On 2/27/12, a skin ulcer care plan was developed for three pressure ulcers that Resident 1 acquired since she was admitted to the facility, five days prior. The perirectal redness noted on admission had worsened to Stage I pressure ulcers on her right and left buttocks, and a new area of breakdown, described as black and unstageable, developed on her coccyx. The National Pressure Ulcer Advisory Panel (NPUAP) defines a Stage I pressure ulcer as intact skin with non-blanchable redness of a localized area usually over a bony prominence. An unstageable pressure ulcer has full thickness tissue loss in which the base of the ulcer is covered by slough or eschar (dead tissue that is tan, brown, or black) in the wound bed. Until enough slough/eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. From Resident 1's admission on 2/22 to 2/27/12, a period of five days, there was no documentation in the record that Resident 1's reddened perirectal area was assessed, or that interventions listed in the facility's Pressure Ulcer Management policy/protocol were implemented by nursing staff to prevent the development of further skin breakdown. On 10/24/12 at 2:54 pm, in a concurrent interview and record review, the DON confirmed that a care plan, that included nursing care interventions to prevent the development of skin breakdown, was not developed to address Resident 1's increased risk for pressure ulcers.