Every finding on record at Marquis Care at Shasta

Based on interview and record review the facility failed to ensure one out of two sampled residents (Resident 1) was provided with activities of daily living (ADL, everyday self-care tasks such as showering, dressing, or eating) when no shower was provided for two weeks. This failure had the potential to cause skin irritation, infection, and a decline in psychosocial well-being.Findings:A review of the facility's policy and procedure (P&P) titled, Shower/Tub Bath Level II, dated 8/2017, indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The P&P indicated documentation of showers would include the date and time the shower was provided and that when a resident declined a shower or bath, the Licensed Nurse (LN) would be notified.A review of Resident 1's admission Record, dated 3/6/25, indicated the most current admission to the facility was on 7/20/26 with the diagnoses of unspecified (unknown) symptoms and signs involving cognitive functioning (how the brain processed information) following cerebral infarction (blood flow to the brain was blocked and caused a stroke), abnormalities of gait (the way one walked) and mobility (ability to move), and weakness. Resident 1 was their own responsible party (made their own decisions).A review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), dated 7/24/26, indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement) was conducted. Resident 1 scored 14 out of 15, indicating intact memory.A review of Resident 1's admission MDS, dated [DATE], Section GG, dated 1/20/26, indicated that Resident 1 had limited function of one upper extremity (shoulder, elbow, wrist, and hand) and required substantial to maximal assistance (the helper provided more than half of the effort) from facility staff to shower.A review of Resident 1's care plan (a personalized plan that outlined the resident's care instructions and needs) titled, Bathing/Personal Hygiene, dated 7/24/26, indicated, Resident 1 preferred taking showers and required the assistance of one person for physical assistance.During an interview on 8/26/26 at 12:06 pm, Resident 1's family member (FM) indicated that Resident 1 had not received a shower for two weeks.During an interview on 8/26/26 at 1:22 pm, Certified Nurse Assistant (CNA) B indicated a shower book located at the nurse's station identified scheduled shower days, the responsible shift, and shower days were based on room number. CNA B indicated a shower would be offered three times prior to the LN being notified that the resident declined. CNA B confirmed CNAs documented showers in the resident's medical record.During an interview on 8/26/26 at 1:26 pm, LN A indicated that when a resident declined a shower or bath, the CNA notified the LN, and the LN documented in a progress note how many attempts were made and why the resident declined.During a concurrent interview and record review on 8/26/26 at 2:07 pm with the Director of Staff Development (DSD), Resident 1's Follow up Question Report (CNA shower documentation), dated 7/1/26 through 8/26/26, was reviewed. DSD confirmed the documentation indicated Resident 1 had not been provided a shower or bath between 7/24/26 through 8/10/26. DSD confirmed Resident 1 should have received four showers during that period. DSD confirmed no documentation was present in Resident 1's medical record indicating whether a shower was provided or whether Resident 1 was offered and declined.

Based on observations, interviews, and record reviews, the facility did not protect one of five sampled residents (Resident 2) from physical abuse when Certified Nursing Assistant (CNA) C was seen putting their hands on Resident 2's shoulders, firmly shaking Resident 2, and telling Resident 2 loudly to stop. This had the potential to result in physical harm, pain, and mental anguish.Findings: A review of the facility's policy and procedure titled, Abuse Prevention Program, dated 12/1/20, indicated, residents had the right to be free from abuse by anyone, including facility staff. A review of the Employee Safety Rules and Responsibilities, dated 3/1/26, indicated, facility staff were expected to always conduct themselves in a professional manner. A review of Resident 2's admission Record, dated 12/7/23, indicated admission to the facility on [DATE] with the diagnoses of delusional disorder (a mental health condition where a person had an unshakable, false belief that was not based in reality), dementia (a disease that caused a decline in language or thinking skills and memory loss), and Alzheimer's disease (a specific physical brain disease that caused dementia). Resident 2 was not her own responsible party (RP, decision maker). A review of Resident 2's Quarterly Minimum Data Set (MDS, a resident assessment tool), Section C, dated 5/17/26, indicated Resident 2's cognitive skills (thinking, learning, or performing daily tasks) for daily decision making was severely impaired and had short and long-term memory problems. Resident 2's Quarterly MDS, Section GG, dated 5/17/26, indicated, Resident 2 required substantial to maximum assistance (helper does more than half the effort) from facility staff to get dressed, put on or take off shoes, roll from side-to-side in bed, and to transfer out of the bed. The Quarterly MDS indicated Resident 2 was dependent on staff for toileting hygiene. A review of Resident 2's care plan (a personalized plan that outlined resident goals, emotional needs, and care instruction for facility staff) titled, Physical Aggression/Abusive, dated 9/8/24, indicated the facility staff would approach Resident 2 slowly, not invade Resident 2's personal space, staff would ensure to have Resident 2's attention before touching or speaking, and to talk to Resident 2 using a low pitch (quiet or soft) and with a calm voice to decrease or eliminate undesired behaviors. A review of the Multidisciplinary Care Conference -V 12, dated, 6/8/26, indicated that Resident 2 had behaviors that included screaming, threatening others, refusing care, and feeling anxious (worried or nervous) and agitated (upset or irritated). During a concurrent observation and interview on 6/24/26 at 10:32 pm, CNA B stated, I've noticed [CNA C] seems a little rough when providing care sometimes. CNA B indicated, approximately two weeks earlier (two weeks ago was 6/7/26 through 6/13/26), CNA B assisted CNA C while providing care to Resident 2 and during that time, Resident 2 had an increase in verbal and physical behaviors and that CNA C appeared to be overwhelmed (feeling of being unable to cope because of the demands of a situation). CNA B stated, [CNA C] grabbed [Resident 2] by the shoulders and shook [Resident 2]. CNA B indicated that CNA C had told Resident 2 to stop with a loud voice. CNA B demonstrated the described incident by placing one hand on top of both of the surveyor's shoulders and supplied pressure by squeezing, gave a firm shake, and loudly stated stop! CNA B stated, I took over [Resident 2's] care and had [CNA C] leave. CNA B indicated Resident 2 was very forgetful and CNA B remained calm, provided redirection, and was able to calm Resident 2 down. During an interview on 6/24/26 at 12:21 pm, with Administrator (Admin), CNA B's witnessed physical abuse was described. Admin indicated that would be considered an allegation of abuse.

Based on observations, interviews, and record reviews, the facility failed to report two allegations of physical abuse to the California Department of Public Health (CDPH, protected the public's health), the local police department, or the Ombudsman's office (an agency that protected resident rights) for two out of five sampled residents (Residents 1 and 2) when: 1.Resident 1 told the Resident Care Manager (RCM) that they sustained a fracture (broken bone) in the left ulna (lower arm) that resulted from rough care that was provided by two Certified Nursing Assistants (CNA). 2. CNA B indicated they had witnessed CNA C physically abuse Resident 2. These failures had the potential for abuse allegations to go unrecognized and placed residents at risk for abuse. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Reporting Abuse to Facility Management, revised 10/1/22, indicated, allegations or suspicions of abuse were to be reported immediately to the facility's Administrator (Admin). The P&P indicated, allegations or suspicions of abuse would be reported immediately or within two hours to CDPH, the police department, and the Local Ombudsman's office. A review of Resident 1's admission Record, dated 7/13/12, indicated admission to the facility on 7/13/12 and had diagnoses of age related osteoporosis (a condition that caused weak bones and increased the risk of fractures even from minor bumps or falls) and flaccid hemiplegia (inability to move half of the body) that affected the left side. On 6/16/26, Resident 1 was diagnosed with an unspecified fracture of the lower end of the left ulna (located in the wrist area), and the fracture did not require surgery. Resident 1 was their own responsible party (RP, made their own decisions). During a concurrent observation and interview on 6/23/26 at 2:00 pm, Resident 2 was observed sitting in a recliner, appeared to be in a pleasant mood and was smiling. Resident 1 indicated, on the evening of 6/6/26, two Certified Nursing Assistants (CNA) had provided Resident 1 with care and did not know their names. Resident 1 indicated the CNAs turned Resident 1 from side-to-side while in bed and when Resident 1 was being turned towards the left side of the bed, their left arm hit the bed cane (a metal grab bar that was attached to the bed), and she had stated, Ow, Ow, Ow. Resident 1 indicated that on 6/6/26, they were having difficulty with breathing, had been transported to the hospital late in the evening, and was ultimately admitted to the hospital. Resident 1 indicated, on 6/8/26, their breathing was better and turned her focus back to her left arm pain. Resident 1 reported to the hospital's Physician what had occurred when the CNAs had provided care on 6/6/26. Resident 1 indicated, the hospital's Physician ordered an x-ray (a picture of the bones) and stated, My left ulna is fractured. Resident 1 was observed to appear sad, was no longer smiling, and began to frown while shaking head from side to side while talking. Resident 1 indicated returning to the facility on 6/16/26 and had notified the Resident Care Manager (RCM) about the incident on 6/6/26. During an interview on 6/23/26 at 2:33 pm, RCM confirmed when a resident alleged that facility staff provided rough care or sustained injuries during care, it would be viewed as an allegation of abuse, Admin would be notified immediately, and Admin would provide further instructions. RCM confirmed, on 6/16/26, when Resident 1 had returned to the facility, Resident 1 alleged sustaining a fracture to the left ulna while two CNAs had provided Resident 1 with care and that it occurred prior to Resident 1 going to the hospital. RCM indicated that due to Resident 1 not reporting the allegation on 6/6/26, and had waited until 6/16/26, and there was no documentation that supported Resident 1 had any pain prior to her hospitalization, RCM did not consider this an allegation of abuse or suspected abuse. RCM confirmed, not reporting Resident 1's allegation to the facility's Admin until the morning of 6/17/26. A review of Resident 1's Progress Note, dated 6/17/26 and written by RCM, indicated that on 6/16/26, Resident 1 had returned to the facility from a hospital stay and while in the hospital, Resident 1 notified the hospital's Physician that Resident 1 had pain in the left arm due to an injury sustained at the facility while receiving care from two CNAs. The Progress Note indicated, RCM spoke with [Resident 1] about her [left] wrist fracture and asked her when and how she thought she hurt it. She said she was being provided care in bed by two CNAs and when rolled, her [left] hand hit her bed cane and started hurting after that. 2. A review of Resident 2's admission Record, dated 12/7/23, indicated admission to the facility on [DATE] with the diagnoses of delusional disorder (a mental health condition where a person had an unshakable, false belief that as not based in reality), dementia (a disease that caused a decline in language or thinking skills and memory loss), and Alzheimer's disease (a specific physical brain disease that caused dementia). Resident 2 was not her own RP. During a concurrent observation and interview on 6/24/26 at 10:32 pm, CNA B stated, I've noticed CNA C seems a little rough when providing care sometimes. CNA B indicated, approximately two weeks earlier (two weeks ago was 6/7/26 through 6/13/26), CNA B assisted CNA C while providing care to Resident 2 and during that time, Resident 2 had an increase in verbal and physical behaviors and that CNA C appeared to be overwhelmed (feeling of being unable to cope because of the demands of a situation). CNA B stated, [CNA C] grabbed [Resident 2] by the shoulders and shook [Resident 2]. CNA B indicated that CNA C had told Resident 2 to stop with a loud voice. CNA B demonstrated the described incident by placing her hands on both of the surveyor's shoulders and applied pressure by squeezing the shoulders, gave a firm shake, and loudly stated stop! CNA B's face was a few inches away from the surveyor's face. CNA B stated, I took over [Resident 2's] care and had [CNA C] leave. During an interview on 6/24/26 at 12:21 pm, Admin confirmed the RCM did not notify Admin of Resident 1's statements regarding an allegation of abuse. The Admin, Director of Nursing, and Director of Staff Development confirmed, CNA B did not notify them regarding the abuse toward Resident 2 by CNA C that she had witnessed. Admin confirmed allegations of abuse were to be reported immediately or within two hours and the allegation of abuse for Resident 1 and witnessed physical abuse to Resident 2 had not been reported to CDPH, the local police department, or to the Ombudsman's office.

Based on observations, interviews, and record reviews, the facility did not thoroughly investigate an allegation of abuse for one of two sampled residents (Resident 1) when Resident 1 reported that facility staff provided rough care that caused an injury. This failure placed residents that lived in the facility at risk for further potential abuse. Findings: A review of the facility's policy and procedure (P&P) titled, Abuse Investigations, revised 10/15/20, indicated that when an allegation of abuse was reported, the facility was required to thoroughly investigate it. The P&P indicated that the investigation included interviewing any possible witnesses, such as staff, the resident's roommate, and other residents cared for by the accused staff member. A review of Resident 1's admission Record, dated 7/13/12, indicated admission to the facility on 7/13/12 and had been diagnosed on [DATE] with age related osteoporosis (a condition that caused weak bones and increased the risk of broken bones from minor bumps or falls). On 7/10/19, Resident 1 was diagnosed with flaccid hemiplegia (inability to move half of the body) that affected the left side. On 6/16/26, Resident 1 was diagnosed with an unspecified fracture of the lower end of the left ulna (the outer bone in the forearm), and the fracture did not require surgery. Resident 1 was their own responsible party (made their own decisions). A review of Resident 1's Quarterly Minimum Data Set (MDS, a resident assessment tool), Section C, dated 5/13/26, indicated a Brief Interview for Mental Status (BIMS, an assessment that tested memory and thinking) was performed. Resident 1 scored a 15 out of 15, which indicated that Resident 1's ability to remember and think were intact. A review of Resident 1's Quarterly MDS, Section GG, dated 5/13/26, indicated that Resident 1 was dependent upon staff for showers, toileting hygiene (wiping or adjusting clothes) and to roll in bed from side-to-side. During a concurrent observation and interview on 6/23/26 at 2:00 pm, Resident 2 was observed sitting in a recliner, appeared to be in a pleasant mood and was smiling. Resident 1 indicated, on the evening of 6/6/26, two Certified Nursing Assistants (CNA) had provided Resident 1 with care and did not know their names. Resident 1 indicated the CNAs turned Resident 1 from side-to-side while in bed and when Resident 1 was being turned towards the left side of the bed, their left arm hit the bed cane (a metal grab bar that was attached to the bed). Resident 1 indicated that on 6/6/26, they were having difficulty with breathing, had been transported to the hospital late in the evening, and was ultimately admitted to the hospital. Resident 1 indicated, on 6/8/26, their breathing was better and she turned her focus to her left arm pain. Resident 1 reported to the hospital's Physician what had occurred when the CNAs had provided care on 6/6/26. Resident 1 indicated the hospital's Physician ordered an x-ray (a picture of the bones) and stated, My left ulna [wrist] is fractured. Resident 1 was observed to appear sad, was no longer smiling, and began to frown while shaking head from side to side while talking. Resident 1 indicated returning to the facility on 6/16/26 and had notified the Resident Care Manager (RCM) about the incident on 6/6/26 and was under the impression RCM would investigate the allegation. Resident 1 indicated, since the initial conversation with RCM, no one at the facility had come back to talk about the investigation results and wanted to know what had happened. A review of the hospital, Progress Note, dated 6/14/26, indicated the hospital's Physician reviewed Resident 1's x-ray from 6/8/26. The X-ray indicated that resident 1 had a minimally displaced distal ulnar shaft fracture (a minor crack or break at the end of the ulnar, in the wrist area). A review of Resident 1's, Progress Note, dated 6/17/26 and written by RCM, indicated that on 6/16/26, Resident 1 had returned to the facility from a hospital stay. RCM reviewed hospital records that included information about Resident 1's ulna fracture and allegations that it occurred in the facility while receiving care from the CNAs. The Progress Note indicated, RCM spoke with [Resident 1] about her [left] wrist fracture and asked her when and how she thought she hurt it. She said she was being provided care in bed by two CNAs and when rolled, her [left] hand hit her bed cane and started hurting after that. During an interview on 6/23/26 at 2:33 pm, RCM confirmed when a resident alleged that facility staff provided rough care or sustained injuries during care, it would be viewed as an allegation of abuse, Admin would be notified immediately, and Admin would provide further instructions. RCM confirmed, on 6/16/26, when Resident 1 had returned to the facility, Resident 1 alleged sustaining a fracture to the left ulna while two CNAs had provided Resident 1 with care and that it occurred prior to Resident 1 going to the hospital. RCM indicated that due to Resident 1 not reporting the allegation on 6/6/26, and had waited until 6/16/26, and there was no documentation that supported Resident 1 had any pain prior to her hospitalization, RCM did not consider this an allegation of abuse or suspected abuse. RCM indicated that RCM had investigated Resident 1's statements and confirmed that RCM had not interviewed any possible witnesses, such as staff, the resident's roommate, and other residents cared for by the accused staff member. RCM indicated it was the Director of Staff's (DSD) responsibility to interview the CNAs. During an interview on 6/23/26 at 3:32 pm, the facility's Administrator (Admin) indicated that the RCM, the DSD, or the Admin could have interviewed the CNAs and that Admin had delegated the investigation to the RCM. Admin confirmed that allegation of abuse was not thoroughly investigated and the facility staff or Resident 1's roommate had not been interviewed.

Based on observation, interview, and record review, the facility failed to ensure federal regulations related to the education qualification requirements of the dietarymanager were followed as outlined in the California Code, Health and Safety Code (HSC1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines.Cross references to F812 examples #1, #2, #3 and #4 . Findings:On 03/02/2026 at 11:07 PM, an interview was conducted with the Dietary Manager (DM). The DM stated he was responsible for managing the kitchen. DM stated that the Certified Dietary Manager credential expired 8/31/22. On 03/03/2026 at 12:50 PM, an interview was conducted with Registered Dietitian Nutritionist (RDN). The RDN stated that her responsibilities included nutrition assessments, nutrition interventions, monitoring of weights, participation in weight committee meeting, monitoring of pressure injuries, and monthly kitchen audits and tray line observations. The RDN stated that she spends 4-6 hours a week overseeing the kitchen. The RDN acknowledged that the DM's Certified Dietary Manager credentials had expired. A review of the Dietary Manager job description dated 9/5/23 and signed by the DM, stated that the education requirement of the position is Certified Dietary Manager. During the recertification survey from 3/2/26 to 3/5/26, multiple issues were found in the kitchen, including floors and equipment that were not cleaned and dried properly. According to the California Code, Health, and Safety Code - HSC S 1265.4, 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 of subdivision (b) to supervise dietetic service operations.According to the California Code, Health, and Safety Code - HSC 1265.4, (4) 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 facility's documents for qualifications of the DM failed to show evidence that he met the qualifications under the California Code, Health and Safety Code - HSC S 1265.4.

Based on observation, interview and facility document review, the facility failed to ensure the menus were followed when:1.The regular zucchini recipe was not followed.2.The puree zucchini recipe was not followed.3.The BBQ chicken recipe for regular diets was not followed.4.The puree BBQ chicken recipe was not followed.These failures had the potential to not meet the residents' nutritional needs for the 8 (Residents 8, 9, 35, 128, 22, 72, 91, 119) of 124 residents who received a pureed diet and 82 of 124 who received a regular diet. Findings:1. On 3/3/26 at 10:30 AM, a concurrent kitchen observation and interview was conducted during preparation of lunch meal with [NAME] 1 (CK 1). Steamed zucchini was in a hotel pan on the counter. It appeared without seasoning. CK 1 stated he does not add seasoning. CK 1 stated he did not refer to a recipe during the cooking process.A review of the facility policy titled, Cooking Food, revised April 2019, showed that Recipes will be followed for the menu items.A review of the facility document titled, Roasted Zucchini Method, dated 2002-2025, showed that 100 servings, in a large mixing bowl, toss the vegetables with the oil (canola oil 1 1/2 cups) and seasoning (granul garlic, sliced 37 1/2 each, Italian seasoning 2 tbs (tablespoons) plus 1/4 tsp (teaspoons), salt 2 Tbs plus 1/4 tsp, black pepper 1 Tbs plus 1/8 tsp.During an interview with Registered Dietitian Nutritionist (RDN) on 3/3/26 at 12:50 PM, RDN confirmed recipes should be followed.2.On 3/3/26 at 10:35 AM, a concurrent kitchen observation and interview during the pureed preparation was conducted with CK 1. CK 1 stated he was preparing pureed (a smooth, thick paste made by crushing or blending cooked or raw food) zucchini. Using a spoon, CK 1 measured 2 large scoops of cooked zucchini into a blender and added a cup of water. CK 1 was unable to state the measurement of the scoops of zucchini. CK 1 blended the zucchini in the blender. CK 1 added 1/2 cup of food thickener (a substance added to a liquid or semi- liquid food to increase its thickness or viscosity without significantly changing its flavor), blended and added another 1/4 cup of thickener. CK 1 poured zucchini out of the blender into a hotel pan (a metal container for use on a steam table to keep food warm in commercial kitchens), and placed in a hot box for holding until lunch tray line. CK 1 did not refer to a recipe during the pureed process. CK 1 stated that he does not measure and instead relies on sight.A review of the facility policy titled, Cooking Food, revised April 2019, showed Recipes will be followed for the menu items.A review of the facility document titled, Roasted Zucchini Method, dated 2002-2025, showed that pureed: remove portions needed from regular recipe; drain. Place portions needed into a food processor (electric kitchen appliance used to chop, slice, grind, mix or puree food quickly). Process until fine. For every 5 portions needed, add 1/4 cup thickener. Process until smooth. Scrape down sides of processor bowl.During an interview with RDN on 3/3/26 at 12:50 PM, RDN confirmed recipes should be followed.3. On 3/3/26 at 10:45 AM, a concurrent kitchen observation and interview was conducted during preparation of the lunch meal with CK 1. Boneless chicken was cooked and cooled on a sheet pan with barbeque seasoning sprinkled on top. CK 1 put 12 pieces of chicken in a blender and add one cup water and blended. CK 1 added 1/2 cup thickener and blended. [NAME] 1 did not refer to a recipe during the puree process.On 03/03/2026 11:50 AM, during lunch tray line observation, it was observed that the puree meal was runny. The puree BBQ chicken, puree roasted zucchini and puree cheese biscuit were running together on the plate. The puree BBQ chicken had a scoop of BBQ sauce on top.A review of the facility policy titled, Cooking Food, revised April 2019, showed Recipes will be followed for the menu items.A review of the facility document titled, BBQ Chicken Method, dated 2002-2025, showed Pureed: Place deboned cooked meat (2 oz - ounces, each ) into a food processor. Progress to a fine texture. For every 5 portions needed, prepare a slurry with 1/4 cup thickener and 1 cup of hot liquid; mix well with a wire whip. Add 1/2 of the slurry to the meat; process for one minute. If too dry, add more slurry (a mixture of starch and a cold liquid, usually water to thicken foods) until meat is pudding consistency (thickness, texture, or firmness of a substance, especially food or liquid). With a rubber spatula, scrape down sides of the bowl; reprocess 30 seconds.A review of the facility document titled, Therapeutic (used in medical treatment for special diets) Spreadsheet (a document used to organize data in rows and columns) Week 2 Tuesday, undated showed for BBQ chicken under puree diet, P #8 scoop size for portion. It did not include a scoop of BBQ sauce on top.During an interview with RDN on 3/3/26 at 12:50 PM, RDN confirmed recipes should be followed.4. On 3/3/26 at 11:00 AM, a concurrent kitchen observation and interview was conducted during preparation of the lunch meal with CK 1. CK 1 pulled a pan of cooked plain deboned chicken out of the oven. [NAME] 1 poured BBQ sauce on top of the chicken and placed in the hot box to keep warm for service. When asked why he waited until the end to add the BBQ sauce instead of 1/2 hour before the end of cooking time, CK 1 stated he didn't know.A review of the facility policy titled, Cooking Food, revised April 2019, showed Recipes will be followed for the menu items.A review of the facility document titled BBQ Chicken Method, dated 2002-2025 showed;Preheat oven to 325 degrees F (Fahrenheit, a unit of temperature measurement)Place chicken in steamtable pans.Cover and bake chicken for 1 hour.Pour BBQ sauce over chicken. Continue baking for an additional 1/2 hour.Serve 1 piece of chicken per portion (2 oz edible meat).During an interview with RDN on 3/3/26 at 12:50 PM, RDN confirmed recipes should be followed.

Based on observation, interview, and facility policy review, the facility failed to ensure food safety and sanitation requirements were followed when:1. The kitchen environment was not cleaned adequately around stoves, ranges, and some refrigerators.2. Kitchen utensils and equipment were stored wet.3. Plastic cutting boards were found to be excessively scored & cut.4. Dry storage floors were found to be dirty. These failures posed the risk of foodborne illnesses in a highly susceptible resident population of 124 facility residents who received food prepared in the kitchen. Findings:1.During an observation of the kitchen on 3/2/26 at 11:07 am, grease and grime were observed on multiple surfaces of the main cooking area. Dark brown grease, food particles, and grime were observed on the sides and doors of stoves, on top of the cooking range, and on sidewalls and surfaces of hot oil fryer. During an interview with Dietary Manager (DM) on 3/4/26 at 10:03 am, DM stated, I clean the [oil] fryer every Friday. The cooks are supposed to clean the stoves, ovens, and ranges.On 3/4/26 at 11:50 am, a concurrent kitchen observation and interview was conducted with DM. At dietary aide food preparation station, exterior fridge walls were seen to be visible coated in grease and dust, along upper sidewalls, directly above the food preparation surface. DM acknowledged this and stated, Yes, that's dirty.A review of facility policy titled, Refrigerators and Freezers, dated 4/2018, showed that Refrigerators shelves, ceilings, and walls should be washed with warm water and a detergent. This policy also showed that Refrigerators and freezers should be cleaned per cleaning schedule.According to the USDA Food Code 2022, Section 4-601.11, Non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirty, food residue, and other debris.2. On 3/2/26 at 2:55 pm, a concurrent kitchen observation and interview was conducted with Dietary Aide B (DA B). Two of two stainless steel blenders were found to be stored wet at the main food preparation area. Two of 10 metal food scoops were found to be stored wet inside a metal drawer at the main food preparation area. DA B acknowledged that the blenders and scoopers were being stored wet, and stated, Those should not be stored wet.On 3/2/26 at 2:55 pm, a concurrent kitchen observation and interview was conducted with DM. Two of five clean plastic food storage tubs were found to be stored wet on clean shelving, with visible water drops on them. DM acknowledged, Yes, those should not be stored wet. Should be dry. A review of facility policy titled, General Dish Room Sanitation, dated 3/27/20, showed that All items are to be air-dried. No moisture can be found on any items.According to the USDA Food Code 2022, Section 4-901.11 Equipment and Utensils items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow.3.On 3/2/26 at 2:55 pm, a concurrent kitchen observation and interview was conducted with DM. Two of four plastic cutting boards were found to be deeply cut and scored (deep slices on the surface), creating potentially un-cleanable and compromised surfaces of food preparation equipment. DM stated that those excessively scored cutting boards should not be used, and should be replaced.According to the USDA Food Code 2022, Section 4-501.12, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.4.During an observation of the kitchen on 3/2/26 at 11:07 am, the floors of the dry storage pantry were found to be soiled with dark grime, especially around the edges of the room, with food particles and dust visible on the floor. On 3/4/26 at 11:50 am, a concurrent kitchen observation and interview was conducted with DM. In the dry storage pantry room, the floors of the dry storage pantry were found to be soiled with dark grime, especially around the edges of the room, with food particles and dust visible on the floor. DM acknowledged the dirty floors, and stated, Yes that's dirty along the edges of the floor. It could use some scrubbing. This floor should be swept nightly, and mopped.A review of facility policy titled, Storeroom, dated 4/2018, showed that in the dry storage pantry room, kitchen staff should sweep and mop storeroom every day.

Based on observation, interview, and record review, the facility failed to provide appropriate discharges for two of five sampled residents when the facility transferred (when a resident goes to the hospital for an evaluation and is expected to return to the facility), the residents the hospital then refused to allow them to return to the facility and discharged (formal and final release of the resident without intention of them returning) them. Resident 3 and 137's medical records contained no documented reasons by their physicians for not allowing them to return to the facility, the residents were not prepared or notified in advance that they were being discharged from the facility, and the residents and their family members (FM) were not provided with a notice that they had the right to appeal the facility's decision to discharge them.This failure had the potential to cause unnecessary prolonged hospitalizations with increased health care issues and compounded mental health, emotional distress and psychosocial decline.During a review of the facility's policy titled, [Facility Name] Facility Assessment, dated 12/3/25, the Facility Assessment indicated that the facility has the capability of managing residents with psychiatric/mood disorders including impaired cognition, mental disorder. (and) behavior that needs intervention.(and) Medication Administration including intravenous (peripheral or central lines).During a review of the facility's policy and procedure titled, Bed Hold Policy, undated, indicated, Facility admission Agreement contains the facility's policy and procedure for Bed Hold Notices.During a review of the facility's copy from the State of California - Health and Human Services Agency, California Department of Public Health (CDPH) document 327 titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, CDPH 327 Attachment F, dated 12/2012, indicated, Transfer and discharge requirements. The facility must permit each resident to remain in the facility, and not transfer or discharge.unless - (i) Necessary for the resident's welfare and the resident's needs cannot be met in the facility; (ii) Resident's health has improved sufficiently; (iii) Safety of individuals (residents) in the facility is endangered; (iv) Health of individuals (residents) in the facility is endangered; (v) Nonpayment to facility; and/or (vi) facility ceases to operate. When the facility transfers or discharges a resident under any of the circumstances specified.it must be documented in the resident's clinical record.Notice may be made as soon as practicable to the resident and/ or representative before transfer or discharge.the notice should include, the reason for discharge, the effective date of discharge.and a statement that the resident has the right to appeal the action to the state .Notice of bed-hold policy and readmission.the nursing facility must provide written information to the resident and a family member or legal representative that specifies.the duration of the bed-hold permitting the resident to return to the facility.During a concurrent interview and policy review on 3/2/26 at 11:30 am, with Administrator (ADMN), in the ADMN office, ADMN states there are no other facility policies regarding readmittance of residents after hospitalization, and the Discharge policies provided use the word transfer and discharge interchangeably. A review of Resident 3's medical record indicated that Resident 3 was admitted on [DATE] with diagnoses that included, Metabolic Encephalopathy (Brain dysfunction due to systemic illnesses that affect chemical and electrolyte imbalances), Acute Kidney Failure (loss of kidney function), and Adult Failure to thrive (rapid decline in health and functional abilities).A review of Resident 3's medical record indicated the most recent Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment of a resident's cognitive and physical capabilities and needs) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 1/20/26 indicated a score of 99 (not enough to score on a scale of 1-15) which equated to severe cognitive impairment. The MDS section D for Mood, indicated that no mood problems and Section E for Behavior, indicated that no behaviors were demonstrated. Patient 3 was not their own representative (RP), does not make their own medical decisions, but can verbalize simple wants and needs.During a concurrent interview and medical record review on 3/2/26 at 10:00 am, with ADMN and Social Services Director (SSD) in the ADMN office, Resident 3's Notice of Proposed Transfer and Discharge form was reviewed. Both ADMN and SSD confirmed resident 3 was sent to the hospital on 2/12/26 for higher level of care needs of Intravenous Catheter (IV) placement and for beating up staff behaviors. On 2/13/26 there was a meeting with the Admissions Director (ADD) and the facility decided they would not be taking Resident 3 back from the hospital. The facility faxed the Notice of Proposed Transfer and discharge, that was prepared and signed by staff on 2/13/26, to the Ombudsman (independent, neutral official who investigates complaints and issues and advocates for fairness). Resident 3's family member (FM 1) was not notified of the proposed discharge. There was no documentation in Resident 3's medical record that Resident 3 had been displaying aggressive, harmful, or dangerous behaviors towards other residents. ADMN and SSD confirmed Resident 3 did not demonstrate that he was a danger to other residents. There was no documentation from Resident 3's physician regarding physical behaviors that endangered other residents, or that Resident 3's needs could not be met by the facility. There was no evidence that a discharge plan or preparation or notice of their right to appeal the facility's decision not to allow Resident 3 to return had been provided to Resident 3 and FM.During a concurrent interview and facility policy and documentation review on 3/2/26 at 11:30 am, with ADMN in the ADMN office, Facility policies on discharge were reviewed. ADMN provided discharge policies that interchangeably used the word transfer and discharge, and stated there were no other facility policies addressing readmittance to the facility after hospitalization. Additionally, there was no documentation by the physician specifying what needs the facility could not meet for Resident 3. According to the ADMIN, the facility discharged Resident 3's due to his combativeness toward staff while attempting to place an IV, and that the family was difficult.During a concurrent interview and record review on 3/3/26 at 9:00 am, with ADMN and ADD, in ADMN office, a text message from the facility to the hospital case management (those who plan discharges for patients in the hospital) was reviewed. ADD confirmed the facility's ADD department sent the text message on the work phone on 2/17/26 to the hospital case management and informed them the facility had decided to discharge Resident 3 while he was in the hospital and would not be allowing Resident 3 to come back to the facility for the following reasons:Behavioral issues that can't be handled by facility staffAggression towards staff creating a dangerous environmentDoes not comply with treatment recommendations/plansHis caregiver interferes with careThe facility could not administer Seroquel (an antipsychotic medication to correct mood and behavior problems), that was ordered while in the hospital, could not be given by the facility.ADD and ADMN confirmed one day after Resident 3 was transferred to the hospital the facility decided not to allow him to return and confirmed there was no supporting documentation in Resident 3's medical record to justify this decision. ADD and ADMIN confirmed there was no documented harmful behaviors or that Resident 3 was a danger to others.During an interview on 3/4/26 at 1:18 pm, with FM 1 on the telephone, FM 1 confirmed they were informed of the transfer to the hospital by the facility but was not informed Resident 3 was discharged and would not be readmitted to the facility following the hospitalization. FM 1 confirmed they were first notified by the hospital case management that Resident 3 had not been accepted back to the facility. FM 1 stated that Resident 3 never had behavior problems but at the time of the hospital transfer, had a bladder infection which contributed to his confusion mood changes.A review of Resident 137's medical record indicated that Resident 137 was admitted on [DATE] with diagnoses that included, Dementia with Behavioral Disturbance (progressive brain syndrome resulting in memory loss, confusion, and personality changes and presents with agitation, aggression, and psychosis), Conduct Disorder (behavioral/emotional disorder such as aggression, bullying, property destruction), and Alzheimer's Disease (progressive incurable neurodegenerative disease causing brain cell shrinkage and death resulting in memory loss, cognitive decline and behavioral changes).A review of Resident 137's MDS BIMS, dated 2/19/2026, indicated Resident 137 had Moderately impaired (cognition)-decisions poor; cues/supervision required. Section E Behaviors, reflected Resident 137 demonstrated physical and verbal symptoms such as hitting, scratching, threatening and cursing at others. Resident 137 was not their own RP, does not make their own medical decisions, but can verbalize wants and needs.During an interview on 3/5/26 at 11:14 am, with ADMN and ADD, in the ADMN office, both confirmed they informed the hospital case management that the facility would not accept Resident 137 back to the facility and that Resident 137 was considered discharged . The reasons provided by the ADMIN and ADD were; staff and other residents were endangered by his presence. ADMIN and ADD stated that Resident 137 was aggressive verbally and physically, and attacked staff with fists, a butter knife, and a fork. No residents were attacked nor threatened. ADMIN and ADD confirmed Resident 137's family member (FM 2) was not notified of the discharge, nor could they locate the Notice of proposed Transfer and Discharge form, nor was Resident 137 and FM 2 notified that they had the right to appeal the facility's decision to discharge Resident 137. There was no evidence that Resident 137 or FM 2 were prepared in advance or given notice that they were going to be discharged from the facility while in the hospital.During a phone interview on 3/5/26 at 1:28 pm, with FM 2, FM 2 stated they were never informed by the facility that they decided not to allow Resident 137 to return to the facility after his hospitalization. FM 2 stated she was not informed that they had the right to appeal the decision to be discharged .

Based on observation, interview, and record review, the facility failed to ensure food served was palatable, appetizing, or at an appealing temperature for eleven of 124 Residents' (Resident 7, 13, 53, 68, 82, 131, as well as five confidentially interviewed residents) whose meals were cold and or unappetizing.These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value and negatively impact the residents' quality of life. (Cross references to F803)Findings During an interview on 3/2/28 at 1:54 pm, Resident 53 stated, Food is horrible. Once in a while it is ok.Once in a while they have a good food. I do not like the watered-down milk. I didn't know I could ask for something else. During an interview on 3/2/26 2:00 pm, Resident 82 stated, Food not good. Does not taste good. Chicken is tough, not good. During an interview on 3/3/26 at 7:40 am, Resident 131 stated [Breakfast] was warm when it arrived, but not hot. I don't like the egg whites, it was cold.Food is cold a lot.They serve a lot of pasta, which is cold often, and cold pasta is not appetizing. During an interview on 3/3/26 at 8:00 am, Resident 13 stated, Food is same thing over again and over again. Choices limited.I would eat if there was decent food. Meat dry, pasta not cooked. During an interview on 3/3/26 at 8:03 am, Resident 7 stated, The food is cold, mostly cold every meal, usually all of them. Now today the sausage is warm.That's the main complaint I have; is the food is always cold. During an interview on 3/3/26 at 8:05 am, Resident 68 stated, The food is not good. A lot of it is tough and bland, and tasteless. During an observation of a lunch test tray on 3/3/26 at 1:26 pm, temperatures were taken of prepared hot and cold foods. A Regular diet tray had chicken that showed 125 Degrees Fahrenheit (F), cooked zucchini that showed 125 degrees F, and a cold dish of potato salad that showed 48 degrees F. A Pureed diet tray had chicken that showed 148 degrees F, pureed zucchini that showed 135 degrees F, and a cold pureed potato salad that showed 52 degrees F. On 3/4/26 at 10:03 am, a concurrent record review and interview was conducted with the Dietary Manager (DM). During a review of facility records titled, Test Tray Evaluation, dated 10/9/25, it showed that hot food items were expected to be served between 135 F and 160F. It also showed that hot food was tested at 122F, 103 F, cold food was tested at 58 F. DM acknowledged that temperatures on test trays were noted to be cooler than expected, and had known about this potential problem since October 2025. During confidential interviews on 3/4/26 at 10:00 am, five out of six confidentially interviewed residents stated facility staff does not turn in their filled out menus to the kitchen. The CNA's take their menu and for some reason the menu does not make it back to the kitchen. The only alternatives they are offered are sandwiches. They would like different choices for alternatives. The food oftentimes is cold. If you eat in your room, they do not heat it back up. The food often does not taste good. During a review of facility policy titled, Food Temperature, dated 2/2025, it showed the temperature of potentially hazardous cold foods will be no greater than 41 degrees F or served according to state regulation.

Based on observation, interview, and record review, the facility failed to ensure glucose testing (blood sugar level check for diabetics) was performed in accordance with the facility's infection control policies and procedures for three of three sampled residents when hand hygiene was not performed before and after wearing gloves and alcohol wipes used to sanitize residents fingers was not allowed to air dry. (Residents 14, 94, and130) This failure put the residents at risk for infections and negatively impact their physical well-being by exposing them to germs.Findings: A review of facility's policy titled, Standard Precautions revised 5/2010 indicated, Standard precautions include the following practices: Change gloves as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one). Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hand immediately to avoid transfer of microorganisms to other residents or environments.A review of the facility's policy titled, Obtaining a Fingerstick Glucose Level -Level III revised 8/2016, indicated, Steps in the Procedure, Perform hand hygiene before placing the glucose testing equipment on the bedside stand or over-bed table upon a clean/protective surface. Wear clean gloves. If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the reading. Obtain a blood sample by using a sterile lancet (a sterile spring-loaded needle used to puncture skin). Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. Perform hand hygiene after removing gloves and discarding them into a designated container.During an observation on 3/3/26 at 11:48 am, with Licensed Nurse (LN) LN F, LN F put on gloves without washing her hands. LN F wiped Resident 94's fingertip with an alcohol wipe and immediately punctured Resident 94's fingertip with a lancet, before the alcohol was dry. During an observation on 3/3/26 at 11:55 am, LN F put on gloves without washing her hands. LN F wiped Resident 130's fingertip with an alcohol wipe and immediately punctured Resident 130's fingertip with a lancet, before the alcohol was dry. During an observation on 3/3/26 at 12:12 pm, LN B put on gloves without washing her hands. LN B wiped Resident 14's fingertip with an alcohol wipe then LN B waved her hand back and forth over the fingertip to dry the alcohol. LN B then walked through the hallway with the same gloves on and went to the medication cart approximately 50 feet away where she disposed of the bloody test strip (a measuring device), bloody cotton ball, and bloody alcohol wipe. LN B disinfected the glucometer and entered data into Resident 14's electronic health record, without removing her contaminated gloves. LN B then removed the dirty gloves without washing her hands and prepared Resident 14's insulin pen (a device used to administer insulin to lower blood sugar). LN B touched the medication cart, medication cart drawers, Resident 14's insulin pen and the outside of a packaged alcohol wipe and cotton ball. LN B then applied gloves without washing her hands, and went to Resident 14's room and administered the insulin to Resident 14, without washing her hands or putting on clean gloves. LN B then walked back to the medication cart (approximately 50 feet away) and put Resident 14's insulin pen back in the medication drawer, touching the medication cart and medication drawer, and computer keys before removing her dirty gloves. During an interview on 3/3/26 at 12:30 pm, with LN F, LN F stated she was unaware that the alcohol needed to dry before puncturing the fingertip. LN F stated she thought she had washed her hands before putting on gloves to perform glucose testing on Resident's 94 and 130. During an interview on 3/3/26 at 1:01 pm, with LN B , LN B stated, I thought I washed my hands when she managed Resident 14's glucose testing and insulin administration. During a concurrent interview and record review on 3/4/26 at 10:10 am, with facility Director of Nursing (DON), DON stated it is the expectation that nurses wash their hands before putting on and after taking off gloves, before doing a glucose test, and that the nurse should allow the alcohol to air dry before using the lancet to prick the finger. DON stated all LNs receive skill competency assessments for using lancets and glucose testing, which included infection control procedures.

Based on interview and record review the facility did not ensure two out of two sampled residents (Residents 11 and 130) were free from chemical restraints (behavioral management medication that could cause excessive sleepiness) when:The facility failed to appropriately monitor the specific symptoms for which psychoactive medications (altered the brain) were prescribed to Resident 11; andThe facility failed to appropriately monitor the specific symptoms for which psychoactive medications were prescribed to Resident 130.This failure caused the inability to know if the medication was working for its intended use. Findings:1.A review of the facility's policy and procedure titled, Psychoactive Medication Management and Chemical Restraint Prevention, dated 4/25/25, indicated, residents would be monitored when the physician prescribed psychoactive medications.A review of Resident 11's admission Record, dated, 8/4/24, indicated admission to the facility on 8/4/24 with the diagnoses of bipolar disorder, current mixed episode, severe, with psychotic features (a mental health illness that included severe mood swings with difficulty distinguishing reality from imagination) and major depressive disorder (feelings of sadness and hopelessness that were constant). Resident 11 was not their own responsible party (RP, decision maker).A review of Resident 11's Order Details, dated 5/28/25, indicated the Physician prescribed olanzapine (an antipsychotic medication that altered the brain) 5 milligrams (mg) by mouth every night at bedtime for bipolar disorder as evidenced by (targeted behaviors the medication treated) severe mood swings.A review of Resident 11's Order Details, dated 8/26/25, indicated the Physician prescribed Rexulti (an antipsychotic medication) 1 mg by mouth daily for bipolar disorder as evidenced by severe mood fluctuations (ups and downs) and mania (intense over the top energy).A review of Resident 11's Order Details, dated 11/17/25, indicated the Physician prescribed Seroquel (an antipsychotic medication) 25 mg by mouth for bipolar disorder as evidenced by delusions (not based in reality), hallucinations (seeing things not there), and manic thoughts (uncontrollable, speeding thoughts).A review of Resident 11's Order Details, dated 2/11/26, indicated the Physician prescribed sertraline (an antidepressant that altered the brain) 150 mg by mouth daily for major depressive disorder as evidenced by statements of sadness and tearfulness.During a concurrent interview and record review on 3/5/26 at 9:40 am, with Resident Case Manager (RCM), Resident 11's CA Behavior Notes (behavior notes) dated 3/5/25 was reviewed. RCM indicated the behavior notes reflected generalized behaviors that were assessed by facility staff. RCM confirmed there were no specific monitors in place that tracked Resident 11's targeted behavior for use of olanzapine, Rexulti, Seroquel, and sertraline.During an interview on 3/5/26 at 10:11 am, the Director of Nursing confirmed that the behavior notes were generalized and there was no specific monitor in place for Resident 11's targeted behaviors for use of olanzapine, Rexulti, Seroquel, and sertraline.2.A review of Resident 130's admission Record, dated 2/15/23, indicated, Resident 130 was admitted to the facility on [DATE] with the diagnosis of major depressive disorder, severe, with psychotic features (a sad mood that included difficulty distinguishing reality from imagination).A review of Resident 130's Order Details, dated 10/31/25, indicated the physician prescribed bupropion (an antidepressant medication) 150 mg by mouth, two times a day for major depressive disorder with psychotic symptoms as evidenced by self-isolation (staying away from people), refusal of care, and sadness.A review of Resident 130's Order Details, dated 2/2/26, indicated the physician prescribed quetiapine (an antipsychotic medication) 25 mg, give half a tablet by mouth every night at bedtime for major depressive disorder with psychotic symptoms as evidenced by hallucinations, paranoia (extreme distrust and suspicion of others), and delusions that caused fear.During an interview on 3/5/26 at 9:25 am, RCM was asked how the facility staff monitored targeted behaviors regarding use of psychotropic medication. PCM stated, when there is a change in the medication I do Alert Charting [progress note] for behaviors for medication and after four-to-six weeks they chart by exception [charting what was not normal]. RCM confirmed there were no monitors in place that tracked Resident 130's targeted behavior for use of bupropion and quetiapine.During a concurrent interview and record review on 3/5/26 at 10:32 am, with Administrator (ADM), a blank behavior notes, dated 3/5/26 were reviewed. ADM confirmed, the behavior note was generalized and was where facility staff documented witnessed behaviors. ADM confirmed there was no monitor in place that tracked Resident 11 and 130's specific targeted behavior for use of psychotropic medications.

Based on observation, interview, and record review, the facility failed to review and revise a comprehensive care plan for two of eight sampled residents (Resident 81 and Resident 131) when: 1.Resident 81 did not have activity interventions for specific needs and preferences. 2.Resident 131 did not have specific nursing interventions for shaving himself and getting out of bed. These failures had the potential to result in the residents' needs not being identified, feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: 1. During a review of the facility's policy and procedure (P&P), titled, Care Planning-Interdisciplinary Team (IDT, a group of experts from different fields working together to provide comprehensive care), revised 11/2017, the P&P indicated, Care planning begins the day of admission for all residents. The care plan is recognized as an interdisciplinary dynamic process that includes at the minimum, nursing, social services, activities and dietary. While the care planning process begins on the day of admission by nursing, the IDT is responsible for the development of an individualized comprehensive care plan for each resident on an ongoing basis. The resident, the resident's family, and/or the family's representative/guardian/or surrogate are encouraged to participate in the development of and revisions to the resident's care plans. During a review of Resident 81's clinical record titled, admission Record, indicated Resident 81 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of first lumbar vertebrae (common spinal injury described as crushed front corner of one of the lower back bones), cardiac pace maker (surgically placed device to regulate a slow heart rate), dysphagia (difficulty swallowing), high blood pressure, unspecified dementia (loss of mental functioning such as thinking, memory, mood and behavior), anxiety (an intense ongoing feeling of fear, dread, worry and uneasiness), and depression (persistent feelings of sadness and loss of interests). During a review of the most recent Minimum Data Set, (MDS, a resident assessment), dated 12/3/25, indicated that Resident 81 had a slight cognitive (process of thinking, knowing, and processing information) impairment, with a brief interview for mental status (BIMS, a screening tool for thinking, reasoning, and memory) score of 12 out of 15. During a review of Resident 81's clinical record, a record titled, Care Plan Report, dated 9/8/25, indicated Resident 81 did not have specific activity preferences for watching channel 44 for her favorite programs or updating her board in her room for the date due to memory loss. During an interview on 3/4/26 at 9:20 am, Resident 81 stated, I don't have any specific complaints, but I feel sort of overlooked, like I don't matter. Everything is more important than me. I like to watch [name of favorite TV show], but I can't remember what channel it comes on. My mind is bad, I forget things. During an interview on 3/4/26 at 9:50 am, Resident 91 stated, [Resident 81] is the best roommate. She was a missionary in Brazil. She loves to watch channel 44, but she cannot remember it so I remind her so she can watch her Christian programs she enjoys. During an interview on 3/4/26 at 10:40 am, the Resident Care Manager (RCM) confirmed Resident 81's care plan should be more resident specific. RCM stated, They need to update [Resident 81]'s board daily with the date. We have plenty of supplies such as puzzles, and pictures to color to take [Resident 81] for her preferences. During an interview on 3/4/26 at 1:05 pm, the Activities Director (AD) confirmed Resident 81 does have dementia and is forgetful. AD stated, I agree, [Resident 81] cannot remember television channels, I will add a sign for a reminder, and I will update her care plan. I will also take her more religious pictures and puzzles and update her board daily with the dates. 2. During a review of Resident 131's clinical record, a record titled, admission Record, indicated Resident 131 was admitted to the facility on [DATE] with diagnoses that included depression, benign neoplasm of the kidney (non-cancer tumor or growth on the kidney), obstructive and reflux uropathy (a blockage causing urine to not flow properly), mononeuropathy of both legs (one single nerve of each leg has damage causing pain, numbness and tingling), pneumonia (infection of one or both lungs that cause inflammation of the air sacs causing them to fill with fluid), chronic obstructive pulmonary disease (COPD, a progressive lung disease that causes shortness of breath), diabetes (too much sugar in the blood), sepsis (the body's reaction to a severe infection), muscle weakness and high blood pressure. During a review of the most recent record titled, MDS, dated 11/24/25, indicated Resident 131 had a slight cognitive impairment, with a BIMS score of 13 out of 15. During a review of Resident 131's clinical record, a record titled Care Plan Report, dated 11/5/25, indicated Resident 131 did not have specific interventions to promote independence for shaving with set up using his electric razor. This record did not have any new nursing interventions to implement for refusals to get out of bed daily. During an interview on 3/3/26 at 8:45 am, Resident 131 stated, I can shave myself, but they do it. If I had a mirror in here I would do it myself. I have an electric razor over there, pointing to the night stand beside the bed. I like to shave every other day, but they do it two times a week. I would get out of bed if they would use the Apex (mechanical device to safely lift or transfer for patients who cannot support their own weight) lift, therapy used to help me. I don't like the Hoyer (mechanical wheeled device to safely lift and transfer patients with limited mobility) lift; I hurt for a week after I use it. During an interview on 3/4/26 at 8:45 am with Certified Nursing Assistant (CNA) E confirmed she shaved Resident 131 two times weekly. CNA E stated, I did not know [Resident 131] had an electric razor. [Resident 131] does refuse to get up; he does not like the Hoyer lift. I update the nurse sometimes; I don't every day. During an interview on 3/4/26 at 10:45 am, RCM confirmed Resident 131 needed multiple care plan revisions. RCM stated, I totally agree the staff needs to update the nurse daily when Resident 131 does not want to get out of bed, and the nurses need to document all the refusals and try to encourage him to get out of bed. Resident 131's last day of physical therapy was 2/11/26. I obtained a lot of new orders for his medication regimen hoping this would help Resident 131. I am working on Resident 131's care plan revisions right now for more interventions needed. I did not know he can shave himself, but I will make sure he gets a mirror in his room so they can provide set up for Resident 131 to use his electric razor to promote his independence. During an interview on 3/5/26 at 7:50 am, the Administrator confirmed the comprehensive care plan needed revisions for Resident 81 and Resident 131.

Based on observation, interview, and record review the facility failed to ensure a telephone order (when the doctor calls the nurse to give an order for a resident) for a medication was correctly transcribed for one of eleven sampled residents when an order to give a medication in the eye was mistakenly written to be given in the ear. (Resident 58)This error has the potential for residents to receive medication via the incorrect route. Not receiving the medication via the correct route, the medication would be ineffective to treat what it was prescribed for.Findings A record review of facility policy titled, Physicians Medication Orders revised 1/16 indicated on line 6, Orders for medication must include d. Route of administration if other than oral. Line 11 stated, Physicians orders are reviewed and sent to the primary care provider monthly for ongoing order reviewing.A record review of facility policy and procedures titled, Identifying and Managing Medication Errors and Adverse Consequences revised 4/15/21 indicated, under Policy Statement The staff and practitioners shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. Under Policy Interpretation and Implementation line 1. The staff and practitioner shall strive to minimize adverse consequences by 1. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.A record review of facility policy titled, Administering Medications revised 12/25 indicated, on line 7 the individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right times, and right method of administration (also known as the 5 rights of medication administration) before giving the medication. A record review of Resident 58's Transfer/Discharge Report indicated Resident 58 was admitted on [DATE] with diagnoses of dementia (memory loss), bladder and intestine infections, and dry, irritated eyes.During an observation on 3/4/26 at 8:31 am, Licensed Nurse (LN) G administered Artificial Tears (lubricant eye drops) Solution 0.4% (percent the strength), 2 drops into each eye to Resident 58. Resident 58 had redness and swelling to both lower eye lids. A record review of Resident 58's Medication Administration Record (MAR), dated 3/1/26-3/31/26, indicated orders for, Artificial Tears Solution 0.4% to be instilled 2 drops in both ears, [instead of both eyes], every day for Dry eye, and every 6 hours as needed for dry, irritated eyes. During a concurrent interview and record review on 3/4/26 at 9:25 am, with LN G, LN G reviewed Residents 58's MARs with surveyor and confirmed the MAR order stated to give Artificial Tears in both ears instead of eyes. LN G stated, There must have been a transcription error for the medication. LN G reviewed and confirmed Resident 58's physician's orders with surveyor and determined that on 7/8/25 she entered the wrong medication route when she transcribed the telephone order for this medication.A record review of Resident 58's, Order Audit Report dated 3/4/26 indicated on 7/8/25 at 2:09 pm, LN G transcribed a telephone order for Artificial Tears, instill 2 drops in both ears every 6 hours as needed AND one time a day. Physician (MD) electronically signed order on 7/8/25 at 8:00 pm and reviewed this order on 8/21/25, 10/8/25, 11/14/25, 1/1/26, and 2/11/26, without recognizing the order entered was for the ears and not the eyes.During a concurrent interview and record review on 3/5/26 at 8:19 am, with Resident Care Manager (RCM 2), RCM 2 stated during the process of monthly order reviews (reviewing each residents MARs and physician's orders for accuracy) nursing, the MD, and their Pharmacy Consultant (PC) had not discovered the error in Resident 58's eye drop directions to be given into her ear, instead of her eye. During a telephone interview on 3/5/26 at 9:31 am, PC stated he does monthly pharmacy inspections at the facility to look at resident's medications (medication labels), orders, and MARS to ensure medication accuracy, effectiveness, and that they are prescribed appropriately for diagnosis. PC stated his last review of Resident 58's medications was on 2/11/26 at 5:00 pm.A record review of the PC's Pharmacy Inspection Dates undated for the facility indicated that on 2/11/26 at 5:00 pm, PC reviewed Resident 58's orders and MARS, there were no recommendations made for the directions on Resident 58's Artificial Tears order.During a concurrent telephone interview and record review on 3/5/26 at 10:20 am, with PC, PC reviewed Resident 58's electronic health record (EHR) for the order for Artificial Tears dated 7/8/25. PC stated, This is a pretty obvious mistake, they [Artificial Tears] directions should be instilled in eyes not ears.

Based on observation, interview, and record review the facility failed to remove expired medications from one of four treatment carts and were available for resident use.This had the potential for residents to receive expired medications which would not be effective or safe for use.Findings:A record review of facility policy titled, Storage of Medications revised 5/10, indicated under Policy Interpretation and Implementation Line 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.A record review of facility pharmacy policy and procedures titled, Medication Storage in the Facility revised 1/1/23, indicated under Procedures, line J stated, Medication storage conditions are monitored on a periodic basis by the consultant pharmacist or consultant nurse and corrective action taken if problems are identified. Line G stated, All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.An observation and concurrent interview with the Treatment Nurse (TXN) on 3/4/26 at 3:30 pm, of the Transitional Care Unit treatment cart (holds supplies for treatments), was conducted. The following expired treatment supplies and medications were identified:One tube of Coloplast Hydrophilic wound dressing gel (a zinc-oxide based paste used to treat wounds) with expiration date of 7/31/25.One tube of Benadryl cream (anti-itch cream for skin) that expired in 6/2025.Five Hemorrhoid (treats swollen veins in the lower rectum) suppositories (medication inserted in the rectum) that had expired in 9/2025.Fifteen (15) Bisacodyl (treats constipation) 10 milligram (mg, a unit of measure) suppositories that had expired in 6/2025. TXN confirmed the above treatment supplies and medications were expired and should not have been available for the residents to use. TXN stated he was not aware of who was responsible to check and remove expired treatment supplies and medications from the treatment cart.During an interview on 3/4/26 at 4:00 pm, with Director of Nursing (DON), DON stated the Infection Control Nurse and Resident Care Managers are responsible for checking for expired treatment supplies and medications on the carts, monthly. DON stated the nursing staff was responsible to check for expired treatment supplies and medications, daily. DON stated she was unaware of the expired medications on the TCU treatment cart.

Based on observation, interview, and facility document review, the facility failed to ensure:1.One of three sampled resident's minced and moist (MM5) therapeutic diets (special needs diet plans), was prepared according to the recipe. (Resident 143)2. Nursing staff had a current and complete diet manual reference.These failures had the potential to result in residents receiving diets that do not match physicians' orders and incorrect preparation of special therapeutic diets and for nursing staff not to have reference material to recognize when a diet is served incorrectly. Findings:1.On 03/03/2026 at 10:30 AM, during a kitchen observation, [NAME] 1 (CK 1) was preparing minced and moist diet (MM5, foods are finely chopped and kept moist so they are easier to chew and swallow) minced (foods that have been cut or chopped into very small, fine pieces), chicken without referring to the recipe.On 03/03/2026 at 11:50 AM, during a kitchen observation during lunch trayline, a MM5 diet tray for Resident 143 included minced chicken with BBQ sauce on top.A review of the facility document titled BBQ Chicken Method, dated 2002-2026, showed MM5: Debone chicken. Mince regular cooked portions.Serve 2 oz (ounces) meat mixed with thick gravy.A review of the facility policy titled, Cooking Food, dated April 2019, showed Recipes will be followed for the menu items. Check the spreadsheets for alternate items needed for diet and texture modification.A review of the International Dysphagia Diet Standardization Initiative (IDDSI) website titled IDDSI, dated 1/2019, the IDSSI guideline indicated, Level 5 Minced and Moist Can be scooped and shaped (e.g. into a ball shape) on a plate and Meat Serve in mildly, moderately or extremely thick, smooth, sauce or gravy, draining excessA review of the facility document titled, Resident CF Order Summary Report, dated 3/4/26, showed Resident 143 had an order for Regular Diet Minced and Moist texture, thin consistencyDuring an interview with Dietary Manager (DM) on 03/04/2026 at 10:03 AM, DM stated when shown the picture of the Minced and Moist tray that it doesn't meet the IDDSI guidelines for texture and is not therefore following the diet order for MM5.2.On 03/03/2026 at 10:15 AM a concurrent interview and observation was conducted with Licensed Vocational Nurse (LVN H) at the nursing station. LVN H could not locate the diet manual. LVN H stated she had never heard of a diet manual and didn't know what it was used for. LVN H called the Registered Dietitian Nutritionist (RDN) to find out more information. RDN delivered diet manual from another nursing station.A review of the facility, [Facility Name]/ HPSI Diet Manual (guide or reference that provides instructions, plans, and information about different diets and nutrition), dated 1/30/26, the manual did not include information on the soft and bite sized diet (SB6) (foods are soft in texture and cut into small, manageable pieces that are easy to chew and swallow) and MM5.A review of the facility, Diet Spreadsheet (a sheet containing the kind and amount of food each diet would receive), dated Tuesday Week 2, indicated SB6 and MM5.During an interview with Dietary Manager (DM) on 03/04/2026 at 10:03 AM, DM stated that he approved of the diet manual 1/30/2026 and acknowledged that the diet manual does not include information regarding the puree, SB6 and MM5. DM stated the mechanically altered diet information for IDDSI should be included so that the nurses have a reference. DM stated that the diet information that is currently in the manual is obsolete and no longer used in the facility.

Based on interview, and record review, the facility failed to ensure one of three sampled residents, (Resident 1) was treated with respect and dignity during direct personal care when Certified Nursing Assistant (CNA) I rushed Resident 1 and held his arms to prevent hitting staff when the bed linen was changed. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes.Findings: During a review of the facility's policy revised 8/2017, titled, Quality of Life-Dignity, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with respect and dignity at all times. Treated with respect and dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. This facility's policy indicated staff shall treat cognitively impaired residents with dignity and sensitivity addressing the underlying motives or root causes for behavior and not challenging or contradicting the residents' beliefs or statements. During a review of Resident 1's record titled admission Record, indicated Resident 1 was admitted the facility on 7/30/25 with diagnoses that included Alzheimer's disease (a progressive brain disorder that slowly destroys a person's memory and thinking skills, eventually leading to dementia), vascular dementia with agitation (brain damage that affects communication, behaviors, slowed thinking, frustration and agitation), delusional disorder (a fixed, false belief), cerebral infarction (commonly known as stroke), diabetes (too much sugar in the blood), atrial fibrillation (irregular and fast heart beat), depression (persistent feelings of sadness and loss of interest), anxiety (a feeling of fear, dread, and uneasiness), chronic pain (ongoing persistent pain), malignant neoplasm of the kidney (kidney cancer), dysphagia (difficulty swallowing) and metabolic encephalopathy (a brain dysfunction caused by an underlying condition). During a review of Resident 1's record titled, Minimum Data Set, (MDS, a resident assessment), dated 8/1/25, indicated Resident 1 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of 1of 15 and and is unable to make his own decisions. Section GG of the MDS indicated Resident 1 needed maximum assistance (helper does more than half the work) for incontinent care and personal hygiene. During a review of a record dated 7/10/25, titled, CNA/HHA/CHT Report Of Misconduct, indicated It is reported during resident care on 7/9/25 at 11:00 pm, the resident became agitated and combative, twisting and punching at staff. In house staff (CNA G) reported that a local registry staff (CNA I) had held Resident 1's hands down on his chest. CNA G told CNA I to stop three times before she would let go. During an interview on 9/10/25 at 1:23 pm, the administrator (Admin) stated, [Resident 1] has hurt some of our staff with combative behaviors, but we terminated CNA I for misconduct. I do think [Resident 1]'s rights and dignity was violated during the incident on 7/9/25 providing direct care. During an interview on 9/10/25 at 1:35 pm, the Director of Nursing (DON) stated, I am not making excuses for CNA I's conduct, but I do believe she was trying to protect herself from getting hurt. I agree [Resident 1] has combative behaviors but he has the right to be treated with respect and dignity in spite of any behaviors. During an interview on 9/10/25 2:25 Licensed Nurse (LN) C stated, [Resident 1] has delusions causing fear. I do know right in the middle of direct care, when you are not expecting he will just start hitting at you. I do confirm no staff should hold [Resident 1]'s hands or continue care if he is really upset or hitting, they should walk away and come back later. During an interview on 9/10/25 at 2:55 pm, CNA G stated, I did witness CNA I hold [Resident 1]'s hands down to his chest while we were changing the linen during direct personal care. I told her to leave the room, and I had another staff member help me complete the bed change. I reported CNA I immediately for her behavior. During an interview on 9/10/25 at 3:30 pm, the Admin and DON confirmed CNA I had not treated Resident 1 with respect and dignity while providing care, which was a violation of Resident 1's rights. Both Admin and DON confirmed treating any resident in a rude, disrespectful manner, or holding their hands down for any amount of time is unacceptable and will not be tolerated under any circumstances.

Based on observation, interview, and record review, the facility failed to ensure that staff responded in a timely manner to residents' requests for assistance for one of four sampled residents, (Resident 1), when call-lights were not answered for greater than 20 minutes multiple times. These failures had the potential to negatively impact residents' physical, emotional and psychosocial well-being and left Resident 4 feeling unfairly treated. Findings: During a review of the facility policy titled, Resident Rights dated 5/2010, the policy indicated that 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity . Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including depression, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), diabetes, insomnia, high blood pressure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue), muscle weakness. A review of Resident 4's Minimum Data Set (MDS, an assessment tool), Resident 4 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 13 out of 15, which indicated she was able to make her own decisions. During an interview on 2/27/25 at 11:38 AM, with Resident 4, Resident 4 stated that she frequently had to wait for the call light to be answered for a long time. Resident 4 stated that this made her feel that facility staff were being unfair to her. During a concurrent interview and record review on 2/28/25 at 11:56 AM, with the Director of Staff Development (DSD) of call light logs for Resident 4 for 2/14/25 to 2/28/25 indicated 54 instances of call light responses being 20 minutes or longer. The longest wait time being 1 hour occurring on 2/16/24, 2/17/25, 2/18/25, and 2/20/25. The DSD stated that staff are expected to answer call lights as soon as possible.

Based on interview, and record review, the facility failed to review and revise the care plan for one of four sampled residents (Resident 4), when Resident 4 had an unintentional significant weight loss of 5 percent (%) in one month. This failure had to potential for Resident 4 to have unwanted weight loss and negatively impact his physical well-being. Findings: Review of admission records for Resident 4 indicated Resident 4 was admitted to the facility on [DATE], with diagnoses including depression, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), diabetes, insomnia, high blood pressure, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue), muscle weakness. Review of the facility's policy titled, Weight Assessment and Intervention dated 5/2018, indicated, 3. Any weight change of 5 pounds or more since the last weight assessment .will be retaken the next day for confirmation , 4. The Dietitian will respond either in person, phone consult or through electronic consult , 1 month - 5% wt loss is significant . , 2. Individualized care plans shall address .a. The identified causes of weight loss, b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment . During an interview on 2/27/25 at 11:38 AM, with Resident 4, Resident 4 indicated that she had lost weight and wanted to gain some weight back. During a review of Resident 4's meal monitoring documentation for 1/29/25 to 2/27/25 indicated that out of 86 meals, Resident 4 consumed 25% or less of the meals 63 times. During a review of Resident 4's Weights and Vitals Summary, the document indicated Resident 4 weighed in on the following dates: 1/14/25 175.8 lbs 1/21/25 173.3 lbs 2/4/25 171 lbs 2/11/25 167.3 Additionally, the document noted, MDS: -5.0% change over 30 day(s) [Comparison Weight 01/14/2025, 176.0 lbs, -5.1%, -9.0 lbs] During a review of Resident 4's Dietary admitted d 9/24/24, the document indicated that Resident 4 had lost weight and, Resident stated she has lost a significant amount of weight and would like to gain some back and that her nutritional goal was To gain some weight back . During a concurrent interview and record review on 2/27/25 at 2:14 PM, with the Registered Dietitian (RD), the RD stated that Resident 4's weight loss was considered a significant weight loss. The RD stated that she had not spoken to Resident 4 about the weight loss. The RD confirmed that Resident 4's care plan had not been revised to reflect Resident 4's significant weight loss. During a concurrent interview and record review on 2/28/25 at 8:51 AM, with the Resident Care Manager (RCM), the RCM stated that the facility usually re-weighs residents after a weight change to confirm that the resident's weight actually changed. The RCM stated that Resident 4 had not allowed them to re-weigh her, so they didn't know for sure if there was a weight loss. Review of the facility's document titled, NAR (Nutrition At Risk) no date, the document indicated that, Every morning review weights and vitals portal. Weekly run a weights and vitals summary report and review , If a weight change of 5# [pounds] or more has occurred- need reweigh-within 24 hours . The document was in flow chart form and gives two options, either the reweigh confirms the weight loss or the reweigh does not confirmed the weight loss. There is no option for how to proceed in the flow chart if the resident refuses to be weighed. During an interview on 2/28/25 at 9:49 AM, with the facility Administrator (ADM), the ADM confirmed that there should have been a care plan item that reflected Resident 4's significant weight loss.

Based on interview and record review, the facility failed to ensure staff demonstrated appropriate competencies (knowledge, skills, and abilities that were required to provide safe and effective care to residents) when providing care for three out of three sampled residents (Residents 1, 2, and 3) when: 1. Licensed Nurses (LN) did not perform an assessment of Resident 1 ' s surgical site. 2. A Certified Nurse Assistant (CNA) documented Resident 2 received a shower when Resident 2 did not receive a shower. 3. Residents 1, 2, and 3 experienced long call light wait times. 4. The competency checklist for registry staff (third party staff, employed by a registry agency and travels to different facilities to work) consisted of a self-evaluation and did not include oversight for evaluation of competencies or skills. These failures had the potential for an infection to go unnoticed and to negatively impact resident ' s physical, mental, and psychosocial well-being. Findings: 1. A review of the facility ' s policy and procedure (P&P) titled, Wound Care-Level II, revised 3/1/17, indicated, the purpose of the P&P was to .provide guidelines for the care of wounds to promote healing and documentation progress. The P&P indicated, LN would document wound assessments and progress of wound healing that included a description of the wound, including the size of the wound, drainage amount, or if there was a change in the condition of the wound. A review of the undated Admissions Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of weakness and encounter for surgical aftercare following surgery on the nervous system (surgery performed on the back near or on the spine). Resident 1 was her own responsible party (RP, made own decisions). A review of the admission Minimum Data Set (MDS, an assessment tool), dated 10/16/24, Section C, indicated, Resident 1 had a Brief Interview for Mental Status (BIMS, tested a resident ' s ability to recall information and memory). Resident 1 scored a 15, (the test was scored from 0-15 where 0 meant the resident was not able to remember and 15 meant the resident had intact memory). A review of Resident 1 ' s Nursing Admission Assessment, dated, 10/15/24, indicated, Resident 1 was admitted to the facility with a surgical incision and there were no signs or symptoms of an infection to the surgical site. A review of Resident 1 ' s Skilled Nursing Progress Note, dated 10/19/24, indicated, Resident 1 ' s had a surgical incision present and the incision was well approximated (the edges of the surgical incision fit together nicely) and there were no signs or symptoms of an infection. During a concurrent interview and record review on 10/30/24 at 2:10 pm, with LN A, Resident 1 ' s Skilled Nursing Progress Note, dated 10/20/24 was reviewed. LN A stated, the Skilled Nursing Progress Note indicated, Resident 1 did not have a surgical incision. LN A confirmed, LN A performed Resident 1 ' s assessment and completed the Skilled Nursing Progress Note documentation. LN A stated, Resident 1 did have a surgical incision, located on her back, and that LN A failed to document the surgical incision site on the Skilled Nursing Progress Note. During a concurrent interview and record review on 10/30/24 at 2:59 pm, with LN B, Resident 1 ' s Skilled Nursing Progress Note, dated 10/21/24 was reviewed. LN B stated, the Skilled Nursing Progress Note, indicated, Resident 1 did not have a surgical incision. LN B confirmed, LN B performed Resident 1 ' s assessment and completed the Skilled Nursing Progress Note documentation. LN B stated, Resident 1 did have a surgical incision on her back and that LN B failed to document the surgical incision site on the Skilled Nursing Progress Note. A review of Resident 1 ' s IDT Progress Note, dated 10/21/24, indicated, Resident 1 ' s . incision to spine found inflamed and hot to touch ., and there was purulent drainage (a thick, milky discharge that usually indicated the wound was infected). The IDT Progress Note, indicated, Resident 1 stated the surgical site itched and was painful. A review of Resident 1 ' s IDT Progress Note, dated 10/21/24 (written on the same date with a different time stamp), indicated, the facility ' s physician ordered an antibiotic (a medication that treated infections) for Resident 1. During a concurrent interview and record review on 11/1/24 at 8:55 am, with Director of Nursing (DON), Resident 1 ' s progress notes, dated 10/16/24 through 10/21/24 was reviewed. DON confirmed, the Skilled Nursing Progress Note, dated 10/20/24 and 10/21/24 indicated, Resident 1 did not have a surgical incision. DON confirmed, Resident 1 did have a surgical incision and stated, the expectancy was for LNs to describe what the incision looked like and if there were signs and symptoms of an infection. DON reviewed both of Resident 1 ' s IDT Progress Notes, dated 10/21/24 and confirmed, the facility ' s physician ordered an antibiotic due to an infection at the surgical site and stated there was no other documentation in Resident 1 ' s medical records that indicated when Resident 1 ' s surgical incision developed drainage or signs and symptoms of an infection and should have. 2. A review of the facility ' s P&P titled, Charting and Documentation, revised 5/1/10, indicated, all services provided to residents would be documented in the resident ' s medical record. A review of the facility ' s P&P titled, Shower/Tub-Level II, revised 8/1/17, indicated, that each time a resident received a shower or bath, the date and time would be documented in the resident ' s medical record. A review of the undated, Admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of surgical aftercare following surgery on the nervous system and depression. Resident 2 was her own RP. A review of the admission MDS, section C, dated 10/29/24, indicated, Resident 2 had a BIMS score of 15. Section GG of the MDS, indicated, Resident 2 was dependent upon facility staff for showers and baths. During an interview on 10/30/24, at 9:28 am, Resident 2 stated that her hair was dirty, and it was driving Resident 2 nuts and had not received a shower since admission to the facility, five days ago. Resident 2 stated, facility staff had also not offered a bed bath or provided Resident 2 with wash cloths so that Resident 2 could clean herself. During a concurrent interview and record review on 10/30/24 at 10:30 am, with Director of Staff Development (DSD), the Schedule for October 2024 (documentation for care provided by CNAs), dated 10/1/24 through 10/30/24 was reviewed. DSD stated, Resident 2 was scheduled to receive a shower on 10/29/24 and stated the documentation indicated, Resident 2 had received a shower on 10/29/24. During an interview on 10/30/24 at 11:45 am, CNA D confirmed, being responsible for providing Resident 2 with a shower on 10/29/24. CNA D confirmed, Resident 2 did not receive a shower or a bed bath and stated, CNA D documented that Resident 2 received a shower by mistake. 3. A review of the facility ' s P&P titled, Answering the Call Light- Level 1, revised 8/1/17, indicated all facility staff was responsible for answering call lights as soon as possible. A review of the undated Admission Record, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of respiratory failure, weakness, and repeated falls. Resident 3 was his own RP. A review of the Resident Council Minutes (a group of residents that met monthly to discuss resident rights and concerns), dated 4/30/24, indicated, residents of the facility had experienced long call light wait times that lasted up to 30 minutes. A review of the admission MDS, section C, dated 10/29/24, indicated, Resident 3 had a BIMS score of 14. The admission MDS section GG indicated; Resident 3 could not move from a sit to stand position without moderate assistance from staff. During an interview on 10/25/24 at 1:27 pm, Resident 1 stated, I pressed the call light one time when . Resident 1 needed assistance to utilize the bathroom. Resident 1 stated, the call light rang for 45 minutes before staff came into the room. Resident 1 stated, I needed to use the bathroom. I ended up wetting myself and the nurse said my dressing [wound bandage located on Resident 1 ' s back] had urine on it. Resident 1 stated, due to long call light wait times, Resident 1 would have to yell out for staff to come assist her, and that it made Resident 1 feel uncomfortable living at the facility. During an interview on 10/25/24 at 9:11 am, Resident 3 stated, waiting up to 45 minutes for facility staff to answer the call light. Resident 3 stated, usually, Resident 3 pressed the call light when Resident 3 needed water or to use the bathroom. During an interview on 10/30/24 at 9:28 am, Resident 2 stated on 10/28/24, it took facility staff one hour to answer the call light. Resident 2 stated inability to recall if Resident 2 needed assistance due to urinating on herself or if she pressed her call bell due to having pain. Resident 2 stated, being angry that facility staff did not answer the call light and utilized her phone to call the facility to request assistance. During a concurrent interview and record review on 10/30/24 at 10:30 am, with DSD, the electronic time log (Call History, captured how long it took staff to answer call lights), dated 10/10/24 through 10/30/24 was reviewed. DSD stated the Call History indicated long call light wait times for Resident 1 on: 10/17/24 at 12:51 pm for 34 minutes, 10/17/24 at 5:25 pm for 30 minutes, 10/20/24 at 7:42 am for 33 minutes, 10/21/24 at 2:24 pm for 39 minutes, 10/22/24 at 9:51 am for 47 minutes, and 10/23/24 at 5:30 pm for 41 minutes. DSD reviewed Resident 2 ' s Call History, dated 10/28/24, and confirmed at 8:35 am, Resident 2 experienced a one-hour call light wait time. DSD stated, it was everyone ' s responsibility to answer call lights as soon as possible and confirmed Resident 1 and 2 experienced long call light wait times. During a concurrent interview and record review, on 10/30/24 at 2:49 pm, with DSD, Resident 3 ' s Call History, dated 10/11/24 through 10/16/24 was reviewed. DSD confirmed, the Call History indicated Resident 3 had experienced long call light wait times, over 20 minutes, on two different occasions, and should not have. Upon further review of Resident 3 ' s Call History, the Call History indicated long call light wait times for Resident 3 on: 10/11/24 at 6:51 pm for 36 minutes, 10/12/24 at 1:02 pm for 26 minutes, 10/12/24 at 2:49 pm for 24 minutes, 10/15/24 at 2:42 pm for 32 minutes, and 10/16/24 at 1:26 pm for 25 minutes. 4. The State Operations Manual (SOM), dated 8/8/24, defined competency as a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. The SOM indicated, Examples for evaluating competencies may include but are not limited to: . lectures, testing, and demonstration. During a concurrent interview and record review on 11/1/24 at 9:38 am, with the facility ' s Administrator (ADMIN), LN A ' s Med Surg/Skilled Nursing Skills Checklist, dated 7/3/23 and CNA D ' s CNA Skills Checklist, dated 4/17/24, was reviewed. Admin stated, the skills check lists for LN A and CNA D indicated that it was a self-assessment (where a person self-identified if they were competent or not in providing safe care to residents). ADMIN reviewed LN A ' s check list in its entirety and confirmed, the self-assessment of LN A ' s competencies and skills did not include whether LN A was competent or had appropriate skills regarding assessing wounds or providing wound care. At 9:54 am, the DSD joined the interview and record review. DSD confirmed, LN A and CNA D ' s check lists indicated they were self-assessments and stated, the facility did not validate registry staff ' s competencies and relied upon the staffing agency to do that.

Based on observation, interview, and record review, the facility failed to ensure that the pureed food (food that is either ground, mashed or blended into a pudding like consistency), recipes were followed. This failure resulted in unappetizing food and had the potential for 11 residents who received pureed food, to receive diets that had not met their nutritional needs. Findings: A review of the facility Matrix (a record of residents and their needs), showed that 11 of 115 residents received pureed diets. A review of the facility's policy titled, Cooking Food dated 8/23/23, indicated, Recipes will be followed for the menu items. A review of the facility's recipe titled, P Seas Spinach no date, indicated that this recipe made 5 servings and called for 2.5 cups of seas spinach, and 3 tablespoons of thickener. The recipe provided instructions to reserve cooking liquid and add the liquid back to the spinach when pureeing it in the Robot Coupe (RC a device used to grind or puree food), and reheat to 165 degrees Fahrenheit (F). During a concurrent observation and interview on 10/8/24 at 11:23 am, [NAME] 1, was observed adding 11 number 8 scoops (equivalent to five and a half cups) of cooked spinach into the RC, instead of 2 and a half cups as the recipe indicated. [NAME] 1 then added an unmeasured amount of hot water to the spinach. [NAME] 1 was observed adding one fourth of a cup, instead of 3 tablespoons, of thickener to the cooked spinach in the RC and blended the product until smooth. A review of the facility's recipe titled, P Cornbread/[NAME] no date, indicated that this recipe made 20 pureed cornbread muffins. The recipe directed to use 1 quart of hot water and 1 teaspoon of margarine for each cornbread muffin. The recipe provided instructions to place the cornbread muffins and margarine into the RC and process until fine crumbs, then add warm milk or water until smooth. During an observation on 10/8/24 at 11:31 am, [NAME] 1 was observed adding 11 cornbread muffins, instead of 20, into the RC and added hot water from a pitcher without measuring the water and blended the product until smooth. A review of the facility's recipe titled, Sweet Potatoes no date, indicated that this recipe made 50 pureed servings and called for 10 pounds plus 6 and a half ounces of potato, sweet, chunks, frozen and 1 and a half teaspoons of spice, nutmeg, ground. The recipe provided instructions to sprinkle the sweet potatoes with nutmeg, heat thoroughly until tender, and for puree to place portions needed into the RC and process until smooth and reheat to 165 degrees F. During an observation on 10/8/24 at 11:38 am, observed [NAME] 1 take the sweet potatoes out of the foil they had been cooked in, then peeled the skins off, and added 20 sweet potatoes, instead of the frozen sweet potato chuncks, into the RC. [NAME] 1 then added hot water from a pitcher without measuring the water, and blended the product until smooth. A review of the facility's recipe titled, P Roast Turkey no date, indicated that this recipe made 5 servings of pureed turkey. The recipe called for 10 ounces of roast turkey, one fourth cup of thickener, and 1 cup of hot liquid, hot water, or low sodium broth. The recipe provided instructions to grind the turkey to a fine texture, prepare a slurry with thickener and hot liquid and mix well with a wire whip, add half the slurry to the processed roast turkey, process for 1 minute and if too dry add more slurry until meat is a pudding consistency, scrape down sides of the RC bowl and reprocess for 30 seconds, and reheat to 165 degrees F. During an observation on 10/8/24 at 12:05 pm, observed [NAME] 1 add 11 two-ounce pieces (22 ounces), of cooked turkey, an unmeasured amount of hot water from a pitcher, and add an unmeasured amount of thickener from an amber colored pitcher with visible white debris on the inside, outside, and handle of the pitcher to the RC and blend the product until smooth. During an interview on 10/10/24 at 9:46 am, with the Registered Dietitian (RD), the RD confirmed that she expected the cooks to follow the recipes exactly. The RD confirmed that recipes could not be altered or revised, without the RD's approval.

Based on observation, interview, and record review, the facility failed to ensure Resident 2's right to be free from abuse and to protect Resident 2 from physical and mental abuse when Certified Nursing Assistant (CNA) 1 was excessively rough and rude toward Resident 2, rushed and shoved Resident 2 into the bathroom during toileting, refused to clean feces off of the toilet, pried Resident 2's fingers from a grab bar and forced Resident 2 down onto the toilet, and after leaving the bathroom, CNA 1 wadded up and threw a blanket at Resident 2. This resulted in physical and mental abuse by CNA 1 toward Resident 2. Resident 2 expressed feeling pain that felt like scalding hot water to his buttocks, helpless and unable to defend himself, and fearful of CNA 1, and had the potential to continue to adversely affect Resident 2's physical and psychosocial well-being. Findings: According to the faxed report received by CDPH (California Department of Public Health) from the facility on 11/6/15, an allegation of physical abuse by CNA 1 toward Resident 2, Resident 2 reported receiving rough personal care from CNA 1. Resident 2 reported that he was afraid of CNA 1 and did not feel safe with him providing his care. Resident 2's record was reviewed. Resident 2 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the facility's Minimum Data Set (MDS, a resident assessment), dated 10/7/15, Resident 2 was alert, oriented and required assistance to use the bathroom. Review of a written statement made by the Social Services Director (SSD) on 11/6/15 (no time), the SSD indicated, in a conversation she had with Resident 2, Resident 2 told her that CNA 1 has been rough with me before, but this was the first time that he had tried to man handle me. I was scared of him .but I'm [AGE] years old so what am I supposed to do. Review of an IDT (interdisciplinary team of various facility staff who meet to discuss resident care needs) progress note, dated 11/6/15 at 1:59 pm, indicated Resident 2 expressed feeling upset and was described to appear to be down and more quiet than usual. Review of a Behavior Note, written by the SSD on 11/9/15 at 8:32 am, Resident 2 stated, I'm still upset, but I'm not scared anymore. Review of a document titled, Disciplinary Action, dated 7/26/15, indicated that another resident had complained that CNA 1 had held her arm too tight while providing personal care. CNA 1 had received corrective retraining following this complaint. During an interview on 11/13/15 at 8:20 am, the Administrator (Admin) reported that Resident 2 had reported that CNA 1 had provided rough and rude care to him around 4 am on 11/6/15. The Admin reported that Resident 2 was alert and oriented. The Admin reported that CNA 1 was terminated following his initial suspension during this investigation, due to job performance concerns, which included a previous report of rough care being provided to a different resident. During an observation and interview with Resident 2 on 11/13/15 at 9:40 am, Resident 2 reported that on 11/6/15 at 4 am, CNA 1 seemed annoyed from the moment that he entered his room to answer his call light for assistance to the bathroom. Resident 2 stated that CNA 1 roughly pushed and rushed me into the bathroom. Upon entering the bathroom, Resident 2 noticed that there was feces left on the toilet seat and asked CNA 1 to please clean it off prior to being placed on the toilet. Resident 2 stated that CNA 1 refused to clean it. Resident 2 stated that he grabbed the bar in the bathroom, but CNA 1 roughly pried his fingers off and forced him down onto the toilet. Resident 2 stated that this movement hurt his arm and his bottom. Resident 2 stated, This hurt a lot. It made me feel terrible and described the pain on his bottom when it made contact with the toilet seat as feeling like scalding hot water. After leaving the bathroom and returning to his recliner, Resident 2 stated that CNA 1 wadded it up and threw a blanket at him. Resident 2 stated that he felt that CNA 1 was excessively rough and rude. Resident 2 stated that he felt helpless and unable to defend himself. Resident 2 became extremely emotional and upset when recounting this episode. During an interview with the Resident Care Manager (RCM, a licensed nurse) on 11/13/15 at 10:10 am, she reported that Resident 2 is alert and oriented and not the type of person to make a big fuss over nothing. The RCM stated that she was absolutely appalled by the care that Resident 2 described receiving from CNA 1, and that this behavior was completely not acceptable. The RCM acknowledged that CNA 1 had been previously written up for providing rough care to a different resident. The facility's policy titled, Abuse Prevention Program, dated 5/2014, indicated that all residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. This facility is committed to protecting their residents from abuse by anyone including, but not necessarily limited to; facility staff, other residents, consultants, volunteers, staff from other agencies providing services, family members, legal guardians, surrogates, sponsors, friends, visitors or any other individuals.

Based on observation, interview, and record review, the facility failed to ensure effective pain management for one of 24 sampled residents, Resident 20, when he was not given ordered pain medication, timely. This resulted in Resident 20 experiencing severe left knee and back pain, which adversely affected his physical and psychosocial well-being. Refer to F 425. Findings: Resident 20's record was reviewed. He was admitted on [DATE] for physical therapy and rehabilitation after left knee replacement surgery. During an observation and interview on 6/2/15 at 4:10 pm, Resident 20 was in a chair in his room, grimacing and restless. He complained of left knee and back pain which he described as nine and a half on a scale of 10 (in which one represents little to no pain and 10 is the worst pain imaginable). He stated he had been in extreme pain since the prior afternoon, and he was in too much pain to be able to sit still. According to a review of Resident 20's Medication Administration Record [REDACTED] [MEDICATION NAME] ER (a long-acting narcotic pain medication) 10 mg (milligrams) every 12 hours; the order was written 6/2/15 at 9:20 am. None had been given until 7:22 pm, 10 hours after it was ordered by the physician. [MEDICATION NAME] (a strong narcotic pain medication) 5 mg every four hours as needed; the order was written 6/2/15 at 1:36 pm, but was not supplied by the facility's supplying pharmacy. A nurse administered one dose from the facility's emergency supply kit at 2:03 pm. [MEDICATION NAME] was not given again until 6/7/15, according to the facility's Controlled Substance History record. [MEDICATION NAME] (another narcotic pain medication) 10/325 mg, one or two tablets every four hours as needed. The physician's orders [REDACTED]. Resident 20 received only three doses, two tabs each time, on 6/2/15 at 12:29 am, 4:47 am, and 8:49 am. The last dose was given on 6/2/15 at 8:49 am, and he continued to complain of severe pain. [MEDICATION NAME] (a drug used to relieve nerve pain and restless legs) 300 mg every four hours as needed. The order was written on 5/31/15; none had been given until 6/2/15 at 9:21 pm. The last dose given was on 6/3/15 at 11:19 am. During an interview on 6/2/15 at 4:20 pm, Licensed Nurse (LN) I stated both the medication cart and the automated medication dispenser were out of the pain medications ordered for Resident 20. She stated he had not received anything for pain since 8:49 am that morning. Resident 20 did not receive pain medications, as ordered, to effectively treat and manage his severe pain. During an interview on 6/3/15 at 10:40 am, the Director of Nurses stated the facility should never be unable to obtain a pain medication because they have a satellite pharmacy that can deliver medications to the facility. During an interview on 6/3/15 at 11:35 am, Resident 20 stated he had to go out to the nurses' station the previous night and make a stink in order to get something for his pain. The facility's Pain Assessment and Management policy, dated 2009, indicated, The pain management program is based on a facility-wide commitment to resident comfort. The policy directed, Implement the medication regimen as ordered.

Based on interview and record review, the facility failed to ensure placement of a nasogastric tube (NGT, a tube passed through the nose into the stomach used to provide liquid nutrition, water, and medications), in accordance with physician's orders [REDACTED]. Placement verification can help prevent aspiration). This failure resulted in Resident 17's condition worsening, due to aspiration of feeding liquid into his lungs, requiring transfer to the hospital emergency room (ER) on [DATE] for further evaluation and treatment where he was determined by the ER physician to have dehydration, requiring intravenous (IV, via the vein) fluid replacement, pneumonia, and suspected urinary tract infection. Resident 17 died on [DATE]. The hospital physician's discharge summary documented Resident 17 died of acute cardiopulmonary (heart and lung) failure secondary to aspiration pneumonia. Findings: Resident 17 was reviewed on [DATE]. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. or muscle. Slough or eschar may be present. Often includes undermining and tunneling) left hip pressure ulcer (tissue loss involving with exposure to muscle or bone that developed from unrelieved pressure), indwelling urinary catheter (a tube inserted into the bladder to drain urine), urinary tract infection, and altered mental state. On [DATE], the Speech Therapy Daily Treatment Note indicated Resident 17 had profound dysphagia (difficulty swallowing), unable to tolerate anything oral at this time, and recommended nothing by mouth (NPO). A physician's orders [REDACTED]. A physician's orders [REDACTED]. A progress note, dated [DATE] at 9:50 pm, written by Registered Nurse (RN) G indicated, MD called back with orders to place a NG tube, start [MEDICATION NAME] 1.2 (liquid nutrition formula) at 40 (8 teaspoons, tsp) cc's (cubic centimeters) per hour for four hours then increase to 60 cc's (four Tablespoons) per hour, and flush with 200 cc's (6 ounces and 4 tsp) of water every six hours (by NG tube). Check placement (of the NG tube) with x-ray. A progress note, dated [DATE] at 12:06 am, written by RN G indicated, NG tube placed in left nostril (nose). Some gastric fluid return noted. Able to hear air over the xiphoid (end of the breast bone, considered to be over the stomach) process when pushing air (with a syringe) into NG tube. Started feeding at 40 cc per hour with no issues. Will Monitor. A progress note dated [DATE] at 4:07 am, written by RN F indicated, NG tube place in left nostril running continuously with Glucerna (not [MEDICATION NAME] as ordered) at 40 cc per hour for four hours, At 4 am, checked for residual (unabsorbed liquid in the stomach) for 10 cc (two tsp). Flushed (NG tube) with 200 cc of water. Increased continuous (pump) rate to 60 cc per hours. Resident tolerated procedure. Head of the bed at 90 degrees (sitting up position). Moments of sleep apnea (period of not breathing), lungs sound course. respirations (breaths) are 20 per minute (12 - 20 considered normal). A progress note, dated [DATE] at 7:20 am, written by RN E, indicated, patient had a NG tube placed in left nostril during the night and awaiting chest x-ray for placement. At 7:49 am, RN E indicated in a progress note, resident weak, audible (able to hear when standing next to the resident) gurgling rales (loud sound indicating fluid in the lungs or throat). He is lying in bed at 90 degrees with mouth wide open and having apnea (pauses in breathing) episodes in between the gurgling rales with wet non-productive cough. Vital signs are . irregular pulse 110 beats per minute (60 to 90 is considered normal), respirations 24. His lungs are very course crackles . On [DATE] at 9:36 am, a progress note written by RN E indicated, MD notified that NG tube not in stomach, order to remove and send to ER for evaluation. On [DATE] at 10:50 am, RN E was interviewed. She stated on [DATE], she received report at 7 am from RN F at the beginning of her shift. RN F had reported that Resident 17 had a hard time during her shift and had a bad night. RN E stated she asked if a chest x-ray had been obtained to check the placement of the NG tube. RN F informed her the x-ray had not been done. RN E stated after report she immediately went to assess Resident 17's condition. She stated she turned off the feeding tube and arranged to have an x-ray taken to check the NG tube placement. She stated Resident 17 had a difficult time breathing. She stated the x-ray was taken by 8 am. RN E stated she called the physician and obtained orders to remove the NG tube and send Resident 17 to the emergency room for evaluation. A X-ray report, dated [DATE], indicated the following: Significant findings. Check x-ray compared to [DATE] x-ray. Indication: congestion. Findings: There is no NG tube visualized. There is right lower lung infiltrate (filling) increased from the prior exam. Impression: No NG tube seen. Increasing right lower lung infiltrate / pneumonia. [MEDICAL CONDITION]. Borderline cardiomegaly (enlarged heart). During an interview on [DATE] at 10:50 am, the Xray Technician stated Resident 17's NGT was visualized on Xray to be located half way down the trachea (wind pipe), in a curled up position, not in the stomach where it should have been. On [DATE] at 3 pm, Resident Care Manager (RCM) A was interviewed. RCM A stated the facility had one type of NG tube that was used and the NG tube inserted by RN F did not have the ability to be seen on x-ray. RCM A stated RN F no longer worked at the facility and acknowledged RN F had not followed the physician's orders [REDACTED]. Review of the hospital's ER documentation, dated [DATE], indicated the ER physician determined Resident 17 had dehydration, requiring IV fluid replacement, pneumonia, and suspected urinary tract infection. The hospital physician's discharge summary, signed by the attending physician on [DATE], documented Resident 17 died on [DATE] of acute cardiopulmonary (heart and lung) failure secondary to aspiration pneumonia.

Based on observation, interview, and record review, the facility failed to provide sufficient fluid intake to maintain proper hydration and to recognize symptoms of dehydration for one of 24 sampled residents, Resident 9. This failure resulted in Resident 9 becoming dehydrated, requiring hospitalization and intravenous (IV, via the vein) fluid replacement for dehydration, acute kidney failure, urinary tract infection. Refer to F 425. Findings: Resident 9's record was reviewed. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/1/15 at 9:30 am, Resident 9 was observed lying in bed, noted to have dry lips, dark material stuck on her teeth, and sunken eyes (signs of possible insufficient fluid or dehydration). Resident 9 was unresponsive when spoken to. Resident 9 had a urinary catheter (a tube inserted into the bladder to drain urine into a collection bag). The collection bag was concealed in a black bag which hung off the side of the bed. Resident 9 was lying on her left side, had IV line (a catheter inserted through the vein for the delivery of medications or fluids) in her right arm, and had a drug infusion device (CADD pump) connected to the IV line. The CADD pump was turned on. A cup of water was noted on the nightstand with a straw in it. On 6/1/15 at 12:30 pm, Resident 9 was observed to be unresponsive to verbal stimulus. Resident 9's lips were dry and there was a dark material stuck on her teeth. The contents of Resident 9's urinary collection bag was observed with Certified Nursing Assistant (CNA) Q. The urine was noted to be cloudy, dark yellow with particles in it (sediment), an estimated total of 70 milliliters (just over two ounces). CNA Q left the room. physician's orders [REDACTED]. The orders did not indicate that Resident 9 was on hospice (end of life care provided by an agency), palliative (care to relieve symptoms or side effects of the disease), or comfort care (supportive care). The orders did not indicate that Resident 9 was not to have intake and output or weights conducted if dehydration or weight loss was known. The orders indicated that Resident 9 was admitted for skilled nursing facility care. A document titled, Physician order [REDACTED]. This document was signed by Resident 9 and the physician on 4/27/15. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The facility's fluid intake documentation indicated Resident 9 had no oral fluid intake (except for medications) on 5/27 and 5/28/15. According to the documentation for fluid monitoring, during meals from 5/23/15-6/1/15, Resident 9's fluid intake was less than 200 milliliters (ml) a day, except for 5/25/15, when Resident 9 took 340 ml of fluid, far below the expected dietary requirement of 1500 milliliters, identified by the facility's registered dietitian (RD) on 4/28/15. A review of a physician's progress note, dated 6/1/15, indicated Resident 9 did not want hospice care or comfort care. A Physician's Progress note, dated 6/1/15, timed 10:22 pm, indicated Resident 9 was transferred to the acute care hospital on [DATE] for [MEDICAL CONDITION] due to dehydration. A nursing progress note, dated 6/1/15, timed 11:54 pm, indicated that Resident 9 was sent to the acute care hospital for decreased respirations and dehydration. A review of the facility's Hydration policy, dated 4/2007, indicated, under the heading, Assessment and Recognition, item 1, the physician and staff were to define the individuals current hydration status. Under subsection a, the physician will distinguish . true dehydration (clinically significant loss of body water). Under item 2, the staff with the physician's input, will identify individuals with signs and symptoms ([MEDICAL CONDITION], lethargy, increased thirst) that might reflect existing fluid and electrolyte imbalance; and suite a, They will report this information promptly to the Attending Physician. Item 3 indicated that The physician and staff will identify individuals with a significant for subsequent fluid and electrolyte imbalance, for example, those .who are not eating or drinking well. There were no orders documented to indicate the recognition of severe dehydration interventions except for those which reflected IV fluid replacement on 5/7 and 5/26/15. There was no documentation in the nursing notes that indicated nursing staff recognized Resident 9's signs and symptoms of dehydration (dry mucous membranes, lethargy, confusion, low urine output) and these symptoms were not reported to the physician. On 6/2/15 at 7:15 am, Licensed Nurse (LN) E stated Resident 9 had been transferred to the hospital the evening of 6/1/15 at 11 pm because of dehydration and her respiratory rate had dropped to four breaths a minute. During an interview conducted on 6/2/15 at 11 am, RCM A stated no intake and output measurements were consolidated to readily identify Resident 9's hydration status and he did not know whose responsibility it was to reconcile intake and output for the facility residents. There were no documented urine output measurements for Resident 9's urine output from the time of admission to the facility. During a concurrent interview conducted on 6/2/15 at 4:45 pm, the the Director of Nursing (DON) and RCM A, the DON stated there was no necessity to do intake and output (documentation of fluid intake and urine output), because treatment of [REDACTED]. The DON stated that the presence of a urine catheter did not necessitate the measuring of urine. The DON and RCM A stated they were treating Resident 9 as comfort measures only, even though an order did not exist to do so and the POLST did not direct this. On 6/2/15 at 5:35 pm, after Resident 9 returned to the facility from the acute care hospital, Resident 9 was observed in her room, unresponsive to verbal stimulus. Resident 9's lips were dry. On 6/3/15 at 7:15 am, Resident 9 was observed to be responsive. She was able to open her eyes, but had difficulty focusing. Resident 9 had oxygen flowing through a nasal cannula (a tube that delivers oxygen via the nose) via an oxygen concentrator (a oxygen delivery device) and had a cup of water with a straw on the nightstand. During an interview conducted on 6/3/15 at 8:36 am, MD F stated Resident 9 did not want hospice care, but wanted to be kept comfortable. MD confirmed that he did not write orders specific to comfort care only, eliminating the need to evaluate Resident 9 for adverse reactions to treatment, because Resident 9 wished to remain in control of her health decisions. Physician (MD) F stated the facility should have notified him for the continued poor fluid intake and poor urine output, especially after Resident 9 needed re-hydration with IV fluids on 5/7 and 5/26/15 for dehydration. MD F stated there was not an order for [REDACTED]. During an interview conducted on 6/3/15 at 9:35 am, the Registered Dietician (RD) stated, according to her documented calculations, Resident 9's fluid requirements were 1500 ml per day. The RD stated standard of practice was that nursing staff should notify the physician and the RD if Resident 9 was not meeting those requirements, so that further assessment and intervention could be conducted. On 6/3/15 at 4 pm, Resident 9 was observed to be responsive, able to say come in to a knock on the door and confirm her name. At 4:40 pm, CNA O came to the room. Resident 9 asked for water. CNA O raised the head of Resident 9's bed and attempted to have Resident 9 drink water from a cup through a straw. Resident 9 was able to take one sip but then had difficulty sucking more water from the straw. CNA O stated that she was not familiar with Resident 9 and would get the CNA responsible for Resident 9's care. CNA N came in the room and stated that she was the CNA responsible for Resident 9. CNA N attempted to provide water for Resident 9 through the straw, but Resident 9 was unable to suck through the straw. CNA O stated she did not know that Resident 9 had just come back from the hospital for dehydration and she did not get a report from other health care providers to inform her of this. CNA O stated she did not have any direction on her CNA tasks (computer generated from care plans) for Resident 9 to encourage fluid to prevent dehydration.

Based on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards/injury by failing to ensure that Resident 1 was transferred, according to the care plan, using the correct assistive device (a Medcare Stand) and to prevent a skin tear during transfer. The facility failed to ensure that Resident 1's signs and symptoms of right upper extremity injury (redness, swelling, verbalized complaints of pain, guarding and grimacing (physical signs of pain)) were assessed by a registered nurse and reported to the physician promptly, and to provide sufficient care and treatment to Resident 1, in a timely manner. These failures resulted in a skin tear and bruising, and delayed treatment and identification of a fractured right upper extremity, which caused Resident 1 moderate to severe pain, compromised her ability to feed herself, and negatively affected her ability to maintain and/or reach her highest practicable level of well-being, comfort, and quality of life. Findings: On 10/12/12 at 11:40 am, during an interview with the Administrator and Director of Nursing (DON), the DON stated that a nursing assistant (CNA A) had used the wrong assistive device while transferring Resident 1 on 8/8/12. The DON stated that, per the facility's investigation of the incident, the Resident's injury (right shoulder fracture discovered on 8/11/12) was believed to be directly related to the transfer on 8/8/12. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, (MDS- a resident assessment tool), dated 8/10/12, showed that Resident 1's cognitive abilities lacked memory, recall, and understanding of conversation. Resident 1 was non-ambulatory and required two staff to physically assist her during transfers because her balance was unsteady and she could only be stabilized with staff assistance. On 10/12/12 at 12:15 pm, Resident 1 was observed and interviewed. Resident 1's right arm was moderately swollen and in a sling. There was purple and green discoloration of her right arm from the shoulder to the hand. Resident 1 stated, "my arm broke when they lifted me and it hurts." Resident 1's spouse was present and stated that he was informed by the facility that Resident 1's injury happened "when they got her out of bed." Resident 1's record was reviewed 10/12/12. A care plan titled, "Dependent with transfer with mechanical lift, non-ambulatory related to lower extremity weakness" was initiated on 7/21/11. The care plan directed, "TRANSFERS: Use total lift for transfers two staff member assist..." On 10/25/12 at 2:15 pm, an interview and concurrent review of the assistive devices used in the facility was conducted with the Director of Nursing (DON). The instructions to use the "Medcare Stand" directed that the assistive device was specifically designed for assisting residents to a standing position and should only be used on residents that had been assessed as able to bear weight and who possessed advanced motor skills. The Medcare Lift was a sling chair device. The instructions directed that it was intended for residents who are non-weight bearing and require total lifting. On 10/12/12, the facility's "Investigation Report Form," dated 8/12/12, was reviewed. The investigation had been conducted by Social Worker (SW) C. SW C documented in the investigative report, "due to increased complaint of pain (by Resident 1) and swelling an x-ray was ordered." SW C's report included, "(CNA A) did not follow resident (Resident 1) care plan during a patient transfer; and this may have resulted in an injury sustained by the resident" and Resident 1 stated, "the nurse that was lifting me drop me." On 10/12/12 at 3:07 pm, CNA A was interviewed. CNA A stated that on 8/6, 8/7, and 8/8/12, she used the Medcare Stand to get Resident 1 out of bed and into her wheelchair for supper. CNA A stated that she "always" used the Medcare Stand alone, when she transferred Resident 1, but on 8/8/12, at approximately 3:30 pm, she asked CNA B to help her. CNA A stated that a couple of hours later, during supper, around 5:30 pm, Resident 1 complained of right arm pain. Resident 1 was unable to lift her spoon to her mouth and CNA A had to feed her. CNA A stated, "I told the charge nurse that Resident 1 couldn't move her right arm and it was hurting her." CNA A also stated that when she and CNA B put Resident 1 back to bed, they used the Medcare Lift. CNA A stated that she knew how to access Resident 1's care plans and acknowledged the importance of implementing the resident care plans to ensure that the resident's needs were properly being met. CNA A then stated, "but I don't look at them." On 10/12/12 at 3:30 pm, CNA B was interviewed. CNA B confirmed that she had helped CNA A transfer Resident 1 using the Medcare Stand on 8/8/12. CNA B stated that she was aware that Resident 1 required a total lift (Medcare Lift) with two staff, but CNA A already had the Medcare Stand in Resident 1's room, "I didn't say anything, I thought she knew what she was doing." CNA B stated, "We tried three times to get her (Resident 1) up, she wouldn't hang on, she couldn't do it, I had to go get the total lift," which contradicted what CNA A had stated. CNA B stated that she had observed Resident 1 during dinner on 8/8/12, and stated that Resident 1 had complained of right arm pain and could not lift her arm to feed herself, "We told the charge nurse." There was no documentation in the nursing progress notes on 8/8/12, that Resident 1 had complained of right arm pain which had affected her ability to feed herself. On 8/9/12, a nurse documented that Resident 1 had a bruise and a skin tear to the right arm, from a transfer at 7:47 am. On 8/10/12, a nurse documented that Resident 1 complained of right shoulder pain "9/10" (10 being the most severe) and stated, "my shoulder hurts real bad-that's why I didn't get up for dinner." The nurses noted that Resident 1 had limited range of motion and slight swelling and redness to the right arm. There was no documentation that the physician was notified of the Resident's change of condition. On 8/11/12, a nurse documented that Resident 1, "guards and grimaces" during care. And, on 8/11/12 at 7:17 am, a nurse documented, "Right shoulder and arm bruised and swelling, limited range of motion, resident is requesting to go to the hospital." Resident 1's physician was then notified and orders were obtained for an x-ray of Resident 1's right arm. The three view x-ray of Resident 1's right shoulder, dated 8/11/12, reported that Resident 1 had an acute-appearing impacted fracture through the surgical neck of the humerus with a displaced bone fragment measuring 11 x 4 mm (millimeters) with possible comminution through the base of the greater tuberosity (meaning that the top of Resident 1's right upper arm bone, that connects with the shoulder, was broken and wedged into the shoulder bone, with a couple of pieces of splintered or crushed bone adjacent to the break). On 10/24/12 at 11:30 am, during interview and record review, the DON confirmed that CNA A had not followed Resident 1's care plan and used an incorrect assistive device, the Medcare Stand, on Resident 1. The DON stated that CNA A should have used the "total" assistive device, the Medcare Lift, each time she transferred Resident 1. The DON stated that she expected CNA A to review Resident 1's care plans, prior to assuming her care, so that she would know which assistive device was appropriate to use. The DON stated that the charge nurse had not documented an assessment or note related to Resident 1's complaint of right shoulder pain and confirmed that both CNAs A and B stated that they had told the charge nurse. The DON stated that the facility's policy for Change in Resident Condition required physician notification and a nurses progress note and care plan update. On 10/25/12 at 2:15 pm, during an interview and review of the August 2012 Activities of Daily Living (ADL) documentation, the DON stated, per CNA A's documentation, CNA A transferred Resident 1 using the wrong assistive device on three separate occasions. Review of Resident 1's July and August 2012 Medication Administration Records (MARs) showed Resident 1 experienced increased pain and required more pain medication in August (after being transferred with the wrong assistive device three times 8/6, 8/7, and 8/8/12, suffering the skin tear during transfer on 8/9/12, and her change of condition with symptoms of acute right upper extremity injury on 8/10/12).

Based on observation, interview, and record review, the facility failed to ensure that four residents were afforded the right to choose activities that were important to them, when the facility chose to be non smoking. The facility announced that in April 2011, they were no longer going to allow smoking. The exception to the new no smoking policy was that those residents that were currently living in the facility that smoked, would be allowed to continue smoking. The facility identified those residents as "grandfathered," however, residents admitted after April 2011, would not be allowed to smoke. In December 2011, the facility changed their smoking policy again and prohibited even the "grandfathered" smokers from smoking on the facility grounds. The facility offered two choices to those existing residents who smoked; quit smoking or transfer to a facility that allowed smoking. Two of the four grandfathered residents reluctantly transferred to another facility and two remained at the facility, but felt that their rights had been violated. (Residents 1, 2, 3, and 4). This violation had the potential for the residents not to meet their highest practicable level of psychosocial well-being and socialization. Findings: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility Admission Record reflected that Resident 1's sister was her decision maker. On 12/27/11 at 11 am, during an observation and concurrent interview with Resident 1 she stated that she did not like not being able to smoke, "I want to smoke, it's my social time with my friends." Resident 1 stated, with a saddened facial expression, that she missed socializing with the other residents that she used to smoke with. Resident 1 stated that since the facility banned smoking, she has no longer socialized with one of her closest friends, "I never see her anymore" and that two others from the "group" had left the facility. Resident 1's voice was trembling as she described how the facility had allowed her to smoke, from the time she was admitted in July 2011 through November 2011, then told her, "no more." Resident 1 stated that she had felt intimidated and that she had, "no choices or rights." On 12/27/11 at 11:50 am, a telephone interview was conducted with Resident 1's sister, the responsible party (RP). RP stated that when Resident 1 was admitted , the Administrator had informed RP that there were still some residents in the facility that smoked. RP stated that the Administrator told her that Resident 1 would be included in that group of "grandfathered" residents still smoking and be allowed to smoke as well. RP stated, "It's was all she had left and I wish they had not let her smoke in the first place, now it's like taking candy away." RP stated that Resident 1 had greatly improved her socialization skills and was happy when she was out smoking with the "group," and now feared that Resident 1 would become "reclusive." RP stated that the facility offered to find another place for Resident 1 to live, that allowed smoking, but she had not felt that the choices they had presented were acceptable. RP stated that her sister, Resident 1, only had two choices, "quit smoking or move out." On 12/27/11 Resident 1's record was reviewed. The Social Service Director (SSD) documented in her notes on 8/19/11, four months after the no smoking policy had been in effect, that Resident 1, "has made friends with another smoker...(Resident 1) and her new friend converse during smoke breaks." Social Service staff member (SS) B documented on 9/9/11, "She (Resident 1) enjoys smoking and the company of some of the other residents." An Activities Admission assessment dated [DATE], four months after the no smoking policy had been in effect, documented that Resident 1 was, "Independent lady likes to go outdoors to smoke..." Resident 1's "Activities" care plan, developed on 7/21/11, described that Resident 1 needed independent and self directed activities and had various mental disorders. The goal was that Resident 1 would participate in activities that she had chosen which included, "...small social group during smoking activity..." 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/12/11 at 1:10 pm, Resident 2 was interviewed at the new facility where she was currently living. Resident 2 stated that she was very upset that she had to move from the facility where she had lived for more than three years. Resident 2 stated that her choices were either quit smoking or move out. Resident 2 stated that because she wanted to continue to smoke, she reluctantly moved to another facility on 11/23/11. Resident 2 stated, "I don't know why they changed the rules." Resident 2 expressed that she enjoyed smoking and that it calmed her nerves and was an important part of her daily routine. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/12/11 at 1:40 pm, Resident 3 was interviewed at the new facility where he was currently living. Resident 3 stated that he was very upset and, "still is," over having to leave his "home of two years." Resident 3 stated, "they made me move," and explained that he was offered two choices, neither of which he was happy with, either quit smoking or be moved to another facility where smoking was allowed. Resident 3 stated that he liked to smoke, it was important to him, and was not going to quit, so he transferred to another facility on 11/28/11. 4. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/27/11 at 11:30 am, Resident 4 was interviewed. Although diagnosed with [REDACTED]." On 12/27/11, Resident 4's record was reviewed. An "Elopement Assessment" dated 12/7/11 at 2:31 pm, documented that Resident 4 had attempted to, "go out the side door." The assessment included documentation by a nurse that, "Resident was accustomed to smoking multiple times a day. The facility went smoke free on 12/1/11, it appears that resident may have been following his typical routine of going outside around this time." As a result an alarm was applied to Resident 4 on 12/8/11. On 12/27/11, the Assistant Administrator (AA) provided a memo that was given to the residents of the facility. The "Memo" had been written on 5/5/11, by the SSD, and described the following: "We are now a "Smoke Free" campus. There are specific Residents who have been grand-fathered in to allow them to continue to smoke." A list of residents then followed, which included Residents 2, 3, and 4, but not Resident 1. The memo continued, "Due to concerns of staying in compliance with the California Law of NOT smoking within 20 feet of a door or window, the smoking area will be moved immediately." "The new smoking area will be in the grassy area by the Main Dining Room...Residents are allowed to sit on the sidewalk...The smoking times are 9:30 am, 1:30 pm, 4:30 pm, and 7:30 pm." On 12/27/11, the AA provided a letter that had been issued to the residents of the facility. On 11/9/11, seven months after the "Smoking Policy" was in effect, the Administrator created a letter that contained the following information: "...earlier this year (the facility name) took great strides to become a smoke free environment. At that time, exceptions to our policy were made to try and accommodate residents with a history of smoking. The harmful effects of secondhand smoke and the fire dangers caused by the presence of smoking in our community are simply too great to ignore...decided to go completely smoke free as of December 1, 2011." On 12/27/11 at 2:35 pm, an interview was conducted with both the SSD and SS B. SS B stated, "we let her (Resident 1) smoke because she saw the others smoking," and confirmed that the facility had not followed their own newly adopted no smoking policy, when they allowed Resident 1 to smoke with the others. The SSD confirmed that the facility had not prepared Residents 1, 2, 3, or 4 for mandatory smoking cessation. SSD stated that the facility, "did nothing between April and December to prepare the grandfathered smokers, Residents 2, 3, and 4, because our original plan was just to let them continue to smoke." The SSD stated that in November 2011, Residents 1-4 were offered nicotine patches, which were not ordered by the physicians until December 2011, or to be transferred to a facility that allowed smoking. On 12/27/11 at 1 pm and 3:30 pm, interviews were conducted with the AA. AA stated that although Resident 1 had been admitted after the no smoking policy had went into effect, they let her smoke. "She was one of the main reasons we went non smoking." AA stated that the facility had difficulty keeping Resident 1 out of the smoking area and difficulty with enforcing the no smoking policy on Resident 1. AA stated that the facility subsequently just allowed Resident 1 smoke. AA confirmed that Residents 2 and 3 transferred to a facility that allowed smoking. AA confirmed that Residents 1 and 4 still remained at the facility, but Resident 1 was not happy that she could not smoke and Resident 4 had begun to wander, looking for a place to smoke. AA stated, "It was not their (the Residents) choice to quit smoking." AA stated that the facility moved the original, fairly secluded, smoking area for the residents to a lawn area just outside of the main dining room in May 2011. AA stated that caused numerous complaints from the other residents and staff, "the staff began bringing notes in from their doctors stating they could not work around second hand smoke." AA stated that during that same time frame, the staff smoking area had caught on fire and the Administrator, "was fed up with smokers." Therefore, the facility had not maintained an environment that allowed Residents 1, 2, 3, and 4 the right to exercise choices which they felt improved their quality of life.