Every finding on record at Meadowood Nursing Center

Based on interview and record review, the facility failed to timely revise the comprehensive person-centered care plan (an individualized document detailing a resident's medical history, current health status, and treatment objectives) and develop individualized interventions for one of five sampled residents (Resident 1) with known behaviors of wandering into other residents' rooms, beds, and personal space. Following a resident-to-resident altercation on 8/4/26 and Resident 1's continued behaviors of entering other residents' rooms and beds, the facility did not revise Resident 1's comprehensive care plan to specifically address these behaviors until 8/25/26.This failure had the potential to increase safety risks and disruptions for Resident 1 and other residents because the comprehensive care plan did not provide individualized interventions to address Resident 1's entry into other residents' rooms, beds, and personal spaceFindings:Record review of Resident 1's admission Record (a document that records basic personal, medical, and contact details for every resident upon arrival) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses which included breast cancer with metastasis (spread) to the brain and metabolic encephalopathy (a condition affecting brain function).During an interview on 8/20/26 at 11:30 a.m., Certified Nursing Assistant (CNA) B, who was familiar with Resident 1, stated Resident 1 frequently wandered, disrobed, entered other residents' rooms and beds, and was difficult to redirect. CNA B stated staff sometimes used hot chocolate to redirect Resident 1.Record review of the facility's incident report documentation indicated on 8/04/26 at approximately 6:00 a.m., Resident 1 entered Resident 2's room and manipulated the controls at the foot of Resident 2's bed. According to the document, Resident 2 instructed Resident 1 to return to bed and moved Resident 1's hand away from the controls with her foot. Resident 1 then struck Resident 2's right foot/toe. Staff separated and assessed the residents.During an interview on 8/20/26 at 11:45 a.m., Resident 2 confirmed Resident 1 manipulated the controls at the foot of her bed and struck her right toe after Resident 2 told Resident 1 to stop. Resident 2 stated her right toe was bruised and sore for approximately two days following the incident.During an interview on 8/20/26 at 12:02 p.m., Licensed Nurse (LN) C stated Resident 1's wandering behavior was known to staff. LN C stated Resident 1 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] following the 8/04/26 incident and subsequently moved again after Resident 1 got into another roommate's bed. LN C stated wandering was a baseline behavior for Resident 1; however, hitting another resident was not.During an interview on 8/20/26 at 1:42 p.m., Resident 6, a former roommate of Resident 1, stated Resident 1 had entered her bed while naked and rummaged through her belongings. Resident 6 stated Resident 1 had not hit or pushed her and she felt safe in the facility.During an interview on 8/20/26 at 3:21 p.m., the Director of Nursing (DON) stated the facility had not anticipated Resident 1 would demonstrate aggressive behavior. The DON stated Resident 1 was subsequently moved to room [ROOM NUMBER], where she was placed in a single room near the nurses' station and CNA charting area for increased staff visibility.During an interview on 8/20/26 at 4:46 p.m., CNA D, who witnessed the 8/04/26 incident involving Resident 1 and Resident 2, stated she heard Resident 2 tell Resident 1 to return to bed and observed Resident 1 manipulating the controls at the foot of Resident 2's bed. CNA D stated Resident 2 moved Resident 1's hand away from the controls with her foot, after which Resident 1 struck Resident 2's right foot/toe.Record review of Resident 1's comprehensive care plan initiated on 8/11/26, after the resident-to-resident altercation, and obtained from the facility on 8/20/26 indicated Resident 1 was identified as a high elopement risk and a wanderer related to exit-seeking. The care plan included interventions to monitor the WanderGuard (an electronic device used to alert staff when a resident at risk for wandering or elopement approaches a monitored exit) for proper placement and functionality and report a missing or dysfunctional WanderGuard. The care plan did not identify Resident 1's behaviors of entering other residents' rooms or beds or entering other residents' personal space and did not contain individualized interventions addressing these behaviors.Record review of Resident 1's comprehensive care plan indicated a behavior problem related to smearing feces throughout the room and going through a roommate's belongings with feces on her hands was initiated on 8/18/26. Interventions included anticipating and meeting Resident 1's needs; approaching and speaking to Resident 1 calmly; diverting her attention; removing her from the situation to an alternate location as needed; and intervening as necessary to protect the rights and safety of others. The care plan did not specifically identify Resident 1's behaviors of entering other residents' rooms, beds, or personal space.During a concurrent interview and record review on 8/25/26 at 1:30 p.m. with the DON, Resident 1's updated comprehensive care plan was reviewed. The updated care plan identified Resident 1 could wander into other residents' rooms or personal space and included interventions to redirect Resident 1 from other residents' rooms and roommates' personal space and engage Resident 1 in activities for redirection. The DON confirmed these interventions were added to Resident 1's care plan on 8/25/26 and were not contained in the care plan provided to the surveyor on 8/20/26.Review of the facility's policy and procedure titled, Comprehensive Care Plans, implemented October 2025, indicated the facility would develop and implement a comprehensive person-centered care plan containing measurable objectives and timeframes to meet each resident's medical, nursing, mental, and psychosocial needs. The policy indicated the care plan would include resident-specific interventions reflecting the resident's needs and alternative interventions as needed.Review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation, implemented and reviewed/revised October 2025, indicated the facility would analyze occurrences to determine why an event occurred and what changes were necessary to prevent further occurrences and define how care would be changed or improved to protect residents. The policy indicated resident-to-resident events would be reviewed for contributing risk factors, including a history of aggressive behaviors and environmental factors, and whether further systemic action was necessary.

Based on interview and record review, the facility failed to revise and implement a comprehensive, person-centered care plan following a significant change in condition for one of three sampled residents (Resident 1) reviewed for falls.The facility's failure to revise Resident 1's fall interventions following the fall on 4/9/26 may have contributed to Resident 1 sustaining a subsequent fall on 6/7/26, resulting in a left hip fracture requiring hospitalization.Record review of Resident 1's face sheet indicated the resident was admitted to the facility in 5/22 and readmitted on [DATE] following hospitalization for a left hip fracture sustained during a fall on 6/07/26. Relevant diagnoses included unsteadiness on feet, difficulty walking and moving safely, history of falls, chronic pain, and major depressive disorder. Record review further indicated Resident 1's most recent Brief Interview for Mental Status (BIMS, a cognition assessment), completed in May 2026, scored 14, indicating the resident was cognitively intact and able to participate in care planning.Record review of Resident 1's comprehensive care plan indicated that prior to the fall on 4/09/26, fall prevention interventions included use of a transfer pole, placement of a non-skid floor mat, a Call, Don't Fall reminder, and physical therapy evaluation as indicated.Record review of the care plan following Resident 1's fall on 4/09/26 indicated the fall prevention interventions remained substantially unchanged. The same interventions continued following the April fall. The Call, Don't Fall intervention was duplicated within the care plan; however, no additional individualized interventions were implemented to address the resident's increased fall risk following the fall.During interview on 6/23/26 at 3:05 p.m., Physical Therapist A stated that following the April 2026 fall, the resident declined restorative nursing services and continued to express the goal of transferring independently rather than walking. The therapist stated interventions included a non-skid floor mat and Call, Don't Fall reminders. The therapist stated Resident 1 was fearful of falling but desired to regain the ability to transfer independently.During interview on 6/23/26 at 3:30 p.m., the Director of Nursing reviewed the September 2025, April 2026, and June 2026 care plans with the surveyor and acknowledged the fall prevention interventions were not escalated following the resident's April 2026 fall. The Director of Nursing stated the interventions remained essentially the same following both falls and acknowledged additional interventions should have been implemented following the resident's change in condition.Record review indicated Resident 1 sustained a second fall on 6/07/26 while attempting to transfer to the bedside commode using the transfer pole. The resident sustained an acute left hip fracture requiring transfer to the hospital for evaluation and treatment.Record review of the facility policy titled, Comprehensive Care Plans, revised October 2025, indicated the interdisciplinary team was responsible for developing and revising comprehensive care plans that reflected the resident's assessed needs, strengths, goals, preferences, and significant changes in condition. The policy further indicated care plans were to be revised when interventions were ineffective or when a resident experienced a significant change in condition.Record review of the facility policy titled, Accident Prevention and Safety of Residents, revised October 2025, indicated the interdisciplinary care team was required to analyze information obtained from resident assessments and observations to identify resident-specific accident hazards and risks, develop individualized interventions to reduce identified risks, monitor the effectiveness of those interventions, and modify interventions as necessary. The policy further indicated resident supervision and interventions were to be adjusted based upon the resident's assessed needs and changes in condition.

Based on interview and records review, the facility failed to ensure one resident out of two sampled residents (Resident 1) was free from abuse when Resident 2 hit him on the left arm.This failure had the potential to result in physical injury and/or psychological issues that can cause further decline in the residents' already frail health condition. Finding:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), indicated he was admitted to the facility on [DATE] with diagnosis including generalized anxiety (mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday things).A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/27/26, indicated he has a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 indicating he has no significant issues regarding memory, thinking, or reasoning abilities.A review of Resident 1's Situation, Background, Assessment, and Recommendation form (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/22/26 at 3:15 p.m., indicated he alleged another resident hit him on the arm on 4/22/26.A review of Resident 2's face sheet indicated she was admitted to the facility on [DATE] with diagnosis including depression and intermittent explosive disorder (a mental health condition characterized by recurring inability to control anger).A review of Resident 2's MDS dated [DATE], indicated she had a BIMS score of 13, indicating she has no significant issues regarding memory, thinking, or reasoning abilities.A review of Resident 2's SBAR, dated 4/22/26 at 7:48 p.m., indicated she allegedly hit another resident on 4/22/26.During an interview on 5/5/26 at 12:22 p.m. with Resident 1, Resident 1 stated, he remembers Resident 2 hit him on his left arm. Resident 1 stated Resident 2 is always screaming, he wanted to keep the peace, did not touch or approach her, but Resident 2 said you son of a bitch and hit his left arm.During an interview on 5/5/26 at 12:35 p.m. with Resident 2, Resident 2 stated she remembers the incident with Resident 1. Resident 2 stated Resident 1 annoyed her that time and she hit him.During a review of the policy Abuse, Neglect and Exploitation, dated 10/25, the policy indicated the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse .The policy define abuse as the willful infliction of injury.with resulting physical harm, pain or mental anguish, which can include.resident to resident altercation.

Based on interview and record review, the facility failed to ensure professional standards of practice were met for three of seven sampled residents (Resident 1, Resident 2 and Resident 4) when:1. Following falls, Resident 4's neurological assessments (an assessment of an individual's nervous system following a fall to help identify neurological injuries and measure the severity of damage caused by head trauma), alert charting, and post fall skin assessments were not completed as required by facility policy and nursing standards of practice,2. Resident 4's abnormal neurological assessment findings were not reported to the physician as required, and;3. Following a resident-to-resident abuse allegation, required alert charting was not completed for Resident 1 and Resident 2.These failures placed residents at risk for unrecognized changes in condition (COC), delayed medical interventions, and inadequate monitoring following potential injury and abuse. Cross reference F600 and F684.1. A review of Resident 4's admission record indicated he was admitted to the facility in January, 2026 with medical diagnosis which included multiple fractures of ribs (broken ribs), traumatic subdural hemorrhage (a life-threatening brain injury where blood collects between the dura mater [a protective layer of the brain] and the brain), and repeated falls.A review of Resident 4's evaluation, titled, Social Services- Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment), dated 3/11/26, indicated his BIMS score was 13, which indicated his cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact).A review of Resident 4's evaluation titled, Nursing-Clinical admission Evaluation Section 5. Fall Risk Evaluation, dated 1/09/26, indicated his risk for falls was moderate.A review of Resident 4's evaluations titled, Nursing- Fall Risk Evaluation, dated 3/09/26, 3/12/26, and 4/06/26 all indicated his risk for falls was high.A review of Resident 4's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a COC among the residents) forms indicated the following:Dated 1/09/26, The COC, symptoms, or signs observed and evaluated is/are: Falls . Summarize your observations and evaluations: RESIDENT [Resident 4] SELF TRANSFERRED TO RESTROOM.Recommendations of Primary Clinicians [physician]: [staff are expected to] MONITOR.Dated 2/05/26, The COC.Falls.Summarize your observations and evaluations: Witnessed by CNA (Certified Nurse Assistant).he [Resident 4] lost his balance and fell about six (6) inches backwards, back and posterior [referring to the back side of the body] head lightly hitting wall.Recommendations of Primary Clinicians: [staff were expected to] neuro checks and nonitor (SIC) [monitor].Dated 2/18/26, The COC.Falls.Summarize your observations and evaluations: PT [patient- Resident 4] FELL ONCE AT 0910 [9:10 a.m.] WITH C/O [complaints of] FEELING DIZZY.FELL AGAIN AT 0940 [9:40 a.m.].Recommendations of Primary Clinicians: [staff were expected to] MD [Medical Doctor] SAID TO MONITOR PER COMPANY POLICY.Dated 3/09/26, The COC.Falls.Skin Evaluation: [was check marked] Not clinically applicable to the COC being reported.Summarize your observations and evaluations: At 1215 [12:15 p.m.] this writer was alerted by the CNA that resident [Resident 4] had fallen and hit his head.Resident [Resident 4] reported head pain.Recommendations of Primary Clinicians: Send to ER [emergency room].Dated 3/12/26, The COC.Falls.Summarize your observations and evaluations: [was left blank].Recommendations of Primary Clinicians: [staff were expected to] MONITOR NVS [neurological vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation [a measurement of how much oxygen is being carried by red blood cells]). Dated 4/06/26, The COC.Falls. Skin Evaluation: [was check marked] Not clinically applicable to the COC being reported. Summarize your observations and evaluations: [was left blank] .Recommendations of Primary Clinicians: no new order.A review of Resident 4's care plan report indicated the following:Date initiated 1/09/26, [Resident 4] is a high risk for falls. [staff were expected to] Follow facility fall protocol.Date initiated 2/05/26, [Resident 4] had a witnessed non-injury fall, hitting head against wall. [staff were expected to] Alert charting every shift x [for] 72 hours.Date initiated 2/19/26, [Resident 4] had an actual fall on with no injury r/t [related to] x2 [twice] with in.10 min [minutes] of each other. [staff were expected to] Continue interventions of the at-risk plan.Neuro checks.Date initiated 3/12/26, The resident [Resident 4] has had an actual fall 3/12/26 with no injury.[staff were expected to] Monitor/document/report PRN [as needed] x 72 h [hour] to MD for s/s [signs and symptoms]: pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation.Neuro-checks PER POLICY.Date initiated 4/06/26, [Resident 4] had a non-injury fall out of bed. [staff were expected to] Alert charting every shift x 72 hours.A review of Resident 4's IDT (interdisciplinary team, typically includes the nursing leadership, social services, and medical records)- Interdisciplinary Post Event Notes indicated the following:Dated 2/06/26, Resident 4 had a fall to the ground and head strike to the wall on 2/05/26. The note further indicated that the MD was notified and alert charting every shift x 72 hours was expected.Dated 2/19/26, at 9:10 a.m. Resident 4 fell on his hip on 2/18/26. Subsequently, Resident 4 fell again on 2/18/26 and he was found on the floor in the middle of the doorway of his room and hallway. The note further indicated that the MD was notified and alert charting and neurological checks were expected.Dated 3/11/26, Resident 4 had a witnessed fall and hit his head on the door on 3/09/26. The note further indicated that the MD was notified and alert charting was expected.Dated 3/16/26, Resident 4 was found on the floor on 3/12/26. The note indicated that the MD was notified and neurological checks were expected.Dated 4/07/26, as per Resident 4, I fell out of bed, on 4/06/26. The note indicated that the MD was notified and alert charting every shift for 72 hours was expected.A review of Resident 4's evaluations titled, Nursing-Neuro Check Evaluation, with dates ranging from 1/10/26 through 4/06/26, indicated that vital signs and neurological assessments were expected to be completed every (q) 15 min x (for) one hour, q 30 min x one hour, q one hour x four hours, q four hours x 24 hour, and q 8 hours x40 hours. Resident 4's neurological assessments indicated the following assessments, and vital signs were not completed:Dated 1/10/26, for two of the q four hours, and one of the q eight hours,Dated 2/05/26, for one of the q eight hours,Dated 3/12/26, for one of the q 30 min, four of the q one hours, two of the q four hours, three of the q eight hours,Dated 3/16/26, for four of the q four hours, six of the q eight hours, and;Dated 4/06/26, for three of the q four hours, and four of the q eight hours.A review of Resident 4 neurological assessments dated 3/09/26 indicated that assessments and vital signs were completed up to the first q one hour only with the last assessment documented at 12:30 p.m.A review of a facility provided document titled, [Name of the Skilled Nursing Facility (SNF)] Census List [Resident 4], indicated on 3/09/26 Resident 4 was discharged to a General Acute Care Hospital (GACH) at 1:11 p.m. and returned to the SNF on 3/10/26 at 4:31 p.m.A review of Resident 4's progress notes dated 1/09/26 at 1 p.m. through 4/09/26 at 12:03 p.m. indicated that progress notes type, Alert Charting, were not completed every shift status post fall for a total of 72 hours.A review of a facility provided document titled, ED [emergency department] Physician Notes, dated 4/08/26 at 4:50 p.m., indicated, .there is a small scratch to his [Resident 4's] left temple [located between the forehead and the ear] area.A review of a GACH provided document titled, [Name of GACH]- Adult Critical Care Consult Note, dated 4/08/26, indicated that Resident 4 was admitted to the GACH on 4/08/26. The document indicated, Skin- comments: Left cheek abrasion [a wound caused by skin rubbing against a rough surface that affects the top skin layer].A review of Resident 4's progress note type, EMAR [electronic medical record]- Administration Note, dated 4/08/26 at 6:55 p.m., indicated, PT [Resident 4] was out at a VA [Veterans Affairs] appointment and his wife was concerned about a bruise on his face from a previous fall on 4/06/26 and took him to the ER at [name of GACH].A review of Resident 4's eMAR dated from 1/09/26 through 4/08/26 indicated no evidence that any changes to Resident 4's skin were assessed, documented, and/or monitored. 2. A review of Resident 4's evaluations titled, Nursing-Neuro Check Evaluation [neurological assessments], indicated the following:Dated 3/12/26, . at 1p.m. Pupil [a circular opening at the center of the iris (color portion of the eye)] Size Bilateral [both] [was check marked as] Not Equal [can indicate a serious brain injury and requires emergency medical evaluation] . at 1:30 p.m . Pupil Size Bilateral [was check marked as] Not Equal- RIGHT EYE 1 MM [millimeter- a unit of measure] LEFT 1.5-2 MM. This indicated Resident 4's pupils were documented as unequal for four more consecutive assessments, and;Dated 3/16/26, . at 10:30 a.m . Pupil Size Bilateral [was check marked as] Not Equal- Right pupil is 1 mm.left pupil is 2-2.5 mm. This indicated Resident 4's pupils were documented as unequal for seven more consecutive assessments. A review of Resident 4's eMAR dated from 1/09/26 through 4/08/26 indicated no evidence that any changes to Resident 4's neurological status was reported to the MD.During an interview on 4/30/26 at 10:27 a.m., the Administrator (ADM) stated that she had no knowledge of a fall or any injury to Resident 4's face prior to him leaving the facility on 4/08/26 for an appointment. The ADM confirmed that Resident 4 had a fall on 4/06/26 and further stated he could had possibly developed a bruise later. The ADM stated that she expected any changes to Resident 4 skin to be documented as a skin assessment or in his progress notes.During an interview and concurrent record review on 4/30/26 at 10:56 a.m., Licensed Nurse 2 (LN 2) confirmed that Resident 4 had multiple falls while admitted to the facility in 2026. LN 2 further confirmed that he transferred Resident 4 to a GACH on 3/09/26 status post-fall because he had a knot (a lump that is usually a localized hematoma [a collection of clotted blood]) from the fall on the top, right-side of his head and complained of head pain. LN 2 stated the knot should have been documented under Resident 4's evaluation forms [which included the SBAR] or in his progress notes as a skin assessment, especially since he complained of pain. LN 2 reviewed Resident 4 SBAR dated 3/09/26 and confirmed the knot he observed on Resident 4's head [which indicated a change to skin] was not documented. LN 2 stated the protocol for neuro check evaluations was that they were completed q 15 min for the first hour, q 30 min for an hour, q 1 hour for four hours, q 4 hours for a whole day, and q 8 hours until the time frame hit 72 hours post fall. LN 2 confirmed neuro checks were expected to be completed for a total of 72 hours. LN 2 stated the purpose of conducting neuro checks was to ensure the resident was not experiencing visual changes, pain, or abnormal vital signs. LN 2 further stated the purpose of the form was, To maintain there are no delayed reactions and to make sure they [the residents] are stable and ok. LN 2 confirmed that it was expected for Licensed Staff to notify the MD immediately if the resident's pupils were not equal or reactive to light. LN 2 further stated the purpose of the neurological assessments was, To make sure there is no further injury, like a brain bleed. LN 2 reviewed Resident 4's neuro check evaluations and confirmed the documentation of his unequal pupils should have been reported to the MD and documented as a progress note or in the neuro check evaluation. LN 2 stated when a resident had a COC, thereafter, the resident was placed on 72-hour monitoring and verified that was considered alert charting. LN 2 confirmed that alert charting was expected to be completed every shift for a total of 72 hours. LN 2 stated the purpose of alert charting was to keep them [nursing staff] informed of any updates or if the staff needed to review how the resident was the day before or prior shift if changes were noted and the MD required notification. LN 2 further stated the purpose of alert charting was, To compare and see if there are any other interventions they need to do. LN 2 confirmed that morning shift (AM) was from 6:30 a.m. through 3p.m., evening shift (PM) from 2:30 p.m. through 11 p.m., and night shift (NOC) was from 10:30 p.m. through 7 a.m.During an interview on 4/30/26 at 11:29 a.m., CNA 2 confirmed she accompanied Resident 4 to his doctor's appointment on 4/08/26. CNA 2 stated Resident 4's wife met them at his doctor's appointment. CNA 2 further stated Resident 4's wife noticed that one side of his face was discolored and red. CNA 2 stated that is when Resident 4's wife was informed of the fall that occurred that morning. CNA 2 stated at that time, she did notice discoloration on one side of Resident 4's face. CNA 2 believed that the discoloration was on the left side of Resident 4's face. CNA 2 described the discoloration as reddish-pinkish in color. CNA 2 stated Resident 4 verbally expressed to his wife that his head hurt. CNA 2 further stated Resident 4's wife wanted him to go to a GACH.During an interview on 4/30/26 at 11:45 a.m., LN 1 confirmed the protocol for neuro checks was that they were completed for a period of 72 hrs. LN 1 stated the purpose of neuro checks was, To make sure there are no brain bleeds, neurological problems, no pain, and should anything happen, to ensure staff is responsive in time. LN 1 further stated if a resident was noted to have unequal pupils during a neuro check evaluation the expectation was that the MD was called immediately. LN 1 stated, They [the resident] could have a brain bleed and the neurological system is going down. It could do a lot of damage. LN 1 stated after a resident had a COC alert charting started. LN 1 further stated alert charting was required to be completed every shift for four to five days. LN 1 stated she was unsure of the length of time but verified that alert charting was conducted every shift. LN 1 stated alert charting let the whole team [care staff] know what was going on with the resident. LN 1 confirmed that Resident 4 had multiple falls during his 2026 admission to the facility. LN 1 further stated, I feel like there could have been more that should have been done.During an interview and concurrent record review on 4/30/26 at 1 p.m., the ADM reviewed Resident 4's neuro check assessment dated [DATE] and verified that his neuro evaluation should have been continued when he returned from the GACH on 3/10/26 because it was still within the 72-hour time frame. The ADM stated the purpose of completing the neuro check evaluation was, To check for any type of adverse event from the fall. The ADM further stated it was expected that any abnormal findings from the neuro check assessment were reported to the MD. The ADM reviewed all of Resident 4's 2026 neurological check evaluations and confirmed that they were not completed as expected. The ADM further confirmed the neurological check evaluations dated 3/12/26 and 3/16/26 contained abnormal findings that should have been reported to the MD. The ADM reviewed Resident 4's progress notes and confirmed that she could not find evidence that the MD was informed. The ADM stated after a resident had a COC they were placed on alert charting for 72 hours. The ADM stated nursing staff were expected to complete alert charting every shift. The ADM further stated, One of the main purposes is to assess how the resident is doing. It's an alert to check on them and to inform the MD if there are any changes.The ADM reviewed Resident 4's progress notes type, Alert Charting, and confirmed the following:No alert charting was completed NOC shift on 1/10/26, 1/12/26, and 2/5/26 - 2/7/26,No alert charting was completed AM, PM, and/or NOC shift on 2/18/26 - 2/22/24,No alert charting was completed PM shift on 3/12/26,No alert charting was completed AM, PM, and/or NOC shift on 3/15/26, andNo alert charting was completed NOC shift on 4/6/26 and 4/7/26.Subsequently, the ADM stated if a resident experienced a change in skin the expectation was that the change was documented in the SBAR, as a progress note, or skin assessment, and that further monitoring was initiated. The ADM reviewed Resident 4's eMAR and confirmed no skin assessments or progress notes were completed that reflected the skin changes observed by staff. The ADM was given the opportunity to provide documented skin assessments for Resident 4 and no evidence was provided. 3. A review of Resident 1's admission record indicated she was admitted to the facility in October 2020 with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 1's MDS dated [DATE], indicated her BIMS score was 13 which indicated her cognition was intact.A review of Resident 1's SBAR form, dated 3/30/26, indicated she was the victim of a resident-to-resident altercation that started on 3/29/26. The form indicated, Resident [Resident 1] initially had not complaints [no complaints] after incident with another resident [Resident 2] where she was kicked in the L [left] knee.A review of Resident 1's evaluation, type, IDT- Interdisciplinary Post Event Note, dated 3/30/26 at 9:46 a.m., indicated, Resident [Resident 1] with a resident-to-resident incident altercation on 3/26/26 at 1615.Interventions at time of Event [staff were expected to] .Alert Charting initiated.A review of Resident 1's care plan report dated 3/29/26, indicated, [Resident 1] was involved in a resident-to-resident incident.Interventions [staff were expected to] .3/29/26: Alert charting initiated every shift x 72 hours.A review of Resident 1's progress notes dated 3/29/26 at 11:10 p.m. - 4/3/26 at 5:04 p.m. indicated that progress notes type, Alert Charting, was not completed every shift status post resident-to-resident abuse allegation for a total of 72 hours.A review of Resident 2's admission record indicated she was admitted to the facility in July 2019 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (conditions that affect blood flow to the brain) and heart failure (inability of the heart to pump blood adequately throughout the body).A review of Resident 2's MDS dated [DATE], indicated her BIMS score was 15 which indicated her cognition was intact. A review of Resident 2's SBAR form, dated 3/29/26, indicated, This resident is aggressor and kicked another resident in the knee and was observed doing it.A review of Resident 2's evaluation, type, IDT- Interdisciplinary Post Event Note, dated 3/30/26 at 10:23 a.m., indicated, Resident [Resident 2] with a resident-to-resident incident altercation on 3/26/26 at 1615.Interventions at time of Event [staff were expected to] .Alert Charting initiated.A review of Resident 2's care plan report dated 3/29/26, indicated, [Resident 2] is involved in an incident as where [Resident 2] is the aggressor and kicked another resident's knee.Interventions [staff were expected to] .3/29/26: Alert charting initiated every shift x 72 hours.A review of Resident 2's progress notes dated 3/29/26 at 7:16 p.m. through 4/3/26 at 11:54 a.m. indicated that progress notes type, Alert Charting, was not completed every shift status post resident-to-resident abuse allegation for a total of 72 hours.During a phone interview on 5/04/26 at 1:49 p.m., the Social Service Director (SSD) stated, With any type of abuse, extra documentation is expected so they [staff] can monitor what is going on.During a phone interview and concurrent record review on 5/4/26 at 2:19 p.m., the Assistant Director to Nursing (ADON) stated alert charting is expected for 72 hours every shift after an allegation of abuse. The ADON further stated nurse staff were expected to complete a narrative note documenting any change in behavior, or ill effects towards the incident. The ADON stated, The purpose is ongoing monitoring to ensure that they [staff] are keeping an eye on them (residents) and also documenting that they are keeping an eye on them. The ADON reviewed Resident 1 and Resident 2's progress notes post resident-to-resident allegation dated 3/29/26 and confirmed that alert charting was not completed every shift for 72 hours.A review of the facility's policy and procedure (P&P) titled, Neurological Assessment, dated 2021, indicated, Neurological assessment is conducted to evaluate the resident for changes that may be indicated of neurological injury.Conduct neurological checks as frequently as ordered.Documentation.The following is recorded in the resident's medical record: The date and time the procedure was performed.Assessment data obtained during the procedure.Reporting.Notify the physician of any change in a resident's neurological status.Report other information in accordance with facility policy and professional standards of practice.A review of the facility's P&P titled, Charting and Documentation, dated 2025, indicated, Services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.A review of the facility's P&P titled, Resident Examination and Assessment, revised 2025, indicated, Reporting.Notifying the physician/nurse practitioner of any abnormalities such as:.change in.neurological status from baseline.wounds.on the resident's skin.Report other information in accordance with facility policy and professional standards of practice.A review of the facility's P&P titled, Falls - Clinical Protocol, revised 2025, indicated, Monitoring and Follow-Up.The staff will monitor the individual's response to interventions intended to reduce falling or the consequences of falling.A review of the facility's P&P titled, Safety, revised 2025, indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Resident supervision is a core component of the systems approach to safety.The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.The type and frequency of resident supervision may vary among residents and over time for the same resident.A review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation, dated 2025, indicated, Prevention of Abuse.ongoing assessment.and monitoring of residents with needs and behaviors which might lead to conflict or neglect.Protection of Resident.Increased supervision of the alleged victim and residents.A review of the facility's document titled, Registered Nurse- Job Description, dated 2023, indicated, Major Duties and Responsibilities.Ensures that policies and procedures are complied with by nursing personnel assigned.Assesses for changes in resident's status, notifying the physician and resident's family or representative and documenting accordingly.Reports any incidents or unusual occurrences to the unit manager, assistant director of nursing or the director of nursing.

Based on observation, interview, and record review, the facility failed to ensure two of seven sampled residents (Resident 1 and Resident 2) were protected from abuse when profanity and a physical altercation occurred between Resident 1 and Resident 2 during which Resident 2 kicked Resident 1 on the knee. The facility's failure to prevent and promptly intervene in the resident to resident altercation placed Resident 1 and Resident 2 at risk for physical harm, emotional distress, and an unsafe environment. Cross reference F658.A review of Resident 1's admission record indicated she was admitted to the facility in October, 2020 with medical diagnosis which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 4/13/26, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 13 which indicated her cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a COC among the residents) form, dated 3/30/26, indicated she was the victim of a resident-to-resident altercation that started on 3/29/26. The form indicated, Resident [Resident 1] initially had not complaints [no complaints] after incident with another resident [Resident 2] where she was kicked in the L [left] knee. A review of Resident 1's evaluation, type, IDT [interdisciplinary team, typically includes the nursing leadership, social services, and medical records]- Interdisciplinary Post Event Note, dated 3/30/26 at 9:46 a.m., indicated, Resident [Resident 1] with a resident-to-resident incident altercation on 3/26/26 at 1615 [4:15 p.m.]. Incident was witnessed by two [2] CNA [certified nurse assistant] staff as they seen this resident coming up to the nursing station pushing her wheelchair into another resident [Resident 2] who was sitting up at the nurse's station as well. The aggressor [Resident 2] asked this resident [Resident 1] to stop and this resident told the aggressor to 'fuck off' and did not stop pushing into the wheelchair. The resident [Resident 2] then kicked this resident [Resident 1] in the left knee. A review of Resident 2's admission record indicated she was admitted to the facility in July, 2019 with medical diagnosis which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (conditions that affect blood flow to the brain) and heart failure (inability of the heart to pump blood adequately throughout the body). A review of Resident 2's MDS dated [DATE], indicated her BIMS score was 15 which indicated her cognition was intact. A review of Resident 2's SBAR form, dated 3/29/26, indicated, This resident is aggressor and kicked another resident in the knee and was observed doing it. A review of Resident 2's progress notes, type, Alert Note, dated 3/29/26 at 7:16 p.m., indicated, This resident was observed by two (2) CNA kick another resident's knee [Resident 1].Resident stated she kicked her and is admitting to it. During an interview and observation on 4/30/26 at 2:21 p.m., Resident 1 stated she was by the front nurse's station and Resident 2 was in her way. Resident 1 stated Resident 2 kicked her in her left knee in front of everyone, including facility staff. Resident 1 further stated it upset her because it hurt. Resident 1 stated staff did not respond immediately to the incident. Resident 1 stated, I give her the finger, and gestured by raising her middle finger, when she saw Resident 2. During an interview on 4/30/26 at 2:35 p.m., Resident 2 stated she and Resident 1 were by the nurse's station in their wheelchairs and Resident 1 told her, Get the fuck out of my way! Resident 2 further stated Resident 1 continued to yell at her. Resident 2 confirmed facility staff witnessed the incident. Resident 2 stated she kicked toward Resident 1 to get her away from her hitting Resident 1's knee. Resident 2 stated that since the incident she would give Resident 1 the middle finger when Resident 1 passed by her room. Resident 2 stated Resident 1 would sit in the hallway outside of her room and call her, a fucking bitch. During an observation on 4/30/26 at 2:46 p.m. Resident 1 was observed in her wheelchair and stopped in front of Resident 2's doorway. Resident 2 yelled, Keep going! Resident 1 stated, Oh yea! and continued to wheel herself down the hallway. A facility staff member was seated approximately 10 feet (ft.- a unit of measure) away and paid no attention to the interaction that transpired between Resident 1 and Resident 2. During an interview on 4/30/26 at 3:02 p.m., CNA 1 confirmed that she witnessed the resident-to-resident incident that occurred between Resident 1 and Resident 2 by the nurse station. CNA 1 stated Resident 1 had rolled up to the nurse station in her wheelchair and yelled for help for her nurse. CNA 1 stated Resident 2 was already seated in her wheelchair at the nurse's station and that Resident 2 yelled at Resident 1 to go away. CNA 1 stated that Resident 2 then kicked Resident 1 in the knee and that the kick was intentional to get Resident 1 away from her. CNA 1 further stated, [Resident 2] could have verbalized to get her away before deciding to kick her [Resident 1] because she [Resident 2] can let her needs be known, but she just kicked her instead. During an interview on 4/30/26 at 3:25 p.m., Registered Nurse 1 (RN 1) stated that Resident 1 had a history of altercations with other residents. RN 1 confirmed that it was the responsibility of the facility staff to protect all residents from abuse. During an interview on 5/04/26 at 1:49 p.m., the Social Service Director (SSD) stated abuse was physical, financial, verbal, neglect, isolation, withholding medications, or withholding visitations. The SSD stated, If staff noticed the verbal altercation and yelling, they should had separated the resident's immediately. The SSD further stated that she considered the physical contact between Resident 1 and Resident 2 as abuse, Because one of the resident's actually physically touched the other resident and because of the verbal- because they were both cursing at each other. The SSD confirmed that it was the facility's responsibility to protect residents from all forms of abuse. During an interview on 5/04/26 at 2:19 p.m., the Assistant Director to Nursing (ADON) stated abuse was verbal, financial, physical and sexual. The ADON stated the resident-to-resident incident between Resident 1 and Resident 2 was considered verbal and physical abuse. The ADON further stated it was verbal abuse because Resident 1 and Resident 2 were talking vulgarly to each other, and it was considered physical abuse because the kick made physical contact. A review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation, dated 2025, indicated, It is the policy of this facility to provide protections for health, welfare and rights of each resident.Physical Abuse includes.kicking.Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents.Prevention of Abuse, Neglect and Exploitation.Identifying, correcting and intervening in situations in which abuse.is more likely to occur.Possible indicators of abuse include.Verbal abuse of a resident overheard.Physical abuse of a resident observed. A review of the facility's document titled, Certified Nursing Assistant-Job Description, dated 2020, indicated, Protects residents from abuse. A review of the facility's document titled, Registered Nurse- Job Description, dated 2023, indicated, Protects residents from abuse.

Based on interview and record review, the facility failed to provide quality of care for one of seven sampled residents (Resident 4) when a fall was not documented in his medical record, and the facility's fall protocol was not initiated status post (after) fall. Cross reference F658. These failures resulted in an unaddressed head injury, inadequate monitoring and implementation of the facility's fall protocol, and a delay in care for Resident 4.A review of Resident 4's admission record indicated he was admitted to the facility in January, 2026 with medical diagnosis which included multiple fractures of ribs (broken ribs), traumatic subdural hemorrhage (a life-threatening brain injury where blood collects between the dura mater [a protective layer of the brain] and the brain), and repeated falls. A review of Resident 4's evaluation, titled, Social Services- Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment), dated 3/11/26, indicated his BIMS score was 13, which indicated his cognition was intact (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 4's SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a COC among the residents) form, dated 3/09/26, indicated that Resident 4 had a witnessed fall and hit his head. The form indicated that Resident 4 was sent to an emergency department of a General Acute Care Hospital (GACH). A review of a facility provided document titled, [Name of GACH]- Hospitalist History and Physical, dated 3/09/26, indicated, ER [emergency room] course: He [Resident 4] was transferred to our hospital for neurosurgical [a specialty concerned with surgical treatments of disorders that affect the nervous system (the brain, spinal cord, and nerves)] consultation he had a repeat CT [computed tomography- an imaging procedure] scan done it showed acute on chronic subdural hematoma [when fresh bleeding occurs on older blood between the brain and its outer covering] there is a four (4) mm [millimeter- unit of length] shift [indicated that brain tissue moved from its center line] neurosurgery was consulted observation recommended. A review of a facility provided document titled, Skilled Nursing Facility [SNF] Transfer Orders, dated 3/10/26, indicated Resident 4 was in stable condition and was transferred back to the skilled nursing facility on 3/10/26. A review of a GACH provided document titled, [Name of GACH]- Hospital Emergency Department ED Provider Note, dated 4/08/26, indicated, Pt [patient- Resident 4] reports that at nine (9) a.m. he had an unwitnessed fall at his SNF. There was a positive head strike. A review of a hospital provided document titled, [Name of GACH]- Adult Critical Care Consult Note, dated 4/08/26, indicated that Resident 4 was admitted to the GACH on 4/08/26. The document indicated, [Resident 4] had a fall in March and sustained a subdural hematoma.but presented to the emergency at [name of GACH] after an unwitnessed fall in the SNF. The patient [Resident 4] hit his head. Patient [Resident 4] was transferred for a new subdural hematoma. The document further indicated, [Resident 4].with an enlarging left sided subdural hematoma that now has mass effect [damage and displacement of normal brain tissue], brain compression [a life-threatening emergency where increased intracranial (within the skull) pressure causes the brain to be squeezed] and shift.Imaging.The subdural hematoma is dramatically larger than it was on his initial presentation on March 9. A review of Resident 4's SNF electronic medical records (eMAR), dated 4/08/26, indicated no evidence that a fall was reported or documented on 4/08/26. Resident 4's eMAR dated 4/08/26 also indicated no evidence of: A status post fall assessment, MD notification,Emergency contact notification,Alert charting, and;An updated care plan. During an interview on 4/30/26 at 11:29 a.m., Certified Nurse Assistant 2 (CNA 2) confirmed she accompanied Resident 4 to his doctor's appointment on 4/08/26. CNA 2 stated that earlier that day, CNA 3 asked her for help to pick Resident 4 off the floor. CNA 2 stated Resident 4's nurse, and named Licensed Nurse 1 (LN 1), had also responded and they assisted him back into bed from a crouched position. CNA 2 verified that Resident 4 was in a crouched position by his bed at the time she responded to assist. CNA 2 stated when she accompanied Resident 4 to his appointment later that day, his wife met them at his doctor's appointment. CNA 2 further stated Resident 4's wife noticed that one side of his face was discolored and red. CNA 2 stated that is when Resident 4's wife was informed of the fall that occurred that morning. CNA 2 stated at that time, she did notice discoloration on one side of Resident 4's face. CNA 2 believed that the discoloration was on the left side of Resident 4's face. CNA 2 described the discoloration as reddish-pinkish in color. CNA 2 stated Resident 4 verbally expressed to his wife that his head hurt. CNA 2 further stated Resident 4's wife wanted him to go to a hospital. During an interview on 4/30/26 at 11:45 a.m., LN 1 stated that she did not remember if Resident 4 experienced a fall on 4/08/26. LN 1 further stated known falls were expected to be documented as an SBAR. LN 1 stated status post fall, the resident was evaluated to ensure he/she was not hurt, and the MD (medical doctor) was notified. LN 1 stated MD recommendations were to be documented and carried out by staff. During a phone interview on 4/30/26 at 12:11 p.m., CNA 3 stated on 4/08/26 Resident 4 yelled for help from inside of his room. CNA 3 stated, When I went into his room he was on the floor next to his bed, and when I asked him what happened, he told me he fell. CNA 3 confirmed Resident 4 was observed on the floor by his bed. CNA 3 stated she retrieved Resident 4's nurse and that the nurse assessed him. CNA 3 stated she did not recall the name of Resident 4's nurse that assisted. CNA 3 stated she left the room after the nurse arrived. During an interview on 4/30/26 at 12:18 p.m., the Administrator (ADM) confirmed that LN 1 was Resident 4's licensed nurse on 4/08/26 for day shift (6:30 a.m. - 3 p.m.). Subsequently, LN 1 was interviewed again and stated she did not recall Resident 4 falling on 4/08/26. LN 1 further stated, A lot happens every day and I just don't recall. During an interview and concurrent record review on 4/30/26 at 1 p.m., the ADM stated that she expected every resident fall to be reported as a change in condition and that the fall protocol was followed to ensure appropriate monitoring for the resident. The ADM confirmed that she was not aware that Resident 4 experienced a fall on 4/08/26. The ADM confirmed there was no documentation in Resident 4's eMAR that indicated he had fallen on 4/08/26. A review of the facility's policy and procedures (P&P) titled, Quality Care, revised 2025, indicated, Residents will be provided with care and services that may attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.Employees are responsible for following established policies and procedures. A review of the facility's P&P titled, Falls- Clinical Protocol, revised 2025, indicated, The staff will evaluate and document falls that occur while the individual is in the facility, including when and where it happened, any observation of events, etc .the staff and IDT [interdisciplinary team, typically includes the nursing leadership, social services, and medical records] will identify pertinent interventions to try to prevent subsequent falls and address the risks of serious consequences.The staff, with the physician's guidance, will follow up on any fall with associated injury.The staff will monitor the individual's response to interventions intended to reduce falling. A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised 2025, indicated, Our facility shall notify the resident, his or her Attending Physician on call/NP [Nurse Practitioner]/PA [Physician Assistant], and representative of changes in the resident's medical/mental condition and/or status.The nurse will notify the resident's Attending Physician/physician on call/NP/PA when there has been a (an): accident or incident involving the resident.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the facility's P&P titled, Charting and Documentation, revised 2025, indicated, .any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.Documentation information in a resident medical record can include: Events, incidents or accidents involving the resident. A review of the facility's P&P titled, Documentation in Medical Record, dated 2026, indicated, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. A review of the facility's P&P titled, Care Plans, Comprehensive, revised 2025, indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change. A review of the facility's document titled, Registered Nurse- Job Description, dated 2023, indicated, Major Duties and Responsibilities.Ensures that policies and procedures are complied with by nursing personnel assigned.Assesses for changes in resident's status, notifying the physician and resident's family or representative and documenting accordingly.Reports any incidents or unusual occurrences to the unit manager, assistant director of nursing or the director of nursing.

Based on observation, interview, and record review, the facility failed to maintain a clean, homelike environment when one of five sampled residents (Resident 1) had a soiled privacy curtain and food splattered on the ceiling above his bed. This failure made Resident 1 feel frustrated that facility staff were not doing their jobs to maintain a clean place for him to live.Review of Resident 1's face sheet (demographics) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including cervical radiculopathy (a pinched nerve in the neck) and depression, among others. During an observation and concurrent interview on 4/28/26 at 12:25 p.m., Resident 1 pointed out a stain on the privacy curtain between his and his roommate's beds. Resident 1 stated the curtain had not been washed for over a year. The privacy curtain was noted to have two brown smears, a cluster of dark gray spots as though a splatter of a liquid had landed on the curtain, and an area of a white crusty substance stuck to the curtain. Resident 1 also pointed to a brown splatter on the ceiling above his bed and stated it was chocolate pudding. Resident 1 stated the pudding had been there for about 9 or 10 months. Resident 1 stated the dirty curtain and ceiling made him feel frustrated that the facility staff did not do their job. During an observation and concurrent interview on 4/28/26 at 1:02 p.m., Environmental Services Supervisor (ESS) observed Resident 1's privacy curtain and verified the brown, dark gray, and white stains on the curtain. ESS verified the curtain needed to be cleaned. ESS observed the brown splatter on Resident 1's ceiling and verified it needed to be cleaned. ESS stated she did spot checks of rooms to ensure EVS staff were cleaning the rooms to her standards, but she had not noticed the curtain or ceiling. ESS stated she had started a deep clean routine recently in March 2026. ESS verified the deep clean included washing the privacy curtains. ESS stated Resident 1's room had not had a deep clean yet due to the Covid outbreak when the EVS department had to stop doing the deep cleans. ESS stated prior to March 2026 there was no set routine for washing the privacy curtains or deep cleaning the rooms. ESS stated the pudding on Resident 1's ceiling had probably been there for a bit. ESS stated she did not look up when doing spot checks and the housekeeper probably did not look up either when doing the daily room cleaning.During a phone interview on 4/29/26 at 3:40 p.m., Administrator stated that if the residents' privacy curtains were soiled, they absolutely need to be changed. Administrator stated she expected the privacy curtains to be washed on a routine schedule. Review of facility policy Homelike Environment, last revised 8/2025, indicated, Residents are provided with a safe, comfortable, and homelike environment . The facility staff shall provide, to the extent possible and within reasonable accommodation, a personalized, homelike setting including a clean and sanitary environment.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of significant medication errors when Resident 1's order for suboxone (prescription medication used to treat opioid use disorder by reducing cravings and withdrawal symptoms) was not renewed timely and the medication was not available for administration.This failure had the potential to result in Resident 1 experiencing withdrawal symptoms (the physical and psychological symptoms that occur when stopping or reducing the use of addictive substances).Findings:A review of Resident 1's admission record indicated he was admitted to the facility on [DATE] with a diagnosis of substance dependence ( condition where a person's body and mind have adapted to regular drug or alcohol use to the point that they feel they need the substance to function normally).During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/27/26, indicated he had no memory impairment.During a review of Resident 1's medication administration record (MAR) for the month of 2/26, indicated Resident 1 did not receive his suboxone (chart code 9 = other/see Nurse Notes) on 2/23/26 at 6 p.m., on 2/24/26 at 8 a.m., and on 2/24/26 at 4 p.m.During a review of Resident 1's Progress Notes (PNs), the PNs indicated:PN, dated 2/4/26 at 4:15 p.m., a physician's order note for suboxone, sublingual Film 8-2 milligram (mg, a unit of measurement), Buprenorphine HCl-Naloxone HCl dihydrate, 1 film sublingually three times a day for opioid dependence.PN, dated 2/23/26 at 5:05 p.m., suboxone sublingual film is pending pharmacy delivery.PN, dated 2/24/26 at 8:08 a.m., suboxone sublingual film was not given.PN, dated 2/24/26 at 1:09 p.m., suboxone sublingual film was unavailable due to the order pending the signature of the physician.PN, dated 2/24/26 6:19 p.m., suboxone sublingual film is pending delivery. During an interview on 3/17/26 at 11:59 a.m. with Resident 1, Resident 1 stated he had not received his suboxone for a week, he had no idea why, and he had experienced shaking and anxiety due to the missed doses. He further stated he was a recovering heroin (a highly addictive opioid drug) addict.During a concurrent interview and record reviedw on 3/17/26 at 12:34 p.m. with the Assistant Director of Nursing (ADON), Resident 1's MAR, dated 2/2026, and Resident 1's PNs, dated 2/23-2/24/26, were reviewed. The ADON stated it was her expectation residents' medications were available for administration and doses were not missed. The ADON reviewed Resident 1's 2/2026 MAR and confirmed Resident 1 had missed one dose of suboxone on 2/23/26 and two doses on 2/24/26. The ADON stated she did not know why the suboxone was not given. The ADON reviewed Resident 1's PNs and confirmed the medication had not been available for administration. The ADON stated it was her expectation nursing ordered the medication timely so that it was available for administration. The ADON further stated if Resident 1 was given suboxone for opioid dependence, not receiving his medication could result in him experiencing withdrawal symptoms.During a concurrent interview and record review on 3/17/26 at 2:58 p.m. with the ADON, the ADON reviewed Resident 1's 2/4/26 PN and confirmed suboxone had been prescribed for opioid dependence and agreed that if Resident 1 had complained he had experienced anxiety and shakiness due to the missed doses it was a significant medication error for him.During a review of the facility's policy titled, Medication Reordering dated 10/25, the policy indicated, It is the policy of the facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident.During a review of the facility's policy titled, Medication Errors, dated 10/25, the policy indicated, It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services in an environment free of significant medication errors.

Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) right to self-determination was honored when Resident 1 was not discharged from the facility per his request on 1/28/26.This failure left Resident 1 at risk for feeling upset and frustrated.Findings: Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission date to the facility in 11/2025 with diagnoses of Essential Hypertension (HTN, high blood pressure and Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).A review of Resident 1's physician's Order Summary (POS, a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive) indicated that on 11/11/25, the physician deemed Resident is capable of understanding rights, responsibilities and informed consent.A review of Resident 1's Alert Note (documentation method used to instantly notify staff of critical, time-sensitive information regarding a resident's status), dated 1/29/26 written at 12:46 a.m., indicated, At aproximatley [sic] [8:30 p.m. on 1/28/26].requesting an explanation as to why [Resident 1] could not leave the facility at this time, this nurse. explained that per facility protocol and due to safety concerns [Resident 1] was not cleared to leave at this time and that a discharge care meeting could be arranged during normal business hours.This nurse informed [Resident 1's visitor] that [Resident 1] could not leave at the time and that leaving would be unsafe and against medical advice.During an interview and concurrent record review with the Social Services Director (SSD) on 2/20/26 at 2:31 p.m., Resident 1's physician orders were reviewed. The SSD verified that based on physician order, Resident 1 was responsible for himself, understanding his rights and responsibilities. The SSD stated Resident 1 had told the SSD he wanted to discharge from the facility on the evening of 1/28/26. The SSD stated, despite being responsible for himself, Resident 1 was not allowed by staff to discharge.During an interview on 2/20/26 at 3:11 p.m., the Assistant Director of Nursing (ADON) verified Resident 1 was responsible for himself and the physician had deemed him capable of making decisions for himself. The ADON stated when Resident 1 wanted to discharge on [DATE], staff should have offered Resident 1 to sign a release of responsibility form and he should have been allowed to discharge. ADON confirmed staff did not offer Resident 1 to sign a release of responsibility form. The ADON stated not allowing Resident 1 to discharge from the facility could be seen as not honoring Resident 1's rights. The ADON added, not allowing Resident 1 to discharge, despite his wish to do so, could result in Resident 1 experiencing anger, frustration and resentment.During a telephone interview on 2/20/26 at 4:18 p.m., Resident 1 stated in regards to wanting to discharge on [DATE], yes, I wanted to go home at that time but was not allowed to do so. Resident 1 stated that when he was not allowed to go home he was really upset and frustrated.During a telephone interview on 2/20/26 at 4:53 p.m., LN B stated on the evening of 1/28/26, Resident 1 stated he wanted to discharge from the facility. LN B stated, I told [Resident 1] it was late, can't figure anything out at night, and there were no administrative staff at night. LN B confirmed when Resident 1 expressed he wanted to discharge she had not provided him with a release of liability form and acknowledged, when Resident 1 wanted to discharge, she did not know the procedure or what to do at that time, there was no management to reach out for guidance and she believed allowing him to discharge at night would compromise his safety. LN B concluded that it was Resident 1's right to discharge from the facility. LN B added, because Resident 1 did not discharge as he requested, he might have felt imprisoned, frustrated, and angry.During an interview on 2/20/25 at 4:35 p.m., the Director of Staff Development (DSD) stated if a resident had an order that stated they could make decisions themselves, they should be allowed to discharge from the facility. The DSD stated residents had the right to leave the facility if they wanted to. The DSD stated not allowing a resident to be discharged from the facility, when this was his wish and he is responsible for himself, could result in resident feeling upset and frustrated.A review of the facility's policy and procedure (P&P) titled Discharging a resident without Physician's Approval, revised 10/2022, the P&P indicated .if the resident or representative request discharge without the approval of the attending physician, the resident or the representative (sponsor) will be asked to sign a release of responsibility form.if a resident wishes to be discharged to a setting that does not appear to meet his or her post discharge needs or appears unsafe, the facility will treat this situation similarly to a refusal of care.A review of the facility's P&P titled Resident's Rights, revised 2/2021, the P&P indicated .Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the residents right to .self-determination.

Based on observations, interviews and record reviews, the facility failed to maintain infection control measures for two out of two residents sampled for infection control concerns (Residents 2 and 3) when:1. three pillows that were on the floor were picked up by the Licensed Nurse (LN) and placed back on Resident 2's bed; and2.the mouthpiece of Resident 3's nebulizer (medical device that converts liquid medication into a fine, breathable mist for direct inhalation into the lungs) was not kept in a clean, dry, and sealed container to prevent cross contamination (happens when bacteria or other germs are unintentionally transferred from one object to another).These failures could put the residents at risk for infection transmission, illness, and worsening of chronic conditions.Findings:1. A review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission to the facility in 1/2026 with diagnoses of Unsteadiness in feet and Dysphagia (difficulty swallowing.During a concurrent observation and interview on 2/20/26 at 1:53 p.m., in Resident 2's room, LN D was observed, and LN D verified, he picked up three pillows from the floor and placed the pillows at the foot of Resident 2's bed.During a concurrent observation and interview on 2/20/26 at 2:02 p.m., the Assistant Director of Nursing (ADON) verified seeing 3 pillows on Resident 2's foot of bed. The ADON stated anything that fell on the floor was already contaminated and the nurse should not have placed the dirty pillows back on Resident 2's bed. The ADON stated having soiled items, or items from the floor was dirty and could put Resident 2 at risk of infection.A review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Committee (IPCC) revised 7/2016, the P&P indicated .the objectives of IPCC.assist in the development and implementation of written policies and procedures for the prevention and control of infections among residents.provide facility guidelines for a safe and sanitary environment.review, establish and monitor environmental infection prevention and control practices in accordance with Centers for Disease Control (CDC)/ Healthcare Infection Control Practices Advisory Committee (HICPAC)/ Occupational Safety and Health Administration (OSHA) guidelines and local and state requirements. 2. A review of Resident 3's face sheet indicated an admission date to the facility in 12/2022 with diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) and Emphysema (chronic lung disease that causes shortness of breath)A review of Resident 3's Physician Order Summary (POS, a healthcare professional's written instruction specifying the care, services, treatment, and medications a patient should receive), for 2/2026, indicated an order for a medication solution (liquid) of three milliliter (ml, a unit of measure) to be inhaled via nebulizer every 8 hours.During a concurrent observation and interview on 2/24/26 at 12:00 p.m., in Resident 3's room, Resident 3's nebulizer mouthpiece was kept on top of the bedside dresser, not stored in a container or bag protecting from cross contamination, along with a soda, and a used drinking cup. Resident 3 stated staff would administer his nebulizer medication but would rarely keep the mouthpiece inside the plastic bag.During a concurrent observation and interview on 2/24/25 at 12:05 p.m., in Resident 3's room, LN E verified Resident 3's nebulizer mouthpiece was not kept inside the plastic bag provided to keep the mouthpiece protected after use. LN E stated after use, the mouthpiece should be kept inside the plastic bag per facility policy. LN E stated leaving the mouthpiece on top of the drawer instead of in the protective bag was a cross-contamination issue and could result in Resident 3 getting sick.During a concurrent observation and interview on 2/24/25 at 12:23 p.m., in Resident 3's room, the Director of Nursing (DON) verified the mouthpiece was not kept inside the plastic bag and was on top of Resident 3's bedside dresser. The DON stated this practice was not acceptable as this could put Resident 3's safety at risk. The DON stated after use, the mouthpiece should be kept in the plastic bag provided to prevent cross contamination and prevent infection.A review of the facility's P&P titled Administering Medications Through Small Volume Handheld Nebulizer, dated 12/2025, the P&P indicated .rinse and disinfect the nebulizer equipment according to facility protocol, store in plastic bag with resident name and date on it.

Based on interviews and record reviews, the facility failed to report a possible financial abuse for one out of two residents sampled for financial abuse (Resident 1), when facility staff suspected financial abuse by Resident 1's Care Giver (CG) that was not reported to law enforcement nor the State Agency (California Department of Health [CDPH]) .This failure could lead to Resident1 experiencing a loss of money and continued financial abuse.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission date to the facility in 11/2025 with diagnoses of Essential Hypertension (HTN, high blood pressure and Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).During an interview on 2/20/26 at 2:31 p.m., the Social Services Director (SSD) stated both she and Resident 1's son felt Resident 1's CG was taking advantage of Resident 1's finances. The SSD stated she suspected there was financial abuse going on and did not feel good about the fact the CG was holding Resident 1's credit card. The SSD stated Resident 1's son thought there was some funny business going on. When asked if this should have been reported as a suspicion of financial abuse, the SSD stated yes. The SSD stated she had not reported the suspected financial abuse because she believed Resident 1 had an emotional attachment to the CG and Resident 1 did not complain about it. The SSD stated not reporting a possible financial abuse could lead to loss of money and continued financial abuse.During an interview on 2/20/26 at 3:11 p.m., the Assistant Director of Nursing (ADON) stated that when Resident 1's son had expressed concerns with Resident 1's credit card being kept by the CG and the CG getting paid while Resident 1 was still at the facility, it warranted further investigation and reporting to the appropriate agencies. The ADON stated not reporting alleged financial abuse to the appropriate agency such as the police, the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) and CDPH could result in continued financial loss and abuse to escalate. ADON stated if staff felt and suspected financial abuse, then it should have been reported so an investigation could be initiated.During a telephone interview on 2/20/26 at 4:53 p.m., Licensed Nurse (LN) B stated she suspected there was financial abuse of Resident 1 when she became aware CG had Resident 1's credit card and she believed CG used Resident 1's credit card. LN B stated these suspicions should have been reported as possible financial abuse. LN B stated at that time she had formed her suspicion of financial abuse, she was not sure if it should have been reported but now realized that it should have been reported to CDPH and the police. LN B stated not reporting this alleged abuse put Resident 1's safety at risk for possible financial abuse to continue.A review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, the P&P indicated .to protect residents from abuse, neglect exploitation and misappropriation of property by anyone including but not necessarily limited to family members, friends, visitors and or any other individual.identify and investigate all possible incidents of abuse, neglect, exploitation and misappropriation of resident's property.investigate and report any allegations within time frames required by federal requirements.A review of All Facilities Letter (an official communication issued by CDPH, sent to health facilities licensed or certified by the CDPH to provide crucial updates, guidance, and regulatory information.) 21-26, dated 7/26/21, indicated, . Mandated Reporting Requirements of Potential Abuse, Neglect, Exploitation, or Mistreatment of Elders or Dependent Adults.facilities must report suspected or known abuse to their local law enforcement agency, long term care (LTC) ombudsman, and [CDPH] district office (DO).

Based on observation, interviews and record reviews, the facility failed to ensure services provided met professional standards for one out of two residents sampled for professional standards (Resident 2), when Resident 2 was not provided an alternating pressure pad (APP, a specialized medical-grade mattress system designed to prevent and treat pressure ulcers in patients with limited mobility) as prescribed by the physician.This failure put Resident 2 at increased risk of developing or worsening pressure ulcers (PU, localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), which could cause severe pain, and infection.Findings:A review of Resident 2's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission date to the facility in 1/2026 with diagnoses of Unsteadiness in feet and Dysphagia (difficulty swallowing).A review of Resident 2's Physician's Orders indicated an active order for APP mattress to bed ordered on 1/16/26.During an interview on 2/20/26 1:21 p.m., Licensed Nurse (LN) C stated physician's order should be followed. LN C stated if the physician ordered an APP mattress, the facility should provide this mattress for the resident. LN C stated if the physician order was not followed, then it also meant the facility policy was not followed, and residents would be at risk for further skin issues. LN C stated an APP mattress was important to ensure residents do not develop any skin issue or a skin issue does not worsen.During a concurrent observation and interview on 2/20/26 at 1:53 p.m., in Resident 2's room, LN D verified Resident 2 was not on an APP mattress and was on a regular mattress. LN D stated Resident 2 has fragile skin and was at risk for developing PU.During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/20/26 at 2:02 p.m., Residents 2's physician's order and Braden (an assessment tool commonly used in health care to assess and document a client's risk for developing pressure) skin score was reviewed. The ADON verified Resident 2 was not on APP mattress although the physician had ordered it on 1/16/26. The ADON verified Resident 2's Braden score was 15, indicating Resident 2 was at risk for PU. The ADON stated since Resident 2 was at risk for PU, using APP mattress was a preventative measure to hopefully prevent development of PU. The ADON stated staff must follow physician's order because that's what we're supposed to do, trust us to follow physician's order so that we could take care of residents' safely. A review of the facility's policy and procedure (P&P) titled Prevention of Pressure Injuries, revised 4/2020, the P&P indicated .select appropriate support surfaces based on resident's risk factors, in accordance with current clinical practice.A review of the facility's P&P titled Administering Medications dated 12/2025, the P&P indicated .medications are administered in accordance with prescribers' orders.A review of the facility's P&P titled Staffing, Sufficient and Competent Nursing, revised 8/2022, the P&P indicated .staff must demonstrate the skills and techniques necessary to care for residents needs including but not limited to skin and wound care.P&P specific to physician orders was requested but was not provided.

Based on observations, interviews and record reviews, the facility failed to ensure all drugs were in locked compartments for one out of four medication carts, when a medication cart was unlocked when it was unattended.This failure could result in access to medications by unauthorized people leading to medication theft and unauthorized medication ingestion with a risk of overdose, drug interactions, or severe adverse effects.Findings:During a concurrent observation and interview on 2/20/26 at 5:14 p.m., Licensed Nurse (LN) A left the medication cart in hall 1 unlocked while inside a resident's room. There were no other LN or unlicensed staff present to look after hall 1 medication cart. Upon return to the medication cart, LN A verified she left the cart unlocked and unattended. LN A stated it was the facility's policy to ensure medication carts were always locked when unattended by the LN for the safety of the residents.During an interview on 2/20/26 at 5:20 p.m., the assistant Director of Nursing (ADON) stated medication carts should always be locked when unattended per facility policy. The ADON stated medication carts should be locked if unattended to ensure unauthorized people could not access the medications in the cart which could put the resident's safety at risk.A review of the facility's policy and procedure (P&P) titled Administering Medications, dated 12/2025, the P&P indicated .during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on interview and record review, the facility failed to properly care for one of three residents' (Resident 1) Peripherally Inserted Central Catheter (PICC line, a long, thin, flexible tube inserted into a peripheral vein and threaded into a large central vein near the heart to provide long-term access for administering medications, fluids, or blood products, and for drawing blood, reducing the need for repeated needle sticks) during several shifts by failing to follow flushing and monitoring protocols.This finding could have led to inability to maintain PICC line patency, the formation of blood clots which could have caused a stroke or heart attack, and a potentially life-threatening infection for Resident 1.A review of Resident 1's admission Record (Facility demographic) indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses which included metabolic encephalopathy (a reversible, acute, or chronic brain dysfunction caused by systemic illness, toxins, or chemical imbalances) and bacteremia (the presence of bacteria in the bloodstream).A review of a nursing progress note dated 2/03/26 at 2:57 a.m., stated, resident [Resident 1] on alert charting for S/P [status post] IV [Intravenous, through the vein] ABO [antibiotics] for bacteremia.A review of a physician order for Resident 1 dated 1/03/26 indicated, CEN (central)-PICC: Monitor every shift for s/s (signs or symptoms) of infection every day shift.A review of Resident 1's Medication Administration Record (MAR) for February 2026 indicated that the above order was not carried out during the day shift (as scheduled) on 2/03, 2/04, 2/09, and 2/10/26, as no staff documented completing it.A review of a physician order for Resident 1 dated 1/30/26 indicated, Heparin (A medication to prevent blood clots) Lock Flush Solution 100 UNIT/ML (milliliters, a unit of measure) Use 500 unit intravenously in the afternoon for PICC line.A review of Resident 1's MAR for February 2026 indicated that the above order was not carried out at 12 pm on 2/01, 2/02, 2/03, 2/04, 2/09, and 2/10/26, as no staff documented completing it. Additionally, the order was not carried out at 2:30 pm on 2/13 and 2/16/26 based on the MAR documentation.During a phone interview with Licensed Staff A on 3/02/26 at 8:05 a.m., who worked with Resident 1 on 2/01, 2/02, 2/03, 2/04, 2/09, 2/10 and 2/13/26 according to Resident 1's MAR, Licensed Staff A confirmed the documentation for Resident 1's PICC line care was missing in the February 2026 MAR. Licensed Staff A explained that, as he was not a Registered Nurse (RN), he could not flush the line himself. Licensed Staff A stated that instead of flushing the line himself, he reminded the RNs on duty to do it, but without documentation, he could not confirm it was done. Licensed Staff A also mentioned that since some RNs worked evening shifts when he was not present, he could not verify their actions. Licensed Staff A stated he monitored Resident 1's PICC line site daily. A review of the MAR indicated this was not documented consistently. Licensed Staff A stated that if a task was not documented, he could not confirm it was completed.During a phone interview on 3/02/26 at 11:30 a.m., Resident 1 stated that staff were flushing and monitoring his PICC line less than half the required times, and definitely not daily. Resident 1 stated he reminded staff repeatedly, but they did not comply. Resident 1 stated he felt neglected and feared acquiring an infection.During a phone interview on 3/02/26 at 12:40 p.m., the Director of Nursing (DON) stated a PICC line that was not flushed consistently could get clogged. The DON also stated that not monitoring a PICC line site could miss a reaction or infection. The DON acknowledged the missing documentation on Resident 1's February MAR and stated that if a task was not documented, it meant it was not completed.A review of the facility policy titled, PICC and Midline Catheter Care, dated December of 2025, indicated, The purposes of this procedure are to maintain patency of midline and PICC line. Flush catheters at regular intervals to maintain patency.Monitor resident for any signs and symptoms of IV complications.The following information should be recorded in the resident's medical record: 1. The date and time the medication was administered.Notify the supervisor, physician, and oncoming shift of any complications. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure eight out of eight sampled residents (Resident 7, Resident 25, Resident 53, Resident 59, Resident 69, Resident 90, Resident 94 & Resident 95) were aware of how to file a grievance and had their complaints resolved when the facility had no current grievance process or appointed officer. In addition, complaints brought up during resident council meetings were not being tracked or responded to. This failure resulted in all eight residents feeling frustrated with the lack of facility response to their complaints.During a Resident Council Meeting on 1/07/26 at 11:00 a.m. in the dining hall, all eight residents present could not describe what the current grievance process was. The entire group expressed frustration with the lack of response to various concerns that had been brought up repeatedly. One resident stated that since the last Social Services Director left there had been no follow up on complaints or grievances.A review of resident council notes from 11/25 and 12/25 indicated there were multiple complaints about cold food and Certified Nursing Assistant (CNA) behavior in the dining hall with no facility or department response documented.During an interview on 1/07/26 at 1:03 p.m., the Activities Director (AD), stated she did her best to meet the resident's needs but currently there was no clear grievance process.During an interview on 1/08/26 at 2:45 p.m., the Assistant Director of Nursing (ADON) stated the Social Services Director was the grievance officer but they did not have one currently and could not provide documentation of tracking facility responses to grievances. The ADON further stated that this could lead to negative outcomes, residents' needs not being met and could make residents feel upset and unheard.A review of the facility policy titled, Grievances/Complaints, Filing, revised in 10/2025, indicated the Administrator had delegated the responsibility of grievance and/or complaint investigation to the grievance officer who was the Social Services Director/designee. It also indicated, Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report to the Administrator within 5 days.The Resident or person filing the grievance or complaint will be informed of the findings of the investigation and the actions that will be taken to correct identified problems.The results of all grievances will be maintained on file.

Based on observation, interview, and record review, the facility failed to safely store residents' food when the two refrigerators used to store residents' personal food from outside the facility were not monitored for proper labeling or outdated items. This failure had the potential to cause food-borne illnesses.During an observation and concurrent interview on 1/06/26 at 2:20 p.m., Licensed Nurse (LN) B stated there was a refrigerator at each nurses' station that was for residents' foods brought in from outside the facility. The refrigerator for residents' foods at Nurses' Station 2 contained several items that were not labeled or were outdated. LN B stated Housekeeping Supervisor (HKS) was responsible for monitoring the foods in the refrigerators and throwing away foods when they needed to be thrown out. LN B stated whoever put items in the refrigerator was responsible for labeling the item, and the label needed to include the resident's name, room number, and the date and time it was put in there. During an observation and concurrent interview on 1/06/26 at 2:27 p.m., HKS verified she was responsible for monitoring food in the refrigerators for residents' foods at the nurses' stations. HKS stated that twice a week she checked the foods in the refrigerators to make sure it was properly labeled. HKS stated if the food had been in there for more than three days, she would let the resident know that it needed to be eaten or tossed. HKS stated that the residents could potentially get moldy food or it could go bad if the food was not properly monitored. From the Station 2 refrigerator, HKS removed two plastic containers of food (one with a sandwich, one with a few sausages) not labeled, a paper grocery bag containing a gallon of milk with a use by date of 12/1/25 and a container of sour cream with a delivery date of 11/16/25, a frozen ice cream milkshake with no date or name, a box of vegetable spring rolls with no name or date, two half-gallons of ice cream with no name or date, several ice cream sandwiches all with no name or date, and a pina colada-flavored fruit drink with a use by date of 12/2025 and no name or date. HKS stated all the removed items needed to be thrown away. HKS verified the use-by date on the milk of 12/1/25 and stated that since it was a whole gallon of milk she would ask the resident before she threw it away. During an observation and concurrent interview on 1/06/26 at 2:35 p.m., the refrigerator for residents' food at Station 1 contained a tub of whipped topping and a container of take-out food, both with no name or date. The freezer contained various frozen treats and had a black and white cloth ice pack with a name written on it in black marker. Licensed Nurse (LN) C stated the black and white cloth item in the freezer was a cold pack for pain relief. LN C stated she did not know the resident whose name was on the ice pack. LN C asked another nurse at the nurses' station, but she did not recognize the name on the ice pack either. LN C stated the ice pack should not be in the freezer with food. During a phone interview on 1/08/25 at 8:56 a.m., Registered Dietitian (RD) stated nursing had their own checklist of tasks and they checked the refrigerators at the nurses' stations for dates on the residents' foods. RD stated she checked periodically herself and has not seen any out-dates. RD stated it had come up in resident council that residents were upset that their food gets tossed, but we need to be throwing away expired food. When queried regarding outdated food, RD stated, depending on the type of food, the risk to residents was possible food-borne illness. RD stated she was unaware of the ice pack, but it should not be in the freezer meant for food due to the risk of cross-contamination with bio-hazard. During an interview on 1/08/25 at 11 a.m., Assistant Director of Nursing (ADON) stated the housekeeping supervisor or the nurses were responsible for monitoring the food in the refrigerators at the nurses' stations. ADON stated if there were concerns about the foods in the refrigerators, HKS was who she would go to first. When queried about the milk that was five weeks past the use-by date, ADON stated she would dump the milk and tell the resident. ADON stated, We have milk in the kitchen. ADON stated that she felt it made sense that the nurses should be in charge of monitoring the residents' personal food in the refrigerators at the nurses' stations. ADON stated no ice packs for pain should be in those refrigerators due to infection control. Review of facility policy Foods Brought by Family/Visitors, last revised 3/2022, indicated, . Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the 'use by' date. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).

Based on observation, interview, and record review, the facility failed to provide food at a palatable temperature for three of eight sampled residents (Resident 90, Resident 7, & Resident 53) at a confidential resident council interview. This failure had the potential to cause loss of appetite and weight loss in a vulnerable population when food is too cold to be appetizing.During a resident council meeting on 1/07/26 at 11:00 a.m. in dining hall, 3 residents who resided in Hall 4 (Resident 90, Resident 7 & Resident 53) complained that the food was always cold because they were served last. A review of the resident council notes indicated that cold food was reported in 08/25, again in 11/25, and in 12/25. During a tray line observation in the kitchen on 1/07/26 at 12:05 p.m., the cook began to plate the food for the residents' lunch. Continuing the tray line observation on 1/07/26 at 1:14 p.m., staff began to pass lunch trays to the residents residing on Hall 4. During a test tray observation and concurrent interview on 1/07/26 at 1:19 p.m., the survey team tested a tray of pureed fish, potatoes, carrots, and bread and a tray of regular texture fish, tater tots, carrots and a roll with Registered Dietitian (RD). RD took the temperatures of the pureed foods as follows: Carrots 100 degrees , potatoes 110 degrees , fish 110 degrees . Upon tasting the pureed food, the survey team agreed the temperature of the carrots was too cold. RD then took the temperatures of the regular texture foods as follows: Tater tots 105 degrees , carrots 105 degrees , fish 100 degrees . Upon tasting the regular texture food, the survey team agreed all the foods were too cold. RD sampled the food on the regular texture tray and agreed the food was cooler than it should be. RD stated, It could be warmer. During a phone interview on 1/08/26 at 8:56 a.m., RD stated she usually would hear people say the food was cold with the last hall (Hall 4). RD stated she thought the food was cool on the test tray because it was a longer tray line because it was fish day and the residents' increased demand for alternatives. Review of facility policy titled, Food and Nutrition Services Staff, last revised on 10/2017, indicated, Food will be palatable, attractive, and served in a timely manner at proper temperatures.

Based on observation, interview and record review, the facility failed to provide face-to-face and in-person physician visits at least once every 60 days for six (6) of 12 sampled residents (Residents 5, 19, 23, 41, 98, and 99). This deficient practice had the potential to result in a decline in medical, health or psychosocial conditions and a delay in necessary care, treatment and services.A review of Resident 19's admission Record indicated Resident 19 was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial skin infection causing red, swollen, warm, and painful skin that spreads quickly, often from bacteria entering a cut or wound), essential hypertension (high blood pressure), acute respiratory failure (a condition where there is not enough oxygen or too much carbon dioxide in the body), and spinal stenosis (the narrowing of spaces within the spine, putting pressure on the spinal cord and nerves, causing pain, numbness, weakness, or cramping, often in the lower back, legs, neck, or arms). A review of Resident 19's physician notes indicated she had only had virtual visits with Physician A in the past 90 days. During an interview on [DATE] at 1:46 p.m., with Resident 19 in her bedroom, Resident 19 was on the verge of tears, and stated she had not seen a doctor except on the screen. Resident 19 stated she was unsatisfied with her medical care and wished to go home. A review of Resident 5's admission Record indicated Resident 5 was admitted to the facility on [DATE], with diagnoses including rhabdomyolysis (a serious condition where damaged muscle tissue breaks down, releasing harmful substances into the blood, which can lead to kidney failure), sepsis (the body's extreme response to an infection that damages its own tissues and organs, potentially leading to septic shock, organ failure, and death), and paraplegia (paralysis affecting the lower half of the body, typically from the waist down, resulting from damage to the spinal cord, leading to loss of movement and sensation). A review of Resident 5's physician notes indicated he had only seen the facility physician once, and it was virtually, since his admission to the facility. A review of Resident 23's admission Record indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including heart failure (condition where the heart can't pump enough blood and oxygen to meet the body's needs), and diabetes mellitus (impaired ability to metabolize blood sugar). Review of Resident 23's physician notes indicated he had only had virtual visits with Physician A in the past 90 days. A review of Resident 41's admission Record indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (a bone infection that occurs when germs enter the bone from an injury, surgery, or open wound, leading to pain, swelling, redness, fever, and fatigue), and schizoaffective disorder (a serious mental illness blending symptoms like hallucinations or delusions with depression or mania), and syncope and collapse (fainting/sudden falling). A review of Resident 41's physician notes indicated he had only had virtual visits with Physician A in the past 90 days. Documentation of in-person physician visits for Residents 5, 19, 23, and 41 was requested from both Physician A (facility physician) and the facility, but they were not provided. During a record review on [DATE] at 9:49 a.m., Resident 98's face sheet indicated Resident 100 was admitted to the facility on [DATE] with multiple diagnoses including but not limited to heart failure, coronary artery disease (cholesterol build-up on the inside of the vessels that bring blood to the heart muscle), end-stage kidney disease (the kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival), diabetes mellitus, left above-the-knee amputation, and an implanted defibrillator (a device implanted in the chest that delivers electrical shocks or pacing to correct life-threatening, abnormal heart rhythms). Review of Resident 98's physician notes indicated he had only had virtual visits with Physician A. During a record review on [DATE] at 10:08 a.m., Resident 98's hospital records indicated that Resident 98 had died at a nearby hospital in the intensive care unit on [DATE]. During a record review on [DATE] at 2:45 p.m., Resident 99's face sheet indicated Resident 99 was admitted to the facility on [DATE] with multiple diagnoses including metabolic encephalopathy (brain dysfunction from a chemical imbalance, often due to severe illness), paralysis on the left side following a cerebral infarct (stroke, a blockage that stops blood flow to the brain), intractable epilepsy (seizures that continue despite anti-seizure medications), coronary artery disease, and heart attack. Review of Resident 99's nurse progress note dated [DATE] indicated Resident 99 had been admitted to comfort care (care team will focus on the patient's comfort while allowing natural death rather than attempting to cure disease) after readmission from the hospital. Review of Resident 99's nurse progress note dated [DATE] indicated Resident 99 had died. Review of Resident 99's physician notes indicated he had only had virtual visits with Physician A in the facility since [DATE]. Documentation of physician visits that were in-person were requested but not provided for Residents 98 and 99. During an interview on [DATE] at 12:35 p.m., the Administrator (ADM) stated Physician A was in the building every Monday for an hour, and stated that while he was here he did rounds, but then did paperwork at her (ADM's) desk with someone who transcribed and then Physician A signed. ADM stated Physician A did virtual visits as well. ADM stated that since there were four hallways, Physician A would see one hall each week, for a total of four halls each month. ADM stated Physician A had always done it this way for as long as she had been here. ADM verified there were over 20 residents on each hall and Physician A could not see every patient on the hallway and do a physical exam in an hour. ADM stated that was why he did the virtual visits. ADM stated Physician A was the physician for almost the whole building. During a phone interview on [DATE] at 12:58 p.m., Physician A stated he saw his patients every Monday. Physician A stated he saw his patients in-person or virtually. Physician A stated the number of patients he saw while he was at the facility varied considerably, depending if the nurses had a patient they were concerned about, or sometimes he saw a whole wing. Physician A stated he had 85 or 90 patients in the facility and he came on Mondays during the noon hour. During a review of the undated facility's policy and procedure titled, Physician Services, it indicated The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident .Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA [the Omnibus Budget Reconciliation Act-U.S. Congressional laws that bundle various budget-related changes, notably establishing federal nursing home standards] regulations.

Based on observation, interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review Level II evaluation (PASRR-following a Level 1 screening, the Level 2 evaluation determines appropriate placement of an individual with a serious mental illness, considering the least restrictive setting, and whether specialized services are needed) was completed for three of six sampled residents (Resident 23, Resident 41, and Resident 68), based on each Resident's documented psychiatric diagnoses and functional status. This failure had the potential for Resident 23, Resident 41, and Resident 68 to receive inappropriate and ineffective care/treatment, or to be inappropriately placed in a long-term care facility. During a review of the Resident 23's admission Record, it indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including diabetes (a chronic condition where the body has trouble regulating blood sugar (glucose)), major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and significant impairment in daily life), anxiety disorder (mental health conditions marked by intense, persistent, and excessive worry or fear about everyday situations, leading to significant distress and impairment in daily life), bipolar disorder (a mental illness causing extreme shifts in mood, energy, and activity), and age-related cognitive decline.During a record review of Resident 23's Minimum Data Set (MDS - an assessment screening tool), dated 12/31/24, active diagnoses included anxiety disorder, depression, and bipolar disorder. During a review of Resident 23's PASRR Level I Screening, dated 9/18/24, it indicated Resident 23 required a PASRR Level II screening due to Positive for SMI [serious mental illness]. During a review of the California Department of Health Care Services (DHCS) correspondence to the facility with the subject, Notice of Attempted Evaluation, dated 9/18/24, the DHCS wrote that after speaking with facility staff, a PASRR Level II examination was not scheduled for Resident 23 due to, the individual has no serious mental illness (SMI), and no functional limitations on the last 6 months. During a review of Resident 23's, Progress Notes, dated 4/25/25 at 12:52 a.m., it indicated Resident 23 had displayed, angry outbursts, and was acting aggressively in the facility, and Resident 23's family had reported a history of similar behaviors. During a review of Resident 23's Progress Notes, dated 6/28/25 at 4:59 a.m., it indicated Resident 23 directly touched a direct care staff in an inappropriate sexual manner. During a review of Resident 23's Care Plan Report, initiated on 8/31/24, it indicated the focus item, [Resident 23] has little or no activity involvement r/t [related to] anxiety, depression, disinterest. During a review of Resident 41's admission Record, it indicated Resident 41 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (hemiplegia is complete paralysis of one side of the body, while hemiparesis is weakness on one side), depression, and schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia (like hallucinations, delusions, disorganized thinking) with a mood disorder (major depression or bipolar mania)). During a record review of Resident 41's Minimum Data Set, dated [DATE], it indicated Resident 41 had active diagnoses of depression and bipolar disorder. During a review of Resident 41's PASRR Level I Screening, dated 9/18/24, it indicated Resident 41 required a PASRR Level II screening due to Positive for SMI. During a review of California DHCS correspondence to the facility with the subject, Notice of Attempted Evaluation, dated 9/18/24, the DHCS wrote that after speaking with facility staff, a PASRR Level II examination was not scheduled for Resident 41 due to, the individual has no serious mental illness (SMI) .no functional limitations on the last 6 months. During a review of Resident 41's, Progress Notes, dated 10/27/25 at 4:39 a.m., it indicated Resident 41 had displayed numerous behaviors primarily stemming from being challenged by people or things. During a review of Resident 41's, Progress Notes, dated 11/1/25 at 12:51 p.m., it indicated Resident 41 engaged in a hostile verbal altercation with another facility resident. During a review of Resident 41's Progress Notes, dated 11/3/25 at 2:12 p.m., it indicated Resident 41, has been exhibiting behaviors that present a danger to himself and/or others, and new psychiatric medications to manage these behaviors had been ordered by Resident 41's physician. During a review of Resident 41's, Care Plan Report, initiated on 10/23/25, it indicated the focus item, [Resident 41] has a psychosocial well-being problem r/t schizophrenic disorder bipolar type. During an interview on 1/06/25 at 1:30 p.m. the MDS Coordinator (MDSC) indicated hospitals that refer residents to the facility for long-term care often did not fill out the PASRR correctly in regard to mental health concerns. The MDSC also indicated it was the responsibility of the Inter-Disciplinary Team (IDT- a group of different professionals (doctors, nurses, therapists, social workers, etc.) collaborating to provide holistic patient care, especially in healthcare settings) to ensure that a resident with a mental illness was correctly re-screened for PASRR, if a mental illness was discovered or newly diagnosed. During an interview on 1/08/25 at 1:25 p.m., the Assistant Director of Nursing (ADON) stated examples of functional limitations for serious mental illness included not getting along with other residents, not caring for oneself, and refusing care/treatment, and/or medications. The ADON also stated it was important the PASRR process was correctly completed, so that residents with serious mental illness were not inappropriately placed in long-term care and skilled nursing facilities. Lastly, the ADON stated the facility's nursing staff was responsible for ensuring PASRR's were completed accurately, and if there was a change in condition, a new PASRR screening was initiated. During a review of the Resident 68's admission Record, it indicated Resident 68 was admitted to the facility on [DATE] with a diagnosis of Schizoaffective Disorder, Bipolar Type (a mental illness causing extreme shifts in mood, energy, and activity, from manic highs (euphoria, high energy, irritability) to depressive lows (sadness, hopelessness, low energy)) dated 7/25/25. During a record review of Resident 68's MDS dated [DATE], it indicated, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer to the question was recorded as, 0 indicating, No. Review of Resident 68's MDS section I – Active Diagnoses - Psychiatric / Mood Disorder, indicated the following diagnoses, I6000. Schizophrenia (e.g., Schizoaffective .disorders [a serious, chronic brain disorder that disrupts how a person thinks, feels, and behaves]). During a review of Resident 68's PASRR Level I Screening, dated 8/01/25, it indicated Resident 68 required a PASRR Level II screening due to Positive for SMI [serious mental illness]. During a review of California DHCS correspondence sent to the facility with the subject, NOTICE OF PASRR LEVEL I SCREENING RESULTS, dated 8/01/25, it indicated the results for Resident 68, Re: A SERIOUS MENTAL ILLNESS (SMI) LEVEL II MENTAL HEALTH EVALUATION IS REQUIRED .Your Level I screening indicates that a SMI Level II Mental Health Evaluation is required. During a review of California DHCS correspondence to the facility with the subject, Notice of Attempted Evaluation Re: UNABLE TO COMPLETE LEVEL II EVALUATION FOR SERIOUS MENTAL ILLNESS (SMI), dated 8/05/25, the DHCS wrote that a SMI Level II Mental Health Evaluation was not scheduled for the following reason, Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. The case is now closed. To reopen, the facility must resubmit a new level I Screening. During a review of Resident 68's Care Plan Report, initiated 7/25/25, it indicated the focus item, [Resident 68] uses psychotropic medications (Haloperidol [a typical antipsychotic medication used to treat psychotic disorders such as Schizophrenia]) used to treat r/t [related to] schizoaffective disorder. Another focus item initiated 7/28/25 indicated, [Resident 68] has a psychosocial well-being problem. During an observation on 1/05/26, at 12:54 p.m., Resident 68 was heard swearing at facility staff when they were delivering his meal tray. During an interview on 1/05/26, at 1:39 p.m., the Assistant Activities Director (AAD), stated she was assigned to sit outside Resident 68's room for 1:1 supervision due to his history of conflict, aggressive interactions, and behaviors with other residents including his roommates and staff. The AAD stated Resident 68 had issues getting along with his roommates and had room changes due to this issue. During an interview on 1/06/25 at 1:35 p.m., the MDSC indicated she was a resource to staff for PASSR processes. When queried about the reason Resident 68 did not receive a Level II PASRR screening after the facility received his positive Level I PASRR screening results on 8/01/25 indicating he required a Level II PASRR screening, the MDSC replied that she did not know the answer, but she would look into it. Later, the MDSC returned to provide a new Level I PASRR screening, dated 1/06/25, to restart the PASRR screening process for Resident 68, with no further information explaining why the initial PASRR Level II screening process was never completed after the facility was notified by DHCS Resident 68 required a PASRR Level II screening on 8/01/25. During an interview on 1/08/25 at 1:55 p.m., the ADON stated it was important that the PASRR process was correctly completed, so that residents with serious mental illness were not inappropriately placed in long-term care and skilled nursing facilities. When queried why Resident 68's PASRR Level II Screening was not completed after receiving his positive PASRR Level I Screening results on 8/01/25, approximately six days after his admission to the facility on 7/25/25, she replied she did not know, and said it should have been completed to ensure he was not inappropriately placed in the facility and to ensure he received any additional services he may have needed. A review of the undated facility policy and procedure titled, Pre-admission Screening and Resident Review (PASRR), indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) process. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the level II (evaluation and determination) screening process. Upon completion of the level II evaluation, the State PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, interview, and record review, the facility failed to protect residents' private health information when lunch tray tickets containing residents' names and diet orders were found thrown in the garbage in the dining room. This failure had the potential for residents' private health information to be obtained by persons who did not have a need to know the residents' information.During an observation on 1/05/26 at 12:46 p.m. in the RNA (Name of dining hall) Dining Hall, resident tray tickets were observed in the trash can.During an interview on 1/08/26 at 2:45 p.m., the Assistant Director of Nursing (ADON) stated that no tray tickets should be in the trash as they contain protected health information.A review of the facility policy titled, Confidentiality of Information and Personal Privacy, revised 10/25, indicated, the facility would safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) received care and services in accordance with professional standards of practice when:1. Registered Nurse 1(RN 1) performed a digital stool dis-impaction (a procedure to remove hardened, impacted stool from the rectum using a lubricated, gloved finger, which is inserted into the rectum to break up and extract the stool) procedure for Resident 1 without a physician's order.2. Facility did not provide licensed nursing staff (RN 1, Registered Nurse 2, Registered Nurse 3) sufficient education and training regarding rectal suppository (a small, solid medication plug designed to be inserted into the rectum. It melts and releases its medication into the bloodstream through the rectal wall) insertion and digital rectal stool dis-impaction (see F726 for additional information).This failure resulted in Resident 1 experiencing discomfort, confusion and anxiety during and after the procedure, and the potential for all facility residents to receive substandard rectal medication administration and treatment. Record review of the facility Face Sheet (facility demographic) indicated Resident 1 was originally admitted to the facility on [DATE] with medical diagnoses which included post laminectomy syndrome (a condition, where part of the bone (lamina) covering the spinal cord is removed and causes persistent or recurring pain, tingling and numbness in the buttocks and legs) and constipation (a condition characterized by infrequent or difficult bowel movements).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 9/12/2025, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact.A review of Resident 1's Clinical Physician Orders, last reviewed on 8/27/25, indicated Resident 1 was prescribed, Dulcolax Rectal Suppository (a small, solid medication plug designed to be inserted into the rectum (the final section of the large intestine, connecting the colon to the anus, where stool is stored before it is expelled from the body). It melts and releases its medication into the bloodstream through the rectal wall to relieve constipation), 10 milligrams (a unit of measure), insert suppository rectally every 24 hours as needed for constipation.Record review of a nursing note dated 9/15/25 at 10:31 p.m., indicated, RESIDENT FELT VIOLATED AFTER RN ADMINITERED (sic) RECTAL SUPPOSITORY.During an interview on 9/17/25 at 9:30 a.m., Resident 1 stated on 9/15/25 at approximately 10:30 p.m., Registered Nurse 1 (RN 1) inserted a suppository into his rectum at his request. According to Resident 1, Certified Nursing Assistant 1 (CNA 1) was assisting by helping turn Resident 1 to his side to facilitate the insertion. Resident 1 stated RN 1 inserted the suppository into his rectum and swirled her finger around one way inside his rectum, then the other way, continuing for a total of about four (4) minutes. Resident 1 stated he complained of pain and requested that RN 1 stop about (3 ) three minutes into the procedure, however RN 1 did not stop. Resident 1 stated that RN 1 told him, I need to do this so it will dissolve. Resident 1 stated he was embarrassed by this, and felt he was raped. During a phone interview on 9/17/25 at 11:20 a.m., CNA 1 confirmed being present during the above incident with Resident 1 and RN 1. CNA 1 stated she assisted RN 1 by turning Resident 1 on his side, so RN 1 could insert the suppository. CNA 1 stated she estimated RN 1 took five (5) to ten (10) minutes to insert the suppository, and she felt this timing to be extensive since other nurses she witnessed giving suppositories could accomplish the procedure in less than a minute. CNA 1 stated a few minutes into the procedure, Resident 1 complained it was taking too long and RN 1 replied, I have to move my finger around so it will activate. According to CNA 1, a few minutes later, RN 1 removed her finger from Resident 1's rectum and left the room. CNA 1 stated Resident 1 looked visibly upset after the procedure and she stayed to comfort him and talk, while Certified Nursing Assistant 2 (CNA 2) reported the incident to the charge nurse on duty. During an interview on 9/17/25 at 12:15 p.m. with the Assistant Director of Nursing (ADON), she stated the process for inserting a suppository involved rolling the resident to his side, inserting the lubricated suppository with a gloved hand and pulling the hand back out immediately after administration. The ADON stated if resistance was met during the procedure due to a collection of stool in the bowel, the nurse should try to push it slightly but if the resident was to complain of pain, the nurse was required to stop right away. During a phone interview on 9/18/25 at 1:40 p.m., RN 1 stated on the evening of 9/15/25, she inserted the suppository into Resident 1's rectum, she felt something hard that she believed to be stool. RN 1 stated she then moved her finger around inside Resident 1 for about (6) six seconds, to break up the stool so she could insert the suppository, and it could dissolve. RN 1 stated stool came out of Resident 1, along with a lot of gas. When asked to describe what dis-impaction was, RN 1 stated moving stool around so it can pass and be removed.During an interview on 10/6/25 at 4:00 p.m., RN 1 explained how she inserted Resident 1's suppository on 9/15/25, stating she inserted suppository using finger, took out some stool, so suppository would dissolve. When asked how the facility measured RN 1's competency to administer rectal suppositories upon hire, RN 1 stated she filled out a form. RN 1 stated she had performed digital (using a finger) dis-impactions in her past employment, and she didn't believe it required a physician's order. RN 1 stated if a resident had excessive stool in the rectum, she would remove it, rather than to let the resident suffer. During an concurrent interview and record review on 10/7/25 at 12:31 p.m. with the Director of Staff Development (DSD), she stated in reviewing employee training files for RN 1, Registered Nurse 2 (RN 2) and Registered Nurse 3 (RN 3), there were no detailed competencies outlining the specific actions required/performed during a rectal medication administration, nor a facility policy on digital stool dis-impaction. The DSD stated that it had been a while, but she did recall a specific past occurrence at the facility when digital stool dis-impaction was performed. At 1:45 p.m., the DSD stated rectal suppository administration was a common skill that needed to be performed competently by nursing staff, and the facility should ensure a return-demonstration should be done and documented prior to nursing staff performing rectal procedures independently. During a phone interview on 10/7/25 at 7:45 a.m. with CNA 2, she stated she went to Resident 1's room after Resident 1 had asked for a suppository on the night of the 9/15/25. CNA 2 stated she became aware that Resident 1 was already being attended to by RN1 and CNA 1, so she left the room. CNA 2 stated she later went back to Resident 1's room after the incident, just prior to reporting the incident to Charge Nurse (CN) on duty. CNA 2 stated Resident 1 was visibly upset with tears in his eyes.During a phone interview on 10/7/25 at 10:45 a.m. with Physician 1 (PHY 1), he stated rectal procedures/dis-impaction could result in harm because of pain, irritation and dignity issues. PHY 1 also stated dis-impaction required a physician's order (crucial for patient health, providing expertise and guidance to ensure proper treatment and avoid complications) prior to the procedure.During an interview on 10/07/25 at 11:00 a.m. with Resident 1, he stated he still experienced PTSD (Post-Traumatic Stress Disorder-a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal assault) and trauma from the suppository insertion on the evening of 9/15/25. Resident 1 stated he was suffering from nightmares and did not want to eat, because he did not feel safe.During an email correspondence on 10/14/25 at 12:53 p.m. from Resident 1, he wrote his nightmares began after 9/15/25, and continued to worsen over time. Resident 1 also wrote he still felt unsafe in the facility because of this incident and investigation, and he feared that staff might try to tamper with his food. A review of California Code of Regulations (16 CCR S 1472) Standardized Procedure Functions, current as of 9/26/25, indicated, An organized health care system must develop standardized procedures before permitting registered nurses to perform standardized procedure functions. A registered nurse may perform standardized procedure functions only under the conditions specified in a health care system's standardized procedures; and must provide the system with satisfactory evidence that the nurse meets its experience, training, and/or education requirements to perform such functions.During a review of Meadowood Registered Nurse Job Description, dated 2023, it indicated, Provides direct care skills.in accordance with current policies and procedures, as assigned .Prepares and administers medications as per physicians' orders.Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.Record review of the facility policy (P & P) titled, Administering Rectal or Vaginal Medications, revised in 2010, indicated, Explain the procedure to the resident.Provide for privacy of the resident. and gently insert the suppository into the anus with the lubricated, gloved index finger. Insert approximately 10 centimeters (a unit of measure) (4 inches) deep along the wall of the rectum.instruct resident to remain in left lateral or lying position for at least five (5) minutes.

Based on interview and record review, the facility failed to provide one of five sampled residents (Resident 1) with nursing care in a manner that maintained his dignity and respect, when Registered Nurse 1 (RN 1):1. Did not cease performing a rectal (of, relating to, or situated near the rectum, which is the final section of the large intestine) treatment/procedure after Resident 1 complained of pain and asked RN 1 to stop.2. Did not ensure privacy during care/treatment which required Resident 1 to be partially unclothed from the waist down.3. Did not provide explanation of care/treatment to Resident 1 prior to performing an invasive (involving the introduction of instruments or other objects into the body or body cavities) rectal medication insertion. (See F552 for additional information).These failures caused Resident 1 to experience pain, anxiety, and to feel violated and embarrassed. These failures also caused Resident 1 to experience serious psychosocial trauma (distressing thoughts and symptoms that last for more than two weeks after a traumatic event). Record review of the facility Face Sheet (facility demographic) indicated Resident 1 was originally admitted to the facility on [DATE] with medical diagnoses which included post laminectomy syndrome (a condition, where part of the bone (lamina) covering the spinal cord is removed and causes persistent or recurring pain, tingling and numbness in the buttocks and legs) and constipation (a condition characterized by infrequent or difficult bowel movements).A review of Resident 1's Clinical Physician Orders, last reviewed on 8/27/25, indicated Resident 1 was prescribed, Dulcolax Rectal Suppository (a small, solid medication plug designed to be inserted into the rectum (the final section of the large intestine, connecting the colon to the anus, where stool is stored before it is expelled from the body). It melts and releases its medication into the bloodstream through the rectal wall to relieve constipation), 10 milligrams (a unit of measure), insert suppository rectally every 24 hours as needed for constipation.During a review of Resident 1's Minimum Data Set - C (MDS- a resident assessment tool), dated 9/12/25, the MDS indicated Resident1's cognitive (the ability to think and process information) skills for daily decision making were intact.During a review of Resident 1's MDS - D (a mood assessment), dated 9/14/25, it indicated Resident 1 was mildly depressed, based on a score of six (6) out of 27 possible points. Assessment questions indicated Resident 1 had no sleep, energy, or loss of interest problems. During a review of Resident 1's MDS - I (active diagnoses), dated 9/14/25, it indicated Resident 1 was not diagnosed with PTSD (Post-Traumatic Stress Disorder-a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal assault), or any other psychiatric/mood disorder other than depression.Record review of a nursing note dated 9/15/25 at 10:31 p.m., indicated, RESIDENT FELT VIOLATED AFTER RN ADMINITERED (sic) RECTAL SUPPOSITORY.During an interview on 9/17/25 at 9:30 a.m., Resident 1 stated that on 9/15/25 at approximately 10:30 p.m., Registered Nurse 1 (RN 1) inserted a suppository into his rectum at his request. According to Resident 1, Certified Nursing Assistant 1 (CNA 1) was assisting by helping turn Resident 1 to his side to facilitate the insertion. Resident 1 stated RN 1 inserted the suppository into his rectum and swirled her finger around one way inside his rectum, then the other way, continuing for a total of about four (4) minutes. Resident 1 stated he complained of pain and requested that RN 1 stop about three (3) minutes into the procedure, however RN 1 did not stop. Resident 1 stated that RN 1 told him, I need to do this so it will dissolve. Resident 1 stated he was embarrassed by this, and felt he was raped. Resident 1 also stated that while this incident was occurring, staff did not pull the privacy curtain around his bed, and the door to the hallway was open.During a phone interview on 9/17/25 at 11:20 a.m., CNA 1 confirmed being present during the above incident with Resident 1 and RN 1. CNA 1 stated she assisted RN 1 by turning Resident 1 on his side, so RN 1 could insert the suppository. CNA 1 stated she estimated RN 1 took five (5) to ten (10) minutes to insert the suppository, and she felt this timing to be extensive since other nurses she witnessed giving suppositories could accomplish the procedure in less than a minute. RN 1 began by inserting the suppository into Resident 1's rectum, and, after about three (3) minutes, CNA 1 stated Certified Nursing Assistant 2 (CNA 2) came back into Resident 1's bedroom and gave CNA 1 a look which she perceived as, this isn't right. CNA 1 stated Resident 1 then complained it was taking too long and RN 1 replied, I have to move my finger around so it will activate. CNA 1 stated a few minutes later, RN 1 removed her finger from Resident 1's rectum and left the room. CNA 1 stated Resident 1 looked visibly upset after the procedure, so she stayed to comfort and talk to Resident 1, while Certified Nursing Assistant 2 (CNA 2) reported the incident to the Charge Nurse (LVN 1) on duty. During an interview on 9/17/25 at 12:15 p.m. with the Assistant Director of Nursing (ADON), she stated the process for inserting a suppository involved rolling the resident to his side, inserting the lubricated suppository with a gloved hand and pulling the hand back out immediately after administration. The ADON stated if resistance was met during the procedure due to a collection of stool in the bowel, the nurse should try to push it slightly but if the resident was to complain of pain, the nurse was required to stop right away. During a phone interview on 9/18/25 at 1:40 p.m., RN 1 stated when she inserted the suppository into Resident 1's rectum, she felt something hard that she believed to be stool. RN 1 stated she then moved her finger around inside Resident 1's rectum for about six (6) seconds, to break up the stool so she could insert the suppository, and it could dissolve. RN 1 stated she was pretty sure CNA 1 provided adequate privacy by closing Resident 1's curtain before this procedure, but was not certain stating, the CNAs are pretty good about doing that.During an interview on 10/6/25 at 4:00 p.m. with RN 1, RN 1 stated she told Resident 1 that he would be turned and didn't tell Resident 1 much else about the procedure since she was forewarned that Resident 1 could cause trouble for staff that engaged with him verbally.During an interview with on 10/06/25 at 4:32 p.m. with CNA 1, she stated RN 1 told Resident 1 that prior to administering the Dulcolax medication, she told Resident 1 she would be inserting a suppository. CNA 1 stated as RN 1 inserted the suppository into Resident 1's rectum, CNA 1 noticed Resident 1 displaying facial grimacing. Afterwards the administration was completed, CNA 1 noticed that Resident 1 appeared upset, with tears in his eyes. CNA 1 also stated CNA 2 told her she saw Resident 1's bedroom door and privacy curtain was open from the hallway, at the time RN 1 and CNA 1 were with Resident 1, and CNA 2 could see his (Resident 1's) butt.During a phone interview on 10/7/25 at 7:45 a.m. with CNA 2, she stated she went to Resident 1's room after Resident 1 had asked for a suppository on the night of the 9/15/25. CNA 2 stated she then returned to Resident 1's room briefly, but left after she became aware that Resident 1 was already being attended to by RN1 and CNA 1. CNA 2 stated she could not recall if Resident 1's privacy curtain was open or closed. CNA 2 stated she again went back to Resident 1's room after the incident, just prior to reporting the incident to the Charge Nurse (CN) on duty. CNA 2 stated Resident 1 was visibly upset with tears in his eyes. During a phone interview on 10/7/25 at 10:45 a.m. with Physician 1 (PHY 1), he stated digital dis-impaction required a physician's order (crucial for patient health, as it provides expertise and guidance to ensure proper treatment and avoid complications), and performing dis-impaction without a physician's order could cause resident harm because of physical pain and irritation, as well as unwanted dignity issues.During an interview on 10/07/25 at 11:00 a.m. with Resident 1, he stated he still experienced PTSD and psychological trauma from the suppository insertion on the evening of 9/15/25. Resident 1 stated he was still suffering from nightmares and did not want to eat, because he did not feel safe.During an email correspondence on 10/14/25 at 12:53 p.m. from Resident 1, he wrote that his nightmares began after 9/15/25, and continued to worsen over time. Resident 1 also wrote he still felt unsafe in the facility because of this incident and the investigation, and feared staff might try to tamper with his food. Record review of the facility policy (P & P) titled, Administering Rectal or Vaginal Medications, revised in 2010, indicated, Explain the procedure to the resident.Provide for privacy of the resident. and gently insert the suppository into the anus with the lubricated, gloved index finger. Insert approximately 10 centimeters (a unit of measure) (4 inches) deep along the wall of the rectum.instruct resident to remain in left lateral (side) or lying position for at least five (5) minutes.Record review of P & P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, revised in February of 2021, indicated, Residents and resident representatives have the right to request, refuse and/or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms, and Residents/representatives are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment and plan of care; b. the risks and benefits of the proposed care, treatment, treatment alternatives or treatment options.Record review of P & P titled Dignity, revised 2021, indicated, Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interviews and record reviews, the facility failed to provide adequate supervision and assistance to prevent a fall for one out of two sampled residents (Resident 1), when: 1. The facility's policy was not followed when Resident 1 was assisted by one staff only while using a mechanical lift to transfer Resident 1 from wheelchair to bed, and the policy indicated at least two nursing staff were needed to safely move a resident with a mechanical lift. 2. The staff completing the transfer for Resident 1 did not have a mechanical lift competency completed prior to Resident 1's fall incident on 3/21/24. These failures resulted in Resident 1 sustaining a fall on 3/21/24, resulting in a left femoral fracture (a break in the thigh bone). Findings: During a review of Resident 1's face sheet (demographics), it indicated she was admitted to the facility on [DATE], with diagnoses of Hyperlipidemia (HLP, high levels of fat particles - lipids, in the blood), Quadriplegia (paralysis below the neck that affects all four limbs), and Anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 1's Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 7/18/24, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning and to help determine if any interventions need to occur) score was 15, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1 needed maximal assistance (staff performs more than half the effort of completing a task) up to dependent on staff, for the provision of personal care. A review of the X-Ray (imaging that creates pictures of the inside of your body) result, dated 3/25/24 at 13:08 (1:08 p.m.), indicated Resident 1 had a left femoral neck fracture. A review of Unlicensed Staff A's (CNA) Core Clinical Competencies-Mechanical Lift (sling lift) indicated he did not receive the competency test prior to Resident 1's fall on 3/21/24. A review of staff record indicated Unlicensed Staff A had an Employee Warning record note, dated 3/26/24, for not following standard of practice and facility protocol and record falsification resulting in Resident 1's injury. A review of the Nursing Readmission Note, dated 3/28/24, indicated Resident 1 came back from the hospital with a diagnosis of left partial hip replacement (removes and replaces the ball of the hip joint. It does not replace the socket) following left trochanteric neck fracture (a type of broken hip). A review of Resident 1's care plan (CP, a plan that specifies your health care and support needs and outlines how your provider will meet your requirements), dated 12/19/24, indicated Resident 1 used a Hoyer lift (mechanical lift) for all transfers with extensive assistance of at least two staff members. During an interview on 7/30/24 at 12:07 p.m., the Director of Nursing (DON) stated there should always be two staff present when using the lift for residents' safety. During an interview on 7/30/24 at 12:14 p.m., Licensed Staff B stated she was a nurse and did not transfer residents, however, she believed using mechanical lifts required two staff for safety precaution to prevent falls and accidents. During an interview on 7/30/24 at 12:16 p.m., Licensed Staff C stated there should be two staff present when using mechanical lifts to prevent falls and accidents. During an interview on 7/30/24 at 12:17 p.m., Unlicensed Staff D stated they were trained to use mechanical lifts before they were allowed to use it on a resident to ensure they knew how to use it safely and properly. Unlicensed Staff D stated there should always be two staff present when using the mechanical lift. Unlicensed Staff D stated this was to protect the residents from falls, accidents, and injuries. During an interview on 7/30/24 12:22 p.m., Unlicensed Staff E stated they were trained to use the mechanical lift to ensure they were using it right for residents' safety. Unlicensed Staff E stated at a minimum, there should always be two staff present when using the mechanical lift to prevent falls, accidents, and injuries. During an interview on 7/30/24 at 4:27 p.m., Resident 1 stated he could not recall if there were two staff that assisted him when he fell while being transferred using the mechanical lift. Resident 1 stated he believed someone could have caught him if there were two staff present during his transfer using the lift. During an interview on 7/30/24 at 4:56 p.m., Unlicensed Staff F stated they were trained to use the mechanical lift to ensure they knew how to use it properly and safely. Unlicensed Staff F stated she did not help Unlicensed Staff A when he transferred Resident 1 using the mechanical lift. Unlicensed Staff F stated, using a mechanical lift required two staff for safety and to prevent falls, accidents, and injuries. During an interview on 7/30/24 at 5:40 p.m., the Assistant Director of Nursing (ADON) stated staff was not following the mechanical lift policy and procedure when Resident 1 fell on [DATE], while using the mechanical lift. The ADON stated, transfers with mechanical lifts required two staff for safety. The ADON stated, if there were two staff present when Resident 1 was being transferred using the mechanical lift, staff could have caught Resident 1, which could result in a better outcome for his fall. During an interview on 7/30/24 at 6 p.m., the Administrator verified Unlicensed Staff A's Employee Warning record note, dated 3/26/24, was due to him not following the facility's protocol of having two staff present when using the mechanical lift. A review of the facility's policy and procedure (P&P) titled, Lifting Machine, using a Mechanical, revised 1/17/23, the P&P indicated, The purpose of this procedure is to establish general principles of safe lifting using a mechanical lifting device .at least 2 nursing staff are needed to safely move a resident with a mechanical lift.

Based on observations, interviews and records review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from accidents when: 1. The facility staff took more than five minutes to answer Resident 1 ' s call light (an alerting device for nurses or other nursing personnel to assist a patient when in need), when Resident 1 turned on his call light for assistance to use the toilet. This failure resulted in Resident 1 to fall on the floor twice while attempting to go to the toilet without staff assistance causing Resident 1 to sustain right arm fracture. 2. The facility staff did not ensure Resident 2 was supervised when smoking. This failure resulted in Resident 2 to sustain cigarette burns to his right thigh and right scrotum (The bag of skin that holds and helps to protect the testicles). Findings: Resident 1 A review of the Admission Record indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to Unsteadiness on Feet and Other Abnormalities of Gait (a manner of walking or moving on foot) and Mobility. A review of the ADL (Activities of Daily Living - the tasks of everyday life like eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) Care Plan initiated on 11/30/23 indicated Resident 1 required moderate assistance (when the assisting person(s) or device(s) are required to perform approximately 50 percent of the work of a mobility task while the resident perform 50 percent of the work) with one-person assist for all transfers. A review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 12/04/23 indicated Resident 1 had a BIMS score of 14 out of 15 (Brief Interview for Mental Status - a 15-point cognitive [relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact). A review of the Progress Notes dated 2/21/24 at 2:07 p.m. indicated Resident was found on his knees facing the bathroom toilet. A review of the document titled Fall Investigative Summary (no date) indicated Resident 1 had a fall incident on 2/22/24 at 6:56 a.m. The document indicated an unidentified CNA (Certified Nursing Assistant) entered Resident 1 ' s room to answer the call light when Resident 1 was observed holding on the bathroom door handle while lowering himself to the floor. The document indicated Resident 1 was noted with skin tear to right elbow and on right forearm with scant blood. A review of the Progress Note dated 2/26/24 at 1:05 p.m. indicated Resident 1 was noted with right hand and arm swelling with large bluish-purple discoloration. The Progress Note indicated the physician gave an order to send Resident 1 to the hospital. A review of the Progress Note dated 2/26/24 at 1:54 p.m. indicated Resident 1 returned to the facility from the hospital with a diagnosis of fractured (broken bone) humerus (upper arm bone). During an observation in Resident 1 ' s room and concurrent interview with Unlicensed Staff A on 5/06/24 at 2:07 p.m., Resident 1 was observed sitting at the edge of his bed, both feet resting on the floor, and his head was resting on a pillow. Resident 1 appeared to be sleeping. Unlicensed Staff A was outside of Resident 1 ' s room documenting. When Unlicensed Staff A was asked if it was normal for Resident 1 to sleep while sitting at the edge of the bed, she stated, sometimes because he feels full. When Unlicensed Staff A asked Resident 1 if he wanted to lay down on bed, Resident 1 said yes. When Unlicensed Staff A was asked how much assistance was needed to transfer and walk Resident 1, Unlicensed Staff A stated Resident 1 required limited assistance (resident highly involve in activity; staff provide guided maneuvering of limbs or other non-weightbearing assistance) with transfer and walking. During an observation and concurrent interview with Resident 1 in his room on 5/06/24 at 3:16 p.m., Resident 1 was sitting at the edge of his bed, awake. When asked about his fall incident on 2/22/24, Resident 1 stated he fell twice while he was in his old room. He stated he turned his call light on because he wanted to use the toilet, but it was taking for the CNAs to answer his call light and could not wait any longer. He stated he had to go, so he attempted to go to the toilet without staff assistance and fell on the floor. Resident 1 stated he waited for more than twenty minutes for the CNA before he decided to go to the bathroom on his own. During an interview with Resident 3 on 5/06/24 at 3:19 p.m., when asked how long he had to wait for the facility staff to answer his call light, Resident 3 stated he had to wait for a long time, maybe 20 minutes or longer. He stated his left foot was amputated and could not transfer without staff assistance to use the toilet. When Resident 3 was asked what happened when he had to wait for a long time, Resident 3 stated he had to sit on his poop for a long time causing him to have sore on his butt. During an interview with Unlicensed Staff A on 5/07/24 at 11:44 a.m., when asked about the facility ' s policy regarding call light response, Unlicensed Staff A stated staff should answer the call light within three to five minutes or as soon as possible. When Unlicensed Staff A was asked about the risks for the residents if they had to wait for a long time for the call light to be answered, Unlicensed Staff A stated residents could fall when attempting to transfer or could choke when eating. She stated the resident might also be needing pain medication. During an interview with Unlicensed Staff B on 5/07/24 at 12:06 p.m., when Unlicensed Staff B was asked about the facility ' s policy regarding call light response, Unlicensed Staff B stated staff should answer the call light within three to five minutes and no more than five minutes. She stated if she could not assist the resident immediately, she would still answer the light and tell the resident she would be back. When Unlicensed Staff B was asked about the risk for the resident if his/ her call light was not answered or if resident had to wait for a long time, Unlicensed Staff B stated resident was at risk for falling from trying to transfer unassisted which could result to serious injuries. During an interview with the Director of Staff Development (DSD) on 5/07/24 at 1:03 p.m.; when the DSD was asked about her expectation from facility staff to answer the call lights, the DSD stated staff were expected to help each other and answer the call light as soon as possible, and no more than five minutes. She stated it could be a safety issue for the residents when they are left waiting for too long for the call light to be answered. A review of the Facility policy and procedure titled Call System, Resident dated September 2022 indicated, Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately. A review of the Facility policy and procedure titled Activities of Daily Living (AD Ls), Supporting revised on March 2018 indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: .b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); Resident 2 A review of the Admission Record indicated Resident 2 was admitted on [DATE] with diagnosis including but not limited to Left side Hemiplegia (the loss of the ability to move [and sometimes to feel anything] one side of the body); Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations) and Nicotine Dependence (also called tobacco addiction). A review of the Smoking Care Plan initiated on 5/23/22 indicated Resident 2 smoked cigarette unsupervised. One of the Care Plan interventions indicated, smoking supplies will be kept in personal locker in activities. A review of the Minimum Data Set, dated dated dated [DATE] indicated Resident 2 had a BIMS score of 15 out of 15 points. A review of the Progress Notes dated 4/22/24 at 1:38 p.m. indicated Resident 2 was observed to have smoke emanating from his pants and brief. The Progress Note indicated an unidentified CNA removed Resident 2 ' s pants and put out the embers that were touching Resident 2 ' s skin. When Licensed Staff C assessed Resident 2, Licensed Staff C found small circular burn marks with ash on Resident 2 ' s right inner thigh and right scrotum. A review of the Progress Notes dated 4/22/24 at 4:11 p.m. indicated Resident 2 sustained two cigarette burns to his right upper thigh and one cigarette burn to his right groin with singed (burned slightly) hair. The burnt skin on the groin measured 0.5 cm. (centimeter - a measure of length) in length, 0.5 cm in width in depth (deepness). The burnt skin close to the groin measured 0.5 cm in length, 0.5 cm in width and 0.1 cm in depth, and the wound far from the groin measured 0.3 cm in length, 1.5 cm in width and 0.1 cm in depth. The Progress Note indicated Resident 2 stated he did not feel anything when the cigarette ash dropped on his lap, but he smelled hair burning. A review of the smoking Care Plan initiated on 4/22/24 indicated, [Resident 2] is now supervised smoker due to unsafe cigarette smoking practices. Care plan interventions indicated, Encourage smoking supervision to prevent any further burn injury from smoking cigarettes; Encourage use of smoking apron to prevent embers and hot ashes falling onto clothes; Encourage/ remind resident to wear smoking apron while smoking for safety PRN (as needed); and Resident to smoke outside with supervision in designated smoking areas set by facility. During an observation and concurrent interview with Resident 2 on 5/07/24 at 11:25 a.m., Resident 2 was sitting on his wheelchair in his room. When Resident 2 was asked about the cigarette burn incident on 4/22/24, he stated his pants caught on fire without knowing it. Resident 2 stated he had been smoking outside without staff supervision and had been keeping his cigarette and lighter. When Resident 2 was asked how often would he go out for a smoke, he stated at least every two hours. During an interview with Unlicensed Staff A on 5/07/24 at 11:50 a.m., when Unlicensed Staff A was asked about the facility ' s smoking policy, Unlicensed Staff A stated the facility had a set schedule for resident to smoke. She stated RNAs (Restorative Nursing Assistant) and activity staff provided close supervision to the resident who were outside smoking. When Unlicensed Staff A was asked about the risks for the residents who were allowed to smoke without staff supervision, Unlicensed Staff A stated resident ' s clothes could catch on fire, burn his/her finger, or could start a fire. During an observation at the back patio with Unlicensed Staff A on 5/07/24 at 11:54 a.m., Resident 2 and Resident 4 were outside smoking with no staff supervision. Both residents were not wearing a smoking apron. When Unlicensed Staff A was asked reason why Resident 2 and Resident 4 had no smoking apron while smoking cigarette, Unlicensed Staff A stated both residents were independent with smoking and did not require smoking apron and staff supervision. During an interview with Unlicensed Staff B on 5/07/24 at 12:11 p.m., when Unlicensed Staff B asked about the facility ' s smoking policy, Unlicensed Staff B stated smoker residents were allowed to smoke at 10:00 a.m., 1:30 p.m., 5:00 p.m., and 8:00 p.m. She stated activity staff provides supervision during daytime and CNAs provide supervision in the evening. When Unlicensed Staff B was asked about the risks for the residents who were allowed to smoke without staff supervision, Unlicensed Staff B stated resident could start a fire if on oxygen (a life-supporting component of the air) therapy, pants could catch on fire when lit cigarette was dropped accidentally. During an interview with the DSD on 5/07/24 at 1:03 p.m., when the DSD was asked about the burn incident involving Resident 2, the DSD stated prior to the incident, Resident 2 was allowed to smoke unsupervised. She stated after the incident, the facility set a smoking schedule for the residents to follow including Resident 2. The schedule was set at 10AM, 1 PM, 4:15 PM, and 8:15 PM. She stated RNA or Activity staff will provide supervision to include donning the smoking apron and lighting the cigarettes. She also stated that resident ' s cigarettes and lighters will be kept at the nurse ' s station. However, when this writer shared my observation with Resident 2 smoking unsupervised and with no smoking apron, the DSD stated Resident 2 always does what he wanted to do. She stated she will have to talk to the administrator to address this issue. A review of the Facility policy and procedure titled Smoking Policy - Residents revised on July 2017 indicated, This facility shall establish and maintain safe resident smoking practices. The policy indicated, Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking.

Based on interviews and records review, the facility failed to ensure one of three sampled residents (Resident 5) was free from pain and discomfort when Resident 5 who had left hip arthroplasty (also known as hip replacement - a surgical procedure to replace some or all of a joint) and Chronic Pain (pain that lasts for longer than 3 months) did not receive her ordered pain medication according to the scheduled administration time. This failure resulted in Resident 5 to experience excruciating pain to the point that she was in tears. Findings: During a telephone interview with Resident 5 on 5/06/24 at 8:40 a.m., Resident 5 stated she was admitted to the facility to receive Physical Therapy after a left hip replacement. She stated she had a lot of pain from the recent hip replacement and past multiple surgeries. Resident 5 stated facility nurses were not giving her pain medication on time. She stated when she asked for her pain medicine, it would take more than two hours or more to get it causing her to experience excruciating pain to the point that she was in tears. A review of the Hospital Record titled Discharge Summary dated 9/29/23 indicated Resident 5 had a left hip arthroplasty (a surgical procedure to replace some or all of a joint) on 9/25/23. The Discharge Summary indicated Resident 5 had chronic pain with multiple surgeries of her neck and lower back. A review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 10/05/23 indicated Resident 5 had a BIMS score of 15 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive [relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact) A review of the Medication Administration Record (MAR) for November 2024 indicated an order for Oxycodone Hydrochloride ER 30 mg (milligram - a measure of weight) Oral Tablet to give one tablet every twelve hours for Chronic Pain at 9:00 a.m. and 9:00 p.m. A review of the Controlled Substance Accountability Sheet for Resident 5 indicated, Oxycontin (also known as Oxycodone) Tab (tablet) 30 mg ER take one tablet by mouth twice a day. The Controlled Substance Accountability Sheet indicated one tablet of Oxycontin 30 mg was signed off on 10/25/23 at 6:30 a.m. and 9:00 p.m. A review of the facility document titled Order Summary Report with date range 11/01/23 to 11/30/23 indicated the following physician ' s orders: Oxycontin (used to help relieve severe ongoing pain) Oral Tablet 20 mg to give one tablet every twelve hours for Chronic Pain for four days written on 11/05/23; and Norco Oral tablet 10-325 mg (Hydrocodone-Acetaminophen - used to relieve moderate to severe pain) to give 1 tablet every four hours as needed for moderate to severe pain written on 11/11/23. A review of the document titled Medication Administration Audit Report from 11/01/23 to 11/22/23 indicated Resident 5 was given Oxycontin 20 mg Oral Tablet on 11/06/23 at 11:50 p.m. when the medication was scheduled to be given on 11/06/23 at 9:00 p.m. A review of the Progress Note dated 11/13/23 at 12:43 p.m. indicated Resident 5 discussed with Licensed Staff E about her concern regarding her pain not being managed. The Progress Note indicated, [Resident 5] stated that she will ask for her pain medicine and the nurse will bring it an hour or 1 1/2 hours later and sometimes even later then [sic] that. A review of the facility document titled Order Summary Report with date range 11/01/23 to 11/30/23 indicated the schedule for Norco was changed on 11/15/23 to Norco Oral tablet 10-325 mg to give 1 tablet by mouth every four hours for Chronic Pain A review of the Medication Administration Record (MAR) for November 2024 indicated an order for Norco Oral tablet 10-325 mg was scheduled to be given at 12:00 a.m.; 4:00 a.m.; 8:00 a.m.; 12:00 p.m.; 4:00 p.m.; and 8:00 p.m. A review of the document titled Medication Administration Audit Report from 11/01/23 to 11/22/23 indicated Resident 5 was given one tablet of Norco Oral Tablet 10-325 mg on the following dates and times: - On 11/15/23 at 12:42 a.m. when the medication was scheduled to be given on 11/14/23 at 4:00 a.m. - On 11/16/23 at 5:38 p.m. when the medication was scheduled to be given on 11/16/23 at 4:00 p.m. - On 11/21/23 at 1:49 p.m. when the medication was scheduled to be given on 11/21/23 at 12:00 p.m. During an interview and concurrent record review with the Director of Nursing (DON) on 5/07/24 at 12:44 p.m., when the DON was asked about the facility ' s policy on medication administration, the DON stated the nurses could administer medications one hour before or one hour after the scheduled medication administration time. She stated nurses were expected to follow the doctors order and sign off the medication as soon as it was given to the resident. A review of the document titled Medication Administration Audit Report for Resident 5 with the DON, the document indicated an order for Norco oral tablet scheduled to be given at 4:00 a.m. on 11/14/23. However, the document indicated the medication was signed off on 11/15/23 at 12:42 a.m. The DON stated there was at least eight minutes delay in their EMAR (electronic medication administration record) when saving the licensed nurses signature; however, she stated it should not take an hour or more to save it. During an interview with Licensed Staff D on 5/07/24 at 1:27 pm., when Licensed Staff D was asked about the facility ' s policy on medication administration, Licensed Staff D stated nurses could administer medications one hour before or one hour after the scheduled medication time. Licensed Staff D stated nurses would sign off the medication as soon as the medication was administered. When Licensed Staff D was asked how would late pain medication administration affect the resident, Licensed Staff D stated administering the medication too late or too soon would affect the next scheduled administration time making pain management ineffective, and the resident could go through a lot of pain. A review of the Facility policy and procedure titled Administering Medications revised in April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy ' s subcategory titled Policy Interpretation and Implementation indicated . 4. Medications are administered in accordance with prescriber orders, including any required time frame; . 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; . 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observations, interviews and record reviews, the facility failed to develop and implement a person-centered Care Plan for one (1) of six (6) sampled residents, Resident 339, when: 1) Resident 339 was evaluated by a Physical Therapist for strength and mobility, which required two people to assist during transfer; and, 2) Resident 339 required two people to assist during transfer using a Hoyer or [NAME] Lift, (a mechanical lift device). These failures resulted in Resident 339 falling and sustaining a right shoulder dislocation, when staff incorrectly used the [NAME] Lift mechanical device during transfer. Resident 339 was subsequently transferred to Emergency Department (ED). The facility staff provided inadequate care to a vulnerable resident when Resident 339's needs were not addressed appropriately. Findings: A record review titled, Interdisciplinary Team (IDT), notes, dated 9/30/21 at 9:10 a.m., indicated a, Fall Meeting was held. [Resident 339] had a fall with injury on 9/29/21 at 8 p.m., when [Resident 339] was being transferred from a shower chair to bed using a [NAME] Lift, per [Staff E]. During an interview on 12/9/22 at 12:25 p.m., the Director of Staff Development (DSD) stated all nursing staff received training before operating the mechanical device such as a Hoyer lift (non standing lift) and [NAME] Lift (standing lift). (A Hoyer Lift or a [NAME] Lift machine is a device to safely transfer a resident from a bed to a wheelchair or vice versa). The DSD stated staff received skills' training yearly. The DSD kept all skills' records in the employee's file. The DSD stated all staff were instructed to have two staff to operate the Mechanical Lift device for safety and to prevent falls. During a concurrent observation and interview on 12/9/22 at 1 p.m., when the DSD (Director of Staff Development) was asked how a Certified Nursing Assistant (CNA) would know when to use a Hoyer lift or [NAME] Lift (A device used to lift a resident during transfer) to care for a resident. The DSD stated each resident who needed a mechanical lift would have a sign inside their closet. An orange piece of paper measuring approximately a size of index card was located inside a resident closet which indicated the resident required Hoyer lift. A review of Resident 339's care plan revealed, prior to fall on 9/29/21, the facility did not include in the plan of care, under intervention, how to use the mechanical lift during transfer, During an interview on 12/9/22 at 12:37 p.m., the DON (Director of Nursing) stated all nursing staff were trained how to use a Hoyer lift and [NAME] Lift. The DON stated all Certified Nursing Assistants (CNAs) must have competency checked off before operating the Lift machine. The DON stated, to use of a Hoyer or [NAME] Lift, they must have two CNAs during the resident's transfer to prevent falls. The DON stated, one CNA operating the Lift machine, and the other CNA was positioned by the resident at the opposite side, to prevent falls. The DON stated the DSD provided in-services and checked the staff's skill on the use of Hoyer/[NAME] Lift machine. The DON stated Licensed Nurses needed to include the use of Hoyer or [NAME] Lift a mechanical device in a resident's care plan. During a concurrent observation, interview and record review on 12/9/22 at 1 p.m., in the [NAME] Lift storage room, Staff F and Staff G (CNA)s stated, to operate the Hoyer or [NAME] Lift Machine you must have two CNAs, one to operate the machine and the other CNA standing by the resident for support during transfer, to prevent falls. Staff F and Staff G demonstrated how to use a [NAME] Lift. Staff G and Staff F stated, the reasons for two CNAs was because one CNA needed to operate the machine, and the other CNA must be behind the resident, with a wheelchair to stand by, in case a resident's knees buckled. Staff F and Staff G stated, once a resident's knee buckled, the other CNA would bring the wheelchair and put it behind the resident to enable the resident to sit down to prevent falling. A review of the care plans for Resident 339, dated prior to 9/29/21, revealed no intervention mentioned for the need to use a mechanical lift. A record review for Resident 339's, Care Plan, dated 9/21/21, under, Problem, revealed no documentation on risk for falls or interventions, such as use of mechanical lift with two CNAs. Under, Problem, dated 9/29/21, the care plan revealed, Resident sent to emergency room (ER) after fall and injury to right arm, unable to feel fingers and move right arm. Pain level 10/10. A record review for Resident 339, by the Physical Therapy Department, titled, Resident Transfer Status, dated 8/24/21, and 9/10/21, revealed, Transfer Status: Maximum assistant of 2 or mechanical lift. A review of the Policy & Procedure titled, Care Plan, Comprehensive Person Center, revised on 12/2016, revealed, A comprehensive, person centered care plan that includes measurable objective to meet the resident's physical, psychosocial and functional needs are developed and implemented for each resident. Under #8: The Comprehensive, person centered care plan will: b) describe the services that are to be furnished to attain or maintain the residents highest physical, mental, and psychosocial well-being. A review of the Policy and Procedure titled, Lifting Machine, using a Mechanical, revised 7/2017, revealed, The purpose of this procedure is to establish the general principle of safe lifting using a mechanical lifting device. Under General Guidelines: 1) At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2) Mechanical lifts maybe used for tasks that required: a) Lifting a resident from the floor, b) transferring a resident from bed to chair . Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility.

Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards and failed to provided supervision to each resident to prevent avoidable accidents, when: 1. One out of 15 residents who required extensive assistance when transferring (Resident 339) was transferred by [Staff E] only. [Staff E] (Certified Nursing Assistant (CNA) was the only staff named in the Intradepartmental Team notes, who operated the mechanical lift that required two staff for safe operation. This resulted in Resident 339 falling out of the lift and sustaining a right shoulder dislocation requiring surgical intervention; 2. One out of five residents at risk for elopement (an unauthorized departure of a patient from an around-the-clock care setting) (Resident 78), exited the facility through the main entrance, without triggering an alarm. This resulted in Resident 78 wandering the area outside the facility for five and one-half hours; and, 3. One out of 16 residents who required oxygen (Resident 185), was roomed with an independent smoker (Resident 48), who was allowed to keep lighters at the bedside. This had the potential to result in a fire. These failures resulted in an unsafe environment for all 80 residents of the facility. Findings: Resident 339 1. A review of a Facility Reported Incident revealed Resident 339 had a fall incident, dated 9/29/21, while being transferred by [Staff E] Certified Nursing Assistant (CNA)) from a wheelchair to bed with the used of a mechanical device, such as [NAME] Lift (standing lift). Resident 339 sustained right shoulder injury (dislocation) which required surgery. A record review of Resident 339's face sheet revealed he was admitted to the facility on [DATE], with diagnoses of pneumonia, heart, and kidney problem. During an interview on 12/9/22 at 12:25 p.m., the Director of Staff Development (DSD) stated staff received skills training on orientation and yearly and kept all skills' records in the employee's file. The DSD did not make a comment when asked DSD whether there was another staff involved in the fall accident with Resident 339. When the DSD was asked whether she provided a competency training on the use of Hoyer and [NAME] Lift to Staff E prior to Resident 339's fall accident of 9/19/21, she stated, Yes, however, the DSD was not able to provide any evidence of a Competency Evaluation completed by Staff E, prior to 9/29/21. During an interview on 12/9/22 at 12:37 p.m., the DON (Director of Nursing) stated all nursing staff were trained on how to use a Hoyer Lift and [NAME] Lift. The DON stated two CNAs must use a Hoyer or [NAME] Lift, during a resident's transfer, to prevent falls. The DON stated one CNA operated the lift machine, and the other CNA was positioned by the resident, at the opposite side to prevent falls. The DON stated the DSD provided in services and checked the staff's skill on the use of the Hoyer/[NAME] Lift machine. The DON stated Staff E was not longer working for the facility. During a concurrent observation and interview on 12/9/22 at 1 p.m., in the [NAME] Lift storage room, Staff F and Staff G (CNAs) stated, to operate the Hoyer or [NAME] Lift Machine, there must be two CNAs, one to operate the machine and the other standing by the resident for support, during transfer, to prevent falls. Staff F and Staff G demonstrated how to use a [NAME] Lift. Staff G and Staff F stated, the reason for two CNAs was because one CNA to operate the machine, the other CNA must be behind the resident with a wheelchair, to standby, in case a resident buckled the knee. A record review of the IDT notes on Resident 339'S fall, dated 9/30/21 at 9:10 a.m., revealed a Post Fall Meeting was held. [Resident 339] had a fall with injury on 9/29/21 at 8 p.m. [Resident 339] was being transferred from a shower chair to bed using a [NAME] lift. Per [Staff E] (CNA who operated [NAME] Lift on 9/29/21), [Resident 339] was, dead weight (means heavy) and slipped through. [Resident 339] complained of pain in his right arm and right shoulder. A skin tear was noted to the right forearm. [Resident 339] was sent to ER (emergency room ) for evaluation and treatment. [Resident 339] had a right shoulder dislocation. Education to be provided on 10/1/2021, regarding transfer status of residents to all staff. A review of the IDT note revealed no additional staff were interviewed by the IDT, the staff member who was involved in operation of the [NAME] Lift with Staff E. A review of IDT Progress Notes, dated 9/30/21 at 12:52 a.m., late entry for 9/29/21 at 8 p.m., under Nurse's Notes, revealed, At approximately 8 p.m., [Resident 339] slid out of the lift then to the floor. [Resident 339] hit his right arm and reportedly hit his head. [Resident 339] had skin tears to right forearm and right elbow. [Resident 339] was assisted back to bed by five CNAs and made comfortable as possible. A review of the Interdisciplinary (IDT) Progress Notes, under, Nurses' Notes/emergency room (ER) visits for Resident 339, dated 9/30/21 at 2:21 p.m., revealed, [Resident 339] returned from ER at 11:45 am by an ambulance. [Resident 339] has a sling onto his right arm. A review of Staff E's Competency Evaluation revealed, after Resident 339's fall accident of 9/29/21, Staff E was checked for skills competency on usage of the [NAME] Lift machine, on 10/1/21. The DSD did not provide evidence Staff E was checked for Competency Evaluation on use of the [NAME] Lift prior to the 9/29/21, fall incident. A review of the Policy and Procedure, titled, Lifting Machine, Using a Mechanical, revised on 7/2017, revealed, The purpose of this procedure is to establish the general principle of safe lifting using a mechanical lifting device. Under General Guidelines: 1) At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 2) Mechanical lifts may be used for tasks that require: a) Lifting a resident from the floor, b) transferring a resident from bed to chair Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. 40090 Resident 78 2. During a review of a Facility-Reported Incident, reported to the State Agency on 11/07/22, indicated Resident 78 eloped from the facility on 11/05/22. The report indicated Resident 78, was gone, found 1:30 pm walking down a nearby road. During a review of the Unusual Incident Report, reported to the State Agency on 11/10/22, the report indicated staff became aware of Resident 78's absence at 10:50 a.m. The report indicated Resident 78 was last seen in the facility at 8:30 a.m. The report indicated Resident 78 was located, down the road, and returned to the facility at 1:30 p.m. Resident 78 was outside the facility for five hours. During a review of the Unusual Injury Report, reported to the State Agency on 11/10/22, the report indicated, on 11/7/22, Resident 78 complained of right ankle pain. The report indicated, upon assessment, Resident 78 had bruising along his chest and side. The report indicated Resident 78 was sent to the hospital for x-rays. The report indicated Resident 78 sustained a right ankle sprain. During a review of Resident 78's Admission Record, dated 12/13/22, the record indicated Resident 78 was admitted to the facility 9/16/22. The record indicated Resident 78 was admitted with active diagnoses of Dementia with Psychotic Disturbance, Delirium due to Known Physiological Condition, Alcohol use with Alcohol-Induced Persistent Amnestic Disorder, and Cognitive Communication Deficient. During a review of Resident 78's Plan of Care, dated 10/6/22, the document indicated the facility identified a focus of Elopement Risk. The document indicated Resident 78 was an elopement risk, as evidenced by a history of attempts to leave the facility unattended. The document indicated interventions assigned to Resident 78 to prevent elopement, were assigned to the Nursing, Certified Nursing Assistant, and Activities departments. 41175 Resident 48 3. During an observation on 12/6/22 at 12:10 p.m., two disposable lighters were on top of Resident 48's bedside table. A resident on the bed adjacent to Resident 48, was receiving oxygen via a nasal cannula. During an interview on 12/7/22 at 8:32 a.m., Resident 48 stated she had been with her roommate, for about two weeks now, and she always kept her lighters on her table since she was transferred [to this room]. Resident 48 confirmed her roommate, always had her oxygen on. During an interview on 12/12/22 10:53 a.m., LN A confirmed smokers, who were identified as able to smoke independently, could keep their smoking supplies, including lighters, at the bedside. LN A stated smokers who were on oxygen, had their oxygen tanks switched off for safety. When asked if lighters were permitted in a room where another resident was on continuous oxygen therapy, LN A stated, That could be a red flag. That's a safety issue. LN A stated she would have explained the situation and the risks to the smoker, to request the lighter be removed from the room. During an interview on 12/12/22 at 11:23 a.m., the DON stated, though she knew Resident 48 would, not light up in the room, she could see how keeping lighters at a bedside when continuous oxygen was used in the room, could be risky. The DON stated fire safety should have been considered when Resident 48, who was allowed to keep lighters on her bedside, was transferred to a room with a resident who was on continuous oxygen therapy. A review of the facility policy titled, Oxygen Administration, dated, October 2010, indicated, Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, etc.) from the immediate area where the oxygen is to be administered .

Based on interview and record review, the facility did not provide care consistent with professional standards of practice, for one of three sampled residents (Resident 71), when it failed to initiate a care plan after his recent, active infection on 12/1/22, and identify and evaluate his response to interventions, and revise interventions as appropriate. These cumulative failures resulted in Resident 71 sustaining unrelieved nausea and vomiting for eight days, causing poor hydration and nutrition intake levels, and a subsequent transfer to the hospital for sepsis (a life-threatening complication of an infection) and renal insufficiency (poor function of the kidneys). Findings: A review of Resident 71's Face Sheet (a document that gives a patient's information at a quick glance) indicated he was initially admitted to the facility with diagnoses including gastroparesis (a chronic condition that affects the stomach muscles and prevents proper stomach emptying), diabetes (a disease that occurs when the blood glucose, also called blood sugar, is too high), and severe protein-calorie malnutrition (happens when not enough protein and calories are consumed). A review of Resident 71's Progress Notes revealed he was recently sent to the hospital on 12/1/22, for, not eating and having c/o (complaints of) nausea and vomiting past 3 days [sic]. Resident 71 was diagnosed with influenza (a contagious illness that infects the nose, throat, and sometimes the lungs. Symptoms include fever, chills, muscle aches, cough, congestion, runny nose, headaches, and fatigue) and was readmitted to the facility later in the evening. Further review of the Progress Notes indicated eight days later, on 12/9/22, Resident 71 was again transferred out to the hospital. During record review and concurrent interview on 12/14/22 starting at 11:30 a.m., the ADON (Assistant Director of Nursing) stated Resident 71 was, kept on Alert Charting. When asked, the ADON stated, Alert Charting, meant that since Resident 71 was a readmission and was taking Tamiflu (a medication for influenza), staff were expected to monitor him for any side effects from the medication, any improvement or worsening of symptoms. During the concurrent record review and interview, the ADON stated Resident 71 was sent to the hospital on 12/9/22, due to continued nausea and vomiting. Review of the Progress Notes revealed nursing staff documented Resident 71 had bouts of nausea and vomiting on 12/2/22, 12/3/22, 12/4/22, 12/5/22, 12/6/22, 12/7/22, 12/8/22 and 12/9/22. The ADON confirmed Resident 71's symptoms occurred throughout all shifts. A review of Resident 71's, Nutrition-Amount Eaten, indicated the following: 1. 12/2/22 = 26-50% of breakfast and dinner was, refused. There was no data for lunch. 2. 12/3/22 = 51-75% of breakfast; lunch and dinner were, refused. 3. 12/4/22 = Breakfast and lunch were refused. Dinner was documented twice: One as 76-100% and the other as, refused. 4. 12/5/22 = All meals were, refused. 5. 12/6/22 = All meals were, refused. 6. 12/7/22 = All meals were, refused. 7. 12/8/22 = 0-25% of breakfast; lunch and dinner were, refused. 8. 12/9/22 = There was no data for breakfast, and lunch was, refused. A review of Resident 71's, Intake & Output indicated the following: 1. 12/2/22 = 500 2. 12/3/22 = 320 3. 12/4/22 = 2100 4. 12/5/22 = 240 5. 12/6/22 = 720 6. 12/7/22 = 340 7. 12/8/22 = 720 During the concurrent record review and interview, the ADON stated the amounts, in milliliters (a unit of measure), were Resident 71's total fluid intake for the day and verbally confirmed his meal intakes were missing entries. When queried, the ADON stated Resident 71's meal and fluid intakes had been poor throughout the week and were, most likely inadequate. The ADON noted the intake level for 12/4/22, and added it might even be a typo [typographical error (a mistake made when typing]), as it would have been unlikely Resident 71 consumed that much, as he had continuous nausea and vomiting. The ADON verbally confirmed Resident 71's food and fluid intakes were, concerning. A review of Resident 71's, Orders - Administration Note, dated, 12/4/2022, indicated, Zofran (an antinausea medication) Tablet 8 mg (milligrams, a unit of measure) PRN (as needed) Administration was: Ineffective. Resident 71's, Progress Note, dated, 12/7/22, indicated, C/O (Complains of) nausea but refused PRN Ondansetron (a generic name for Zofran) stating it does not help . During an interview, when asked if and how the staff addressed Resident 71's continuous nausea and vomiting, the ADON stated staff monitored and documented his symptoms and encouraged fluids. The ADON stated she expected staff to at least notify the physician of any resident who had poor intake for a day, or as soon as a pattern of poor intake was identified, and if current medications were ineffective. The ADON stated all interventions made by the staff should have been documented, and confirmed there was no documentation the physician was notified of Resident 71's continued symptoms. The ADON stated, There was not even a care plan initiated for his current condition. When asked if there should have been, the ADON stated, Yes. A review of Resident 71's, Progress Note, dated, 12/9/2022 09:35 (a.m.), indicated, Complain [sic] of body aches, headache and fatigue . Resident noted vomiting medium to large amount dark green to dark red fluid. Resident is pale in color, sunken eyes, stomach pain and requesting to be sent to ER . Review of Resident 71's, CMP (Comprehensive Metabolic Panel is a test that measures 14 different substances in the blood which provides important information about the body's chemical balance and metabolism [the process by which the body changes food and drink into energy]), dated, 12/9/22, indicated the following abnormal results: a. Sodium = 148 mmol/L (millimoles per litre, a unit of measure) b. Potassium = 3.1 mmol/L c. Total Bilirubin = 2.3 mg/dL (milligrams per deciliter, a unit of measure) d. BUN (Blood Urea Nitrogen)= 90 mg/dL e. Creatinine = 4.2 mg/dL. (Reference Range [normal values] for sodium = 135-145 mmol/L, potassium = 3.5-5.1 mmol/L, total bilirubin = 0.0-1, BUN = 7-25, and creatinine = 0.7-1.3. Sodium is one of several electrolytes [minerals in your blood and other body fluids] that help control the body's fluid levels, acid-base balance [the level of acids and bases in the blood at which the body functions best], and nerve and muscle activity. Potassium is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells. Bilirubin is a waste product created by the breakdown (destruction) of hemoglobin, a major component of red blood cells. BUN is a waste product the kidneys remove from the blood. Creatinine is a waste product made by your muscles. High BUN-to-creatinine ratios occur with sudden (acute) kidney problems, which may be caused by shock or severe dehydration, and a very high BUN-to-creatinine ratio may be caused by bleeding in the digestive tract or respiratory tract). A subsequent review of a Progress Note, dated, 12/9/2022 19:35 (7:35 p.m.), indicated, Received report resident [71] is to be transferred to another hospital for renal insufficiency and sepsis . A review of the facility policy, titled, Change in a Resident's Condition or Status, dated, May 2017, indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a . significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times . A significant change of condition is a major decline in the resident's status that: Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); requires interdisciplinary review and/or revision to the care plan .