Every finding on record at Newport Subacute Healthcare Center

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medication was administered as ordered by the physician for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's aztreonam (antibiotic) and ceftazidime- avibactam (antibiotics) IV medications were administered as ordered. This failure had the potential to not clear the infection and negatively affect the resident's health.Findings: Review of the facility's P&P titled Medication Administration revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 1 was initiated on 7/28/26. Resident 1 was readmitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/19/26, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 7/12/26, showed a physician's order dated 7/12/26, to administer aztreonam 2 gram IV three times a day for sepsis for three days and ceftazidime- avibactam 2.5 gram IV three times a day for sepsis for three days. Review of Resident 1's Progress Note dated 7/11/26 at 2220 hours, showed Resident 1 was readmitted and to continue with continuing with Avycaz (ceftazidime- avibactam) and aztreonam IV antibiotic for sepsis. The progress notes further showed the admission/medication orders were verified with the physician. Review of Resident 1's Progress Notes dated 7/12/26 at 0841 hours, showed a late entry documentation. The note showed the cetazidime-avibactam and aztreonam IV medication orders were submitted to the pharmacy via PCC.follow up with pharmacy. Review of Resident 1's IV MAR for July 2026 showed on 7/12/26, the first dose of aztreonam was administered at 1700 hours and ceftazidime- avibactam at 1800 hours. On 7/30/26 at 0753 hours, a telephone interview and concurrent medical record review was conducted with RN 2. RN 2 stated he transcribed the orders in the PCC system including the two antibiotics when Resident 1 was admitted . RN 2 stated after he gave the report to the incoming nurse, he realized the IV antibiotics were not in the system. When asked how long it would take the pharmacy to deliver the medications, RN 2 stated, it depends, usually two to four hours. On 7/30/26 at 0848 hours, a telephone interview and concurrent medical record review was conducted with RN 3. RN 3 stated after she got the report, she did not see the antibiotics; called the pharmacy and they said they just got the orders. Furthermore, RN 3 stated the antibiotic needs approval from the COO. RN 3 stated she notified physician for the late administration. When asked when Resident 1's medications were delivered by the pharmacy courier, RN 3 stated she received them on 7/12/26, at around 1700 hours. On 7/30/26 at 1150 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the medication was administered late.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete for two of five sampled residents (Residents 2 and 4). * The facility failed to ensure Resident 2 and 4's MAR were complete. These failures had the potential for the residents' health care needs to not be met as the medical records were incomplete.Findings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed all 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Implementation section showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.The following information is to be documented in the resident medical record: medications administered and treatments or services performed. Review of the facility's P&P titled Administering Medications revised 4/2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. 1. Medical record review for Resident 2 was initiated on 7/28/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 7/20/26, showed the resident was unable to make decisions. Review of Resident 2's Order Summary Report showed the following orders:- dated 6/8/26, calcitriol oral capsule 0.25 mcg (hormonal form of vit D medication), give one capsule by mouth one time a day for supplement;- dated 11/5/25, sennosides oral tablet 8.6 mg (stool softener), give one tablet by mouth two times a day for bowel management; and- dated 5/20/26, sevelamer HCL tablet 800 mg (phosphorus binder medication), give 4 tablets by mouth with meals for high phosphorus;- dated 6/6/26, cyproheptadine HCl oral tablet 4 mg (appetite stimulant), give one tablet by mouth three times a day for appetite stimulant. Review of Resident 2's MAR for July 2026 showed the following medications were not signed as administered on the following dates:- calcitriol oral capsule 0.25 mcg was not signed as administered on 7/11/26 at 1700 hours;- sennosides oral tablet 8.6 mg was not signed as administered on 7/11/26 at 1700 hours;- cyproheptadine HCL oral tablet 4 mg was not signed as administered on 7/11/26 at 1700 hours; and- sevelamer HCL tablet 800 mg was not signed as administered on 7/11/26 at 1700 hours; On 7/29/26 at 1330 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 3. LVN 3 stated the staff should document after they administered the medications. On 7/30/26 at 1150 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON verified the incomplete documentation in Resident 2's MAR for July 2026. 2. Medical record review for Resident 4 was initiated on 7/28/26. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 1/15/26, showed the resident is unable to make decisions. Review of Resident 2's Order Summary Report showed the following orders:- dated 1/13/26, Insulin Lipro Injection solution (insulin medication) inject as per sliding scale; 70-150 mg/dL = 0 units, if BS less than 70 mg/dL, may give 8 oz orange juice; 151-200 mg/dL = 2 units; 201-250 mg/dL = 4 units; 251-300 mg/dL = 6 units; 301-350 mg/dL = 8 units; 351-400 mg/dL = 10 units, if BS is greater than 400 mg/dL give 10 units and call the physician, to inject subcutaneously before meals and at bedtime related to Diabetes Mellitus. Review of Resident 4's MAR for July 2026 showed the medications were not signed as administered on the following dates:- Insulin Lispro was not signed as administered on 7/15, 7/20, 7/21, and 7/25/26 at 0630 hours and 7/11, 7/15, and 7/19/26 at 1630 hours. On 7/29/26 at 1330 hours, an interview and concurrent medical record review for Resident 4 was conducted with LVN 3. LVN 3 stated the staff should document after they administered the medications. On 7/30/26 at 1150 hours, an interview and concurrent medical record review for Resident 4 was conducted with the DON. The DON verified the incomplete documentation in Resident 4's MAR for July 2026.

Based on interview, closed medical record review, and the facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of 12 sampled residents (Resident 2). * The facility failed to ensure Resident 2's change of condition was monitored every shift for at least 72 hours accordingly. This failure had the potential to negatively affect the resident's health and well-being and increase the risk of not providing the resident with an appropriate and individualized care.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status dated 2/2021 showed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of the facility's P&P titled Charting and Documentation dated 2001 showed all 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Closed medical record review for Resident 2 was initiated on 6/3/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 2/21/26, showed Resident 2 could make needs known but could not make medical decisions. Review of Resident 2's Change of Condition Report dated 5/6/26 at 0953 hours, showed Resident 2 was observed with redness and moderate drainage to the right eye. Review of Resident 2's Order Summary Report dated 5/10/26, showed a physician's order dated 5/7/26, for Maxitrol Ophthalmic Suspension (a prescription eye drop medication to treat or prevent bacterial infections) 3.5-10000-0.1 to instill one drop to both eyes four times a day for eye redness and discharge. Review of Resident 2's Care Plan Report showed a focus problem dated 5/6/26, for redness and moderate drainage to the right eye with the goal to reduce redness and drainage within three to five days. However, further review of Resident 2's closed medical record failed to show the resident's change in condition was monitored for at least 72 hours after the resident's initial change in condition was observed. On 6/10/26 at 0943 hours, an interview and concurrent closed medical record review for Resident 2 was conducted with RN 2. RN 2 stated that when a resident had a change in condition, there should be a monitoring note every shift for at least 72 hours to evaluate the resident's status and response to the treatment as prescribed. RN 2 further verified Resident 2 had missing monitoring notes for the night shift from 1900 to 0700 hours on 5/6, 5/7, and 5/8/26. On 6/11/26 at 1020 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the findings.

Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 12 sampled residents (Resident 3) was complete and accurate. * The facility failed to ensure Resident 3's date of death was recorded accurately by different IDT members. This failure had the potential to show inconsistency of care as the clinical information was not accurate.Findings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Closed medical record review for Resident 3 was initiated on [DATE]. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated [DATE], showed Resident 3 required assistance with decision making capabilities. Review Resident 3's nursing progress notes dated [DATE], showed Resident 3 was found unresponsive on [DATE], at 0540 hours. The paramedics responded to the emergency and Resident 3 was pronounced deceased at 0603 hours. Review of Resident 3's Physician's Discharge Summary showed resident expired in the facility on [DATE]. Further review of Resident 3's progress note showed the following:- dated [DATE], documented by social services, showed resident expired on [DATE];- dated [DATE], documented by activities, showed resident expired on [DATE];- dated [DATE], documented by nursing, showed on [DATE] at 1115 hours, received an order from the physician to release the body to Mortuary Representative. Mortuary picked up the resident's body at approximately 1115 hours. Family at bedside. On [DATE] at 0943 hours, an interview and concurrent closed medical record review for Resident 3 was conducted with RN 2. RN 2 stated Resident 3 expired on [DATE], in the facility. RN 2 verified that the information documented by different staff were inaccurate and inconsistent regarding the resident's date of death . RN 2 further stated that it was important to have accurate documentation of the resident's information as it served as proof of care and professionalism. On [DATE] at 1020 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the findings.

Based on observation, interview, closed medical record review, and facility P&P (Policy and Procedure) review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of nine sampled residents (Resident 4).* The facility failed to ensure Resident 4 was adequately monitored and provided with the necessary care and interventions to prevent multiple incidents of ingesting foreign objects. In addition, the facility failed to initiate a change in condition and notify the physician when Resident 4 had vomited a foreign object on 4/22/26.These failures resulted in Resident 4's multiple hospitalizations and two surgical procedures for the removal of a foreign object and potentially contributed to diagnosis of sepsis (the body's extreme, life-threatening response to an infection).Findings: Review of the facility's P&P titled Change in Resident's Condition or Status revised 2/2021 showed the following:1. The nurse will notify the resident's attending physician or physician on call when there has been a (an):accident or incident involving the resident;discovery of injuries of unknown source;adverse reaction to medication; 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;need to transfer the resident to a hospital/ treatment center; discharged without proper medical authority; andspecific instruction to notify the physician if changes in the resident's condition.2. Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR (situation/background/assessment/recommendation) communication form.3. Unless otherwise instructed by the resident, the nurse will notify the residents' representative when:a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source;b. There is a significant change in the residents physical, mental, or psychosocial status there is a need to change the resident's room assignment;c. A decision has been made to discharge a resident from the facility; and/ord. It is necessary to transfer the resident to a hospital/ treatment center. Review of the facility's P&P titled Interdisciplinary Team (IDT)/Resident Care Plan Conference Review (RCC) dated 7/2021 showed the Interdisciplinary Team (IDT) in conjunction with the resident and/or resident representative, as appropriate, shall meet to develop a comprehensive person centered care plan with quantifiable objectives for the highest level of functioning the resident may be expected to attain, to meet the residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and CAA (Care Area Assessment) summary. Closed medical record review for Resident 4 was initiated on 5/5/26. Resident 4 was initially admitted to the facility on [DATE]. Review of Resident 4's H&P (History and Physical) examination dated 2/19/26, showed a past medical history of chromosome eight syndrome (rare disorder characterized by severe intellectual disability). The H&P further showed Resident 4 does not have the capacity to understand and make decisions. Review of Resident 4's Order Summary Report showed the following physicians orders dated 5/9/25 and10/6/25, to monitor for episodes of ingesting non-edible items every shift. Review of Resident 4's Care Plan Report initiated on 5/9/25, showed a care plan problem to address Resident 4's risk of choking as manifested by ingestion of non-edible items. The care plan Goal showed Resident 4 will have no episode of ingestion of non-edible items. The interventions included to apply mitten (similar to boxing gloves, that cover the hands and prevent patients from pulling out any lines or tubes) as ordered, monitoring the episodes of ingesting non-edible objects every shift, provided frequent visual monitoring, and removing non-edible objects within resident's grasp. a. Review of Resident 4's Change of Condition dated 1/24/26, showed the change of condition, symptoms or signs observed were dark brown drainage from tracheostomy (a surgical opening in the trachea (windpipe) and a tube placed into the opening to assist with breathing) and GT (gastrostomy tube- a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) with foul stool like odor. Review of Resident 4's Progress Notes dated 1/24/26 at 1407 hours, showed the resident was noted with what appeared to be stool coming from tracheostomy, nose, and GT. The note further showed Resident 4 was transferred to the acute care hospital for further evaluation. Review of Resident 4's Hospitalist Progress Note dated 2/8/26, showed the following:- readmitted on [DATE], with fever/sepsis, thought to be pneumonia (infection of the lungs); - foreign body seen on abdomen/pelvic CT (computed tomography - a scan of the body as part of the diagnosis or treatment of illnesses) done on 1/24 (1/24/26), underwent surgery on 1/27 (1/27/26) to remove, and the object showed tan-green colored crumbled firm material, possibly plastic, resembling gloves and cloth drawstring. Review of Resident 4's admission Summary Progress Notes dated 2/9/26, showed Resident 4 was readmitted back to the facility with a diagnosis of sepsis with foreign body in the gastrointestinal tract (the continuous muscular passageway running from the mouth to the anus). Review of Resident 4's Care Plan Report initiated on 2/10/26, showed a care plan problem addressing Resident 4's use of physical restraint hand mittens due to pulling out is tracheostomy tubes and the resident is picking up items within his reach and swallows them. The interventions included to keep bedside table clean and free from clutter and small object within the resident's reach. b. Review of Resident 4's Change of Condition form dated 2/25/26, showed the change of condition, symptoms, or signs observed was non-edible item found in stool, brief like material. Review of Resident 4's Care Plan Report showed a care plan problem revised on - dated 2/25/26 to address the following: - Resident 4 was noted to eat and swallow object or non-food items within his reach. The interventions included a jumpsuit so he cannot pick up diapers and minimize nonfood items; and- Resident 4's risk of choking as manifested by ingestion of non-edible items. The care plan Goal revised on 2/25/26, showed the resident will have no episode of ingestion of non-edible items. Review of Resident 4's Progress Notes dated 2/25/26, showed the nurse was called to check on Resident 4. The CNA (Certified Nursing Assistant) was observed providing the care and showed the resident's stool. The progress notes showed the stool was noted with non-edible brief like items and the nurse pulled out the item from the anus, plastic like brief/diaper. The progress notes further showed Resident 4 had a physician's order to be sent to the acute care hospital for a CT scan. Further review of Resident 4 medical records failed to show the result of the CT scan done on 2/25/26. Review of Resident 4's Physician's Progress Notes dated 2/26/26, showed Resident 4 was transported to the acute care hospital yesterday (2/25/26) for CT of abdomen and pelvis with follow-up testing and returned in stable condition, and the results were pending. Further review of Resident 4's physician's progress note dated 3/1/26, 3/3/26 and 3/4/26, showed the CT abdomen and pelvis previously performed, results pending review. On 5/12/26 at 0927 hours, a follow-up request for Resident 4's CT scan result was made with the Medical Records Director. On 5/12/26 at 1506 hours, the Director of Medical Records responded there was no CT scan results found in Resident 4's medical record. Review of Resident 4's IDT notes dated 2/26/26, showed the IDT met with the resident's family member over the phone. The note had an entry for the Social Service, Activities and Dietary department. However, the portion for the Nursing department was blank. c. Review of Resident 4's Change of Condition form dated 3/7/26, the nursing notes showed Resident 4 had episode of vomiting and the emesis (the forceful expulsion of stomach contents through the mouth) noted on shirt was brown in color, with pieces of diaper noted in emesis. Review of Resident 4's Care Plan Report dated 3/7/26, showed a care plan problem addressing Resident 4 had vomiting related to [NAME] (an eating disorder characterized by the persistent craving and consumption of non-food substances). The care plan Goal showed Resident 4 will have no episode of ingesting any material and objects within his reach. The care plan interventions included activity as tolerated, avoid foods that cause intestinal hyperactivity caffeine, carbonated beverages, chocolate, or acidic items like orange juice, diet as tolerated, ice chips as tolerated, advance to clear liquids as tolerated, diet consult as PRN (as needed), educate resident/family/caregivers about relationship of nausea and vomiting to food, medicine, treatment regimen, disease process, and psychosocial factors, teach resident/family/caregivers to identify and avoid causative factors, eliminate smells from the environment. However, the care plan failed to show the interventions to address Resident 4's Pica. d. Review of Resident 4's Medication Administration Note dated 4/22/26 at 2056 hours, showed Resident 4 vomited a foreign object, plastic in appearance. Review of Resident 4's Subacute Nursing assessment dated [DATE], showed a CNA reported Resident 4 had vomited. The emesis observation was found to have a clear rigid plastic object and smaller plastic particles and there was no further vomiting episodes until 0500 hours. The note further showed also worth mentioning that patient had a fever the prior night. Decided with RN (Registered Nurse) supervisor to send patient out to be further checked for residual object. Review of Resident 4's Health Status Progress Note showed the following:- dated 4/23/26 at 0500 hours, Resident 4 had episode of dark colored emesis, with new order to transfer Resident 4 to the emergency department; and- dated 4/23/26 at 2055 hours, showed a call made to the acute care hospital. The note showed Resident 4 was admitted in the sub-acute ICU (Intensive Care Unit) for sepsis with acute organ dysfunction (sudden rapid decline of organ function), and septic shock (severe life-threatening stage of sepsis when an infection causes an extreme immune response leading to dangerously low blood pressure, and widespread organ failure). Review of Resident 4's Operative Note from the acute care hospital dated 4/29/26, showed the following:- Preoperative (the period before a surgical operation) Diagnosis: small bowel obstruction (partial or complete blockage of the small intestine that prevents food, fluids, and gas from passing through), bezoar (a tightly packed, indigestible mass of material that gets trapped most commonly in the stomach), and pica;- Postoperative (the period immediately following a surgical procedure) Diagnosis: same, and gastric foreign body; and- Operative Findings: two nitrile gloves (durable, synthetic rubber gloves) removed from stomach endoscopically (a medical examination or treatment inside the body using an endoscope - a thin, flexible tube with a camera and light). On 5/5/26 at 1007 hours, an observation was made of Resident 4's room. Resident 4 was still in the acute hospital. Resident 4's bed was observed close to the wall, with a glove rack containing two open full boxes of frosty white transparent gloves near the foot of the bed, and a dresser was observed to be on the right side of the bed. On 5/6/26 at 1109 hours, an interview was conducted with LVN (Licensed Vocational Nurse) 5. LVN 5 stated she observed a clear cylindrical plastic, ridged, and lightly opaque substance expelled from Resident 4's emesis on 4/22/26. LVN 5 stated the second time the resident vomited, it had a smell like feces and seemed to have been in Resident 4's system for a while for it to smell like that. When asked if Resident 4 had full mobility of both arms, LVN 5 stated, yes he uses both of his arms. When asked how Resident 4 was monitored, LVN 5 stated we do our best, put everybody on alert to look and check on the resident. LVN 5 stated Resident 4 would need a 1:1 (one-on-one sitter - is a dedicated healthcare staff who would provide constant, direct supervision to high-risk residents to prevent falls, self-injury, or dislodgement of medical tubes), as he is super quick and super smart. When asked if the physician was notified when Resident 4 had vomited a foreign object, which appeared to be plastic on 4/22/26, LVN 5 stated the supervisor did not notify the physician until 4/23/26 at 0500 hours, when Resident 4 was being sent out to the acute care hospital. On 5/6/26 at 1407 hours, an interview was conducted with CNA 1. CNA 1 stated she had observed Resident 4 eating his feces in the past. CNA 1 stated Resident 4 was always in bed. When asked how resident was monitored, CNA 1 stated when we don't have too many residents, we can check more, sometimes we don't have time do rounds. CNA 1 stated further Resident 4 was unable to walk but was able to bend forward, and one foot was strong. On 5/6/26 at 1434 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 4 could remove his mittens with his mouth, and grabs whatever is around. When asked how mobile Resident 4 was, RN 1 stated normal, like a kid, he can reach and grab things and covers head with a blanket. When asked what other interventions Resident 4 would need, RN 1 stated a 24 hour sitter. On 5/6/26 at 1503 hours, an observation of Resident 4's room and concurrent interview was conducted with RN 1. A drawer was observed with a taped label showing do not leave any items inside the drawer. RN 1 opened the drawer and noted tracheostomy supplies and gauze packs in a plastic bag were inside the drawer. When asked if the drawer belonged to Resident 4, RN 1 stated yes. When asked if the items in the drawer belonged to Resident 4, RN 1 stated I'm assuming so. On 5/7/26 at 0925 hours, a follow up interview and concurrent medical record review for Resident 4 was conducted with RN 1. When asked if the facility provided sitters to Resident 4, RN 1 stated since she started, she had not seen any sitters. RN 1 stated it was mostly families that would come, but not for the whole 12 hour shift. When asked if the physician was notified on 4/22/26 when Resident 4 vomited plastic as documented, RN 1 verified the physician was not notified until after the second emesis on 4/23/26 at 0500 hours. On 5/7/26 at 1249 hours, an interview was conducted with the RT (Respiratory Therapist) Supervisor. The RT Supervisor stated she had seen Resident 4 picking things up and stated Resident 4 was a resident that would need a 1:1. On 5/8/26 at 0935 hours, an interview and concurrent medical record for Resident 4 was conducted with the DON (Director of Nursing). When asked how the facility would ensure the frequent visual monitoring and non-edible items were not left in the resident's room, the DON stated, she and the licensed nurses would check the rooms. When asked if the physician should have been notified when the resident was observed to vomit plastic on 4/22/26, the DON stated the physician should have been notified. When asked if Resident 4 had a 1:1 sitter, the DON stated no, we don't have any residents with a 1:1. When asked if the facility would provide a 1:1 sitter, the DON responded, that's why it's hard for us to accept him back. When asked if there was an IDT discussion about Resident 4 needing a 1:1 sitter, the DON stated she could not recall. The DON further stated there was a discussion about 1:1 possibly last week, but nothing prior to April 2026. On 5/8/26 at 1519 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware of Resident 4's multiple incidents of ingesting foreign objects and hospitalizations. The Administrator and DON acknowledged the findings.

Based on interview, closed medical record review, and the facility P&P, the facility failed to ensure an injury of unknown source was reported for one of nine sampled residents (Resident 1). * The facility failed to report an incident of unknown source when the facility was informed by the acute care hospital of Resident 1's admission to the ICU related to subdural hematoma. This failure had the potential for the injury of unknown origin to go unreported and posed a delay in the injury prevention to other residents.Findings: Review of the P&P titled Accidents and Incidents Investigating and Reporting dated 2001 showed all accidents, or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director shall promptly initiate and document investigation of the accident or incident. Review of the facility's P&P titled Unusual Occurrence revised 12/2007 showed as required by state or federal regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current laws and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. Review of the facility's P&P titled The Reporting and Abuse Prevention (undated) showed all alleged violations including injuries of unknown source, such as skin tears, bruises, and abrasions on residents who cannot speak for themselves, or misappropriation of resident property as reported to the administrator, or designated representative as outlined in this policy and procedure. Evidence that alleged violations are investigated and necessary correction is maintained in facility files. Notification of the incident of abuse will be reported to the Department of Health licensing and certification unit, within five calendar days of the incident by mail, following a fax reporting the incident. Closed medical record review for Resident 1 was initiated on 5/1/26. Resident 1 was readmitted to the facility on [DATE], and discharged on 4/30/26. Review of Resident 1's H&P examination dated 1/18/26, showed the resident had no capacity to make medical decisions. Review of Resident 1's MDS assessment - Section GG for Functional Abilities dated 4/15/26, showed Resident 1 was dependent in self-care and mobility. Review of Resident 1's Progress Notes showed the following:- dated 4/23/26 at 2120 hours, showed Resident 1 was discharged to the acute care hospital for an elevated heart rate at 140 beats per minute and increased work of breathing (body is exerting extra effort to breathe). The note further showed Resident 1 was tachypneic (rapid breathing) on the ventilator breathing rate of 25-30 breaths per minute; and - dated 4/24/26 at 1131 hours, showed the nurse called the acute care hospital. The facility was informed of Resident 1's admission to the acute care hospital ICU related to subdural hematoma. On 5/1/26 at 1635 hours, an interview was conducted with the DON. The DON stated Resident 1 had a brain injury and was unable to move and was totally dependent on the staff. The DON was made aware about the nurse's documentation of Resident 1's admission to the acute care hospital related to subdural hematoma. The DON verified the incident would be considered an injury of unknown origin, and the reporting would need to be conducted. On 5/8/26 at 1519 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON was made aware of the unreported incident of injury of unknown source and acknowledged the findings. * Cross Reference F610.

Based on interview, closed medical record review, and the facility P&P, the facility failed to ensure an injury of unknown source was investigated for one of nine sampled residents (Resident 1). * The facility failed to investigate an incident of unknown source when the facility was informed by the acute care hospital of Resident 1's admission to ICU related to subdural hematoma. This failure had the potential for the injury of unknown source to go uninvestigated and posed a risk for the delay of injury prevention to other residents of the facility.Findings: Review of the facility's P&P titled Accidents and Incidents Investigating and Reporting dated 2001 showed all accidents, or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director shall promptly initiate and document investigation of the accident or incident. Review of the facility's P&P titled Unusual Occurrence revised 12/2007 showed as required by state or federal regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees, or visitors. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current laws and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. Review of the facility's P&P titled The Reporting and Abuse Prevention (undated) showed all alleged violations including injuries of unknown source, such as skin tears, bruises, and abrasions on residents who cannot speak for themselves, or misappropriation of resident property as reported to the administrator, or designated representative as outlined in this policy and procedure. Evidence that alleged violations are investigated and necessary correction is maintained in facility files. Notification of the incident of abuse will be reported to the Department of Health licensing and certification unit, within five calendar days of the incident by mail, following a fax reporting the incident. Closed medical record review for Resident 1 was initiated on 5/1/26. Resident 1 was readmitted to the facility on [DATE], and discharged on 4/30/26. Review of Resident 1's H&P examination dated 1/18/26, showed the resident had no capacity to make medical decisions. Review of Resident 1's MDS assessment - Section GG for Functional Abilities dated 4/15/26, showed Resident 1 was dependent in self-care and mobility. Review of Resident 1's Progress Notes showed the following:- dated 4/23/26 at 2120 hours, showed Resident 1 was discharged to the acute care hospital for an elevated heart rate at 140 beats per minute and increased work of breathing (body is exerting extra effort to breathe). The note further showed Resident 1 was tachypneic (rapid breathing) on the ventilator breathing rate of 25-30 breaths per minute; and - dated 4/24/26 at 1131 hours, showed the nurse called the acute care hospital. The facility was informed of Resident 1's admission to the acute care hospital ICU related to subdural hematoma. On 5/1/26 at 1635 hours, an interview was conducted with the DON. The DON stated Resident 1 had a brain injury and was unable to move and was totally dependent on the staff. The DON was made aware about the nurse's documentation of Resident 1's admission to the acute care hospital related to subdural hematoma. The DON verified the incident would be considered an injury of unknown source, and the investigation would need to be conducted. On 5/8/26 at 1519 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON was made aware of the uninvestigated incident of injury of unknown origin and acknowledged the findings. * Cross Reference F609.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the care plan for one of nine sampled residents (Resident 3). * The facility failed to timely develop a care plan and implement the neuro check intervention when Resident 3 had a fall on 4/1/26. In addition, the facility failed to update the care plan interventions when Resident 3 had another fall on 4/24/26. These failures had the potential to place the resident at risk for falls and injury.Findings:Review of the facility P&P titled Falls and Fall Risk Managing dated 2001 showed based on previous evaluation and current data, the staff will identify interventions related to the resident's specific needs and causes to try to prevent the resident from falling and try to minimize complications from falling .The staff, with the input of the attending physician will implement a resident centered fall prevention plan to reduce the specific risk factor(s) a falls for each resident at risk or with a history of falls.If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant.The staff will monitor and document each resident's response to interventions intended to reduce falling or risks of falling.If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff consider possible causes that may not previously have been identified.Medical record review for Resident 3 was initiated on 5/1/26. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE].Review of Resident 3's H&P examination dated 1/15/26, showed Resident 3 does not have the capacity to make medical decisions.Review of Resident 3's Change of Condition (SBAR Communication Form) dated 4/1/26, showed Resident 3 had an unwitnessed fall in the room. a. Review of Resident 3's Care Plan Report showed a care plan focus problem when Resident 3 had an actual fall on 4/1/26. However, the care plan focus, goals and interventions were initiated on 4/28/26, 27 days later. On 5/7/26 at 1607 hours, an interview was conducted with the DON. The DON verified Resident 3's care plan for an actual fall which occurred on 4/1/26 was initiated on 4/28/26. The DON stated it should have been revised right after the fall incident. b. Review of Resident 3's Care Plan Report showed a care plan focus problem when Resident 3 had an actual fall on 4/1/26. The care plan interventions included neuro checks for 72 hours. Review of Resident 3's medical record failed to show documented evidence the neuro checks were conducted for Resident 3's falls episode on 4/1/26. On 5/6/26 at 1434 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the process for fall episode would include an assessment, start neuro checks, notify the physician, risk management, fall risk assessment, and an IDT. RN 1 stated the neuro checks were conducted for all residents, especially for the residents who were non-verbal. On 5/7/26 at 0925 hours, a follow up interview with RN 1 was conducted. RN 1 stated Resident 3 was non-verbal. On 5/8/26 at 1450 hours, an interview was conducted with the DON. The DON stated she reviewed Resident 3's medical record and verified Resident 3's neuro checks were not done when Resident 3 had a fall on 4/1/26. c. Review of Resident 3's Health Status Note dated 4/24/26 at 2230 hours, showed Resident 3 was found on the floor. Review of Resident 3's Care Plan Report showed a care plan problem created on 11/24/25, for high risk for falls and injury. The care plan further showed the focus problem, goal and interventions were updated when Resident 3 was found on the floor next to the bed on 4/20/26. Further review of Resident 3's care plan failed to show the new focus, goals, and interventions when the resident had another fall on 4/24/25. On 5/8/26 at 0935 hours, an interview was conducted with the DON. The DON stated she could not find the care plan when Resident 3 had another fall on 4/24/26.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of nine sampled residents (Resident 2). * The facility failed to obtain a physician's order for the administration of cough medication for Resident 2. In addition, the facility failed to follow its Medication Administration P&P when Resident 2's cough medicine was left at bedside table, despite the resident not being assessed or approved to self-administer medications. These failures had the potential to result in negative outcomes for the resident.Findings: Review of facility's P&P titled Medication Administration revised 4/2019 showed medications are administered in accordance with prescriber orders, including any required time frame. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. On 4/15/26 at 0858 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed awake in bed and stated she was not feeling well, with occasional coughing observed. A medicine cup containing a half-full amount of cherry-colored liquid and a second medicine cup containing two unlabeled red capsules were observed on top of the bedside table. When asked about the medications, Resident 2 stated the liquid was cough medicine and the capsules were her stool softeners. Resident 2 stated the licensed nurse provided the medications that morning and left them at her bedside because she preferred to take the cough medicine a little at a time. Medical record review for Resident 2 was initiated on 4/15/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident was cognitively intact. Review of Resident 2's Self Administration assessment dated [DATE], showed the resident did not wish to self-administer her own medications and not capable of self-administering medication. Review of Resident 2's Order Summary Report dated 4/15/26, showed a physician's order dated 6/12/24, to administer docusate sodium (stool softener) oral capsule 250 mg by mouth two times a day for bowel management. Further review of Resident 2's Order Summary Report failed to show a physician's order for cough medication or an order for Resident 2's to self-administer medication. On 4/15/26 at 1121 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 stated she observed the medications at the start of her shift. LVN 1 stated the resident told her she was coughing and the night shift nurse gave her cough medication. LVN 1 stated she had not received any report from the night shift that the resident was coughing or that cough medication had been administered. LVN 1 was asked to show documentation Resident 2 had a change of condition related to coughing. LVN 1 reviewed the resident's medical record, which failed to show documentation about resident coughing. LVN 1 verified the physician had not been notified, no order had been obtained for cough medication, and the medication should not have been left at the bedside. On 4/15/26 at 1425 hours, an interview and concurrent review of medical record for Resident 2 was conducted with RN 1. RN 1 stated she did not receive any endorsement from the previous shift regarding Resident 2's coughing or administration of cough medication. RN 1 reviewed the communication logbook and found there was no related information about the resident's cough. RN 1 verified the night shift did not notify the physician or obtain an order for cough medication. RN 1 stated the day shift nurse later notified the physician and obtained an order. RN 1 verified the cough medication had been administered without a physician's order and acknowledged there was no order for the resident to self administer medications. On 4/15/26 at 1550 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's physician's progress notes were accurate. In addition, Resident 1's Task Documentation had multiple missing entries. These failures had the potential for the resident's care needs to not be met as their medical information was inaccurate and incomplete. Findings: Review of the facility's P&P titled Charting and Documentation dated July 2017 showed all 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective, complete and accurate. Medical record review for Resident 1 was initiated on 4/1/26. Review of Resident 1's Facesheet dated 4/1/26, showed Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 6/27/25, showed Resident 1 had the capacity to understand and make decisions. a. Review of Resident 1's Progress Notes showed the following:- dated 3/26/26 at 1331 hours, MD 1 documented a system review, laboratory and chest x-ray results. System review for Resident 1 showed a Shiley XLT size 7 cuffed (tracheostomy) on the neck, ongoing treatment to the tracheostomy, GT skin, Foley catheter, with diagnosis of chronic respiratory failure, perforation of the esophagus, pyothorax without fistula, oxygen at a rate of three liters per minute FIO2 via T-bar with humidifier as tolerated daytime only and enhanced barrier precaution for history of candida auris;- dated 3/20/26, a late entry for 3/3/26 at 1310 hours, MD 1 documented a system review for Resident 1 which showed a Shiley XLT size 7 cuffed (tracheostomy) on the neck, ongoing treatment to the tracheostomy, GT skin, Foley catheter, with diagnosis of chronic respiratory failure, perforation of the esophagus, pyothorax without fistula, oxygen at a rate of three liters per minute FIO2 via T-bar with humidifier as tolerated daytime only and enhanced barrier precaution for history of Candida Auris; and- dated 2/24/26 at 1449 hours, MD 1 documented a system review for Resident 1 which showed a Shiley XLT size 7 cuffed (tracheostomy) on the neck, ongoing treatment to the tracheostomy, GT skin, indwelling urinary Foley catheter, with diagnosis of chronic respiratory failure, perforation of the esophagus, pyothorax without fistula, oxygen at a rate of three liters per minute FIO2 via T-bar with humidifier as tolerated daytime only and enhanced barrier precaution for history of Candida Auris. Review of Resident 1's Order Summary Report dated 4/1/26, did not show Resident 1 had orders for tracheostomy, GT, indwelling urinary Foley catheter, oxygen to be administered via T-bar, and enhanced barrier precaution due to history of Candida Auris. On 4/1/26 at 1523 hours, an observation was conducted for Resident 1 in his room. Resident 1 was observed with no tracheostomy, GT, indwelling urinary Foley catheter, oxygen via T-bar and did not have a sign for enhanced barrier precaution outside of Resident 1's door. On 4/2/26 at 1103 hours, an interview with concurrent medical record review for Resident 1 was conducted with the Medical Records Director. The Medical Records Director verified the physician's progress notes written on 2/24, 3/10, and 3/26/26 were inaccurate. Medical Records Director stated, that's a big mistake, I will speak to MD 1. The Medical Records Director further stated, I know the resident never had a tracheostomy and all of these, maybe he was thinking of another resident. On 4/2/26 at 1120 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the documentation in the physician's progress notes dated 2/24, 3/10, and 3/26/26 were inaccurate. The DON stated the MDS nurses check the progress notes, H&P documentations during assessment. When asked what happened to these notes, DON stated it was not read. b. Review of Resident 1's CNA Task Document Survey Report showed the following:* dated 3/21/26, on the day shift for the bathing, there were missing entries for Resident 1's self- performance, support provided and the CNA initials.* dated 3/21/26, on the day shift; 3/13 and 3/29/36, on the evening shift; and 3/31/26, on the night shift, there were missing entries for the following tasks:- bladder continence - Resident 1's urinary continence, toileting used, perineal care provided and the CNA initials, and if Resident 1 had indwelling urinary catheter, the amount of the urine output, and the CNA initials; and - bowel movements - Resident 1's bowel movement, the number of, size and consistency of the bowel movements and the CNA initials.* dated 3/21/26, on the day shift; and 3/13 and 3/29/36, on the evening shift, there were missing entries for the following tasks: - bed mobility - Resident 1's self- performance, the support provided and CNA initials;- bowel continence - Resident 1's bowel continence, toileting used and the CNA initials; - corrective lenses - if Resident 1 is wearing the lens, refused, lenses not available or not applicable and the CNA initials;- dental - if Resident 1 had dentures and the CNA initials; - dressing - Resident 1's self- performance, the support provided and CNA initials;- locomotion off unit - Resident 1's self- performance, the support provided and CNA initials;- locomotion on unit - Resident 1's self- performance, the support provided and CNA initials;- personal hygiene - Resident 1's level of assistance in hair care, nail care, oral care and shaving and the CNA initials.- rejection of care - if Resident 1 refused or rejected ADL care and the CNA initials;- skin observation - if Resident 1 had new skin problems noted and the CNA initials; - toilet use - Resident 1's self- performance, the support provided and CNA initials;- transfers - Resident 1's self- performance, the support provided and CNA initials;- walk in corridor - Resident 1's self- performance, the support provided and CNA initials;- walk in room - Resident 1's self- performance, the support provided and CNA initials;- amount eaten / eating performance - Resident 1's percentage of meal eaten, self-performance and the support provided and CNA initials; and- nourishments - Resident 1's percentage of snacks taken, if nourishment was offered, and fluids were taken, and the CNA initials. On 4/2/26 at 1103 hours, an interview and concurrent medial record review for Resident 1 was conducted with the Medical Records Director. The Medical Records Director verified the missing entries in Resident 1's Task Documentation Summary. The Medical Records Director stated CNAs should have completed the documentation. On 4/2/26 at 1245 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete for two of seven sampled residents (Residents 2 and 5). * The facility failed to ensure Resident 2's MAR and TAR were complete. * The facility failed to ensure Resident 5's progress notes were complete. These failures had the potential for the residents' health care needs to not be met as the medical records were incomplete.Findings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed all 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The Policy Interpretation and Implementation section showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.The following information is to be documented in the resident medical record: medications administered and treatments or services performed. 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one. Medical record review for Resident 2 was initiated on 2/10/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed the following orders: - dated 11/26/25, Polyethylene Glycol 3350 powder (laxative medication), give 17 grams via GT one time a day for bowel management; - dated 11/26/25, Pro-Stat Sugar Free oral liquid (protein supplement), give 30 ml via G-Tube one time a day for supplement; - dated 11/26/25, Sennosides oral tablet 8.6 mg (laxative medication), give two tablets via GT at bedtime for bowel management; - dated 11/26/25, Famotidine oral tablet 20 mg (indigestion medication), give one tablet via GT two times a day for GERD; - dated 11/26/25, Sinemet Oral Tablet 25-100 mg (tremor medication), give one tablet via GT every eight hours for Parkinson's Disease; - dated 11/26/25, Chlorhexidine Gluconate Mouth/Throat Solution 0.12% (mouthwash), give 5 ml orally every shift for oral care; - dated 11/26/25, Ammonium Lactate External Lotion 12% (moisturizer lotion), apply to generalized body topically every day shift for generalized dryness; and - dated 12/11/25, GT site care, cleanse with normal saline and pat dry, apply T-drain dressing daily and as needed for maintenance every shift. Review of Resident 2's H&P examination dated 11/27/25, showed the resident did not have the capacity to understand and make decisions. Review of Resident 2's MAR for January to February 2026 showed the following medications were not signed as administered on the following dates: - Polyethylene 17 grams was not signed as administered on 1/2, 1/16, 1/17, 1/18, 1/28, 2/4, 2/6, 2/8, 2/9/26 at 1700 hours; - Pro-Stat Sugar Free Oral Liquid 30 ml was not signed as administered on 1/2, 1/16, 1/17, 1/18, 1/28, 2/4, 2/6, 2/8, 2/9/26 at 1700 hours; - Sennosides Oral Tablet 8.6 mg was not signed as administered on 1/13, 1/16, 1/17, 1/24, 1/30, 1/31, 2/1, 2/6, 2/7, 2/8, 2/9/26 at 2100 hours; - Famotidine oral tablet 20 mg was not signed as administered on 1/13, 1/16, 1/17, 1/24, 1/30, 1/31, 2/1, 2/6, 2/7, 2/8, 2/9/26 at 2200 hours; - Sinemet Oral Tablet 25-100 mg was not signed as administered on 1/13, 1/16, 1/17, 1/24, 1/30, 1/31, 2/1, 2/6, 2/7, 2/8, 2/9/26 at 2200 hours; and - Chlorhexidine Gluconate Mouth/Throat Solution 0.12% was not signed as administered on 1/16, 1/30, 1/31, 2/1, 2/6, 2/7 and 2/8/26 at night time. Review of Resident 2's TAR for January to February 2026 showed the following treatments were not signed as administered on the following dates: - Ammonium Lactate External Lotion 12% was not signed as administered on 1/1, 1/2, 1/15 and 2/4/26; and - GT site care was not signed as administered on 1/1, 1/2, 1/15 and 2/4/26. On 2/10/26 at 1601 hours, an interview and concurrent medical record review for Resident 1 was conducted with RN 1. RN 1 stated staff should document after they administered the medications or treatments. On 2/11/26 at 1432 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the multiple gaps and incomplete documentation in the MAR and the TAR for January and February 2026. 2. Closed medical record review for Resident 5 was initiated on 2/10/26. Resident 5 was admitted to the facility on [DATE], and discharged on 2/6/26. Review of Resident 5's H&P examination dated 9/18/25, showed the resident did not have the capacity to understand and make decisions. Review of Resident 5's Progress Notes from 10/23/25 to 1/4/26, showed six health status notes and one IDT note was incomplete. On 2/11/26 at 1406 hours, an interview and concurrent closed medical record review for Resident 5 was conducted with the DON. The DON stated view draft in Resident 5's progress notes meant the staff did not sign their notes. The DON verified Resident 5's six health status notes and the IDT note from 10/23/25 to 1/4/26 were incomplete. The DON stated the staff should have gone back, sign, and close the charting. The DON further stated the medical record was open for somebody to alter because it was not signed. The DON stated the medical record staff should have audited the medical record and the audit should have been done every day.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) reviewed for restraints was free from physical restraints. * The facility failed to ensure the use of physical restraints was based upon identified medical symptoms. Additionally, the facility failed to conduct an assessment to determine the existence of medical symptoms, attempt less restrictive measures, and develop a care plan for Resident 1's bilateral hand mittens. * The facility failed to inform Resident 1's responsible party of the potential risks and benefits and obtain consent for the use of Resident 1's bilateral hand mittens. * The failed to document the length of time the restraint was anticipated to be used, failed to identify who could apply the restraint, when the restraint could be applied and how the restraint was to be used. In addition, the facility failed to document Resident 1's circulation, mobility, and skin when bilateral mittens were used. These failures posed the risk of compromising the resident's independence and psychosocial well-being.Findings: Review of the facility's P&P titled Use of Restraints, revised on 4/2017 showed the following:- physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot move easily, which restricts freedom of movement or restricts normal access to one's body;- examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions, and trays that the resident cannot remove;- restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to treat the medical symptom, protect the resident's safety, and help resident attain the highest level of his/her physical or psychological well-being;- prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions that may improve the symptoms;- treatment restraints may be used for the protection of the resident during treatment and diagnostic procedures if the resident and/or representative has consented to the treatment or procedure and the use of treatment restraints;- restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the specific reason for the resident as it relates to the resident's medical symptom, how the restraint will be used to benefit the resident's medical symptom, and the type of restraint and period for the use of the restraint;- the following safety guidelines shall be implemented and documented while a resident is in restraints. The opportunity for motion and exercise is provided for a period of not less than 10 minutes during each two hours in which restraints are employed;- restraints and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use;- restrained individuals shall be reviewed regularly at least quarterly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination;- care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use; and- documentation regarding the use of restraints shall include full documentation of episode leading to the use of physical restraint, a description of the resident's medical symptoms that warranted the use of restraints, how the restraint use benefits the resident by addressing the medical symptom, type of the physical restraint used, the length of effectiveness of the restraint time, and observation, range of motion, and repositioning flow sheets. On 2/10/26 at 0940 hours, during the initial tour, Resident 1 was observed lying in bed, awake, and nonverbal. Resident 1 was observed with bilateral hand mittens on. Medical record review for Resident 1 was initiated on 2/10/26. Resident 1 was admitted to the facility on [DATE], readmitted on [DATE]. Review of Resident 1's H&P examination dated 10/7/25, showed Resident 1 did not have the capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1's BIMS score was 0 indicating severe cognitive impairment. Review of Resident 1's Order Summary Report showed physician's order dated 2/10/25, for hand mittens to prevent from pulling out medical devices. However, the physician's order failed to show medical symptoms, frequency, duration, and monitoring for the use of bilateral hand mittens. Further review of Resident 1's medical record failed to show an assessment was conducted for the use of bilateral hand mittens. Additionally, there was no documented evidence the least restrictive measures were used prior to using the restraints. There was no documented evidence Resident 1's responsible party was notified of the potential risks and benefits and consented to the use of the restraints. Resident 1's medical record failed to show a care plan was developed for the use of bilateral hand mittens. On 2/10/26 at 1119 hours, an observation of Resident 1 and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 1 was wearing bilateral hand mittens. LVN 1 stated Resident 1 had episodes of pulling the tracheostomy tubing. On 2/10/26 at 1505 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 verified Resident 1's medical record failed to show the medical symptoms, frequency, duration, and monitoring for the use of bilateral hand mittens. In addition, Resident 1's medical record failed to show an assessment was conducted for the use of bilateral hand mittens, documentation of least restrictive measures used before using the restraints, notification of Resident 1's responsible party for the potential risks and benefits and obtaining the consent. Furthermore, a care plan was not developed for the use of bilateral hand mittens. LVN 1 verified the above findings. Furthermore, LVN 1 stated it was considered a physical restraint when required assessments were not completed and consent was not obtained. On 2/11/26 at 1432 hours, an interview was conducted with the DON. The DON stated all licensed staff must follow facility's restraint policy for new admit and readmit residents. In addition, the DON stated the facility staff must start with least restrictive measures prior to applying the restraint. On 2/11/26 at 1630 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) was provided the necessary GT services. * The facility failed to ensure Resident 1 was administered the TwoCal HN (a nutritional supplement that is calorie and protein dense) enteral feeding as per the physician's order and failed to ensure it was documented in the MAR. These failures had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Enteral Tube Feeding via Gravity revised November 2018 showed the person performing this procedure should record the following information in the resident's medical record:- The date and time the procedure was performed.- Verification of tube placement.- Amount and type of enteral feeding and amount of flush.- The name and title of the individual(s) who performed the procedure.- All assessment data obtained during the procedure.- How the resident tolerated the procedure.- If the resident refused the procedure, the reason(s) why and the intervention taken.- The signature and title of the person recording the data. Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Review of the facility's P&P titled Administering Medications revised April 2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. On 12/1/25, the CDPH, L&C Program received a complaint alleging Resident 1 was denied a food supplement that was supposed to be given every three hours. Medical record review for Resident 1 was initiated on 12/4/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 9/18/25, showed the resident had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report showed the following physician's enteral feed orders:- dated 10/17/25, to provide 3300 kcal/1659 ml TwoCal HN 237 ml every two hours daily; and- dated 11/22/25, to provide 3300 kcal/1659 ml TwoCal HN 237 ml every three hours daily. Review of Resident 1's Progress Note dated 11/10/25, showed per the resident's family, the resident ate a big lunch and bolus feeding was not necessary. Review of Resident 1's MAR for November 2025 showed the above enteral feed orders were not administered to Resident 1 on the following dates:- 11/10, 11/12, 11/16, 11/22, and 11/26/25 at 1800 hours;- 11/14/25 at 2100 hours; and- 11/15/25 at 1200 hours. Review of Resident 1's Progress Note dated 11/26/25, showed the resident's enteral feeding scheduled at1800 hours was given at 1900 hours due to Resident 1's family member requesting the nurse to come back in 20 minutes. The nurse continued with medication administration and came back at 1900 hours to administer the enteral tube feeding. On 12/9/25 at 0914 hours, a telephone interview was conducted with LVN 4. LVN 4 stated she was just hired two weeks ago and did not recall the resident. On 12/9/25 at 1001 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified the MAR showed the enteral feed orders were not administered to Resident 1 on 11/10, 11/12, 11/16, 11/22, and 11/26/25 at 1800 hours, 11/14/25 at 2100 hours, and 11/15/25 at 1200 hours. RN 3 stated she was not sure why the MAR was blank on the those dates. RN 3 further stated the licensed nurses sometimes gave the enteral tube feeding and then forgot to sign. RN 3 stated the licensed nurse should have signed the MAR. RN 3 stated if the MAR was not signed, it was not done. On 12/9/25 at 1241 hours, a telephone interview was conducted with LVN 5. LVN 5 stated she did not remember what she documented. LVN 5 further stated sometimes when that happens, her guess was she forgot to sign. LVN 5 stated Resident 1's family member usually tell the licensed nurse when to give Resident 1's enteral tube feeding. LVN 5 stated she always gave Resident 1's enteral tube feeding unless the resident was not in the facility. LVN 5 stated she should have documented or signed the MAR right away. On 12/9/25 at 1405 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged above findings. The DON stated the licensed nurse should also document if the resident refused and should not leave the MAR blank.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) had accurate and complete medical records. * The facility failed to ensure Resident 1's MAR documentation regarding multiple medication orders were completed. This failure had the potential for the resident's health care needs not be met as the medical record was incomplete and inaccurate. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the facility's P&P titled Charting and Documentation revised July 2017 showed all 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. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Medical record review for Resident 1 was initiated on 12/4/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 9/18/25, showed the resident had no capacity to understand and make decisions. Review of Resident 1's Order Summary Report showed the following physician's orders:- dated 9/17/25, to administer multivitamin-minerals (supplement) oral tablet. Give one tablet by mouth one time a day for supplement;- dated 9/17/25, to administer lactobacillus (a medication to aid digestive system) oral tablet. Give one tablet by mouth one time a day for supplement;- dated 9/17/25, to administer famotidine (antacid) oral tablet 20 mg. Give one tablet via GT two times a day related to GERD without esophagitis; and- dated 11/2/25, to administer Docuprene (stool softener) oral tablet 100 mg (docusate sodium). Give one tablet via GT two times a day for bowel management. Review of Resident 1's MAR for November 2025 showed the above medications were not administered to Resident 1 on 11/26/25. On 12/9/25 at 0914 hours, a telephone interview was conducted with LVN 4. LVN 4 stated she was just hired two weeks ago and did not recall the resident. When asked if she missed a dose of a resident's medication, LVN 4 answered no. On 12/9/25 at 1001 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified the MAR showed the multivitamin-minerals, lactobacillus, famotidine, and Docuprene medications were not administered to Resident 1 on 11/26/25. RN 3 stated Resident 1's family told LVN 4 to give the medications after Resident 1's shower. RN 3 stated Resident 1's family member followed up with LVN 4 and she saw LVN 4 prepared the medications before giving it to Resident 1. RN 3 stated the licensed nurse should have documented the medication she administered the medications in the MAR. On 12/9/25 at 1405 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings. The DON stated the licensed nurse should have signed the MAR, put a progress note to prove, and document the resident received the medication.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents (Resident 10). * The facility failed to monitor Resident 10 who was on antibiotic treatment for UTI. In addition, the facility failed to ensure Resident 10's plan of care was updated to address Resident 10's treatment interventions and management of the UTI. This failure had the potential for the delay of the identification of the adverse effects related to the resident's use of antibiotic treatment and for the resident to not receive the appropriate and individualized care that could potentially affect the resident's health and well-being. Findings: Review of the facility's P&P titled Care Planning-Interdisciplinary Team revised 3/2022 showed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 4/2021 showed a significant change in condition is a major decline or improvement in the resident's status that requires interdisciplinary review and or revision to the care plan; and the nurse will record in the resident's medical record information relative to changes in resident's medical/mental condition or status. According to CDC Healthy Habits: Antibiotic Do's Administrator Don'ts dated 9/23/25, showed the common side effects of antibiotics range from minor to severe health problems and can include rash, dizziness, nausea, diarrhea, yeast infection. The more serious side effects can include C. diff infection which causes diarrhea that can lead to severe colon damage and death and severe and life threatening allergic reactions. Medical record review for Resident 10 was initiated on 9/17/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 8/10/25, showed Resident 10 required assistance to make medical decisions. Review of Resident 10's Order Summary Report showed the following physician's orders:- dated 7/20/25, for Ceftriaxone (an antibiotics) sodium solution reconstituted 1 gram, to give 1 gram intravenously every 24 hours for infection for five days and discontinued on 7/21/25; and- dated 7/22/25, for Ertapenem sodium (an antibiotics) injection solution reconstitute 1 gram, to give 1 gram intravenously one time a day for UTI until 7/27/25. a. Review of Resident 10's nursing assessment dated [DATE] at 1508 hours, showed Resident 10 was noted with a change of condition including tachycardia (increased heart rate). The physician was notified and ordered urinalysis stat and antibiotic treatment of Ceftriaxone 1 gm IV every 24 hour for five days. Review of Resident 10's Change of Condition Report dated 7/21/25 at 1600 hours, showed Resident 10 with a change of condition related to urinary tract infection as evidenced by the urinalysis result with an order for antibiotic therapy initiation. However, further review of Resident 10's medical record failed to show if the resident's change in condition was monitored after the initiation of the antibiotic therapy. b. Review of Resident 10's plan of care failed to show a care plan problem was developed related to the treatment interventions and management of the UTI. On 9/17/25 at 1615 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 10's care plan was not updated to include the treatment interventions and management of the UTI. RN 2 verified that there was no documented evidence to show Resident 10's condition and antibiotic therapy were monitored. RN 2 further stated for the residents on the antibiotics treatment, the residents should have been monitored every shift during the entire course of antibiotic therapy plus three additional days after the completion of the antibiotic therapy. On 9/19/25 at 1345 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with a cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried and free of food residue prior to storing and stacking. * The facility failed to ensure the ice machine drainpipes had an air gap and not touching the drains. * The facility failed to ensure the kitchen staff performed hand hygiene during dishwashing. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 8/25/25, showed 54 of 91 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed the hoods must be cleaned every two weeks and must be free of dust and grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention, the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The kitchen hood over the stove had black and dirt residue. The DSS acknowledged the findings. The DSS stated the dietary staff cleaned the hood every two weeks and was also cleaned by an outside company every six months. The DSS stated the kitchen hood should not be greasy due to fire hazard. 2. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. The plastic ware, China, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. The plastic ware is bleached as necessary to prevent staining. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:- Basting brush used to spread butter was observed with the bristles frayed, discolored and worn out.- Three stainless steel scoops for food portioning were observed with the cream colored handles discolored and peeling.- Two stainless steel scoops for food portioning were observed with the gray colored handles worn out and peeling.- One stainless steel scoop for food portioning was observed with the black colored handle worn out and peeling.- One dough cutter was observed with the wooden handle discolored and deformed at the corners. The DSS acknowledged the above findings and stated the worn out utensils should have been replaced and discarded. 3. Review of the facility's P&P titled Dishwashing dated 2023 showed gross food particles shall be removed by careful scraping and pre-rinsing in running water. The dishes are to be racked loosely without overlapping. Appropriate chemicals will be used to wash, de-stain, and rinse dishes. The flatware is to be pre-soaked in a solution of water and detergent per manufacturer's instructions. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:- One heavy duty blender for puree preparation was observed with white food residue inside.- Two stainless steel slotted scoops were observed with the red handles fuzzy with dry crusted food particles and cloudy film.- Two stainless steel scoops were observed with the red handles with dry white, crusted residue.- One stainless steel slotted scoop was observed with the green handle with dry, crusted residue and cloudy film.- One stainless steel slotted scoop was observed with the black handle with dry, crusted residue and cloudy film.- One stainless steel slotted scoop was observed with the cream handle with dry, crusted residue and cloudy film.- One stainless steel slotted scoop was observed with the blue handle with dry, crusted residue and cloudy film.- Three stainless steel scoops were observed with the blue handle with dry, crusted residue and cloudy film- Three stainless steel scoops for food portioning were observed with the cream handles with dry watermarks.- Two stainless steel scoops for food portioning was observed with the gray handles with dry, crusted residue and watermarks.- One stainless steel scoop for food portioning was observed with the black handle with dry watermarks.- One stainless steel scoop for food portioning was observed with the yellow handle with dry watermarks and cloudy film.- Seven stainless steel scoops were observed with dry, crusted residue, watermarks and cloudy film. The DSS acknowledged the above findings and stated all the dirty and crusted kitchen utensils should have been rewashed for infection control purposes. 4. Review of the facility's P&P titled Sanitation dated 2023 showed separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The brown, yellow, green and blue cutting boards were observed fuzzy, heavily marred and had deep groves. The DSS verified the findings and stated the cutting boards should have been replaced. 5. Review of the facility's P&P titled Dishwashing dated 2023 showed the dishes are to be air dried in racks before stacking and storing. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. One heavy-duty blender used for puree preparation stored on the countertop shelf was observed to be wet with visible water and white food residue inside. The DSS verified the findings and stated all the kitchen utensils and dirty equipment should have been washed and air dried to prevent bacteria growth. 6. Review of the facility's P&P titled Accident Prevention- Safety Precautions dated 2023 showed an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. According to the USDA 2017 Food Code, Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 8/25/25 at 0908 hours, during the initial kitchen tour, an inspection of the ice machine in the kitchen and concurrent interview was conducted with the Maintenance Supervisor. The ice machine drainpipe was observed touching the drain, there was no air gap observed between the ice machine drainpipe and the drain. The Maintenance Supervisor acknowledged the findings and stated the drainpipe needed to be fixed to prevent back flow. 7. Review of the facility's P&P titled Sanitation dated 2023 showed all Food and Nutrition Services staff shall know the proper handwashing technique. Review of the facility's P&P titled Hand Washing Procedure dated 2023 showed hands needed to be washed after handling soiled dishes and utensils. According to the USDA Food Code 2022 2-301.14, When to Wash, food employees shall clean their hands and exposed portions of their arms after engaging in other activities that contaminate the hands. According to the USDA Food Code 2022 2-301.11, Clean Condition, the hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. On 8/27/25 at 0938 hours, an observation and concurrent interview was conducted with the Dietary Aide during dishwashing. The Dietary Aide was observed wearing gloves and scraping the food from the dirty plates and meal trays for dishwashing. While wearing the same pair of gloves, the Dietary Aide was observed handling the clean dishes from the dishwashing machine. The Dietary Aide then touched the dishwashing racks with clean dishes and utensils with the same gloves. The Dietary Aide verified the findings and stated she rinsed her gloves prior to touching the clean dishes. On 8/27/25 at 0940 hours, an interview was conducted with the DSS. The DSS was informed of the above findings. The DSS stated the Dietary Aide should have performed hand hygiene and changed her gloves to prevent cross contamination. On 8/28/25 at 1539 hours, an interview was conducted with the DON and DSS. The DON and DSS were informed and verified the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure an infection control surveillance report/log and mapping were completed for the months of May and June 2025. * The facility failed to ensure Resident 24 was placed on EBP (Enhanced Barrier Precautions) per the physician's order. * The facility failed to ensure an EBP sign was placed outside of Room C for Resident 37 who had a Quinton catheter and indwelling urinary catheter, and for Resident 67 who had an AV fistula. * The facility failed to ensure the facility staff did not refill the residents' water from the bathroom sink. In addition, the facility failed to ensure the trash was emptied when filled and a used washable gown was discarded properly for Room B. * The facility failed to ensure Resident 65's water jug was not kept on the floor. * The facility failed to ensure to the licensed nurse donned the proper PPE and performed hand hygiene after picking up the dropped medication cup from the ground during the medication administration observation. These failures had the potential for the facility to not accurately identify, investigate, and prevent new infections from developing within the facility, and posed the risk of the transmission of communicable diseases to the residents and employees throughout the facility.Findings: Review of the facility's P&P titled Antibiotic Stewardship – Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed the antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The Policy Interpretation and Implementation section showed all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The intonation gathered will include resident name and medical record number, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. Review of the facility's P&P titled Infection Control Guidelines for All Nursing Procedures revised 8/2012 showed under the General Guidelines all employees must wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials and must wash their hands for ten to fifteen seconds using antimicrobial or non­antimicrobial soap and water under the following conditions: - Before and after direct contact with residents; - When hands are visibly dirty or soiled with blood or other body fluids; - After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; - After removing gloves; - After handling items potentially contaminated with blood, body fluids, or secretions; - Before eating and after using a restroom; and - When there is likely exposure to spores. 1. On 8/28/25 at 1554 hours, an interview and concurrent facility document review was conducted with the IP. Review of the Infection Control Surveillance binder failed to show the infection control surveillance report/log and mapping were completed for May and June 2025. The IP verified these findings and stated he just started a month ago as the IP in the facility. The IP stated he reviewed all the reports from the previous months and did not have the chance to update all the reports or logs for the infection control surveillance. The IP stated without the surveillance report, the facility would not be able to identify the infection within the facility. The IP further stated it was important to complete the infection surveillance report for each month to be able to see the pattern of a certain infection, which would help the facility plan what observations, interventions, and/or in-service trainings to be provided to prevent or control the increased number of infections. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON stated it was very important to complete the infection control surveillance and mapping for each month because it would help the facility to identify the infections in the facility. The DON stated the infection surveillance report and mapping could also be used to help the facility complete a root cause analysis, to investigate the causes of the infections present in the facility. This in turn they could plan interventions to prevent or limit those infections from spreading throughout the facility. 2. According to the CDC, assuming contact precautions do not otherwise apply, EBP is recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO (Multi-Drug Resistant Organism infection is a serious illness caused by microorganisms, primarily bacteria, that have developed resistance to multiple antibiotics, making them difficult or impossible to treat with standard medications). Examples of indwelling medical devices include, but are not limited to, central vascular catheters including hemodialysis catheters, peripherally inserted central catheters, indwelling urinary catheters, feeding tubes, and tracheostomy tubes. EBP involves gown and glove use during high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use and wound care. The EBP signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the residents. a. Medical record review for Resident 37 was initiated on 8/26/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed the following physician's orders: - dated 8/11/25, to observe/monitor for tenderness, redness, or bleeding at site of Quinton catheter; and - dated 8/11/25, for indwelling urinary Foley catheter care every shift. b. Medical record review for Resident 67 was initiated on 8/26/25. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's Order Summary Report showed a physician's order dated 8/18/25, to may place the resident on EBP related to an indwelling medical device: hemodialysis, and wound management every shift; to wear the proper PPE during high contact activities. On 8/27/25 at 1420 hours, an observation for Residents 37 and 67 and concurrent interview was conducted with CNA 12. Residents 37 and 67 were observed lying in the bed in Room C. There was no sign observed outside the door of Room C to indicate the residents were on EBP. An isolation cart containing gowns and gloves was observed outside the room. CNA 12 was observed assisting Resident 67 with turning, wearing only a mask and gloves, and not a gown. CNA 12 acknowledged she did not wear a gown and only donned the mask and gloves when turning Resident 67. CNA 12 stated Residents 37 and 67 were just moved to Room C and she missed donning the gown because there was no EBP sign outside the room. CNA 12 stated she knew both residents had dialysis, but she did not know about the type of dialysis access they had. CNA 12 stated for the residents with a Foley catheter, she had to wear the gown, gloves and mask when she had to empty the drainage bag. On 8/27/25 at 1440 hours, an observation for Room C, interview and concurrent medical record review were conducted with the IP. The IP verified there was no EBP sign outside the door of Room C. The IP stated the residents with wounds, surgical stitches, GT, any indwelling medical devices, any dialysis access, and any central lines should be placed on EBP to prevent the spread of MDROs. The IP stated an EBP sign was placed outside the door to remind the facility staff and visitors the residents were on EBP, to wash their hands when going in and out of the room, and for the facility staff to wear the proper PPE when providing high-contact activities such as changing linen, showering, hygiene care to the residents on EBP. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 24 was initiated on 8/25/25. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24’s Order Summary Report showed a physician’s order dated 8/2/25, to may place the resident on EBP related to the medical indwelling device: PEG/GT. On 8/27/25 at 0907 and 1011 hours, and on 8/28/25 at 0857 hours, Resident 24 was observed in bed. There was no sign observed outside the door of Resident 24’s room to indicate the resident was on EBP. An isolation cart containing gowns, and gloves was observed inside the room. On 8/27/25 at 1011 hours, CNA 4 was observed assisting Resident 24, and changing Resident 24’s incontinence brief. CNA 4 was observed wearing a mask and gloves, however, CNA 4 was not observed wearing a gown. On 8/28/25 at 1120 hours, an observation for Resident 24 and concurrent interview was conducted with CNA 4. Resident 24 was observed in bed. There was no sign observed outside the door of Resident 24’s room to indicate the resident was on EBP. An isolation cart containing gowns, and gloves was observed inside the room. CNA 4 verified the above findings. CNA 4 acknowledged she did not wear a gown but only mask and gloves when providing care to Resident 24. CNA 4 stated she did not receive any information that the resident was on EBP, nor the need to wear a gown when providing high-contact activities to Resident 24. CNA 4 stated she would know a resident was on EBP by looking at the sign outside the door. On 8/28/25 at 1122 hours, an observation for Resident 24, interview, and concurrent medical record review was conducted with the IP. The IP verified there was no EBP sign outside the door of Resident 24’s room. The IP stated the residents with wounds and medical dwelling devices such as a catheter, GT, and fistula were placed on EBP to prevent the spread of the MDROs. The IP stated an EBP sign was placed outside the door to remind the facility staff and visitors the residents were on EBP, to wash their hands when going in and out of the room, and for the facility staff to wear the proper PPE when providing high-contact activities such as changing linen, showering, hygiene care to the residents on EBP. 4. According to the CDC article titled Considerations for Reducing Risk: Water in Healthcare Facilities dated 10/24/24, water can carry germs that threaten resident safety and spread antimicrobial-resistant pathogens or cause HAIs. One of the considerations included healthcare facilities can reduce splashing from sinks and drains that can expose people to pathogens. Splashes can occur when water hits the contaminated drain cover, or a person flushes a toilet or hopper. Splashes can spread droplets containing OPPP (opportunistic premise plumbing pathogens, which are microorganisms that live and grow in building water systems. These infections primarily affect individuals with weakened immune systems) to the surrounding environment, residents and providers. Recent evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilitate can become contaminated with MDROs. One of the ways to reduce the risk of OPPP exposure through sinks and drains in healthcare facilities is to avoid placing resident care or personal items on counters next to sink. a. On 8/29/25 at 1006 hours, an interview was conducted with Resident Representative 2. Resident Representative 2 stated she was concerned about the source of water given to Resident 66. Resident Representative 2 stated she asked one of the charge nurses who worked last night if she could refill Resident 66’s water from the water dispenser at the nursing station, but she was told to get the water from the bathroom sink. Resident Representative 2 stated she asked the CNAs where they got the water, and she was told they got the water from the kitchen. On 8/29/25 at 1023 hours, an interview was conducted with Resident 35, with Resident Representative 2 present. Resident 35 stated she walked to the nursing station to ask the facility staff to refill her water pitcher from the water dispenser in the nursing station, however, she had seen the facility staff refill Resident 66’s water pitcher from the bathroom sink. b. On 8/29/25 at 1030 hours, an observation for Residents 32 and 66 in Room B was conducted. Residents 32 and 66 were observed asleep in bed. [NAME] water pitchers were observed at the bedside for Residents 32 and 66. A trash bin was observed full, and a used washable gown was observed on top of the trash bin inside Room B. On 8/29/25 at 1037 hours, an observation for Room B and concurrent interview was conducted with LVN 8. LVN 8 verified the trash bin in Room B was full, and the used washable gown was on top of the trash bin. On 8/29/25 at 1045 hours, an interview was conducted with CNA 2. CNA 2 stated the residents in Room B were part of his assignment. CNA 2 stated all the residents with GT have a water pitcher at the bedside for the licensed nurses to use when flushing the GT, or for the residents to drink if the residents did not have the GT. CNA 2 stated the night shift CNAs changed and refilled the water pitchers every night, then when it was empty, the morning CNAs would refill them by getting the water from the bathroom sink. CNA 2 stated they only got ice and water from the kitchen when the residents wanted cold water. On 8/29/25 at 1054 hours, an observation for Room B and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the trash bin in Room B was full and a used washable gown was on top of the trash bin. The Maintenance Supervisor stated the housekeeping staff were in charge of emptying the trash bin, and the trash bin should be emptied twice in the morning shift. On 8/29/25 at 1336 hours, a telephone interview was conducted with CNA 7. When asked where he got the water for the residents, CNA 7 stated he would get the water from the water dispenser in the nursing station. When asked where he would get the water if the water ran out at during the night, CNA 7 stated he would get the water from the residents' bathroom sink. On 8/29/25 at 1350 hours, an interview was conducted with the DSD and IP. The DSD stated the kitchen staff set up the water dispenser in the nursing station, and the night shift nurse refilled the water pitchers by getting the water from the kitchen. The DSD stated the water dispenser in the nursing station was also refilled by the kitchen staff, and the facility staff also transported the water dispenser from the nursing station near the resident rooms to refill the water pitchers for the residents. The DSD stated the kitchen had been opened for the facility staff to access the water from the kitchen, however, the new DSS had been locking the kitchen. The DSD and IP were informed the water pitchers for the residents were being refilled with the water from the bathroom sink. The IP stated the water pitchers for the residents should not be refilled with the water from the bathroom sink because of cross-contamination (bacteria, E.Coli, feces or urine in the sink could be transferred to the water pitchers). 5. According to the American Journal of Infection Control article titled “Are Hospital Floors an Underappreciated Reservoir for Transmission of Healthcare-Associated Pathogens?” dated 2017, the resident rooms were frequently contaminated with healthcare-associated pathogens, and it was not uncommon for high-touch objects such as medical devices, personal items, and linens to be in direct contact with the floor. Touching these objects frequently resulted in the transmission of pathogens to hands, and because floors are frequently contaminated, it would be reasonable to educate health care personnel and residents to avoid placing high-tough objects on the floor when possible. On 8/25/25 at 0831 hours, during the initial tour of the facility, Resident 65 was observed in bed. A water jug was observed on the floor near the resident's bed. Medical record review for Resident 65 was initiated on 8/25/25. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65’s H&P examination dated 5/15/25, showed Resident 65 had the capacity to understand and make medical decisions. On 8/25/25 at 0907 hours, an observation for Resident 65 and concurrent interview was conducted with the Case Manager. Resident 65 was observed in bed, and a water jug was observed on the floor. The Case Manager verified the above findings. The Case Manager was observed picking up the water jug from the floor and placing it on the bedside table, without wiping the water jug clean. The Case Manager acknowledged she did not wipe the water jug before placing it on the bedside table. The Case Manager stated the water jug on the floor was an infection control issue and could be a trip hazard as well. On 8/28/25 at 1445 hours, an interview with the IP was conducted. When asked what the facility's expectation was for the storage of the residents’ personal belongings on the floor, the IP stated the residents’ personal belongings should not be kept on the floor. When asked if the water jug could be placed on the floor, the IP stated the water jug should not be on the floor due to infection control and cross-contamination. On 8/28/25 at 1526 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings. 6. Review of the facility's P&P titled Administering Medications revised April 2019 showed all staff must follow established facility infection control procedures such as handwashing, aseptic technique and isolation precautions when administering medications. Failure to follow these infection control procedures has the potential to compromise highly vulnerable residents’ health. On 8/25/25 at 0831 hours, a medication administration observation was conducted with LVN 3 for Resident 89. Resident 89 had a GT with an EBP signage and PPE cart outside of the resident’s door. LVN 3 was observed administering the resident’s medication via the GT, without donning the gown. In addition, during the medication administration observation, LVN 3 dropped a medication cup on the ground. LVN 3 then retrieved the medication cup from the ground with her gloved hand and continued with the medication administration, without removing her soiled gloves, performing hand hygiene and donning clean gloves. On 8/25/25 at 1142 hours, an interview was conducted with LVN 3. LVN 3 verified she failed to wear the ordered PPE (gown) during the medication administration for Resident 89. LVN 3 also verified she retrieved the dropped medication cup from the floor with her gloved hand and did not remove her soiled gloves, perform hand hygiene and don clean gloves before continuing the medication administration. On 8/29/25 at 1115 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consent (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and bedrails from the residents or from the responsible party (person designated to make decisions on behalf of the residents). The facility failed to obtain the informed consent for the psychotropic medications for three of five sampled residents (Residents 3, 20, and 70) reviewed for unnecessary medications and one nonsampled resident (Resident 24) reviewed for the use of the bedrails. * The facility failed to obtain renew the informed consents for the Abilify (antipsychotic medication) and Prolixin (antipsychotic medication) medications after six months for Resident 3. * The facility failed to renew the informed consents for the divalproex sodium (used to treat seizures and bipolar disorder), buspirone (antianxiety medication), Remeron (antidepressant), Neudexta (used to treat a neurological condition that causes sudden, frequent, and involuntary episodes of crying or laughing), and Seroquel (antipsychotic medication) medications for Resident 20 six months after the previous informed consents were obtained. * The facility failed to obtain the informed consents for the bilateral 1/4 side rails for Resident 24. The informed consent obtained for the use of the side rails for Resident 24 was for the bilateral 1/2 side rails. * The facility failed to obtain the informed consents for the sertraline (antidepressant), olanzapine (antipsychotic), and trazodone (antidepressant) medications for Resident 70. These failures posed the risk for the residents and or their responsible parties to not be informed of their medications and the potential side effects, and the use of bedrails and the risks of their usage.Findings: Review of the AFL 24-07 titled AB 48 – Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, showed the following: - Facilities must renew the written informed consent every six months. At that time, the facility must provide the residents with any recommended dosage adjustments and the option of revoking consent; and - Facilities must review and revise their P&Ps to ensure compliance with the new law. The P&P must specifically consider and plan for how the facility will verify that the resident provided informed consent or refused treatment or a procedure pertaining to the administration of psychotherapeutic drugs. Review of the facility's P&P titled Restraint Assessment: Chemical (Psychotropic) Meds and Physical (undated) showed each resident or responsible party will give consent for the purposes of prescribing and administering psychotherapeutic medications for the purpose of chemically restraining a resident. 1. Medical record review for Resident 20 was initiated on 8/27/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 12/11/24, showed Resident 20 had no capacity to understand and make decisions. Review of Resident 20's Order Summary Report for August 2025 showed the following physician's orders: - dated 10/8/24, to administer Remeron 7.5 mg one tablet orally at bedtime for major depressive disorder manifested by poor appetite. - dated 2/10/25, to administer buspirone HCL oral tablet 10 mg by mouth three times per day for anxiety manifested by screaming. - dated 3/26/25, to administer Nuedexta oral capsule 20-10 mg by mouth two times a day for pseudobulbar affect (neurological condition that causes sudden, frequent, and involuntary episodes of crying or laughing) manifested by inappropriate laughing and crying. - dated 4/15/25, to administer divalproex sodium oral capsule delayed release 250 mg twice a day for unspecified mood disorder manifested by constant screaming/yelling; - dated 4/15/25, to administer Seroquel 25 mg by mouth two times a day for psychosis manifested by talking to unseen others. Review of Resident 20's informed consents showed the following: - the Seroquel medication consent was obtained on 4/18/24; - the Remeron medication consent was obtained on 10/3/24; - the buspirone HCL medication consent was obtained on 11/8/24; - the Nuedexta medication consent was obtained on 2/12/25; and - the divalproex medication consent was obtained on 2/24/25. However, further review of Resident 20's informed consents for the above psychotropic medications showed the informed consents were past the six-month mark and required a renewal for the informed consents to be current and active. On 8/28/25 at 1347 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the informed consents for the five listed psychotropic medications for Resident 20 were not current and needed to be renewed after six months from when the informed consent was obtained. 2. Review of the AFL 24-07 titled AB 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, showed the following: - Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with the signature of the health care professional declaring the required material information has been provided. If the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. The personal exam and the signatures of the prescriber, resident, or representative can be completed and signed using remote technology. - The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures. For a prescription written prior to facility admission, the facility staff must verify that the resident or the resident's representative gave informed consent and make a notation in the resident's records. The record does not need to be checked every time the drug is administered. Review of the facility’s P&P titled Restraint Assessment: Chemical (Psychotropic Meds) and Physical (undated) showed the facility shall verify that the attending physician of a resident has obtained consent for the purposes of prescribing and ordering the use of a physical or chemical restraints on a resident, (or increasing an order for antipsychotic medication). This shall be documented in the resident’s health record. Medical record review for Resident 70 was initiated on 8/25/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70's Order Summary Report showed the following physician's orders: - dated 8/7/25, to administer olanzapine 10 mg via GT at bedtime; - dated 8/7/25, to administer sertraline 100 mg via GT one time a day; and .- dated 8/7/25, to administer trazodone 50 mg via GT at bedtime. Review of Resident 70’s H&P examination dated 8/12/25, showed Resident 70 had fluctuating capacity to understand and make medical decisions. Review of Resident 70’s MDS admission assessment dated [DATE], showed Resident 70 has a BIMS score of 15, indicating cognitively intact. Further review of Resident 70’s medical record failed to show the informed consents for the above psychotropic medications were obtained from the resident and/or their responsible party. On 8/27/25 at 1212 hours, an interview and concurrent medical review was conducted with RN 2. RN 2 verified there were no informed consents obtained for Resident 70’s use of the olanzapine, sertraline, and trazodone medications. RN 2 stated if the resident’s responsible party was not present in the facility, there should be two licensed nurses to verify the verbal consent was obtained. RN 2 further stated the facility should not have administered the olanzapine, sertraline, and trazodone medications until the informed consents were obtained from the resident or their responsible party. On 8/27/25 at 1518 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the psychotropic medications should not have been administered if there were no informed consents obtained from the resident or their responsible party. 3. Medical record review for Resident 3 was initiated on 8/25/25. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3’s Order Summary Report showed the following physician’s orders: - dated 2/9/24, to administer Abilify 30 mg one tablet by mouth a day; and - dated 7/23/25, to administer fluphenazine (Prolixin) 5 mg by mouth at bedtime. Review of Resident 3’s MAR for August 2025 showed the following: - Resident 3 was administered the Abilify medication from 8/1 to 8/10, and 8/12 to 8/27/25 at 0900 hours; and - Resident 3 was administered the fluphenazine medication from 8/1 to 8/26/25 at 2100 hours. Review of Resident 3’s Informed Consent Verification dated 2/9/24, showed the informed consent for Abilify was obtained from Resident 3. Review of Resident 3’s Informed Consent Verification dated 7/3/24, showed the informed consent for Prolixin was obtained from Resident 3. Further review of Resident 3’s medical record failed to show documented evidence the informed consents for Abilify and Prolixin were renewed after six months. On 8/27/25 at 1149 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 verified the informed consents for Abilify and Prolixin medications for Resident 3 were not renewed after six months. RN 1 stated the informed consents for psychotropic medications were not renewed after six months, unless the resident was discharged then readmitted with a new chart. On 8/28/25 at 1051 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON verified the informed consents for Abilify and Prolixin medications for Resident 3 were not renewed after six months. The DON stated when the facility conducted the quarterly IDT meetings, they also checked the informed consent, to which the medical records department would inform the nursing department about the informed consents needed to be renewed. 4. On 8/27/25 at 0907 hours, on 8/28/25 at 0957 and 1120 hours, Resident 24 was observed lying in bed with bilateral ¼ (quarter) side rails elevated. Review of Resident 24’s Order Summary Report showed a physician’s order dated 8/13/25, for bilateral ¼ side rails. Review of Resident 24’s Informed Consent Documentation (undated) showed the informed consent obtained was for bilateral ½ (half) side rails. On 8/27/25 at 1204 hours, an interview and concurrent medical record review for Resident 24 was conducted with RN 1. RN 1 verified the above findings. On 8/28/25 at 1029 hours, the DON was informed and verified the above findings.

Based on interview, medical record review, and facility document review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days for one of three residents reviewed for closed records (Resident 101). * The facility failed to provide Resident 101's requested medical record and facility documents to the legal representative until 13 days after the initial request was received. In addition, the facility's resident care policies and daily posting of the staffing record were not provided as requested to Resident 101's legal representative. This failure had the potential for violating Resident 101's and their legal representative rights to access their medical health information.Findings: On [DATE] at 1038 hours, a telephone interview was conducted with the Legal Assistant. The Legal Assistant stated Resident 101 expired on [DATE] in the facility, so the resident's representative had filed a case through the Law Firm. The Legal Assistant stated the Law Firm required Resident 101's medical record, facility's resident care policies, and the posting of the staffing data for each day of the last 18 months. The Legal Assistant further stated resident's representative had signed the written authorization to release the medical record for Resident 101. The Legal Assistant stated she first mailed the request on [DATE], via federal express and it was hand delivered to the facility staff on [DATE]. The Legal Assistant stated it had been more than 13 days since she requested the records but had not received the requested records from the facility. On [DATE] at 1529 hours, a follow up telephone interview was conducted with the Legal Assistant. The Legal Assistant stated she made multiple attempts to request the medical record for Resident 101. The Legal Assistant stated after she mailed the initial request, she called the facility and left a voice message on 8/14, 8/18, and [DATE]. The Legal Assistant further stated she also emailed the Director of Medical Records on [DATE], regarding the same request but had not received the records yet. Closed medical record review of Resident 101 was initiated on [DATE]. Resident 101 was admitted to the facility on [DATE], and expired on [DATE]. Review of Resident 101's MDS assessment dated [DATE], showed Resident 101 had moderately impaired cognitive function. Review of Resident 101's admission Record dated [DATE], showed Resident Representative 1 had the Power of Attorney for Health Care for Resident 101. Review of Law firm's Medical request dated [DATE], showed the following records were requested:- - Resident 101's medical records, billing records, photographs, charts and writings. In addition, all admission agreements, reviews, utilization review committee records, and x-rays;- - Facility's resident care policies and procedure; and- - Posted nurse staffing data for each day of the eighteen months prior to the date of the letter. Further review of the Law Firm medical record request showed Resident Representative 1 electronically signed the authorization for the release of Resident 101's medical information. On [DATE] at 0815 hours, an interview and concurrent closed medical record review for Resident 101 was conducted with the Director of Medical Records. The Director of Medical Records stated the residents and/or resident's legal representatives were entitled to access their medical records, patient care policies, and posted staffing data. The Director of Medical Records further stated the medical records department would assist with providing the residents and/or their representatives with the copies of the requested records. The Director of Medical Records stated she received the above medical request for Resident 101 on [DATE], and verified Resident Representative 1 had the power of attorney for Resident 101. The Director of Medical Records verified Resident Representative 1 signed the authorization for the release of Resident 101's medical information. The Director of Medical Records verified the above request for the records was not provided to the Law Firm and it was 13 days overdue. The Director of Medical Records stated the above requested records, including Resident 101's medical record, should have been provided to the Law Firm within two working days as per the regulation. On [DATE] at 1133 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding how to formulate an advanced directive for five of 16 final sampled residents (Residents 5, 6, 8, 83, and 90) reviewed for advanced directives. * The facility failed to provide the written information and assistance regarding how to formulate the advanced directive for Residents 5 and 90. * The facility failed to inform, provide, and document the written information regarding the residents' right to formulate the advanced directives for Residents 6 and 83. * The facility failed to provide the written information regarding the right to formulate the advanced directive for Resident 8. These failures had the potential for the residents to receive inaccurate and delayed treatment compatible with the residents' wishes during an emergency.Findings: Review of the facility's P&P titled Advance Directives revised on 9/2022 showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The Determining Existence of Advanced Directive section showed the following: - The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so; - Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative; and - If the resident is incapacitated und unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident’s legal representative. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. 1. Medical record review for Resident 5 was initiated on 8/26/25. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 had moderate cognitive impairment. Review of Resident 5's POLST dated 12/20/24, showed under Section D-Information and Signatures, Resident 5 had no advanced directive. Further review of Resident 5's medical record failed to show the documented evidence the facility followed up with Resident 5 and/or the resident's representative to provide the information and assistance on formulating the advance directive. 2. Medical record review for Resident 90 was initiated on 8/26/25. Resident 90 was readmitted to the facility on [DATE]. Review of Resident 90's H&P examination dated 3/31/25, showed Resident 90 had the capacity to understand and make decisions. Review of Resident 90's MDS assessment dated [DATE], showed Resident 90 was cognitively intact. Review of Resident 90's POLST dated 8/21/24, showed under Section D-Information and Signatures, Resident 90 had no advanced directive. Further review of Resident 90's medical record failed to show the documented evidence the facility followed up with Resident 90 to provide the information and assistance on formulating the advanced directive. On 8/27/25 at 1536 hours, an interview and concurrent medical record review for Residents 5 and 90 was conducted with the MDS Coordinator. The MDS Coordinator stated she just started following up with the residents regarding their advanced directives two weeks ago when the primary staff who was responsible for following up with the advanced directives left. The MDS Coordinator stated she met with the resident and resident’s representative upon admission to discuss the POLST and the advanced directive with them. The MDS Coordinator stated the resident or the resident’s representative would complete the POLST and when the Section D- Information and Signatures showed discussed with the resident or legally recognized decision maker, it meant the information regarding the formulation of the advanced directive was provided. The MDS Coordinator acknowledged the POLST did not show any documented evidence a written information was provided to Residents 5 and 90 regarding how to formulate an advanced directive in a manner that was easily understood by the residents. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 5 and 90. 3. Review of Resident 6's medical record was initiated on 8/25/25. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 5/20/25, showed Resident 6 had the capacity to understand and make medical decisions. Review of Resident 6's POLST dated 5/17/25, failed to show under Section D for Information and Signatures, if Resident 6 had an advanced directive. Review of Resident 6's Social Services progress notes dated 5/27/25, failed to show documented evidence if the formulation of an advance directive was offered to Resident 6 and/or his representative. Further review of Resident 6's medical record failed to show the Advance Directive Acknowledgment form was completed for Resident 6. On 8/28/25 at 1329 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator acknowledged the above findings and stated the advanced directive was completed upon the resident's admission to the facility by the Social Services staff. The MDS Coordinator stated the facility currently had no SSD and the POLST was completed by the licensed nurses. In addition, MDS Coordinator stated she was unsure if the Advance Directive Acknowledgment form was used in the facility. On 8/28/25 at 1539 hours, the DON was informed and verified the above findings. 4. Medical record review for Resident 83 was initiated on 8/25/25. Resident 83 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 83's POLST dated 5/24/19, failed to show under Section D for Information and Signatures, if Resident 83 had an advanced directive. Review of Resident 83's Social Services progress notes dated 7/16/24, showed the POLST was discussed with the resident's family member who had pending conservatorship. However, the progress notes failed to show further Social Services documentation to follow up if the advance directive formulation was offered to Resident 83’s responsible party. Review of Resident 83's H&P examination dated 8/22/25, showed Resident 83 had anoxic brain injury (condition where the brain is deprived of oxygen for a period of time) and was in persistent vegetative state, contracted, unable to communicate, track, or make needs known. Further review of Resident 83's medical record failed to show the Advance Directive Acknowledgment form was completed for Resident 83. On 8/28/25 at 1313 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator acknowledged the above findings. On 8/28/25 at 1539 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 5. Medical record review for Resident 8 was initiated on 8/27/25. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's POLST dated 7/15/25, showed under Section D, “No” was marked for the Advanced Directive. Review of Resident 8's H&P examination dated 7/17/25, showed Resident 8 had no capacity to understand and make decisions. Further review of Resident 8’s medical record failed to show documented evidence the advanced directive was offered and discussed with the resident’s representative. On 8/27/25 at 1552 hours, an interview and concurrent medical record review was conducted with MDS Coordinator for Resident 8’s advanced directive. The MDS Coordinator verified there was no documentation of the acknowledgment to show the advanced directive was offered or discussed with the resident’s representative. On 8/27/25 at 1604 hours, an interview was conducted with the DON. The DON verified there was no advanced directive, acknowledgment and/or documentation in the resident’s medical records to show if the advanced directive was offered or discussed with the resident’s representative.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe practices were followed for two of four sampled residents (Residents 1 and 2) when: * The facility failed to provide two staff's assistance as required during a mechanical lift for Resident 1. As a result, Resident 1 fell from the mechanical lift and sustained the acute spinal processes fractures in the cervical and thoracic spines. * The facility failed to ensure the facility's P&P for safe transfers was followed when Resident 2's shower bed was not locked during the resident's transfer from bed to the shower bed. These failures resulted in the actual harm for Resident 1 and placed Resident 2 at risk of serious injuries.Findings: Review of the facility's P&P titled Hoyer Lift dated 2001 showed at least two nursing assistants are needed to safely move a resident with a mechanical lift. Prepare the environment: clear an unobstructed path for the lift machine, ensure there is enough room to pivot, position the lift near the receiving surface, and place the lift at the correct height; place the sling under the resident. Visually check the size to ensure it is not too large or too small; lower the sling bar closer to the resident; attach sling straps to sling bar, according to the manufacturer's instructions; make sure the sling is securely attached to the clips and that it is properly balanced; check to make sure the resident's head, neck and back are supported; before the resident is lifted, double check the security of the sling attachment; examine all hooks, clips or fasteners; check the stability of the straps; and ensure the sling bar is securely attached and sound. 1. Medical record review for Resident 1 was initiated on 7/15/25. Resident 1 was admitted to the facility on [DATE], and discharged to an acute care hospital on 6/28/25. Review of Resident 1's Quarterly MDS assessment under Section GG dated 5/13/25, showed Resident 1 was dependent on the staff's assistance for ADL care. Review of Resident 1's Fall Risk assessment dated [DATE], showed Resident 1 was at high risk for falls. Review of Resident 1's Progress Note dated 6/28/25 around 0845 hours, showed the staff was preparing the medications by the medication cart in front of Room A when the staff had witnessed the resident falling from the sling while being transferred to the shower bed via Hoyer lift by one CNA. Review of Resident 1's Progress Note dated 6/28/25 at 1921 hours, showed in subsequent conversation, the CNA reported she had already transferred Resident 1 from the bed to the Hoyer lift sling and was navigating the lift to position the resident to be transferred to the shower bed when through the momentum of the movement, the sling swung enough to tip Resident 1 out of the sling and on to the floor. The LVN reported being at the medication cart with her back at the resident's room preparing the medications when a loud noise and CNA's voice alerted her. The LVN turned around and witnessed the resident falling from the sling and landing directly on the floor on her back. Review of Resident 1's IDT note dated 6/30/25, showed on 6/28/25 around 0845 hours, while the CNA was preparing the resident for the shower, the resident fell from the Hoyer lift. Upon the investigation, according to the CNA, while she was checking the hook of the sling attached to the Hoyer lift, Resident 1 made a big wiggle of her shoulder and body. The sling made a big swing, resulting in Resident 1 falling on the floor. Review of Resident 1's Hospitalist Discharge Summary note from the acute care hospital dated 7/7/25, showed Resident 1 was being lifted with a lift and accidentally dropped on her back. Upon the evaluation in the acute care hospital, Resident 1 was discovered to have the acute spinal processes fractures in the cervical and thoracic spines. On 7/15/25 at 0950 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked about Resident 1's fall from the mechanical lift used during the transfer on 6/28/25. The DON stated CNA 1 was working with the Hoyer lift and had transferred Resident 1 from the bed to the shower bed by herself. The DON stated there must be two people when transferring a resident using the Hoyer lift. CNA 1 told her that she should have called another staff member for help. On 7/15/25 at 1200 hours, Resident 1 was observed lying on a low air-loss mattress and appeared to be overweight. Resident 1 stated she was back from the acute care hospital. Resident 1 stated she fell from the mechanical lift. Resident 1 was asked if the staff were transferring her with a mechanical lift. Resident 1 stated one staff member was trying to transfer her from the bed to the shower bed with the lift and she fell on her back. On 7/15/25 at 1215 hours, an interview was conducted with LVN 1. LVN 1 stated the resident was bedbound and totally dependent on the staff's assistance for care, including transfers. On 7/15/25 at 1240 hours, an interview and concurrent medical record review for Resident 1 was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 1 was totally dependent on the staff's assistance for care and needed two or more people's assistance for transfers. The MDS Coordinator further stated for Resident 1 using a mechanical lift for transfers, there should have had two people transfer the resident. On 7/15/25 at 1530 hours, an interview and concurrent medical record review for Resident 1 was conducted with CNA 1. CNA 1 was asked about Resident 1's fall. CNA 1 stated Resident 1 requested to have a shower, and CNA 1 transferred Resident 1 from the bed to the shower bed using a mechanical lift. CNA 1 stated Resident 1 made a shaking movement when she was lifted and the sling was moving, then the resident was out of the sling. CNA 1 also stated Resident 1 was big and fell on the ground. CNA 1 further stated she did not ask another nurse to help because she thought LVN 3 was in the room. When asked if LVN 3 assisted CNA 1 with the mechanical lift, CNA 1 stated LVN 3 was working with Resident 1's roommate. In addition, CNA 1 stated she was aware Resident 1 needed two people to transfer using a mechanical lift. On 7/15/25 at 1645 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked for a care plan to address the assistance needed for Resident 1's transfers and bed mobility and if there was a plan of care developed status post fall on 6/28/25. The DON was not able to provide any documentation. The DON verified the findings. 2. Medical record for Resident 2 was initiated on 7/15/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's care plan dated 3/11/24, showed the resident had ADL self-care performance deficits related to fatigue, limited mobility, limited range of motion, musculoskeletal impairment, and stroke. The care plan showed for the interventions, Resident 2 required total assistance for two persons with transfers. On 7/15/25 at 0845 hours, Resident 2 was observed being transferred from the bed to the shower bed. RNA 1 was observed lifting Resident 2 using a mechanical lift. CNA 2 was standing at the head of the shower bed and CNA 3 on the other side of the shower bed further away from Resident 2. Both CNAs tried to reposition the shower bed. CNA 3 was observed not in close proximity to Resident 2 while RNA 1 was maneuvering the Hoyer lift with the resident in the sling. RNA 1 was observed lowering Resident 2 to the shower bed and the shower bed was observed in an unlocked position. CNA 2 elevated the rail of the shower bed when Resident 2 was lying in the shower bed. The shower bed was observed with little movement while in an unlocked position. On 7/15/25 at 0905 hours, an interview was conducted with RNA 1 and CNA 2. Both RNA 1 and CAN 2 were informed of the observation regarding no other staff monitoring Resident 2 in close proximity while the resident was being transferred in a sling, using a mechanical lift. Both staff members acknowledged they should have had one staff member close to the resident to monitor the resident in a sling while RNA 1 was controlling the mechanical lift. Both staff also acknowledged and stated they should have locked the shower bed while Resident 2 was being transferred to the shower bed. RNA 1 and CNA 2 verified the findings. On 7/15/25 at 1435 hours, an interview was conducted with the DSD. The DSD was asked about the safe transfers for the residents using the mechanical lift. The DSD stated they must have two people transfer the residents using the mechanical lift. One person would be doing the maneuvering and controlling the mechanical lift, and another person needed to touch and monitor the sling and be close to the resident. The DSD stated the shower bed should be in a locked position when transferring the resident to the shower bed.

Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure adequate assistance and supervision were in place to prevent a fall for one of two sampled residents (Resident 1), which resulted in major injuries requiring hospitalization . * Resident 1 was inappropriately transferred to a shower chair by two CNAs (CNAs 1 and 2). Resident 1 was not capable of holding himself upright and had never been transferred to a shower chair before. Resident 1 was not provided physical assistance to prevent him from falling forward onto the floor and landing on his face. As a result of the fall, Resident 1 sustained [MEDICATION NAME] force facial trauma, including a dislocated jaw and fractures to the nose, requiring admission to the acute care hospital for oral surgery and sutures to his nose. Findings: On 10/11/19 at 1046 hours, Resident 1 was observed lying in bed with the head of the bed elevated at approximately 30 degrees. Resident 1 was observed to have sutures on the bridge of his nose and a swollen left upper lip which was also noted to have sutures. a. Medical record review for Resident 1 was initiated on 10/11/19. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's history and physical examination [REDACTED]. Review of Resident 1's MDS dated [DATE], showed Resident 1 was severely cognitively impaired, had left-sided weakness, and required total assistance from one person for bed mobility, toilet use, and bathing. Resident 1 required total assistance from two people for all transfers including being transferred from bed to a wheelchair. Resident 1 had functional limitation on one side of both upper and lower extremities. Resident 1 was assessed to be 5 foot and 5 inches tall and weighed 200 pounds. Review of the Fall Risk assessment dated [DATE], showed Resident 1 was assessed to be a high risk for falls. Review of Resident 1's plan of care showed a care plan problem dated 7/17/19, addressing deficit in ADL care related to activity intolerance, confusion, and history of [MEDICAL CONDITION]. The plan of care showed Resident 1 was bedfast all or most of the time. Review of Resident 1's Occupational Therapy Treatment Encounter Notes dated 10/1/19, showed Resident 1 had poor grade sitting balance and needed maximum assistance. Review of Resident 1's Physical Therapy Discharge Summary dated 10/2/19, showed Resident 1 had poor static sitting balance and needed maximum assistance to maintain his balance. On 10/2/19, Resident 1 sustained a fall from a shower chair onto the floor, landing on his face. Review of the facility's Investigation of Incident/Accident/Injury of Unknown Origin form dated 10/2/19, showed on 10/2/19 at 0830 hours, Resident 1 had a witnessed fall from a shower chair. Review of Resident 1's Progress Notes dated 10/2/19 at 0857 hours, showed at approximately 0830 hours, RN 1 heard the staff asking for help from Resident 1's room. When RN 1 entered the room, she observed Resident 1 on the floor. The RN documented Resident 1 was receiving a haircut from two CNAs (CNAs 1 and 2) while Resident 1 was sitting up in a shower chair. CNA 2 left the room to attend to another resident, which left CNA 1 alone in the room with Resident 1. CNA 1 noticed a kink in Resident 1's indwelling urinary drainage catheter tubing so she moved to the side of Resident 1's shower chair to bend down and adjust the tubing. During this time, Resident 1 lost his balance and fell forward onto the floor, landing on his face. Resident 1 was assessed to have a laceration to the bridge of the nose, a cut on the left upper lip, bleeding gums and loosened teeth as result of the fall. Review of the Change of Condition note dated 10/2/19 at 0840 hours, showed Resident 1's physician was notified of the incident and ordered STAT x-rays of Resident 1's skull, chest, and bilateral hips. Review of Resident 1's Progress Notes dated 10/2/19 at 0910 hours, showed RN 1 notified Resident 1's responsible party (Responsible Party 1). Review of Resident 1's Progress Notes dated 10/2/19 at 1005 hours, showed Resident 1 was transferred to an acute care hospital (Acute Care Hospital 1) emergency department via ambulance. Review of Resident 1's Acute Care Hospital 1's emergency department's medical records dated 10/2/19 at 1056 hours, showed Resident 1 sustained [MEDICATION NAME] facial trauma which included the following injuries: - An open nasal fracture with a 0.5 cm laceration extending across to the bridge of the nose requiring four stitches. - An inner upper lip laceration measuring 3 cm by 1 cm with [MEDICATION NAME] (outer layer of the skin) tissue loss and [MEDICATION NAME] abrasions, requiring seven stitches. - Displacement of the left upper front tooth (incisor) - Loosened left upper second tooth (incisor) Review of the acute care hospital's CT scan report dated 10/2/19, showed Resident 1 sustained a dislocation of the right jaw, acute fractures of the nasal bone, and nasal septum (structure that separates the right from the left nasal cavity) with swelling. Further review of Resident 1's Acute Care Hospital 1's medical records showed a consultation for an oral and maxillofacial surgeon was obtained. Resident 1 had to be transferred to another acute care hospital (Acute Care Hospital 2) to be seen by the consulting surgeon for his dental injuries as Acute Care Hospital 1 was unable to provide this needed surgery. On 10/2/19 at 2314 hours, Resident 1 was transferred from Acute Care Hospital 1 to Acute Care Hospital 2 where he was admitted for further treatment of [REDACTED]. Review of the Oral and Maxillofacial Surgery Consultation dated 10/3/19, showed Resident 1 had a maxillary alveolar ridge (part of the upper jaw that contains tooth sockets) fracture. Review of Resident 1's acute care record titled Operative Record dated 10/5/19, showed Resident 1 underwent a surgical repair of his jaw and teeth. This procedure was done under general anesthesia and included applying an arch bar (a type of stainless steel splint that conforms to the arch of the teeth to stabilize injured teeth. The arch bar was stabilized using multiple stainless steel wires). Resident 1 was identified to have displacement of front teeth which was positioned back within the tooth socket and stabilized. Review of Resident 1's Clinical Summary dated 10/8/19, showed Resident 1 was discharged from Acute Care Hospital 2 and transferred back to the facility. On 10/11/19 at 1215 hours, an interview was conducted with CNA 1. CNA 1 was assigned to care for Resident 1 on 10/2/19. CNA 1 stated Resident 1's hair was long, dirty and had flakes and she wanted to cut it. CNA 1 stated she asked Resident 1 if she could give him a haircut and Resident 1 nodded yes. CNA 1 stated she asked CNA 2 to help her cut Resident 1's hair and transfer him from the bed to the shower chair. CNA 1 stated she and CNA 2 used a Hoyer lift (mechanical lift) to transfer Resident 1 from his bed to the shower chair. CNA 1 stated neither she or CNA 2 consulted with a respiratory therapist or a licensed nurse about transferring Resident 1 to a shower chair. When asked if the shower chair had any type of device to prevent Resident 1 from leaning forward, CNA 1 said no. CNA 1 stated she stood in front of Resident 1 to prevent him from leaning forward while CNA 2 cut the resident's hair. CNA 1 stated when they were done cutting Resident 1's hair, CNA 2 was paged from the overhead speakers to assist another resident in another room. CNA 2 left Resident 1's room, leaving CNA 1 alone with Resident 1 who was still sitting on the shower chair. CNA 1 stated she noticed a kink in Resident 1's urinary drainage bag tubing and decided to lean down to the side of the chair and fix the kink, which left Resident 1 unsupported in the shower chair. CNA 1 stated while she was bent over fixing the urinary drainage tubing, Resident 1 fell forward hitting his face on the floor. CNA 1 stated she yelled for help and a few staff members including two licensed nurses came to assess Resident 1. CNA 1 stated she observed Resident 1 bleeding from his nose and mouth. CNA 1 stated she had never used a shower chair to shower Resident 1, he was always been placed on a shower gurney when showered, which made it difficult to thoroughly wash the resident's hair. CNA 1 stated, It was a bad decision to put him in a shower chair. On 10/11/19 at 1230 hours, an interview was conducted with CNA 2. CNA 2 stated he had taken care of Resident 1 before and was familiar with the resident's care needs. CNA 2 was asked about Resident 1's needs and ability to sit upright. CNA 2 stated when Resident 1's head of the bed was elevated Resident 1 tended to lean to his left side. CNA 2 stated he had never seen Resident 1 use a chair, wheelchair, or a shower chair before the fall incident on 10/2/19. CNA 2 stated he was assisting CNA 1 with cutting Resident 1's hair. CNA 2 stated he had been behind Resident 1 while cutting the resident's hair and CNA 1 was standing directly in front of Resident 1 but was not physically supporting Resident 1. When asked about the use of the shower chair, CNA 2 stated he made sure the shower chair was locked. CNA 2 stated upon completing Resident 1's haircut, he was called to help another resident in another room and he left CNA 1 alone with Resident 1 while the resident was still sitting in the shower chair. CNA 2 stated he left the room and no more than 20 seconds later, he heard an overhead page stating help was needed in Resident 1's room. CNA 2 stated when he arrived to Resident 1's room he observed Resident 1 lying on the floor, he was awake and had blood on his face. A few staff members were helping Resident 1. On 10/11/19 at 1258 hours, an interview was conducted with COTA 1. COTA 1 stated she took care of Resident 1 before his fall and was familiar with his needs. COTA 1 stated Resident 1 was assessed to have poor sitting balance and needed maximum assistance to hold himself up. COTA 1 stated Resident 1 required the assistance of one person physically holding him up when he was in a sitting position. On 10/14/19 at 1429 hours, an interview was conducted with Responsible Party 1. The Responsible Party stated she made medical decisions for Resident 1 as he was not capable to do so. She stated she had been informed of Resident 1's fall on 10/2/19 around 0930 hours. The Responsible Party stated she became very upset when she went to the acute care hospital and saw Resident 1's face with blood and stitches on his nose and blood in his mouth. When asked about Resident 1's haircut, the Responsible Party stated she was never asked by anyone from the facility for permission to cut Resident 1's hair. The Responsible Party stated, it (hair) was fine the way it was. She stated Resident 1 had muscle weakness and she had never seen him sitting up in a chair. The Responsible Party stated Resident 1 was crying while he was at the acute care hospital because he did not want to return to the facility, they both felt it was unsafe. On 10/11/19 at 1453 hours, an interview was conducted with RN 1. RN 1 stated Resident 1 was not capable of supporting himself in a sitting position. On 10/15/19 at 0919 hours, an interview was conducted with LVN 1. LVN 1 stated she was assigned to care for Resident 1 on 10/2/19. LVN 1 stated she had never seen Resident 1 in a wheelchair, chair or shower chair since his admission to the facility. LVN 1 stated Resident 1 did not have upper trunk control or balance and could not sit up in a chair by himself. LVN 1 stated she did not see Resident 1 in a shower chair on 10/2/19, and did not know CNA 1 and CNA 2 were going to put him in a shower chair. When asked if she knew CNA 1 and CNA 2 were giving Resident 1 a haircut, LVN 1 stated she did. LVN 1 stated she heard yelling for help from the hallway and when she arrived in Resident 1's room she observed Resident 1 lying on the floor on his side with blood on his face and a few staff members were attending to Resident 1. b. Review of the facility's Investigation of Incident/Accident/Injury of Unknown Origin form dated 10/2/19, showed the cause of the fall was failure of staff to verify appropriate use of medical equipment (shower chair) with the licensed staff. Review of the entire investigation documents showed the only staff member interviewed was CNA 1. There was no other documentation to show any other staff interviews were conducted regarding Resident 1's care or other possible witnesses to the fall on incident. The one interview showed when CNA 1 leaned over to grab Resident 1's urinary drainage bag tubing Resident 1's body jerked and fell forward to the floor. Review of the facility's investigation of the fall did not show all of the circumstances regarding this fall incident. The documentation failed to address Resident 1's poor sitting balance and that he had never been placed in a chair, wheelchair or shower chair since his admission to the facility. On 10/11/19 at 1541 hours, an interview and concurrent medical record review for Resident 1 was conducted with the Administrator. The Administrator verified there was only one staff interview conducted during the resident's fall investigation. When asked about any attempts to interview CNA 2, Administrator stated an interview with CNA 2 was not conducted.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for one of 21 final sampled residents (Resident 58). Resident 58 was readmitted to the facility without pressure ulcers to the heels and was assessed to be at high risk for developing pressure ulcers. * The facility failed to ensure the interventions such as offloading of the heels were developed and implemented to prevent the development of pressure ulcers. * The facility failed to ensure Resident 58's skin assessments were consistently conducted prior to Resident 58 developing a pressure ulcer to the right heel. * The facility failed to ensure Resident 58's heels were offloaded as care planned after Resident 58 had developed a pressure ulcer to the right heel. * The facility failed to ensure Resident 58's heel protectors were applied as ordered by the physician after Resident 58 had developed a pressure ulcer to the right heel. These failures resulted in Resident 58 developing a pressure ulcer to the right heel while at the facility and posed the risk for delayed healing and worsening of the pressure ulcer. Findings: Review of the facility's P&P titled Pressure Sore Prevention (undated) showed it is the policy of the facility to identify at risk residents and to define early interventions for prevention of pressure ulcers. In individuals who are at high risk, the goal will be aimed at reducing the risk factors and at instituting preventative measures. Interventions will have four overall goals including to protect against the adverse effects of external mechanical forces (pressure, friction, and shear). Strategies to prevent pressure ulcers for bed bound individuals included to use devices that totally relieve pressure on the heels. Skin care included to inspect the resident's skin at least every day. The above interventions should be included on the written care plan for each resident assessed to be at risk for developing pressure ulcers. Review of the facility's P&P titled Pressure Ulcers/Injuries Overview revised 7/17 showed the pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominent area. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear, and may be painful. Avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors; and definition or implementation of interventions that are consistent with the resident's needs, goals, and professional standards of practice. Stage 2 pressure ulcers appear as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer, and may also present as an intact or open/ruptured blister. An Unstageable pressure ulcer appears as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar (dead tissue). Review of the National Pressure Ulcer Advisory Panel's Clinical Practice Guideline titled Prevention and treatment of [REDACTED]. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. The recommendations showed to inspect the skin of the heels regularly and to ensure the heels are free of the surface of the bed for preventing and treating heel pressure ulcers. Ideally, the heels should be free of all pressure - a state sometimes called floating heels or offloading. Pressure on the heels can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. On 7/9/19 at 0939 hours, during the initial tour of the facility, Resident 58 was observed lying on a regular mattress. One pillow was observed under Resident 58's legs, but the heels were observed resting directly on the mattress. No heel protectors were observed in place. Medical record review for Resident 58 was initiated on 7/9/19. Resident 58 was readmitted to the facility on [DATE]. Review of the Body assessment dated [DATE], completed on readmission, showed Resident 58 did not have any identified skin issues or pressure ulcers to the heels on readmission. Review of Resident 58's plan of care showed care plan problems dated 12/11/18, to address Resident 58's impaired skin integrity and the potential for pressure ulcer development. The interventions failed to address any preventive measures to prevent the pressure ulcer development for the resident. Review of the Pressure Ulcer Risk assessment dated [DATE], showed Resident 58 was at high risk for developing pressure ulcers related to a poor general physical condition, mental status, and activity/mobility; and fair moisture factors (may be incontinent of bowel and/or bladder, but not continually soiled and/or wet, or have profuse diaphoresis; frequently damp, but not continually damp) and nutritional factors. Review of Resident 58's MDSs dated 3/5 and 6/5/19, showed Resident 58 was totally dependent on the staff for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned the body while in bed) and had impairment on both sides of the lower extremities. Review of the Dietary Quarterly Progress Note dated 6/6/19, showed Resident 58 was within her usual body weight range and had no significant changes. Review of the Wound Evaluation Flow Sheet dated 6/12/19, showed Resident 58 developed a facility-acquired pressure ulcer to the right heel presenting as a fluid-filled blister that measured 4 cm (length) x 4 cm (width) x 0 cm (depth). On 7/4/19, the pressure ulcer to the right heel was reclassified as an Unstageable pressure ulcer. The Wound Evaluation flow sheet showed the wound bed was 100% eschar on 7/4/19. Further review of Resident 58's plan of care showed a care plan problem dated 6/12/19, with a revision date of 7/4/19, to address Resident 58's Unstageable pressure ulcer to the right heel. The interventions included to offload the heels from pressure at all times and apply bilateral heel protectors. Review of the Order Summary Report showed a physician's orders [REDACTED]. On 7/9/19 at 1221 hours, Resident 58 was observed lying in bed with one pillow under the legs. However, both heels were observed resting directly on the mattress and no heel protectors were in place. On 7/10/19 at 0754, 0855, 0942, and 1020 hours, Resident 58 was observed lying in bed with both heels resting directly on the mattress. No heel protectors were observed in place. On 7/10/19 at 1021 hours, an interview was conducted with CNA 1. CNA 1 stated he was familiar with Resident 58 and was assigned to her on 7/9 and 7/10/19. CNA 1 stated Resident 58 could not move by herself and was dependent on the staff for repositioning. CNA 1 verified Resident 58 was on a regular mattress and stated he turned Resident 58 every two hours. When asked about Resident 58's skin, CNA 1 stated Resident 58's skin was ok and she had no pressure ulcers. CNA 1 verified Resident 58's heels were not offloaded and were resting directly on the mattress. CNA 1 verified he did not offload Resident 58's heels the previous day either because he was not aware Resident 58 had a pressure ulcer on the right heel. When asked how to offload the heels, CNA 1 stated by placing enough pillows under the legs so the heels do not touch or rest on the mattress. CNA 1 verified Resident 58 did not have heel protectors in place today (7/10/19) or the previous day. When asked to locate Resident 58's heel protectors, CNA 1 stated Resident 58 did not have heel protectors available after looking in Resident 58's closet and drawers. CNA 1 stated the treatment nurse was responsible for applying the heel protectors in the morning. When asked what preventative measures were taken for Resident 58 before she developed the pressure ulcer to the right heel, CNA 1 stated he kept the resident clean and dry and turned her every two hours. On 7/10/19 at 1039 hours, an interview was conducted with LVN 5. LVN 5 stated she was one of the treatment nurses. LVN 5 stated Resident 58 had a facility-acquired Unstageable pressure ulcer to the right heel that started as a fluid-filled blister. LVN 5 stated Resident 58 did not have any skin impairments or pressure ulcers to the heels on readmission. LVN 5 was asked to observe Resident 58 in bed. LVN 5 verified Resident 58's heels were not offloaded and were resting directly on the mattress. LVN 5 verified Resident 58 did not have heel protectors in place. When asked if Resident 58 could move, LVN 5 stated Resident 58 could move her legs slightly, but her lower extremities were not contracted and her heels could still be offloaded with pillows. When asked if Resident 58 was at risk for developing pressure ulcers, LVN 5 stated yes. LVN 5 was asked what preventative measures were in place prior to Resident 58 developing the Unstageable pressure ulcer to the right heel. LVN 5 stated Resident 58's heels were supposed to be offloaded because she was totally dependent on the staff. When asked how she ensured the resident's heels were offloaded, LVN 5 stated the nurses were supposed to make rounds to ensure the resident's heels were offloaded. When asked why Resident 58's heels were not offloaded, LVN 5 stated she did not know, but the CNA should have offloaded the resident's heels. On 7/10/19 at 1230 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 was asked how the blister on Resident 58's right heel could have developed. LVN 5 stated blisters could develop from shearing or pressure. When asked if the blister could have developed on its own, LVN 5 stated no. LVN 5 was asked if Resident 58's pressure ulcer to the right heel was avoidable. LVN 5 stated the pressure ulcer to Resident 58's heel was avoidable. LVN 5 was asked how often the skin assessments were conducted. LVN 5 stated the charge nurses were responsible for conducting the skin assessments and documented the skin assessments in the weekly summaries. Review of the Weekly Progress Notes dated 6/9/19, under the Skin Condition section (where a head to toe skin assessment was supposed to be conducted and documented) showed to Please see TAR. LVN 5 stated the charge nurses were supposed to be conducting their own skin assessments to identify any new skin concerns instead of relying on the TAR. LVN 5 stated the TAR only showed the wounds or pressure ulcers that had already been identified that had existing orders. LVN 5 verified Resident 58's plan of care did not show to offload the heels as an intervention to prevent the development of pressure ulcers to the heels. When asked which residents required their heels to be offloaded as a preventative measure, LVN 5 stated all residents who were totally dependent for bed mobility should have their heels offloaded to prevent pressure ulcers from developing. On 7/11/19 at 1342 hours, an interview and concurrent medical record review was conducted with the RD. The RD was asked about Resident 58's nutrition and hydration status. The RD stated Resident 58 had a history of [REDACTED]. The RD stated Resident 58 received a tube feeding formula that provided adequate nutrition and protein levels to promote wound healing. The RD stated Resident 58 was also on supplements including vitamin C and zinc to promote wound healing. The RD was asked about Resident 58's nutrition and hydration status prior to developing the blister on the right heel. The RD stated Resident 58's nutrition and hydration status was stable prior to Resident 58 developing the pressure ulcer to the right heel and continued to be adequate to promote healing of the pressure ulcer. On 7/12/19 at 0720 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified he completed the Weekly Progress Notes dated 6/9/19. When asked what type of skin assessment was conducted as part of the Weekly Progress Notes, LVN 6 stated a head to toe skin assessment was supposed to be conducted. LVN 6 was asked what Please see TAR meant. LVN 6 stated, Please see TAR meant to go see the Treatment Administration Record to see the pressure ulcer condition and physician orders [REDACTED]. LVN 6 verified there was no documentation to show he conducted a head to toe skin assessment on Resident 58 to identify new skin issues or pressure ulcers. LVN 6 stated the nurses also conducted assessments, including of the skin every shift that was documented on the Subacute Nursing Assessment. Review of the Subacute Nursing assessment dated [DATE], showed to see the TAR under the skin assessment section. LVN 6 verified the findings. LVN 6 was asked which residents required their heels to be offloaded. LVN 6 stated the residents who could not move or reposition themselves required their heels to be offloaded. LVN 6 was asked how he communicated the residents' care needs and ensured they were being met to the CNAs. LVN 6 stated he communicated the residents' care needs to the CNAs at the beginning of each shift and had to check during the shift to ensure they were being met. LVN 6 stated he sometimes had to offload the resident's heels if the CNAs forgot to or did not know to do so. On 7/12/19 at 0831 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated she was one of the unit supervisors. Review of the Subacute Nursing Assessments dated 6/1 to 6/12/19, failed to show documentation Resident 58's heels were offloaded. Further review of the Subacute Nursing Assessments showed the skin assessments were not completed (left blank) on some shifts or had entries that showed to see the TAR. RN 2 verified the findings and stated the nurses were supposed to be conducting skin assessments on each shift to identify new skin issues. RN 2 was asked what preventative measures were in place to prevent the residents from developing pressure ulcers on the heels. RN 2 stated totally dependent residents who were immobile were supposed to have their heels offloaded as an intervention to prevent heel pressure ulcers. RN 2 stated the charge nurses were supposed to conduct rounds to ensure the residents' heels were offloaded. On 7/12/19 at 0842 hours, the observations of Residents 2 and 70 were conducted with LVN 8. When asked what preventative measures were in place to prevent pressure ulcers on the heels, LVN 8 stated for the residents who were immobile or dependent on the staff, their heels needed to be offloaded. LVN 8 stated Residents 2 and 70 were totally dependent on the staff and required their heels to be offloaded. Residents 2 and 70 were observed lying in their beds with their heels resting directly on their mattresses. LVN 8 verified Residents 2 and 70's heels were not offloaded. On 7/12/19 at 0847 hours, the observations of Residents 7 and 64 was conducted with LVN 9. When asked which residents required their heels to be offloaded to prevent pressure ulcers on the heels from developing, LVN 9 stated totally dependent residents. LVN 9 stated Residents 7 and 64 were totally dependent on the staff and required their heels to be offloaded. Residents 7 and 64 were observed lying in their beds with their heels resting directly on their mattresses. LVN 9 verified Residents 7 and 64's heels were not offloaded.

Based on observation, interview, medical record review, and facility document review, the facility failed to prevent the sexual abuse against one of two sampled residents (Resident 1). Resident 3 was found in Resident 1's room on 12/14/18, with his hand down Resident 1's pants at the perineal area. On another occasion, Resident 3 was observed to take Resident 1's hand and placed it on his crotch. Resident 1 did not have capacity to make decisions or give informed consent. The facility failed to identify Resident 3's behaviors towards Resident 1 as abuse, and therefore, did not monitor Resident 3's behavior. Resident 3 had no cognitive impairment and could self-propel his wheelchair and move freely around the facility. Resident 1 was dependent on others for mobility in her wheelchair. This placed Resident 1 at risk for further abuse by Resident 3 due to the delay in developing and implementing any interventions to keep Resident 1 safe and away from Resident 3. This delay permitted Resident 3 to display further inappropriate sexual behaviors towards Resident 1, including grabbing Resident 1's hand and placing it on his crotch, making inappropriate comments and flickering his tongue (in a sexual manner) towards Resident 1. The facility's failure to monitor Resident 3's behaviors placed other female residents at risk as potential victims of abuse. On 2/6/19 at 1106 hours, the Administrator and DON were informed of an Immediate Jeopardy (IJ) regarding the following: * The facility failed to prevent the sexual abuse to Resident 1. Resident 3 was found in Resident 1's room on 12/14/18, with his hand down Resident 1's pants at the perineal area. On other occasions, Resident 3 was observed in the dining room flickering his tongue with two fingers in the V shape held at his mouth, directing the gesture to Resident 1, made inappropriate comments to Resident 1, and was observed to take Resident 1's hand and placed it on his crotch. * The facility failed to follow their abuse P&P and failed to conduct thorough investigations on the four documented incidents of sexual abuse and harassment to Resident 1. * The facility failed to inform Resident 1's responsible party of the incidents, resulting in Resident 1's family encouraging Resident 1 to be friends with Resident 3. * The facility failed to implement measures to separate both residents and ensure Resident 1's safety. * The facility failed to conduct a comprehensive assessment of Resident 1 after the witnessed sexual abuse incident on 12/14/18. On 2/13/19 at 1545 hours, the IJ was abated after the facility had submitted the following plan of correction: * Immediately place Resident 3 on 1:1 supervision. * Immediately notify Resident 1's responsible party and family of the four documented abuse incidents. * Immediately in-service all staff on the facility's abuse P&P and reporting requirements. * Conduct a thorough investigation of the four documented abuse incidents to Resident 1. * Conduct a full body assessment and obtain a psychiatric evaluation for Residents 1 and 3. Findings: On 1/25/19 at 0813 hours, Resident 1 was observed in her room lying in bed. Resident 1 was asked if she felt safe living at the facility. Resident 1 stated she did not feel safe living at the facility but could not elaborate why. Resident 1 stated, I just don't. Resident 1 was asked if she was touched inappropriately. Resident 1 stated some man touched her down there and pointed to her groin area. Resident 1 stated she did not like it. When asked who had inappropriately touched her, Resident 1 stated the man who came into her room did. a. Medical record review for Resident 1 was initiated on 1/25/19. Resident 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's history and physical examination [REDACTED]. Review of Resident 1's MDSs dated 10/3/18 and 1/3/19, showed Resident 1's cognition was moderately impaired. Review of Resident 1's Progress Notes showed a nursing entry by LVN 1 dated 12/14/18, showing the CNA reported Resident 1 was seen laying in bed with the company of a male resident (Resident 3) at bedside with his hand down her pants and the privacy curtain pulled. The male resident was escorted out of the room. Review of Resident 1's Progress Notes identified an entry by the Activities Director dated 12/20/18 at 1357 hours, showing the Activities Director was approached by Family Member 1 regarding Resident 1 being removed from the group activities. The Activities Director documented Resident 1 was removed from the group activities for safety monitoring due to Resident 1 receiving inappropriate sexual advances from a male resident. The Activities Director documented Family Member 1's response as I don't have a problem if the male resident comes close to my (Resident 1) if the closeness is for encouragement and motivation, I'm okay with that; but if is sexual inappropriate I'm not okay. Review of Resident 1's Progress Notes showed an entry by the SSD dated 12/20/18 at 1417 hours. The SSD documented they had a discussion with Family Member 1 about Resident 1 being removed from the resident group activities due to a male resident making inappropriate gestures towards Resident 1. The progress notes showed Family Member 1 did not want Resident 1 to be in physical contact with the male resident and was not okay with the male resident being inappropriate. Review of Resident 1's plan of care failed to show a care plan problem was developed to address Resident 1 receiving inappropriate sexual behavior from a male resident until 12/20/18, after further incidents had occurred. The care plan problem showed Resident 1 had limited ability to follow redirection and required multiple cues, prompts, and separation from male resident. There were no interventions on how the staff was to monitor or keep Resident 1 safe from the male resident's sexual advances and gestures. On 1/25/19 at 0930 hours, an interview was conducted with CNA 2. CNA 2 stated the facility's Abuse Coordinator was the Administrator. CNA 2 stated any allegation or suspicion of abuse were supposed to be reported to the Administrator immediately. CNA 2 stated about a week ago (approximately one month after the 12/14/18 incident), she witnessed Resident 3 in Resident 1's room. CNA 2 stated Resident 3 left Resident 1's room after being seen by her. CNA 2 stated she reported the incident to the RN Supervisor for that shift because male residents were not supposed to be in the female residents' rooms. On 1/25/19 at 0947 hours, an interview was conducted with CNA 3. CNA 3 stated she was familiar with Resident 1 and was sometimes assigned to care for Resident 1. CNA 3 stated she was not aware of the incident on 12/14/18, where Resident 3 was found in Resident 1's room behind closed curtains with his hands down her pants. CNA 3 stated she was not aware of any interventions to keep Resident 1 safe and was not notified by any supervisors or managers to keep an eye out for potential abuse against Resident 1 by Resident 3. On 1/25/19 at 1001 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she was familiar with Resident 1. LVN 2 stated Resident 1 was alert and oriented to her name, but was otherwise confused. LVN 2 stated Resident 1 did not have the capacity to make her own decisions. LVN 2 stated she was not aware of the incident on 12/14/18. LVN 2 was asked what was considered sexual abuse. LVN 2 stated sexual abuse could be inappropriate touching without the consent of the person being touched. On 2/6/19 at 0855 hours, an interview was conducted with CNA 1. CNA 1 stated on 12/14/18, she found Resident 3 in Resident 1's room with the curtain drawn, sitting next to Resident 1's bed with his entire hand inside Resident 1's pants. CNA 1 stated she said, what are you doing and Resident 3 removed his hand right away and left the room. CNA 1 stated she transferred Resident 1 to her wheelchair and left her by the nurses' station and reported the incident to LVN 1. CNA 1 verified she was not asked to put Resident 1 back to bed to be examined by the nurse. CNA 1 stated Resident 3 could move around by himself and CNA 1 was scared it would happen again. b. Medical record review for Resident 3 was initiated on 1/25/19. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's history and physical examination [REDACTED]. Review of Resident 3's MDSs dated 3/30 and 12/31/18, showed Resident 3 was alert, oriented, and had no cognitive impairment. He was independent with his mobility using a wheelchair. Review of Resident 3's Progress Notes showed an entry by the DON on 12/14/18 at 1357 hours, showing the DON had a discussion with Resident 3 regarding his behavior with another resident. The Progress Notes showed the other resident (Resident 1) was not capable of consenting to a relationship. Resident 3 had been observed in the other resident's (Resident 1) room with the privacy curtains closed earlier that morning, then in the dining room making sexually suggestive motions with his tongue at this other resident (Resident 1). Additional review of Resident 3's Progress Notes showed the following entries: * On 12/14/18 at 1444 hours, Resident 3 was observed in Resident 1's room behind the closed privacy curtain with his hand down Resident 1's pants. In addition, the treatment nurse reported Resident 3 was observed in the dining room sticking out his tongue in a sexual manner directed at Resident 1. * On 12/20/18 at 1046 hours, Resident 3 was witnessed by the Activities Assistant making inappropriate comments to another resident (Resident 1), and when Resident 3 was told to stop, he became verbally abusive to the Activities Assistant. * On 12/20/18 at 1248 hours, Resident 3 was in the dining room, approached Resident 1 and began to hold Resident 1's hand. * On 12/20/18 at 1408 hours, RN 1 documented Resident 3 was noted touching a female resident sexually. The physician was notified. * On 12/20/18 at 1627 hours, there was an entry showing the Activities Director and the Administrator met with Resident 3 to discuss Resident 3's inappropriate sexual behavior towards a female resident. * On 12/20/18 at 1637 hours, there was an entry showing the IDT, including the Administrator and DON met with Resident 3 due to the noted inappropriate sexual behavior with the female resident (Resident 1) who did not have the capacity to give proper consent. * On 1/15/19, a nurse's note showed Resident 3 was found in Resident 1's room. Review of Resident 3's plan of care showed a care plan problem dated 12/4/18, which addressed Resident 3 found holding hands with a female resident, sitting close to her, and appearing very attentive to her, no sexual overtones; however, the female resident was married. Resident 3 was .deemed competent to make decisions, other residents may not be. Review of the the care plan problem showed a revision date of 12/14/18, to address Resident 3 was found making inappropriate gestures towards a female resident (Resident 1) and being in the room with the privacy curtain pulled close. The goal was for Resident 3 to understand the inappropriateness of physical contact with another resident not capable of making a consensual decision. The interventions included to approach the resident if observed holding hands or other personal attention to female resident, explain again that some behaviors were not acceptable within the facility, encourage the resident to keep a reasonable distance from female residents in the hallway and dining room, and remind the resident as needed that not all residents here were able to give consents for physical touching or involvement. A care plan problem dated 12/20/18, addressed Resident 3 displaying inappropriate sexual gestures towards a female resident: flickering his tongue at females, grabbing the female resident's hand and placing it on his crotch, and placing his hand up the female resident's panties. The interventions included to monitor inappropriate behavior every shift, remind Resident 3 not to take advantage of other residents who did not or might not have the mental competence to consent to sexual advances, remove the resident from female resident area when inappropriate sexual behaviors were present, and report any behaviors to the charge nurse and administrative staff. On 1/25/19 at 1223 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 was asked about the Progress Notes entry dated 12/20/18. RN 1 was asked who the female resident referred to in the Progress Notes was. RN 1 stated this was referring to Resident 1. RN 1 stated a CNA approached her and RN 2 to inform them the CNA had witnessed Resident 3 touching Resident 1 in a sexual manner. RN 1 stated she did not recall how Resident 3 touched Resident 1 in a sexual manner. RN 1 verified Resident 1 did not have the capacity to make decisions. RN 1 was asked if the incident between Resident 3 and Resident 1 could be considered sexual abuse. RN 1 stated yes, in hindsight because Resident 1 did not have the capacity to consent. On 1/25/19 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 1 did not have the capacity to consent and she is definitely impaired. The DON stated prior to the incident on 12/14/18, Residents 1 and 3's relationship started out as innocent hand holding and progressively escalated to inappropriate behavior. The DON was asked if Residents 1 and 3 were assessed to have the capacity to consent to be in a relationship or to engage in sexual activity. The DON replied no and stated Resident 1 did not have the capacity to consent or the capacity to make decisions. The DON verified a care plan problem was not developed to address how staff were to keep Resident 1 safe until 12/20/18, which was six days later. The DON was asked if she considered this incident to be sexual abuse. The DON stated no, because Resident 3's hand was just under the covers. The DON stated she was not aware of the documented incident on 12/20/18, where Resident 3 was noted touching a female resident sexually. On 1/28/19 at 0846 hours, a telephone interview was conducted with the Long-Term Care Ombudsman. The Ombudsman stated she was familiar with Resident 1 and Resident 3. The Ombudsman stated she noticed Resident 1 and Resident 3 were really touchy with each other. The Ombudsman stated she did not believe Resident 1 had the capacity to consent because Resident 1 was like an infant. The Ombudsman stated no reports of sexual abuse allegations were reported to her in (MONTH) (YEAR). On 1/30/19 at 0818 hours, a telephone interview was conducted with the MDS Coordinator. The MDS Coordinator stated she was asked by the Administrator to create a care plan problem for Resident 3 to address Resident 3 showing inappropriate sexual behavior towards a female resident (Resident 1). The MDS Coordinator stated Resident 3 was observed flickering his tongue at Resident 1 by an LVN in the dining room and was observed grabbing Resident 1's hand and placing it on his crotch by another staff member but could not recall who the staff member was. The MDS Coordinator stated the incident where Resident 3 grabbed Resident 1's hand and placed it on his crotch was a separate incident than the incident on 12/14/18, but could not recall the date. On 1/30/19 at 0828 hours, a telephone interview was conducted with LVN 3. LVN 3 stated sometime between 12/14/18, and 12/20/18, she witnessed Resident 3 in the dining room flickering his tongue with two fingers in the V shape held at his mouth. LVN 3 stated Resident 3 directed this gesture at Resident 1. LVN 3 stated she was appalled at Resident 3's behavior considering the dining room was full of people. She said she asked Resident 3 to stop. LVN 3 stated during a lunch meal on 12/20/18, in the dining room, Resident 3 approached Resident 1 and held Resident 1's hands. LVN 3 stated she believed Resident 3 was testing the waters because he had been warned to stay away from Resident 1. On 1/31/19, at 1334 hours, an interview was conducted with LVN 4. LVN 4 stated Resident 3 was sent to the general acute care hospital this morning for a scheduled surgery and was not coming back for approximately three days. On 1/31/19 at 1350 hours, a follow-up interview was conducted with Resident 1. Resident 1 was observed lying in her bed. When asked if she felt safe living at the facility, Resident 1 replied no. Resident 1 was asked if she was touched inappropriately. Resident 1 replied yes and pointed to and touched her perineal area and simulated a rubbing motion with her hand at the perineal area. Resident 1 stated she did not like it. Resident 1 was asked who touched her. Resident 1 stated a man who lived at the facility touched her and stated it happened more than once. On 1/31/18 at 1423 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified Resident 3 had a physician's orders [REDACTED]. When asked what behavior was being monitored, RN 3 stated he did not know and acknowledged the order was not specific enough. After review of the Progress Notes dated 12/20/18, RN 3 verified the physician's orders [REDACTED]. RN 3 stated any behavior monitoring should be documented in the Medication Administration Record. Review of Resident 3's Medication Administration Record [REDACTED]. RN 3 verified the findings. On 2/6/19 at 0640 hours, an interview was conducted with RN 4. RN 4 stated Resident 3 was moved to a new room when he returned from the acute care hospital two days earlier because his old room was under construction. The old room was located in a different hallway than Resident 1's room. On 2/6/19 at 0720 hours, Resident 3 was observed lying in bed in a room three rooms away from Resident 1's room and was in the same hallway. Resident 1's room was not visible to the staff at the nurses' station. On 2/6/19 at 0833 hours, an interview was conducted with CNA 10. CNA 10 stated she was assigned to care for Resident 3 today (day shift 0700 to 1500 hours). CNA 10 stated she had not received any instructions about Resident 3 from the licensed nurses. CNA 10 stated she was not familiar with Resident 3 as she worked for a registry agency and was not employed by the facility. When asked if she was to monitor Resident 3's whereabouts or any special monitoring, CNA 10 said she was not aware if there was any monitoring in place for Resident 3. On 2/6/19 at 0924 hours, an interview was conducted with RN 3. RN 3 stated he wanted to relay new information about Resident 3. RN 3 stated Resident 3 informed a CNA that Resident 1 and her family had visited him (Resident 3) while he was at the hospital recovering from his recent surgery. On 2/6/19 at 0915 hours, an interview was attempted with Resident 3 inside his room. A moment later, Resident 1 was observed being wheeled in her wheelchair into Resident 3's room by her family (Family Member 1). Resident 1 was observed to attempt to give Resident 3 a hug, but Family Member 1 stated no. On 2/6/19 at 0933 hours, an interview was conducted with Family Member 1. Family Member 1 stated she could not understand why the facility was now not allowing Resident 1 to be friends with Resident 3. Family Member 1 stated she believed Resident 3 protected, encouraged, and motivated Resident 1. Family Member 1 stated they had taken Resident 1 to visit Resident 3 while Resident 3 was at the hospital last Sunday. Family Member 1 stated she felt the facility was keeping a secret and was not telling her everything. Family Member 1 stated they did not mind if Residents 1 and 3 were in the same room because Resident 3 was looking out for Resident 1. On 2/6/19 at 1000 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated he was Resident 1's designated decision maker. Family Member 2 stated Resident 1 had no short-term memory; he had to re-introduce family members to Resident 1 every time they visited her. Family Member 2 stated the facility's DON had called him three weeks or maybe a month ago regarding an incident where a male resident was found in Resident 1's room. Family Member 2 stated there were no other details given to Family Member 2 except the two residents had been seen holding hands and their legs were touching when seated next to one another in their perspective wheelchairs. Family Member 2 stated he made sure the facility understood these behaviors were not okay with him. The facility assured Family Member 2 they would take care of the situation. On 2/6/19 at 1103 hours, an interview was conducted with the Administrator and DON. When asked about notification of Resident 1's responsible party regarding the sexual abuse, the DON stated she had informed Family Member 2 but not Family Member 1 because Family Member 1 was not the responsible party. The DON stated Family Member 2 was made aware a male resident was in Resident 1's room with his hand under the covers. The DON stated she was surprised Family Member 2 was so calm and did not react. The DON stated she did not ask Family Member 2 if he understood what she was telling him. Cross references to F607 and F609.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their abuse P&P and failed to ensure the staff identified abuse and immediately reported all suspicions of abuse to the Administrator, state agency, and all other required agencies for two of four sampled residents (Residents 1 and 4). * Resident 3 was found with his hand down Resident 1's pants at the perineal area. Resident 1 did not have the capacity for decision making or giving consent. CNA 1, LVN 1, and the DON all had knowledge of the incident between Residents 1 and 3 but failed to initiate an investigation or immediately report the abuse incident to the Administrator who was the facility's Abuse Coordinator. In addition, the Administrator failed to identify the potential sexual abuse and conduct a thorough investigation. These failures placed Resident 1 and other residents at risk for further abuse by Resident 3 due to a delay in developing and implementing interventions to keep Resident 1 safe as well as identify other potential victims of abuse. This permitted Resident 3 to perpetrate further incidents where he displayed inappropriate sexual behaviors towards Resident 1 including grabbing Resident 1's hand and placing it on his crotch and flickering his tongue (in a sexual manner) at Resident 1. * On 2/8/19, Resident 4 reported a licensed nurse was verbally abusive to her. The Administrator was immediately informed, however, failed to follow their abuse P&P in reporting, investigating the abuse allegation, and protecting the resident from the alleged abuser. Resident 4 was assigned to the same nurse the day after she reported the alleged verbal abuse. On 2/13/19 at 1545 hours, the Administrator and the DON were informed the Immediate Jeopardy was abated. Findings: Review of the facility's P&P titled Abuse Prevention Program revised 12/16 showed the residents have the right to be free from abuse including, but not limited to sexual abuse. As part of the resident abuse prevention, the administration will identify and assess all possible incidents of abuse and investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of the facility's P&P titled Abuse Investigation and Reporting revised 7/17 showed all reports of resident abuse shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility's management. Findings of abuse investigations will also be reported. The Administrator will ensure any further potential abuse is prevented. The individual conducting the investigation will, at a minimum, obtain the following in writing: - Interview the person(s) reporting the incident, - Interview any witnesses to the incident, - Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition, - Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, - Interview the resident's roommate, family members, visitors, and - Interview other residents. Review of the facility's P&P titled Abusive Investigation and Reporting Procedures (undated) showed all staff members and others are responsible for reporting any alleged or witnessed abuse (mental, physical, sexual, seclusion, verbal, or fiduciary). Do not assume that someone has reported the incident. 1. According to an anonymous report received on 1/16/19, Resident 1 was observed being sexually abused by a male resident at Resident 1's bedside with his hand down Resident 1's pants, with the privacy curtain pulled. The report showed the DON did not report this incident and did not notify Resident 1's responsible party of the incident. On 1/25/19 at 0813 hours, Resident 1 was observed in her room lying in bed. Resident 1 was asked if she felt safe living at the facility. Resident 1 stated she did not feel safe living at the facility but could not elaborate why. Resident 1 was asked if she was touched inappropriately. Resident 1 stated some man touched her down there and pointed to her groin area. Resident 1 stated she did not like it. When asked who had inappropriately touched her, Resident 1 stated the man who came into her room did. On 2/6/19 at 0855 hours, an interview was conducted with CNA 1. CNA 1 stated on 12/14/18, she found Resident 3 in Resident 1's room with the curtain drawn, sitting next to Resident 1's bed with his entire hand inside Resident 1's pants. CNA 1 stated she said what are you doing and Resident 3 removed his hand right away and left the room. CNA 1 stated she transferred Resident 1 to her wheelchair and left her by the nurses ' station and reported the incident to LVN 1. Medical record review for Resident 1 was initiated on 1/25/19. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's history and physical examination [REDACTED]. Review of Resident 1's MDSs dated 10/3/18 and 1/3/19, showed Resident 1's cognition was moderately impaired. On 1/25/19 at 0930 hours, an interview was conducted with CNA 2. CNA 2 stated the facility's Abuse Coordinator was the Administrator. CNA 2 stated about a week ago (approximately one month after the 12/14/18 incident), she witnessed Resident 3 in Resident 1's room. CNA 2 stated Resident 3 left Resident 1's room after being seen by her. CNA 2 stated she reported the incident to the RN Supervisor for that shift because male residents were not supposed to be in the female residents' rooms. On 1/25/19 at 1223 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 stated a CNA approached her and RN 2 to inform them the CNA had witnessed Resident 3 touching Resident 1 in a sexual manner on 12/14/18. RN 1 stated she did not report the incident to the DON or to the Administrator because she thought reporting to the physician was enough. When asked who the facility's Abuse Coordinator was, RN 1 stated she did not know. RN 1 was asked if the incident between Resident 3 and Resident 1 could be considered sexual abuse. RN 1 stated yes, in hindsight, because Resident 3 did not have the capacity to consent. On 1/25/19 at 1244 hours, a telephone interview was conducted with RN 2. RN 2 was asked about the Progress Notes entry dated 12/20/18. RN 2 stated she remembered a CNA reporting Resident 3 was observed touching Resident 1 in a sexual manner. RN 2 stated she did not ask the CNA for more details regarding the incident and she did not interview the residents involved. When asked why she did not ask the CNA for further details, RN 2 stated she did not remember. When asked why she did not interview Residents 1 and 3, RN 2 stated she did not remember. RN 2 stated the incident was only reported to the physician. On 1/25/19 at 1412 hours, an interview and concurrent facility document and medical record review was conducted with the Administrator. The Administrator stated she was not aware of the incident that occurred on 12/14/18, where Resident 3 was found with his hand down Resident 1's pants until six days later, on 12/20/18, when she was notified by the Case Manager. The Administrator stated CNA 1, LVN 1, and the DON did not immediately notify her of the incident. The Administrator stated she was the Abuse Coordinator and needed to know about the incidents so she could keep the residents safe by putting measures into place. The Administrator was asked to provide any documentation for the investigation related to the incident between Residents 1 and 3 on 12/14/18. The Administrator provided a one-sided document titled Administrator Progress Notes dated 12/20/19 (sic). The document showed the Administrator was notified of Resident 1 and Resident 3 engaging in a developing relationship where Resident 1 and Resident 3 have been found holding hands several times including in activities and the staff had concerns due to Resident 1 being married. The document showed the IDT discussed the residents' right to have private relationships with anyone of their choice and both residents were alert and oriented and able to express their wants and needs. The Administrator was asked why an abuse investigation was not conducted. The Administrator stated Resident 1 and Resident 3 had the right to be in a relationship, therefore she did not constitute it as abuse. The Administrator was asked if Resident 1 had the capacity to consent. The Administrator stated Resident 1 had the capacity to consent based on the nurses' documentation showing Resident 1 was alert and oriented. When asked what Resident 1 was alert and oriented to, the Administrator stated she did not know. The Administrator reviewed Resident 1's history and physical examination [REDACTED]. The Administrator stated Resident 3 agreed to boundaries via a written contract dated 12/24/1/8, which prohibited Resident 3 from entering female residents' rooms and keeping an arm's length distance from female residents while in group. The Administrator was asked why she had boundaries in place if she believed the relationship between Resident 1 and Resident 3 was consensual. The Administrator replied because Resident 1 and Resident 3 each had spouses. The Administrator was asked if Resident 1 and Resident 3 were assessed to have the capacity to consent to a relationship. The Administrator replied no. The Administrator verified her investigation did not include documentation to show interviews with any witnesses to the incident (CNA 1 and LVN 1), interview with the resident's attending physician to determine the resident's current level of cognitive function and medical condition, interviews with other staff members on all shifts who have had contact with these residents, interviews with Resident 1's roommate, or other residents to identify other potential victims of Resident 3. When asked why these interviews were not conducted, the Administrator replied because she did not constitute it as abuse because the residents have a right to be in a relationship. The Administrator was asked what sexual abuse was. The Administrator stated any non-consensual inappropriate touching would constitute as sexual abuse. On 1/25/19 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated she was notified of the incident between Resident 1 and Resident 3 on 12/14/18, when CNA 1 discovered Resident 3 in Resident 1's room and Resident 3 had his hand under the covers and below Resident 1's waist level. The DON stated Resident 1 did not have the capacity to consent and she is definitely impaired. The DON stated prior to the incident on 12/14/18, Resident 1 and Resident 3's relationship started out as innocent hand holding and progressively escalated to inappropriate behavior. The DON stated both Resident 1 and Resident 3 had spouses and children. The DON was asked if Resident 1 was interviewed after the incident on 12/14/18 (a Friday). The DON stated no, no one spoke to Resident 1 after the incident because it was not appropriate to do so because Resident 1 did not have capacity. The DON was asked if she reported the incident to the Administrator. The DON stated no, but stated the Administrator knew about the incident because everyone knew about it and the incident was discussed during the next daily standup meeting (the following Monday) and the Administrator and the other department heads were present. The DON was asked if Resident 1 and Resident 3 were assessed to have the capacity to consent to be in a relationship or to engage in sexual activity. The DON replied no and stated Resident 1 did not have the capacity to consent or the capacity to make decisions. The DON was asked if she considered this incident to be sexual abuse. The DON stated no, because Resident 3's hand was just under the covers. The DON was asked why sexual abuse was not suspected since Resident 1 did not have the capacity to consent and she was inappropriately touched by Resident 3. The DON stated Resident 3 considered the relationship with Resident 1 to be consensual. The DON stated she was not aware of the documented incident on 12/20/18, where Resident 3 was noted touching a female resident sexually. On 1/25/19 at 1553 hours, an interview was conducted with Resident 1's attending physician, Physician 1. Physician 1 stated the facility did not report any incidents of Resident 1 being inappropriately touched by another resident. On 1/28/19 at 0846 hours, a telephone interview was conducted with the Ombudsman. The Ombudsman stated she was familiar with Resident 1 and Resident 3. The Ombudsman stated she noticed Resident 1 and Resident 3 were really touchy with each other. The Ombudsman stated she did not believe Resident 1 had the capacity to consent because Resident 1 was like an infant. The Ombudsman stated no report(s) of sexual abuse allegations were reported to her in (MONTH) (YEAR). On 1/28/19 at 1148 hours, a telephone interview was conducted with CNA 1. CNA 1 stated, while making rounds on 12/14/18, she observed Resident 3 in Resident 1's room behind the closed privacy curtain touching Resident 1. When asked where Resident 3 was touching Resident 1, CNA 1 stated Resident 3 was touching Resident 1 in the private area with his hand inside Resident 1's pants. CNA 1 stated Resident 3 got scared and left Resident's 1's room when CNA 1 found him. CNA 1 stated she immediately reported the incident to LVN 1. CNA 1 stated she did not report the incident to the Administrator or anyone else because she reported the incident to LVN 1. On 1/28/19 at 1205 hours, a telephone interview was conducted with LVN 1. LVN 1 stated she was informed by CNA 1 Resident 1 was in bed and Resident 3 was in his wheelchair in Resident 1's room behind the privacy curtain and Resident 3 had his hand down Resident 1's pants. LVN 1 stated Resident 1 had confusion and could not make her own decisions. LVN 1 stated she did not report the incident to the Administrator. On 2/6/19 at 0855 hours, a follow-up interview was conducted with CNA 1. CNA 1 stated, after witnessing the incident between Resident 1 by Resident 3, she immediately reported the incident to the nurse supervisor because she thought this was sexual abuse. CNA 1 stated as of today, the Administrator nor the DON asked her about the incident she had witnessed on 12/14/18. On 2/26/19 at 1000 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated he was Resident 1's designated decision maker. Family Member 2 stated the facility's DON called him three weeks or maybe a month ago regading an incident where a male resident was found in Resident 1's room. Family Member 2 stated there were no other details given to Family Member 2 except the two residents had been seen holding hands and their legs were touching when seated next to one another in their perspective wheelchairs. Family Member 2 stated he made sure the facility understood these behaviors were no okay with him. The facility assured Family Member 2 they would take care of the situation. On 2/7/19 an S[NAME]-341 (a form used to report elderly/adult dependent abuse) dated 2/7/19, filled out by the Administrator, showed a report of the following resident to resident allegation of sexual abuse dated: *12/14/18, Resident 3 was observed in Resident 1's room with the privacy curtain pulled, and Resident 3's hand was under resident 1's sheets; *12/14/18, Resident 3 made inappropriate gestures with his hands and tongue towards Resident 1; *12/20/18, Resident 3 made inappropriate comments and held Resident 1's hands while in activities; *12/20/18, Resident 3 allegedly placed Resident 1's hand in his crotch area. On 2/11/19 at 1239 hours, CDPH L&C received a five-day follow up letter from the Administrator regarding the abuse investigations. The Administrator SUBSTANTIATED sexual abuse occurred with the two incidents on 12/14/18. Cross references to F600 and F609. 2. On 2/8/19 at 1252 hours, an interview was conducted with Resident 4. Resident 4 stated there was a nurse during the 2300 to 0700 hours shift who got verbally abusive to her. Resident 4 stated she did not like the way the nurse talked to her, and the nurse made her feel it was her fault to be dependent on staff for all care. On 2/8/19 at 1350 hours, the allegation of verbal abuse made by Resident 4 was reported to the Administrator who was also the facility's Abuse Coordinator. The Administrator stated she would investigate. Medical record review for Resident 4 was initiated on 2/12/19. Resident 4 was admitted to the facility on [DATE]. Review of the history and physical examination [REDACTED]. On 2/12/19 at 1207 hours, an interview was conducted with Resident 4. Resident 4 stated the verbal abuse she felt from the nurse (LVN 9) had .progressed way beyond. When asked why, Resident 4 stated, after reporting the verbal abuse last Friday (2/8/19), LVN 9 was assigned to take care of her on Saturday on the 2300 to 0700 hours shift. Resident 4 stated at around 0130 hours, she informed LVN 9 her indwelling urinary drainage catheter was not draining and needed to be irrigated. Resident 4 stated she had to wait for approximately two hours and ended up calling 911 to get assistance because LVN 9 did not come return to irrigate her catheter. Resident 4 stated whenever she had LVN 9 as her nurse, she was full of dread and was worried about her health and safety. Review of the Emergency Department report dated 2/10/19 at 0444 hours, showed Resident 4 had [MEDICAL CONDITION], the indwelling urinary catheter was not draining and was replaced. Resident 4 was also found to have a urinary tract infection. On 2/12/19 at 1239 hours, an interview was conducted with the Administrator. The Administrator stated the verbal abuse allegation reported to her on 2/8/19, was not investigated and reported according to the facility's abuse P&P because the Administrator did not think it was verbal abuse. The Administrator was asked how she came to the conclusion the allegation was not verbal abuse since she did not investigate the allegation. The Administrator stated she determined it was not verbal abuse after talking to Resident 4. The Administrator stated Resident 4 told her .the charge nurse was kind of rude every time she asked for help, and Resident 4 felt the nurse always reminded her of her situation. The Administrator stated she instructed the DON not to assign LVN 9 to take care of Resident 4. The Administrator stated she felt, after talking to Resident 4, there was no verbal abuse. Review of the Staff Interview Form dated 2/8/19, showed the SSD conducted an interview with Resident 4 regarding her concern with one of the nurses taking care of her. Resident 4 named LVN 9 as the nurse she was referring to during the 2300 to 0700 hours shift on 2/7/19. The interview showed Resident 4 was repositioned by her CNA around 0330 to 0400 hours; however, the CNA forgot to apply her ankle boots. Resident 4 pushed her call light and LVN 9 answered through the intercom. Resident 4 told LVN 9 she needed her CNA back to apply the ankle boots. LVN 9 responded .she was already there for a long time, more than 15 minutes. Why are you taking so long? There are residents out here who are waiting 10 minutes because of you. Resident 4 further stated .she kept saying I was making it harder for other residents. I felt like I was being chastised. Review of the staff assignment dated 2/9/19, showed LVN 9 was assigned to take care of Resident 4 during the 2300 to 0700 hours shift.