Every finding on record at North Pointe Care Center

Based on observation, interview and record review, the facility failed to protect one of three residents sampled for abuse investigation (Resident 2) from physical abuse, when Resident 1 pushed Resident 2 and Resident 2 landed on the floor face down, sustaining a fracture to her right upper arm (humerus) and a right hip (femoral) fracture. This failure resulted in Resident 2 experiencing physical pain and had a significant decline in functional status from being totally independent, to requiring maximum assist (where staff provide most of the activities for the resident) for mobility and with daily activities.A review of the admission Record printed on 7/24/26 indicated the facility admitted Resident 1 on 6/11/26 with multiple diagnoses which included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills), dementia (a progressive state of decline in mental abilities), bipolar disorder (a mental health condition characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety (intense worry, fear, nervousness or unease about everyday situations). A review of Resident 1's hospital referral documents dated 5/6/26 indicated Resident 1 had history of aggressive outbursts and exhibited increased aggression towards other residents prior to being admitted to the facility. A review of the physician order dated 6/11/26 directed nursing staff to monitor Resident 1 for episodes of behavioral and psychological symptoms, including physical aggression, striking out and hitting. A review of Resident 1's Minimum Data Set (MDS- a federally required assessment) dated 6/17/26 indicated that Resident 1 had severe cognitive impairment (person's brain not working as well as it used to, making it harder to think, learn, and make decisions). The MDS indicated Resident 1 had frequent verbal and physical behaviors directed toward others. The MDS further indicated Resident 1's behavioral symptoms put others at significant risk for physical injury.significantly intrude on the privacy or activity of others. significantly disrupt care or living environment for others. A review of Resident 1's comprehensive care plan addressing antipsychotic drugs (medications that affect brain activities associated with mental processes and behaviors) dated 6/12/26 indicated Resident 1 required antipsychotic medication for his behavioral and psychological (related to the mind) symptoms manifested by physical aggression, striking, and hitting. The care plan approaches included; Administer antipsychotic medication as ordered.attempt non-pharmacological approaches [identify and treat possible causes of distress, including hunger, thirst, fatigue] prior to medication administration.assess the presence of pain/discomfort.offer warm beverages.encourage to verbalize feelings.observe resident's mood.observe the effectiveness of drug treatment.Social Services visits as indicated. The care plan did not include individualized interventions to manage Resident 1's aggressive behaviors. The care plan did not specify the level of monitoring and supervision needed to protect other residents from Resident 1's aggressive behaviors and did not provide nursing staff with instructions regarding the type and frequency of supervision necessary to reduce the risk of Resident 1 hitting and striking others. A review of the nursing progress notes (NPN) dated 6/13/26 at 11:23 a.m., indicated that Resident 1 had escalation in combative behaviors. The NPN indicated that Resident 1 was verbally abusive using curse words, and racially inappropriate comments towards staff, attempted to hit them and raised concerns for the safety of Resident 1 and others. A review of NPN dated 6/17/26 at 1:57 a.m., indicated that Resident 1 displayed very aggressive behavior, entered neighboring room and attempted to take the blankets from another resident who was in bed resting quietly. A review of NPNs dated 6/25/26 at 00:16 a.m. [12:06 a.m.], and at 4:03 a.m., indicated that Resident 1 urinated on the floor next to the other resident's bed in another room and then attempted to take blanket off the bed, disrupting another resident's sleep and visibly upsetting other resident. A review of the Interdisciplinary Team notes (IDT, a meeting of different disciplines meeting and discussing resident's care issues) dated 7/1/26 at 11:04 a.m., indicated, IDT met to discuss peer to peer incident. Resident [sic] incident occurrence time/date: 06/30/2026@12:45 [p.m.]. The IDT note indicated that Resident 1 suddenly pushed a female resident (Resident 2), who was ambulating [walking] in the hallway. A review of the admission Record printed on 7/24/26 indicated the facility admitted Resident 2 earlier this year with multiple diagnoses which included dementia and muscle weakness. A review of Resident 2's quarterly MDS dated [DATE] indicated that Resident 2 had severe cognitive impairment. The MDS indicated that Resident 2 did not have any verbal or physical behaviors directed toward others. A review of Resident 2's care plan titled, Cognitive Impairment dated 3/31/26 directed nursing staff to anticipate her needs and meet promptly. A review of a NPN dated 6/30/26 at 2:34 p.m., indicated, Resident [2] was walking in hallway when suddenly resident [Resident 2] was pushed by peer [Resident 1]. Resident [2] has pain to R [right] shoulder. A review of SBAR note (an acronym for Situation- Background- Assessment-Recommendation; a tool used to provide a framework for communication between members of the healthcare team) dated 6/30/26 at 2:37 p.m., indicated that Resident 2 had a change in condition (COC). The SBAR note indicated, Resident [2] was walking in hallway.when suddenly a peer [Resident 1] pushed [Resident 2's name] on her left shoulder causing her to land on R [right] shoulder. Resident [2] appears to have limited ROM [reduced mobility; unable to move] to R [right] shoulder. The SBAR note indicated Resident 2's physician ordered an X-ray [radiologic study] for Resident 2's right upper and lower extremities (limbs). A review of NPN dated 6/30/26 at 9:31 p.m., indicated that Resident 2 complained of worsening of the pain in right shoulder. The NPN indicated that Resident 2 had swelling in her right shoulder and complained of pain when she attempted to move her right shoulder. The NPN indicated Resident 2's right hand and arm were warm to touch. The NPN indicated that the X-ray result showed right humerus fracture and the resident's physician recommended sending the resident to the hospital for further evaluation. A review of NPN dated 7/4/26 at 10:39 p.m., indicated that Resident 2 was status post (after) hospitalization due to her injury. The NPN indicated, Purple discoloration and swelling still noted to her right hand extending towards her right shoulder. Pain is noted when touching the affected side. The NPN indicated that Resident 2 was complaining of right shoulder pain 8 out of 10 (scale from zero to 10, where zero- is no pain and 10 is the worst imaginable pain). The NPN indicated that after Resident 2 received pain medication, it provided only partial relief and the resident continued experiencing pain. A review of the NPN dated 7/7/26 at 9:49 p.m., indicated Resident 2 continued having pain in her right shoulder upon touching and was unable to straighten her right upper arm. The NPN indicated that Resident 2 experienced pain in her right hip when it was touched. The NPN further indicated that Resident 2 was unable to ambulate and required the assistance of two staff members to transfer to the toilet using a wheelchair. A review of the NPN dated 7/8/26 at 9:50 a.m., indicated that Resident 2 continued to complain of pain 8 out of 10 in her right hip and knee and the pain medication was not effective. NPN indicated that Resident 2 was sent to the hospital to be evaluated for delayed injuries after the fall on 6/30/26 per physician recommendations. A review of Resident 2's nursing progress notes from 7/8/26 through 7/10/26 indicated that Resident 2 was hospitalized and returned back to facility on 7/10/26 with a diagnosis of right femoral (thigh bone) fracture. A review of Resident 2's NPN dated 7/11/26 at 1:50 p.m., indicated that Resident 2 complained of severe pain in the right hip with movement. NPN indicated that Resident 2 was noted to have yellowish discoloration on the right shoulder and RT [right] arm and slightly swollen right hip/knee. During an observation on 7/24/26 at 1:35 p.m., Resident 1 was observed standing near the window in his room with his eyes half closed. When Resident 1 attempted to ambulate, he appeared drowsy. Resident 1 was mumbling and was not understood and did not reply when greeted. A Certified Nursing Assistant (CNA 1) entered Resident 1's room and informed the surveyor that Resident 1 can become aggressive and combative. During an interview on 7/24/26 at 1:40 p.m., CNA 1 stated that Resident 1 was verbally and physically aggressive, would throw punches directing them at a specific area, and had ripped the CNA 1's name badge off earlier that day. When CNA 1 was asked whether Resident 1 got along with his roommates, CNA 1 responded, I don't think so - he's so explosive, every little thing or word will set him off. CNA 1 explained that on 6/30/26 she was walking in the hallway with lunch tray and noted Resident 1 walking toward Resident 2. CNA 1 stated she did not witness the incident, but I heard loud punch sound. and the next thing I see [Resident 2's name] on the floor face down. I hear her screaming very loud ouch and saw staff running toward her. During an interview on 7/24/26 at 1:48 p.m., CNA 2 stated that Resident 1 demonstrated aggressive behaviors from the first day of admission and that Resident 1's behaviors had not improved. CNA 2 added, He gets agitated and combative with ADL's [activities of daily living, including personal hygiene, feeding, toileting] all the time. CNA 2 stated that Resident 1 was ambulatory and walked in his room and hallway frequently. When CNA 2 was asked if Resident 1 showed aggression toward other residents, CNA 2 stated, He's always verbally aggressive, gets agitated every time. you can never predict his behaviors. CNA 2 stated she was assigned to Resident 1 on 6/30/26. CNA 2 explained that during lunch, she was assigned to assist other residents with feeding in the dining room on 6/30/26. CNA 2 stated Resident 1 was sleeping in his bed when she left to the dining room on 6/30/26. CNA 2 added, When I am assigned to the dining room, other CNAs cover my residents on the floor and monitor them. CNA 2 stated when returned back to the floor around 1:30 p.m., she noted that Resident 2 was bruised up pretty bad on her inner arm and was holding onto her right shoulder. During an interview on 7/24/26 at 2:03 p.m., CNA 3 stated she was working on the floor on 6/30/26. CNA 3 stated, I came out of resident's room and saw [Resident 1's name] suddenly move quickly.and then I heard [Resident 2's] frightened voice and screams. During an observation and interview on 7/24/26 at 2:08 p.m., Resident 2 was observed sitting in the wheelchair next to her bed. Resident 2 had purple and yellowish bruising on her inner aspect of right arm, extending from the wrist to the upper arm. Resident 2 was pleasant and smiling on observation and was able to verbalize her first and last name in a soft voice. When asked regarding the incident, Resident 2 explained the following, I was walking in the hall, and it was crowded and this.man suddenly pushed me. He hit me in here, [Resident 2] pointed to the chest area. Resident 2 stopped for a moment and continued, Unfortunately I lost my balance and flew into the open door, face down. With her left hand, Resident 2 pointed to her right arm and shoulder and stated, It hurt really bad and still hurts when I have to move my arm. I can't lift my arm without pain. And my side, [Resident 2] pointed to right hip is very painful too. I can't walk like I used to walk. Resident 2 added, I saw a doctor a few days ago and he told me arm is damaged and there is not a whole a lot they can do about it, I have to live with this. During an observation on 7/24/26 at 2:10 p.m., observed CNA 3 and CNA 4 entering Resident 2's room and transferring the Resident 2 from the wheelchair to the bed. During the transfer, Resident 2 moaned, indicating pain or discomfort. Resident 2 was unable to bear weight on her right foot and unable to stand. During an interview on 7/24/26 at 2:12 p.m., CNA 3 described Resident 2 as the sweetest resident here, always happy. CNA 3 stated Resident 2 had some confusion, occasionally was able to verbalize her needs, and did not have any aggression or other behaviors. CNA 3 stated that prior to Resident 2's fall, the resident was ambulatory and would independently walk out of her room and ambulate in the hallway to the dining room. CNA 3 explained that after the fall, Resident 2 remained in bed or in wheelchair and required extensive assistance of two-staff with transfers. CNA 3 stated Resident 2 was independent with eating before the incident and currently required assistance with eating. CNA 3 added that following the incident on 6/30/26, Resident 2 required pain medications before staff would assist her with ADLs. CNA 3 stated that several days after the incident, Resident 2 would cry out when staff assisted her into wheelchair. CNA 3 stated that several days after Resident 2's fall, staff had observed that Resident 2's right knee was swollen, and Resident 2 was unable to stand or bear weight on her right foot. CNA 3 stated that Resident 2 was sent to the hospital, where she was diagnosed with a hip fracture in addition to another injury. During an interview on 7/24/26 at 2:20 p.m., CNA 4 stated Resident 2 was pretty alert (attentive and aware of surroundings) and followed commands. CNA 4 stated, She was completely independent, walking around and now she is dependent on staff. CNA 4 further stated that Resident 2 was fearful that her hip would hurt when staff offered to get her out of bed and that Resident 2 sometimes cried out in pain during transfers. During an interview on 7/24/26 at 2:28 p.m., Licensed Nurse (LN 1) described Resident 2 as quiet, no behaviors, never had any [behaviors], never bothered other residents. LN 1 stated that Resident 2 experienced a recent fall as a result of being pushed by Resident 1. During a telephone interview on 7/30/26 at 2:50 p.m., LN 3 stated he was assigned to Resident 1 on 6/30/26 when the incident in which Resident 1 pushed Resident 2 occurred. LN 3 stated that Resident 1 started showing physical aggression upon admission. LN 3 stated he was at the nursing station when he heard Resident 2's scream at the time of the fall but did not witness the incident. LN 3 stated that Resident 2 reported to him that she was pushed by Resident 1 and fell. LN 3 stated that Resident 2 was able to communicate her needs and provide details of what happened. During a joint interview and record review on 7/24/26 at 2:45 p.m., with Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON acknowledged that Resident 1 was admitted with a history of aggression toward other residents while he lived at his prior facility. The DON stated that Resident 1 had not exhibited physical behaviors toward other residents at the facility, however, the resident had demonstrated frequent verbal and physical aggression toward staff. The DON acknowledged that the facility was aware that Resident 1 had been found in other residents' rooms and attempted to take other residents' blanket. The DON stated that Resident 1 exhibited unpredictable behaviors and unprovoked outbursts and acknowledged that Resident 1's aggression toward staff indicated the potential for aggression toward residents. The DON stated that it was an expectation that the assigned nurse and the other CNAs on the unit were responsible for supervising Resident 1 to ensure the safety of the resident and other residents while his assigned CNA was assisting residents in the dining room during lunch on 6/30/26. During a continued interview on 7/24/26 at 2:45 p.m., the DON stated that it was unclear whether Resident 1 pushed Resident 2 or accidentally bumped into her, as the incident was unwitnessed. The DON added, What we were told, the staff heard the sound and the next thing she [Resident 2] was on the floor. Upon assessment, she was complaining of right-side flank area [side of the body between ribs and hip] and shoulder pain, she was guarding that area with her other arm and would not allow [staff] to move her. The DON stated that Resident 2 was very confused and was unable to describe what happened. The Department discussed with DON and ADON that during an interview earlier with Resident 2, on 7/24/26 at 2:08 p.m., Resident 2 was able to recall that she fell face down and landed on the floor in the doorway of the room after a man [Resident 1] pushed her while the door was open. The DON was informed that Resident 2 recalled being seen by a doctor recently and stated she was told there was not much that could be done for her broken arm. The DON validated that Resident 2 indeed was found face down in doorway and yes, the resident had been seen by ortho [medical specialty in broken bones surgery] doctor very recently. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, with the revision date of 8/2006, indicated, Our residents have the right to be free from abuse.Our facility is committed to protecting our residents from abuse by anyone, including, but not necessarily limited to.other residents. During a follow-up telephone interview on 7/30/26 at 2:03 p.m., with ADON, ADON reviewed Resident 1's MDS section and confirmed that the MDS had documented evidence of Resident 1's history of verbal and physical aggression. The ADON validated that per MDS, Resident 1 exhibited striking and hitting behaviors that disrupted environment for other residents and placed other residents at risk for injuries. The ADON was asked how the facility ensured the safety of other residents and protected them from verbal and/or physical abuse by Resident 1. ADON explained that upon admission, each resident was observed by CNA for any behavioral concerns, and the observed behaviors were documented and reported to the IDT. Based on those observations and report, the IDT developed individualized care plan with appropriate interventions to address resident's specific behaviors, and the care plan was to be implemented. During a continued telephone interview on 7/30/26 at 2:03 p.m., ADON stated that the purpose or goal of the care plan was to provide direction regarding the type of care or supervision the resident needed. ADON reviewed Resident 1's care plan addressing antipsychotic medication and confirmed that the care plan did not include individualized interventions to manage Resident 1's aggressive behavior other than observation. The ADON acknowledged that the care plan primarily focused on the resident, rather than addressing his aggressive behaviors of striking and hitting. The ADON agreed that the care plan did not provide guidance to the nursing staff regarding the level of supervision needed to ensure the safety of other residents. ADON stated that the care plan should have included individualized interventions to prevent Resident 1's aggressive behaviors and ensure safety of other residents. ADON reviewed Resident 1's care plans and was not able to identify the care plan addressing Resident 1's aggressive behaviors. ADON stated that on 7/1/26, a day after the incident with Resident 2, the facility developed and implemented a care plan addressing Resident 1's behavioral symptoms and individualized supervision approaches. A review of the facility's P&P titled Dementia, with a revision date of 3/2015 indicated, For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life.The IDT will identify and document the resident's condition and level of support needed.

Based on observation, interview and record review, the facility failed to develop and implement an individualized care plan for one of three sampled residents (Resident 1), when interventions to mitigate Resident 1's aggressive behaviors of hitting and striking at other residents were not put in place. This failure potentially contributed to Resident 1 pushing Resident 2, and as a result Resident 2 sustained fractures to upper arm and hip in addition to physical pain. This failure also placed other vulnerable residents residing in the facility at risk for physical harm.A review of the admission Record printed on 7/24/26 indicated the facility admitted Resident 1 on 6/11/26 with multiple diagnoses which included Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory and thinking skills), dementia (a progressive state of decline in mental abilities), bipolar disorder (a mental health condition characterized by mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety (intense worry, fear, nervousness or unease about everyday situations).A review of Resident 1's hospital referral documents dated 5/6/26 indicated Resident 1 had history of aggressive outbursts and exhibited increased aggression towards other residents prior to being admitted to the facility. A review of the physician order dated 6/11/26 directed nursing staff to monitor Resident 1 for episodes of behavioral and psychological (related to thinking, feeling or behavior) symptoms, including physical aggression, striking out and hitting.A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 6/17/26 indicated that Resident 1 had severe cognitive impairment (person's brain not working as well as it used to, making it harder to think, learn, and make decisions). The MDS indicated Resident 1 had frequent verbal and physical behaviors directed toward others. The MDS indicated that Resident 1's behavioral symptoms put others at significant risk for physical injury, intruded on the privacy or activity of others, and significantly disrupt[ed] care or living environment for others.A review of Resident 1's comprehensive care plan addressing the use of antipsychotic drugs (medications that affect brain activities associated with mental processes and behaviors) dated 6/12/26 indicated Resident 1 required antipsychotic medication for his behavioral and psychological symptoms manifested by physical aggression, striking, and hitting. The care plan approaches included; Administer antipsychotic medication as ordered.attempt non-pharmacological approaches [identify and treat possible causes of distress, including hunger, thirst, fatigue] prior to medication administration.assess the presence of pain/discomfort.offer warm beverages.encourage to verbalize feelings.observe resident's mood.observe the effectiveness of drug treatment.Social Services visits as indicated. The care plan did not include individualized interventions to manage Resident 1's aggressive behaviors. The care plan did not specify the level of monitoring and supervision needed to protect other residents from Resident 1's aggressive behaviors. The care plan did not provide directions to the nursing staff regarding the level, type and frequency of supervision necessary to reduce the risk of Resident 1 hitting and striking other residents.A review of Resident 1's nursing progress notes (NPN) dated 6/13/26 through 6/30/26 indicated that Resident 1 exhibited escalating and combative behaviors and demonstrated intrusive behaviors that interfered with other residents' safety and privacy. A review of the Interdisciplinary Team notes (IDT, a meeting of different disciplines meeting and discussing resident's care issues) dated 7/1/26 at 11:04 a.m., indicated, IDT met to discuss peer to peer incident. Resident [sic] incident occurrence time/date: 06/30/2026@12:45 [p.m.]. The IDT note indicated that Resident 1 suddenly pushed a female resident (Resident 2), who was walking in the hallway. The IDT notes indicated further, During the investigation, the peer resident [Resident 2] stated that this resident [Resident 1] allegedly pushed him [sic]. A review of the admission record indicated the facility admitted Resident 2 earlier this year with multiple diagnoses which included dementia and muscle weakness.A review of Resident 2's MDS dated [DATE] indicated that Resident 2 had severe cognitive impairment. The MDS indicated that Resident 2 did not have any verbal or physical behaviors directed toward others.A review of a NPN written by Licensed Nurse (LN) 3 dated 6/30/26 at 2:34 p.m., indicated, Resident [2] was walking in hallway when suddenly resident [Resident 2] was pushed by peer [Resident 1]. Resident [2] has pain to R [right] shoulder. A review of SBAR note (an acronym for Situation- Background- Assessment-Recommendation; a tool used to provide a framework for communication between members of the healthcare team) dated 6/30/26 at 2:37 p.m., indicated that Resident 2 had a change in condition (COC). The SBAR note indicated, Resident [2] was walking in hallway.when suddenly a peer [Resident 1] pushed [Resident 2's name] on her left shoulder causing her to land on R [right] shoulder. Resident [2] appears to have limited ROM [range of motion- reduced movement] to R [right] shoulder. The SBAR note indicated Resident 2's physician ordered an X-ray [radiologic study] for Resident 2's right arm and right extremities (limbs).A review of NPN dated 6/30/26 at 9:31 p.m., indicated that Resident 2 complained of worsening of the pain in right shoulder, Resident 2's right hand and arm were swollen and warm to touch. The NPN indicated that the X-ray result showed right humerus fracture and per Resident 2's physician recommendation, Resident 2 was sent to the hospital for further evaluation.A review of nursing progress notes dated 7/3/26 through 7/8/26 indicated that Resident 2 continued having pain severe pain in right shoulder and was unable to straighten right upper arm. The NPN indicated that Resident 2 experienced pain in right hip, was unable to ambulate, and required the assistance of two staff members to transfer to the toilet using a wheelchair.A review of Resident 2's nursing progress notes dated 7/8/26 through 7/10/26 indicated that Resident 2 was hospitalized and returned back to facility on 7/10/26 with a diagnosis of right femoral (thigh bone) fracture in addition to fractured upper arm on 6/30/26.During a joint interview and record review on 7/24/26 at 2:45 p.m., with Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON acknowledged that Resident 1 was admitted with a history of aggression toward other residents while he lived at his prior facility. The DON stated that Resident 1 had not exhibited physical behaviors toward other residents at the facility, however, Resident 1 had demonstrated frequent verbal and physical aggression toward staff. The DON acknowledged that the facility was aware that Resident 1 had been found in other residents' rooms and attempted to take other residents' blankets. The DON stated that Resident 1 exhibited unpredictable behaviors and unprovoked outbursts and acknowledged that Resident 1's aggression toward staff indicated the potential for aggression toward other residents. The DON stated the care plan interventions to manage Resident 1's aggressive behaviors was frequent observation. The DON was unable to identify additional individualized care plan interventions to prevent or minimize Resident 1's known unpredictable behaviors and unprovoked outbursts.During a follow-up telephone interview on 7/30/26 at 2:03 p.m., with ADON, ADON reviewed Resident 1's MDS section and confirmed that the MDS had documented evidence of Resident 1's history of verbal and physical aggression. The ADON validated that per MDS, Resident 1 exhibited striking and hitting behaviors that disrupted environment for other residents and placed other residents at risk for injuries. The ADON was asked how the facility ensured the safety of other residents. ADON explained that upon admission, each resident was observed by CNA for any behavioral concerns, and the observed behaviors were documented and reported to the IDT. Based on those observations and report, an IDT developed individualized care plan with appropriate interventions to address resident's specific behaviors, and the care plan was to be implemented. During a continued telephone interview on 7/30/26 at 2:03 p.m., ADON stated that the purpose or goal of the care plan was to provide direction regarding the type of care or supervision the resident needed. ADON reviewed Resident 1's care plan addressing antipsychotic medication and confirmed that the care plan did not include individualized interventions to manage Resident 1's aggressive behavior other than observation. The ADON acknowledged that the care plan primarily focused on the resident, rather than addressing his aggressive behaviors of striking and hitting. The ADON confirmed that Resident 1's care plan did not provide guidance to the nursing staff regarding the level of supervision needed to ensure the safety of other residents. ADON stated that the care plan should have included individualized interventions to prevent Resident 1's aggressive behaviors and ensure safety of other residents. ADON reviewed Resident 1's clinical records, including other care plans and was not able to identify the care plan with individualized interventions addressing Resident 1's aggressive behaviors. ADON stated that on 7/1/26, a day after the incident with Resident 2, the facility developed and implemented a care plan addressing Resident 1's behavioral symptoms and individualized, person-centered supervision approaches.A review of the facility's policy and procedures (P&P) titled Dementia, with a revision date of 3/2015 indicated, For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life.The IDT will identify and document the resident's condition and level of support needed.

Based on interview and record review, the facility failed to follow the Physician Orders for Life-Sustaining Treatment (POLST, a medical order that tells healthcare providers what treatments a person does or does not want) for one of four sampled residents (Resident 1) when Cardiopulmonary Resuscitation (CPR- an emergency procedure that involves chest compressions and rescue breathing to a person whose heart has stopped beating) was initiated on Resident 1 despite Resident 1's documented orders to not perform CPR.This failure violated Resident 1's right to have their treatment choices respected and implemented.Findings:Resident 1 was admitted to the facility in early 2025 with diagnoses that included a brain tumor, heart failure, kidney failure with dependence on a machine to remove waste from the blood, and dementia.During a review of Resident 1's POLST form dated [DATE], the POLST indicated, Cardiopulmonary Resuscitation [CPR]: If patient has no pulse and is not breathing. Do Not Attempt Resuscitation/DNR [Allow Natural Death].During a review of Resident 1's Order Summary Report [OSR], order date [DATE], the OSR indicated, DNR.During a review of Resident 1's Progress Note (PN), dated [DATE] at 11:50 a.m., written by Licensed Nurse (LN 1), the PN indicated, Approx [Approximately] 1128 hrs [11:28 a.m.] CNA [Certified Nursing Assistant] was pushing [Resident 1] w/c [wheelchair] to go smoke, he noticed resident was twitching.LN assessed lips blue ,(sic)not breathing , Heimlich maneuver performed because she thought resident was choking but ineffective noted resident still no pulse so staffs (sic) lower [Resident 1] to the floor and started initial CPR , called code blue and (sic) finished only one cycle [of CPR] when confirmed that res code was DNR selective .Compression was stopped, @1138 .During a phone interview on [DATE] at 12:38 p.m. with LN 1, LN 1 stated that while she was the author of the PN, a different nurse performed the actual CPR. LN 1 stated that when the nurse found out Resident 1 had a DNR, she stopped CPR. LN 1 stated she did not remember the name of the other nurse.During a concurrent interview and record review on [DATE] at 12:48 p.m. with the Assistant Director of Nursing (ADON), the ADON confirmed Resident 1 had a POLST that indicated she had elected DNR status. The ADON stated the purpose of the POLST was to communicate a resident's choices for life-sustaining treatment. The ADON confirmed the PN indicated Resident 1 was given one cycle of CPR, which went against the physician orders and the resident's wishes. The ADON stated that according to the PN, staff started initial CPR on Resident, then stopped compressions after reviewing the POLST form. The ADON stated she expected staff to follow the POLST as it was Resident 1's written choice.During a review of the facility policy and procedures (P&P) titled, Advance Directives, dated 9/25, the P&P indicated, The resident has the right to formulate and advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.The facility defines the following in accordance with current OBRA definitions and guidelines.Do Not Resuscitate [DNR]- indicates that, in the case of respiratory or cardiac failure, the resident, legal guardian.has directed that no cardiopulmonary resuscitation [CPR] or other life sustaining treatments or methods are to be used.Physician Orders for Life Sustaining Treatment [or POLST] .a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency.The resident has the right to refuse medical or surgical treatment.A resident will not be treated against his or her own wishes.

Based on interview, and record review the facility failed to ensure the facility was free from abuse for one of six sample residents (Resident 1) when Resident 1 was pushed to the floor by Resident 2.This failure resulted in Resident 1 landing on the floor and experiencing left hip pain.During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted January of 2025 with a diagnosis of Dementia (a decline in thinking, memory, reasoning and ability to make decisions).A review of Resident 1 Minimum Data Set (MDS- an assessment tool) dated 3/3/25 indicated Resident 1 had moderate cognitive impairment.A review of Resident 1's progress note, dated 2/6/25 indicated Resident 3 reported that Resident 1 got pushed by Resident 2. The progress note indicated Resident 1 was laying on his back and when Resident 1 started walking he verbalized his left hip area hurt. The progress note indicated the abuse coordinator was notified. A review of Resident 2's clinical record indicated Resident 2 was admitted [DATE] with a diagnosis of Bipolar Disorder (a mental health condition characterized by extreme, often dramatic shifts in mood, energy, and activity levels).A review of Resident 2's MDS dated [DATE] indicated, Resident 2 had severe cognitive impairment.A review of Resident 2's progress notes titled . change of condition. dated 2/6/25, indicated Resident 3 reported that Resident 2 pushed Resident 1 when he entered their room and Resident 1 .fell to the floor on his back. Staff ran up when they hear loud voices. What they found was [Resident 2] standing in the room and [Resident 1] laying on the floor . on his back. When asked what happened both of the parties were not able to explain. Notified Abuse coordinator MD [Medical Doctor] and RP [Responsible Party] notified. Ombudsman notified.A review of Resident 2's IDT (interdisciplinary team) note dated, 2/7/25, indicated, . Per LN [Licensed Nurse] -2/6/25 @ 1450 [2:50 p.m.] - per [Resident 3] . [Resident 2] pushed [Resident 1] when he entered their room and [Resident 1] fell on the floor . on his back. Notified Abuse coordinator, MD, and RP notified. Ombudsman notified.A review of Resident 3 clinical record indicated, Resident 3 was admitted in January of 2025 with a diagnosis of Multiple fractures of ribs, left side, subsequent encounter of fracture of routine healing.A review of Resident 3's MDS Cognitive Patterns, dated 2/17/25 indicated Resident 3 had moderate cognitive impairment.A review of Resident 3's Social Services notes dated 2/7/25 indicated, Resident 3 reported that she witnessed a peer to peer altercation in her room.During a concurrent interview and record review on 3/27/25 at 1:47 p.m. with Director of Nursing (DON) and Administrator (ADM) present on telephone, the DON confirmed a peer to peer altercation occurred on 2/6/25 between Resident 1 and Resident 2. The DON and ADM confirmed there was no documented evidence indicating the peer to peer abuse was reported to the Department.During a review of facility's Policy and Procedure (P&P) titled, .types of abuse., dated September 2025, indicated, .Abuse of any kind against residents is prohibited. Abuse toward a resident can occur as. resident to resident abuse.During a review of facility P&P titled, .Abuse, Neglect. dated April 2025, indicated, .Protect residents from abuse. Investigate and report any allegations within timeframes required by federal requirements.

Based on interview, and record review the facility failed to report allegations of abuse to the Department as required by the regulations when one of six sample residents (Resident 1) was pushed to the floor by Resident 2.This failure to report allegations of abuse resulted in delay in conducting investigation by the Department. During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted January of 2025 with a diagnosis of Dementia (a decline in thinking, memory, reasoning and ability to make decisions).A review of Resident 1 Minimum Data Set (MDS- an assessment tool) dated 3/3/25 indicated Resident 1 had moderate cognitive impairment (moderate problems with thinking and memory).A review of Resident 1's progress note, dated 2/6/25 indicated, Per Resident 3, Resident 1 got pushed by Resident 2, when he came to a room and out of nowhere Resident 2 pushed Resident 1 to the floor. When staff approached because of screaming, Resident 1 was laying on his back. Resident 1 stated that his left hip area hurts. The abuse coordinator was notified. There was no documentation indicating the department was notified of the abuse incident. A review of Resident 2's clinical record indicated Resident 2 was admitted [DATE] with a diagnosis of Bipolar Disorder (a mental health condition characterized by extreme, often dramatic shifts in mood, energy, and activity levels).A review of Resident 2's MDS dated [DATE] indicated, Resident 2 had severe cognitive impairment (profound decline in mental ability that interferes with daily life).A review of Resident 2's progress notes titled . change of condition. dated 2/6/25, indicated, Resident 2 pushed Resident 1 and Resident 1 fell to the floor on his back. There was no documented evidence indicating the Department was notified of the abuse incident.A review of Resident 2's IDT (interdisciplinary team) note dated, 2/7/25, indicated, . Per LN [Licensed Nurse] -2/6/25 @ 1450 [2:50 p.m.] - per [Resident 3], [Resident 2] pushed [Resident 1] when he entered their room and [Resident 1] fell on the floor in front other on his back. Notified Abuse coordinator, MD [Medical Doctor], and RP [Responsible Party] notified. Ombudsman notified.A review of Resident 3 clinical record indicated, Resident 3 was admitted in January of 2025 with a diagnosis of Multiple fractures of ribs, left side, subsequent encounter of fracture of routine healing.A review of Resident 3's MDS Cognitive Patterns, dated 2/17/25 indicated Resident 3 had moderate cognitive impairment.A review of Resident 3's Social Services notes, dated 2/7/25 indicated, .Resident [Resident 3] reported that she witnessed a peer to peer altercation in her room. Resident verbalized she was uncomfortable at the time and expressed her concerns with a staff member.During a concurrent interview and record review on 3/27/25 at 1:47 p.m. with Director of Nursing (DON) and Administrator (ADM) present on telephone, the DON confirmed a peer to peer altercation occurred on 2/6/25 between Resident 1 and Resident 2. The DON and ADM confirmed there was no documented evidence indicating the peer to peer abuse was reported to the Department.During a review of facility's Policy and Procedure (P&P) titled, .types of abuse., dated September 2025, indicated, .Abuse of any kind against residents is prohibited. Abuse toward a resident can occur as. resident to resident abuse.During a review of facility P&P titled, .Abuse, Neglect. dated April 2025, indicated, .Protect residents from abuse. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview, and record review, the facility failed to ensure facility residents were free from accident and safety hazards when a personal items (one broken pair of glasses, dentures, and hearing aides) cart was left unlocked in the hallway for a total census of 160.This failure had the potential for residents to access the cart without staff supervision. During an observation on 3/27/26 12:40 p.m. in hallway near room [ROOM NUMBER], the Personal Items cart was observed with three nursing staff present. The 3 nursing staff left the cart unlocked.During an observation on 3/27/25 at 12:45 p.m. at the personal items cart, the cart was unlocked and three residents were observed walking by the cart.During a concurrent observation and interview on 3/27/26 at 12:47 p.m. with Certified Nurse Assistant 1 (CNA 1), CNA 1 confirmed that she checked out resident dentures from the personal items cart. CNA 1 confirmed three nursing staff were present at the cart when CNA 1 left the cart after logging her item. CNA 1 confirmed the personal item cart was unlocked and contained items such as a pair of broken glasses, resident dentures, and resident hearing aides with no staff present and was easily accessible to facility residents. CNA 1 stated that the cart should be locked at all times and if a resident were to access the items, they could harm themselves by cutting themselves with the glasses or breaking the dentures, if not supervised appropriately. CNA 1 confirmed the presence of three residents wandering near the personal items cart.During an interview on 3/27/26 at 12 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed that all medication and personal item cart should be locked to prevent access to residents. LN 1 confirmed that accessing the personal item cart could result to an accident for residents who wander about the facility.During an interview on 3/27/26 at 1:47 p.m. with Director of Nursing (DON), the DON stated the expectation is for all carts to be locked in the facility. The DON further confirmed that if a resident did access the facility cart items it could have led to an accident resulting in resident harm and it could have led to missing resident items. The DON confirmed that there were missing pages and dates in the personal item log binder and that items were not monitored accurately by staff.During a review of facility P&P titled, .Safety/Supervision. dated July 2019, indicated, .make the environment as free from hazards as possible. Safety risks and environmental hazards are identified on an ongoing basis. and try to prevent avoidable accidents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision of assistive devices.

Based on observation, interview, and record review the facility failed to report injuries of unknown origin (IUO) to the Department as required by the regulations for one of four sampled residents (Resident 1) when Resident 1 was noted with a scald injury (a type of burn injury caused by hot liquids that causes damages to the skin and tissue) to his right hand of unknown origin/cause.This failure resulted in a delay of investigation by the Department.A review of Resident 1's clinical record indicated Resident 1 was admitted in June of 2024 with a diagnosis of Alzheimer's Disease (a progressive irreversible brain disorder that destroys memory and thinking skills over time).A review of Resident 1's MDS (minimum data set - an assessment tool) dated 12/22/25 indicated Resident 1's score was NA indicating no cognition score could be determined.During an observation on 3/4/26 at 11:55 a.m. in the dining room area, Resident 1 was observed sitting up in his wheelchair with a bandage observed on his right hand.A review of Resident 1's physician order dated 2/27/26 indicated, .updated tx (treatment) right dorsal hand Scald injury [sic. Cleanse] . apply bacitracin (type of wound medication ointment) ointment with xeroform cover dry dressing.every day shift for Blister until 03/12/2026.A review of Resident 1's progress notes dated 2/19/26 indicated, . Staff notified this writer of blisters to the right hand . with unknown cause . noted with facial grimacing when touched .A review of Resident 1's IDT skin management note dated, 2/19/26 indicated, right dorsal hand scald injury 8.0 x 6.0 x 0.1 cm . The appearance is consistent with a scald injury. The cause of the injury is presumed as there is no documentation of this.During an interview on 3/4/26 at 12:41 p.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed she was the treatment nurse for the facility. LN 1 confirmed that the wound provider indicated Resident 1's wound was a scald injury. LN 1 confirmed Resident 1 had an injury of unknown cause.During an interview on 3/4/26 at 1:37 p.m. with Director of Nursing (DON), the DON confirmed there was not a witness to the incident that occurred with Resident 1 and Resident 1 did sustain an injury of unknown origin. The DON further confirmed the wound doctor categorized the injury as a scald.During an interview on 3/4/26 at 2:20 p.m. with Administrator (ADM), the ADM confirmed Resident 1's injury was of unknown cause. ADM confirmed he did not report the incident of unknown origin to the department thus delaying department investigation.During a review of facility Policy and Procedure (P&P) titled, . Identifying Types of Abuse. dated September 2025, the P&P indicated, . Physical abuse includes . injuries that are non-accidental or unexplained .During a review of facility P&P titled, .Unusual Occurrence Reporting ., dated December 2025, indicated, . As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of our residents, employees or visitors . Our facility will report the following events to appropriate agencies . Allegation of abuse, neglect and misappropriation of resident property . Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services and implement measures for the prevention of pressure injuries (painful wounds caused as a result of prolonged pressure or friction) for two of 37 sampled resident (Resident 4 and Resident 32), who were at risk for skin injuries when, Resident 4 obtained a skin tear (a traumatic wound of the top layer of skin) from the use of bolster (part of a mattress cover with raised foam edges on each side of the bed to prevent resident from rolling out of bed), did not implement interventions addressing use of bolster, did not document accurate assessments of the wound every shift as indicated by resident's care plan; and Failed to ensure pressure ulcer risk factors were thoroughly assessed, daily skin checks completed as indicated in the care plan, and interventions were implemented to prevent avoidable wound to Resident 32's elbow.These failures contributed to Resident 4's mid back skin tear progressing into deeper wound requiring surgical excision of damaged tissue and in the development of open wound for Resident 32' left elbow that got infected and had the potential for Resident 4 and Resident 32 to experience pain.A review of the admission Record indicated the facility admitted Resident 4 in 2015 with multiple diagnoses, which included metabolic encephalopathy (brain dysfunction, leading to confusion, memory issues, and personality changes), dementia (a progressive state of decline in mental abilities), and functional quadriplegia (a complete inability to move due to severe disability, or frailty caused by advanced dementia or other health conditions).A review of Resident 4's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/29/2025, indicated that the resident had severely impaired abilities remembering things, making decisions, concentrating, or learning. The MDS indicated that Resident 4 was non-ambulatory, totally dependent on staff with all activities of daily living (ADLs - activities related to personal care), and incontinent for bowel and bladder. The MDS section for skin conditions indicated the resident was at risk for developing pressure ulcers or injuries but did not have any open wounds. Resident 4's clinical records were reviewed and indicated the following:A Braden Scale (an assessment tool used to assess skin for breakdown and/or pressure injury), dated 10/4/25, indicated a score of 12. The scoring criteria indicated a score of 10-12 placed the resident At High Risk for pressure ulcer development. The scoring indicated that Resident 4 was unable to communicate discomfort and pain and was unable to make frequent and significant changes and control of body position and frequently slid down in bed or chair. The assessment indicated that resident's medical conditions led to almost constant friction [physical force created when person's skin slides against another surface] and shearing (sliding injury when the skin gets pulled during repositioning causing damage to skin, including skin tears and pressure injuries).At risks for skin breakdown care plan, dated 5/27/23, and revised 12/23/25 indicated the goal was for resident to not have skin breakdown. The care plan listed multiple interventions, which included performing daily body assessments, monitoring for any skin injury, and keeping bed clean, dry, and wrinkle-free. There were no interventions addressing Resident 4's risk for skin injuries due to friction and shearing.A nursing weekly summary dated 11/23/25 at 12:46 p.m., indicated resident's skin was pink .no new skin issues were identified.Impaired skin integrity care plan initiated 11/25/25 addressed a skin tear to Resident 4's mid lower back. One of the interventions directed nursing to document location, size (length, width, depth), color, surrounding skin, presence/absence of drainage and/or signs of healing. The care plan did not address bolster mattress overlay and did not include interventions related to the bolster, including frequent checking the resident's skin under bolsters and making sure the resident was not lying directly on bolster straps or Velcro.IDT (Interdisciplinary Team, a group of healthcare disciplines who discuss resident care needs) Skin Management note dated 11/26/25 at 11:48 a.m., indicated that Resident 4 had skin tear to her mid lower back measuring 0.8 by 0.8 cm (centimeters, unit of measurement, length and width respectively).A Skin Issues Note by treatment nurse (TN), who was responsible for assessing residents' skin and managing wounds, dated 11/28/25 indicated Resident 4 developed a new wound, described as abrasion [scrapped off by friction to her midback]. The note did not contain description of the abrasion and there were no measurements to compare with initial skin tear developed 3 days prior and as directed by Resident 4's care plan interventions.Resident 4's nursing progress notes indicated that the resident was hospitalized from [DATE] through 12/3/25 related to respiratory issues and shortness of breath.A Skin Issues Note dated 12/3/25 at 11:18 a.m., indicated Resident 4 was readmitted back to facility and the skin tear/abrasion to her midback was classified as pressure ulcer/injury [localized, pressure-related damage to the skin and/or underlying tissue]. The treatment nurse documented pressure injury (PI) was measuring 2 by 2 cm in length and width. The evaluation note did not contain the wound description and color, appearance of surrounding tissue and presence or absence of drainage as directed by resident's care plan.IDT Skin Management note dated 12/4/25 at 11:14 a.m., indicated that Resident 4's mid back pressure injury was measuring 1.7 by 1.6 by 0.5 (length, width, and depth respectively and was covered with slough (yellowish or whitish dead tissue, delaying healing and harboring bacteria).A Surgical Consult note dated 12/4/25 located in resident's clinical records indicated that Resident 4 developed a traumatic injury to her back due to exposure to bolster straps. The Wound Consultant (WC) documented that Resident 4 had to undergo a surgical procedure to remove dead, damaged, or infected tissue to improve wound healing.During an observation in resident's room on 1/6/26 at 10:30 a.m., Resident 4 was in her bed lying on her back. The resident's bed had a low air loss mattress (a specialized therapeutic mattress with internal air cells that constantly circulate a flow of air, commonly used to heal pressure injuries). Resident 4's eyes were opened but the resident did not reply when greeted and did not provide any answers.Resident 4 was observed in her room and was noted to be in the same position lying on her back on 1/6/26 at 12:55 p.m., 1/7/26 at 10:05 a.m. and 12:35 p.m., 1/8/26 at 4:33 p.m., and 1/9/26 at 9:20 a.m.During an observation and interview in Resident 4's room on 1/6/26 at 1:35 p.m., a Certified Nursing Assistant (CNA 11) stated that the resident was dependent on staff for all ADL's (activities of daily living, which included feeding, personal hygiene, turning, and repositioning). CNA 11 stated the resident was always in bed, except during showers. CNA 11 explained that last month Resident 4 developed skin wound to her back. CNA 11 stated the low air loss mattress was initiated a few weeks ago and that prior to that the resident had a bolster mattress overlay.During an observation and interview on 1/8/26 at 8:05 a.m., the TN and WC were observed in Resident 4's room assessing resident's mid back wound. The WC stated she was informed that Resident 4 developed trauma injury from lying on bolster straps. The WC stated that Resident 4 had very limited mobility and was at high risk for developing skin issues. The WC described Resident 4's wound and explained that the resident had a skin tear first, then excoriation, then turned into deeper wound and got worse, wider and deeper.During a concurrent interview and record review on 1/8/26 at 9:35 a.m., skin assessments and wounds management were discussed with the Director of Nursing (DON) and Administrator (ADM). The DON stated that that the expectation was that nurses were to assess and record accurate skin assessments during daily and weekly summaries and during wound dressing changes. The DON added, They [are] supposed to check residents' skin and document any issues.] The DON stated that IDT meeting determined that bolster straps caused skin tear to Resident 4's mid back, which later deteriorated into deeper wound. The DON was asked what resident centered and resident specific interventions to prevent further damage to her skin tear were implemented after the skin tear was identified. The DON explained, Our standard treatment - cleanse, monitor for infection.I am not sure what other interventions at that time. After the DON reviewed Resident 4's wound photo dated 11/28/25, taken three days after the skin tear was identified, the DON acknowledged that the wound looked deeper, round with uneven edges, had exposed subcutaneous (deeper layer of fat tissue), and no longer looked like skin tear. The DON stated that Resident 4's wound to mid back got worse when the resident returned from brief hospitalization when staff compared the wound photos taken before and after hospitalization. The DON acknowledged that Resident 4's skin notes and wound assessment dated [DATE] did not contain wound descriptions and measurements and had inconsistencies in documentation.During a follow up interview on 1/9/26 at 8:35 a.m., a manual guide for bolster mattress overlay was reviewed and discussed with DON. The DON explained that the bolster had 2 straps with Velcro that go across the bed and Resident 4's mid back skin tear was caused by shearing on the bolster straps when she was pulled up in her bed or repositioned. The DON added that the expectation was that the straps and Velcro were covered with drawsheet and residents had to be handled very carefully to prevent skin injuries. The DON stated that Resident 4's mid back wound could have been avoided if nurses and CNAs assessed the position of the bolster straps every time the resident was repositioned and made sure the resident was not lying directly on the straps or Velcro.2. A review of the admission Record indicated the facility admitted Resident 32 in December of 2025 with multiple diagnoses, which included dementia, communication deficit, and muscle weakness.A review of Resident 32's MDS dated [DATE], indicated that the resident had severely impaired cognitive skills, including remembering things, making decisions, and concentrating. The MDS indicated the resident was at risk for developing pressure injuries, but no open skin wound was identified.A review of Resident 32's care plan initiated 12/9/25 indicated that the resident was at risk for skin breakdown. The care plan interventions directed nursing staff to check resident's skin during daily provision of care.A review of the care plan dated 12/10/25 indicated that Resident 32 had decline in ADL's and required one or two staff's assistance with bed mobility, turning, and repositioning.A review of Resident 32's admission skin assessment dated [DATE] indicated that resident had scattered discoloration and scabs (dry hard covering of dried blood that forms over a wound) to both of his arms, small, scattered scabs to his left lower leg and feet, redness to his heels and had no open wounds.A review of Braden Scale dated 12/16/25 and 12/23/25 were incomplete and did not indicate Resident 32's score.A review of Resident 32's care plan initiated 12/28/25 addressed the open wound to his left elbow with the goal to not develop infection. The interventions directed nursing to staff to assess wound each shift for size, depth, tissue type, drainage, odor, and surrounding skin.A review of nursing progress notes (NPN) dated 12/28/25 at 5:33 a.m., indicated Resident 32 was noted to have an approximately 4 by 4 cm full thickness (deeper wound that goes through the top skin layer into fat tissue or muscle) open wound with exposed subcutaneous (deep layer of skin) tissue on left elbow. Unknown cause. No bleeding present.A review of NPN titled, Skin/Wound Note, dated 12/29/25 at 7 a.m., indicated Resident 32 had two open wounds. The wound to his left forearm measured 0.5 cm in length, 1.2 cm wide, and 0.1 cm deep and the wound to resident's left elbow (identified day prior) had serosanguineous drainage (thin pink or red watery fluid).A review of NPN dated 12/30/25 at 11:59 a.m., indicated a physician order to start antibiotic (a medication to treat infections) for Resident 32's left elbow wound infection.A review of Infection Note dated 1/2/26 at 10:42 a.m., indicated that Resident 32 had redness, warmth, tenderness, slight swelling, and purulent [thick, milky or yellowish pus drainage, indicating an infection] drainage.at wound site to left elbow.A review of the Skin Issues Note dated 1/3/26 at 12:30 p.m., indicated that Resident 32's open wound to left elbow was assessed by WC. The wound description indicated it had 80% of slough tissue (yellowish or whitish dead tissue, delaying healing and harboring bacteria), had moderate amount of serosanguineous drainage, was edematous (swollen) and reddened.During an observation on 1/6/26 at 10:05 a.m., in resident's room, Resident 32 was observed lying in his bed. Resident 32 opened his eyes when called by name but did not provide any answers.During an observation and interview on 1/8/26 at 9:09 a.m., in resident's room, the TN and WC assessed Resident 32's wound to left elbow. The TN removed old dressing which was saturated with green-yellow drainage and cleaned the wound. The TN stated she was not aware how the resident developed such deep wound to his elbow in less than 2 weeks and stated that the wound was classified by WC as trauma wound. The TN stated that wound had lots of bloody drainage and looked infected a few days prior but has improved since.During an interview and concurrent record review with DON and ADM on 1/8/26 commencing at 9:23 a.m., the DON stated that residents' skin assessments were done by CNA's when they performed personal care and during showers or bed bath and if the new skin issue was noted, they had to report to the nurse. The DON added that the daily and weekly assessments were done by nurses. The DON stated that it was the expectation that nurses included skin assessment, especially if there was new wound identified. The DON stated that conducting a Braden assessment was done upon admission and then weekly for 5 weeks and it was very important that the assessments were accurate.During a continued interview and record review with DON and ADM on 1/8/26 at 9:23 a.m., the DON acknowledged that Resident 32 did not have open skin wounds upon admission. The DON reviewed Resident 32's bathing flowsheets from 12/10/25 through 1/8/26 and validated that no open areas were identified during bathing activity on 12/26, 12/27, and 12/28/25. The DON stated the flowsheet documentation was not accurate. Upon reviewing daily nursing evaluations dated 12/26/25 and 12/27/25 the DON confirmed that the evaluations indicated the skin was clear. The DON stated that when Resident 32's left elbow wound was identified on 12/28/25, it was already deep with subcutaneous tissue exposed and acknowledged that such wound could not develop overnight. The DON stated she was unable to state if the evaluations were done accurately and added, I was not there. The DON stated that nurses were expected to do a thorough skin assessment in order to identify any skin issues. A review of the facility's policy and procedure (P & P) titled, Pressure Injury Risk Assessment, with the last revision date of 3/25, indicated, The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing.When conducting a skin assessment.document the findings.Develop the resident- centered care plan and the interventions based on the risk factors identified in the assessments, the condition of the skin, the residents' overall clinical condition.The care plan must be modified as the condition changes, or if current interventions are deemed inadequate.

Based on observation, interview and record review, the facility failed to ensure food was labeled, prepared, stored, served, or distributed in accordance with professional standards of food safety when:Kitchen utensils were stored wet in the clean and ready-to-use bin;unlabeled, undated, opened food items were found in kitchen area;metal pans were stacked wet at the clean and ready-to-use area;mislabeled food items were found in resident refrigerator in medication room; andunlabeled, undated food items were found in Resident 90's room.These failures increased the potential for food-borne illnesses among the census of 157 residents.Findings: 1. During the initial kitchen tour on 1/6/26 at 8:20 a.m., accompanied by the Dietary Manager (DM), there was a large bin labeled, Utensils with multiple wet kitchen utensils stored inside. 2a. During the initial kitchen tour on 1/6/26 at 8:25 a.m., an unlabeled container had a food product stored inside. 2b. During the initial kitchen tour on 1/6/26 at 8:30 a.m., a maple syrup container did not have an expiration date. 2c. During the initial kitchen tour on 1/6/26 at 8:40 a.m., two opened pancake mix bags were not labeled with open date. 3. During a follow up visit to the kitchen on 1/6/26 at 3 p.m., multiple large metal pans used for distributing food were stacked wet at the clean and ready-to-use area. During a concurrent observation and interview on 1/6/26 at 3:05 p.m., with the DM, DM confirmed that kitchen utensils were stored wet in the clean and ready-to-use bin, and metal pans were stacked wet in the clean and ready-to-use area. The DM stated the utensils and metal pans should have been properly dried before storing for use due to the potential growth of mold. During an interview on 1/7/26 at 3:24 p.m., with the DM and Registered Dietitian (RD), the DM and RD both confirmed all opened food items should have been clearly labeled with an open date. They further stated that mislabeling could have led to food-borne illnesses among the residents that were served. During an interview on 1/7/26 at 3:35 p.m., with DM and RD, the DM and RD both confirmed the expectation of clean dish storage was to be: washed, sanitized, and properly dried with no moisture prior to storage. Both further confirmed if metal pans and utensils were stored wet; there could be mold growth. A review of the 2022 Federal Food and Drug Administration (FDA) Food Code, under section 4-901.11, titled Equipment and Utensils, Air-Drying Required, indicated, .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. A review of the facility's undated Policy and Procedure (P&P) titled, Dishwashing, indicated, Dishes are to be air died in racks before stacking and storing. A review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Newly opened food items will need to be closed and labeled with an open date and use by date. 4. During a concurrent observation and interview on 1/6/26 in the Medication Storage Room of Nursing Station 2, at 10:12 a.m. with Licensed Nurse 10 (LN 10), a bag containing six sandwiches was observed in the fridge and labeled, . use by 1-5-26. LN 10 confirmed the date on the bag was past the use-by date and stated, . these [sandwiches] should have been removed. During an interview on 1/8/26 at 3:36 p.m. with the Registered Dietitian (RD), the RD stated that staff are to label all resident food items with a use-by date to ensure that residents are not served food that is expired. The RD further stated that her expectation was that food that is past the use-by date is removed from the fridge to . prevent possible food-borne illness. During an interview on 1/9/26 at 10:30 a.m. with the Director of Nursing (DON), the DON stated it was the policy of the facility that food items have a use-by date and that food items are removed by that date. The DON further stated that her expectation is that nurses check the fridge each shift and remove any food items that are past the use-by date to ensure residents do not receive food that was expired. 5. During an observation on 1/6/26 at 10:28 a.m., in Resident 90's room, personal food items were seen at bedside undated and unlabeled. Resident 90 was noted to have a box of personal food items next to her bed including, a box of canned diet soda, multiple individual chocolate pudding containers, one opened bag of potato chips, one opened bag of crackers, a box of individual zero sugar coffee creamers and numerous unopened dry food items. During an interview on 1/6/26, at 10:30 a.m., with Resident 90, Resident 90 stated, she got the food items delivered to her from her daughter who sent them to the facility. Resident 90 stated, the staff did not label the food items with her name or dates. Resident 90 stated, she had a box of cereal taken from her a few weeks ago by another resident and is concerned about other people taking her food from her room. During a concurrent observation and interview on 1/8/26, at 12:40 p.m., with the Director of Nursing (DON) in Resident 90's room, multiple personal food items were observed unlabeled and undated. DON stated, she will alert staff to label and date Resident 90's food, all personal food items need to be labeled and dated with an expiration date, and Resident 90's food items were not labeled or dated. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage dated 2014, the P&P indicated, 13. Food items and snacks kept on the nursing units must be maintained as indicated below: .b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date.

Based on interview and record review, the facility failed to identify trauma triggers for six out of 37 sampled residents (Resident 2, Resident 9, Resident 29, Resident 113, Resident 93, and Resident 152) with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) or identified traumatic events. This failure had the potential for the residents to experience re-traumatization (re-experience/relives a traumatic event or experiences causing similar stress reactions to a new event), and possible increased symptoms such as restlessness, irritability and social withdrawal. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in December 2023 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- death of brain tissue due to blockage of blood supply to the brain), vascular dementia (cognitive decline due to disrupted blood flow to the brain), depressive disorder (mood disorder causing persistent sadness), and PTSD. A review of Resident 2's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 12/8/25, indicated Resident 2 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 11 out of 15 that indicated Resident 2 had moderate cognitive impairment. A review of Resident 2's Physician Diagnosis Verification (PDV), dated 12/11/23, indicated diagnoses including Post- Traumatic Stress Disorder with Attestation .This verifies that all diagnoses listed are currently active in this facility . A review of Resident 2's Social History Assessment (Admission/Annual), dated 12/13/23 and 3/11/24, indicated .Significant Life Events .difficult or stressful things that sometimes happen to people . for Resident 2 that included transportation accident, combat or exposure to a war-zone, life- threatening illness or injury, severe human suffering, and sudden unexpected death of someone close to you. A review of Resident 2's Care Plan . [Resident 2] demonstrated physical behaviors and high risk for recurrence of behavior with staff and others r/t [related to] Anger, History of harm to others, Poor impulse control, hx [history] peer to peer DX [Diagnosis] .POST-TRAUMATIC STRESS DISORDER ., initiated 4/1/25, indicated .Interventions .Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document . A review of Resident 2's Care Plan . [Resident 2] exhibits repeated physical and verbal aggression toward staff and peers, likely due to cognitive impairment, PTSD triggers ., initiated 9/19/25, indicated .Interventions .Monitor for patterns of behavior and identify triggers (e.g., specific staff, time of day, noise) . A review of Resident 2's Care Plan .Trauma-informed Care: [Resident 2] is at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control . related to combat or exposure to a warzone, PTSD ., initiated 10/29/25, indicated .Interventions . Approach in a calm, reassuring manner Offer a quiet place to calm down .Reorient and redirect as necessary . During an interview on 1/8/26 at 3:00 p.m. with the Social Services Director (SSD), the SSD stated the PTSD assessment is included in the Social History Assessment but acknowledged that there was no indication in Resident 2's Social History Assessment (Admission/Annual) on 12/13/23 and 3/11/24 of Resident 2's triggers for PTSD. When asked how triggers for PTSD were identified, the SSD stated that trauma is care planned but did not state how triggers were identified. The SSD stated Care Plans indicate to monitor for signs of distress, provide support and reassurance as needed, respond to needs effectively, and react appropriately to calm them down. When asked why Care Plans for Resident 2 for trauma informed care did not start until 2025 when he had been admitted in December 2023 with diagnosis of PTSD, the SSD stated she was not working at the facility at time of his admit but was not aware of any Care Plans addressing trauma informed care prior to 2025. During an interview on 1/9/26 at 9:25 a.m. with Licensed Nurse (LN) 7, LN 7 stated Resident 2 had a diagnosis of PTSD. LN 7 stated in order to know what a resident's triggers may be for PTSD, need to get to know resident. When asked what triggers a resident may have for PTSD, LN 7 stated she would introduce herself, see how they react, and see what behaviors they may have. LN 7 stated if not familiar with the resident LN may check the Care Plan. During an interview on 1/9/26 at 10:57 a.m. with LN 5, LN 5 stated Resident 2 had behaviors including verbal aggression and not taking his medications. LN 5 stated he would check the medical record to determine if a resident had a diagnosis of PTSD. When asked where in the medical record Resident 2's triggers were, LN 5 stated he was not sure where to locate the triggers in the record. A review of the facility's Policy and Procedure (P&P) titled Trauma Informed Care, revised 3/19, indicated .To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma . Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization .Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers .Implement universal screening of residents for trauma . As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools . A review of the facility's P&P titled Social Assessment, revised 7/14, indicated . A social assessment will be done to help identify the resident's personal and social situation, needs and problems . A review of the admission Record indicated the facility admitted Resident 9 in the summer of 2025 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities) and chronic (persisting for a long time) post-traumatic stress disorder (PTSD). A review of Physician Diagnosis Verification dated 8/11/25 contained Resident 9's diagnosis of PTSD. The physician documented the following, I verify that above medical diagnoses are active and have a direct relationship to the resident's current functional, cognitive, mood or behavior status, medical treatment, nursing monitoring, or risk of death. A review of Resident 9's 'Trauma-Informed Care' care plan indicated the resident was At risk for decreased psychosocial well-being.emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental.social, or spiritual wellbeing related to combat or exposure to a warzone. The interventions included approach resident in a calm, reassuring manner, encourage relaxation techniques, encourage resident to verbalize feelings. The care plan did not contain any triggers or identified behaviors that might be indicators of Resident 9's traumatic events related to combat or warzone. A review of Resident 9's admission Resident Centered Social History and Discharge Planning Assessment, dated 8/15/25 conducted by the SSD, indicated that the resident was veteran. The section #7 of the assessment titled Significant Life Events/Trauma History, listed 17 difficult or stressful events that sometime happen to people. The document directed staff who conducted the assessment to choose the event from the provided list that might indicate what trauma the resident had experienced. The list contained, .j. Combat or exposure to warzone.k. Captivity. (held hostage, prisoner of war) .m. Severe human suffering. and none of these were checked. The checkmark at the end of assessment indicated, None of the above reported or are known to have occurred. During an interview on 1/8/26 at 3 p.m. with the SSD, the SSD stated she was responsible for conducting residents' social history assessments, including trauma assessment. During an interview on 1/9/26 at 9:17 a.m. with LN 2, LN 2 stated Resident 9 had issues with behaviors, including verbal aggression and refusals of care. LN 2 reviewed Resident 9's clinical record and acknowledged that the resident had a diagnosis of PTSD. When asked where Resident 9's PTSD triggers were documented, LN 2 did not provide the answer. During a concurrent interview and record review with the SSD on 1/9/26 at 12:33 p.m., the SSD was asked to describe the process for identifying the triggers for the residents that have diagnoses of PTSD and had experienced traumatic life events. The SSD stated that the assessment for traumatic events and PTSD was included in the Social History and Discharge Planning Assessment completed upon admission. The SSD reviewed Resident 9's 'Trauma-Informed Care' care plan and stated that Resident 9 was a veteran had experienced combat or warzone. The SSD stated that care plan did not specify any behaviors that Resident 9 might have experienced as a result of combat or warzone and did not identify any triggers related to PTSD. The SSD reviewed Resident Centered Social History and Discharge Planning Assessment, dated 8/15/25 and acknowledged that Resident 9's experience in 'Combat or exposure to warzone' was not marked and the resident's assessment was not completed accurately. A review of Resident 29's admission Record indicated Resident 29 was admitted to the facility in November of 2025 with multiple diagnoses including Schizophrenia (a mental illness that disrupts thought, perception, and emotion, causing symptoms like hallucinations such as hearing or seeing things that are not there), Bipolar disorder ( a mental illness causing extreme mood swings) and major depressive disorder (mood disorder causing persistent sadness). A review of Resident 29's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 11/20/25, indicated Resident 29 had Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 12 out of 15 that indicated Resident 29 had moderate cognitive impairment. A review of Resident 29's Social History Assessment, dated 11/17/25, indicated in . SIGNIFICANT LIFE EVENTS/TRAUMA . that Resident 29 had experienced . sudden unexpected death of someone close to you . institutionalized for bipolar and Schizophrenia . Daughter taken away by CPS [Child Protective Services] A review of Resident 29's Care Plan, initiated on 11/17/25, titled Trauma-informed Care indicated . [Resident 29] is At risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control . related to sudden, unexpected death of someone close to you (husband passed away) . was institutionalized for bipolar disorder and schizophrenia . No triggers identified on care plan. A review of Resident 113's admission Record indicated Resident 113 was admitted to the facility in April of 2025 with multiple diagnoses including Parkinson's (a brain disorder that makes it hard to control movement, causing symptoms like shaking, stiffness, slow movements, and balance problems) and post-traumatic stress disorder (PTSD-mental health condition triggered by experiencing or witnessing a traumatic event causing symptoms that disrupt daily life). A review of Resident 113's MDS, Cognitive Patterns, dated 11/13/25, indicated Resident 113 had BIMS score of 8 out of 15 that indicated Resident 113 had moderate cognitive impairment. A review of Resident 113's Social History Assessment (Admission/Annual), dated 4/30/25, indicated in . Significant Life Events . difficult or stressful things that sometimes happen to people . that he experienced . combat or exposure to a war-zone . A review of Resident 113's Care Plan, initiated on 10/29/25, titled Trauma-informed Care indicated . [Resident 113] is At risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control . related to combat or exposure to a warzone, dx [diagnosis] of PTSD . No triggers identified on care plan. During an interview on 1/8/26 at 3 p.m. with the Social Services Director (SSD), the SSD stated the PTSD assessment is included in the Social History Assessment. When asked how triggers for PTSD are identified, the SSD stated that trauma is put in a care plan. The SSD could not provide a document where triggers for PTSD or trauma was captured. The SSD stated care plans indicate to monitor for signs of distress, provide support and reassurance as needed. During an interview and concurrent record review on 1/9/26 at 9:39 a.m. with the Director of Nursing (DON), the DON stated the PTSD assessment is done by the Social Services Director (SSD). When asked how triggers for PTSD/Trauma are identified, the DON stated that triggers are put in a care plan. The DON further explained that it is the duty of all medical staff to get to know the residents and find out what their triggers are and document it in the care plan. When asked how triggers for PTSD/Trauma are identified, the DON stated that triggers are put in a care plan. The DON verified, in a concurrent record review, that Resident 29 and Resident 113 did not have triggers indicated in either of their care plans. During an interview on 1/9/26 at 9:49 a.m. with Licensed Nurse (LN) 8, LN 8 stated Resident 113 had a diagnosis of PTSD. LN 8 stated that he knew Resident 113 had PTSD but did not know what his triggers were. LN 8 stated that triggers for PTSD/Trauma should be in the care plans. A review of the facility's Policy and Procedure (P&P) titled Trauma Informed Care, revised 3/19, indicated . To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma . Nursing staff are trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization . Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers . Implement universal screening of residents for trauma . As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools . A review of the admission Record indicated Resident 93 was admitted to the facility in September 2021 with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and PTSD. A review of Resident 93' s care plan dated 4/24/25 indicated, Psychosocial-Emotional/Trauma-informed Care: [Resident 93] is at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills .related to [PTSD]. History of Domestic violence with husband many years ago. The care plan did not indicate the trigger(s) for Resident 93's PTSD. A review of Resident 93's Resident Centered Social History and Discharge Planning assessment dated [DATE] signed by the Social Services Director (SSD) indicated [Resident 93] had a very stressful event or experience. The event/trauma was described as history of domestic violence with husband many years ago. The assessment did not include triggers for the stressful event. During an interview on 1/8/26 at 3:01 p.m. with the SSD, the SSD stated she was responsible in conducting the Resident Centered Social History and Discharge Planning Assessment. The SSD confirmed the assessment did not include the triggers for the event/trauma. During a concurrent interview and record review with the Director of Nursing (DON) on 1/9/26 at 9:39 a.m., the DON stated her expectation was for the facility to identify the history of residents with PTSD. The DON further stated the SSD should initiate the assessment, and if staff identified triggers, these triggers should be added to the care plan. The DON confirmed Resident 93's care plan did not indicate the triggers. A review of the Facility Assessment (FA) updated 8/1/25 indicated, the facility provides general care for mental health and behavior. The FA further indicated specific care or practices were provided to Manage the medical conditions . identify and implement interventions to help support individuals with issues such as dealing with .PTSD. A review of Resident 152's clinical record indicated Resident 152 was admitted February of 2025 and had diagnoses that included dementia (memory loss that interferes with daily functions), PTSD, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily lives). A review of Resident 152's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/3/25, indicated Resident 152 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 9 out of 15 which indicated Resident 152 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 152's SOCIAL HISTORY ASSESSMENT, dated 2/7/25, indicated, C. Significant Life Events .10. Combat or exposure to a war-zone (in the military or as a civilian) .Happened to me. The assessment did not indicate the trigger(s) for Resident 152's PTSD. A review of Resident 152's care plan, revised 10/29/25, indicated, Psychosocial- Emotional/Trauma: [Resident 152] is At risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills, poor impulse control, adverse effects on function, mental, physical, social, or spiritual wellbeing related to history of combat or exposure to a warzone, DX [diagnosis] of PTSD. The care plan did not indicate the trigger(s) for Resident 152's PTSD. During a concurrent interview and record review on 1/8/26 at 11:18 a.m. with the Social Services Director (SSD), Resident 152's clinical records were reviewed. The SSD confirmed that there was no PTSD trigger(s) identified for Resident 152 in his social history assessment and care plan. The SSD agreed that they would not know what to avoid for Resident 152 not to get re-traumatized if the trigger(s) was not identified. During an interview on 1/8/26 at 3:42 p.m. with Licensed Nurse (LN) 11, LN 11 stated she was the nurse assigned to Resident 152 for the shift and she was not sure if Resident 152 had PTSD diagnosis. LN 11 also stated she had no idea what were Resident 152's trauma trigger(s). LN 11 further stated Resident 152's trauma triggers should have been identified for them to care for him better and prevent him from re-experiencing the traumatic event. During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated the trigger points of residents with PTSD should be identified so they could plan their care properly and prevent re-traumatization. A review of the facility's policy and procedures (P&P) titled, Trauma Informed Care, revised 3/2019, indicated, Resident-Care Strategies .1. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 157 when:1. Two facility staff did not wear required personal protective equipment (PPE) when transferring, assisting with personal care, and handling the foley catheter (a tube inserted through the urethra into the bladder to drain urine) for Resident 38 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2. A clean resident's personal items delivery cart had a thick layer of dust on the inside surface;3. Staff did not wear PPE when transferring Resident 32 who was on EBP and when handling the foley catheter; 4. Resident 125's room did not have EBP sign posted outside the room for a resident who had an indwelling urinary catheter. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure to germs, and may cause infection to Resident 38, Resident 32, and Resident 125.1. A review of Resident 38's clinical record indicated Resident 38 was admitted June of 2023 and had diagnoses that included dementia (memory loss that interferes with daily functions), neuromuscular dysfunction of bladder (the nerves and muscles in the urinary bladder don't work together properly), obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract), retention of urine (caused by a blockage or a failure of the bladder to squeeze hard enough to expel all of the urine), catheter use, and muscle weakness. A review of Resident 38's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/17/25, indicated Resident 38 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 2 out of 15 which indicated Resident 38 had severely impaired cognition. A review of Resident 38's MDS Bladder and Bowel Status, dated 11/17/25, indicated Resident 38 uses indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time). A review of Resident 38's care plan, revised 2/19/25, indicated, Enhanced Barrier Precautions: [Resident 38] requires enhanced barrier precautions during high-contact resident care activities due to the presence of: Indwelling device(s) (urinary catheter) .Utilize PPE (gown and gloves; face-shield as indicated) during high-contact resident care activities (e.g. [for example], dressing .transferring, hygiene .brief changes .device care .). A review of Resident 38's active physician's order, dated 6/4/25, indicated, Indwelling Urinary (Foley) Catheter .related to .NEUROMUSCULAR DYSFUNCTION OF BLADDER .change catheter when dislodge. every 24 hours as needed. A review of Resident 38's active physician's order, dated 9/28/25, indicated, Enhanced barrier precautions every shift for foley catheter. A review of the list of residents on EBP, provided by the Director of Staff Development (DSD), on 1/6/26 at 9:38 a.m. indicated Resident 38 was on EBP due to his foley catheter. During an observation on 1/6/26 at 3:43 p.m. in Resident 38's room, two facility staff were observed changing Resident 38's shirt, placing his briefs on, transferring Resident 38 from the shower chair to his bed, and handling Resident 38's foley catheter while only wearing gloves and not wearing a gown. After which, the staff went to empty Resident 38's catheter bag into a urinal while only wearing gloves. There was an EBP signage posted outside of Resident 38's room which indicated, STOP .ENHANCE BARRIER PRECAUTIONS .PROVIDERS AND STAFF MUST .Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing .Transferring .Providing Hygiene .Changing briefs .Device care or use: .urinary catheter . During a subsequent interview on 1/6/26 at 3:55 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 confirmed that she and another staff were only wearing gloves when they changed Resident 38's shirt, placed his briefs on, transferred him from the shower chair to his bed, and handled his foley catheter. CNA 3 further confirmed she emptied Resident 38's catheter bag into a urinal while only wearing gloves. CNA 3 stated she was aware that Resident 38 was on EBP and they should have worn gown to prevent possible infection of Resident 38. During a phone interview on 1/8/26 at 1:44 p.m. with the Infection Preventionist (IP), the IP stated that staff should be wearing both gloves and gown when providing high-contact care to a resident who was on EBP to prevent spreading germs and prevent the risk of the resident getting infection. During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated that staff should follow EBP and wear both gloves and gown when transferring, assisting with personal care, and handling the foley catheter of a resident who was on EBP. A review of the facility's policies and procedures (P&P) titled, Enhanced Barrier Precautions, revised 12/2025, indicated, 2. Enhanced barrier precautions apply when: .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .8. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include: a. dressing .c. providing hygiene or grooming; d. changing briefs .e. transferring .i. device care or use ( .urinary catheter .) . 2. During an observation on 1/6/26 at 11:57 a.m. at Station 1, a staff was observed delivering clean resident clothes to resident rooms using a cart covered with reddish mesh tarp. The delivery cart was checked, and thick layers of dust were observed on the inside surface of the cart. During a subsequent interview on 1/6/26 at 11:59 a.m. with Laundry Staff (LS), LS confirmed that the delivery cart had thick layers of dust on its inside surface. The LS stated staff cleans the delivery carts daily. The LS further stated the delivery cart should always be clean to prevent contamination of clean resident clothes. During an interview on 1/7/26 at 8:42 a.m. with the Laundry Director (LD), the LD stated staff were supposed to be cleaning the delivery cart before and after they use it. The LD further stated there should not be any dust inside the clean linen carts because if the carts are dirty, it can cause bacteria to grow and get the resident's sick. During a phone interview on 1/8/26 at 1:44 p.m. with the IP, the IP stated laundry staff should always be cleaning the delivery carts after use to prevent the buildup of dust which could cause infection. During an interview on 1/9/26 at 9:13 a.m. with the DON, the DON stated delivery carts have to be covered and should always be cleaned to prevent contamination of the clean clothes and to prevent infection. A review of the facility's P&P titled, Departmental (Environmental Services) – Laundry and Linen, revised 1/2014, indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen .7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. 3. A review of the admission Record indicated the facility admitted Resident 32 earlier this year with multiple diagnoses, which included dementia, communication deficit, and retention of urine. A review of Resident 32's MDS, dated [DATE], indicated Resident 32 had an indwelling urinary catheter. A review of the clinical records contained a physician order dated 12/15/2025, which indicated, Enhanced Barrier Precautions every shift for Indwelling Catheter. During an observation on 1/6/26 at 12:40 p.m., observed a bright orange signage posted on the wall next to Resident 32's room entrance which indicated, Enhanced Barrier Precautions [EBP] STOP. The signage indicated that everyone must wear gloves and gown for High-Contact Resident Care Activities, including transferring and providing care to urinary catheters. During a continued observation and interview on 1/6/26 at 12:59 p.m., CNA 16 was observed entering Resident 32's room. CNA 16 put gloves on but did not wear isolation gown before assisting Resident 32's transfer from wheelchair to the bed. CNA 16 was observed grabbing the urinary catheter from wheelchair and attaching it to the bed frame. CNA 16 then transferred the resident and rearranged resident's linen and blanket. After the task was completed, CNA 16 was asked what the EBP signage posted outside the room indicated. CNA 16 acknowledged that Resident 32 was on EBP but was not able to explain the reason for precautions. CNA 16 explained, It indicates that we have to sanitize our hands, wear gloves, and isolation gown every time we are providing resident's care. CNA 16 acknowledged that he did not follow the facility's process and did not wear a protective gown. During an interview on 1/9/26 at 9 a.m., the DON stated that it was the expectation for staff to have an isolation gown and gloves every time they have direct contact with resident or residents care equipment for residents who were on EBP precautions, including handling resident's urinary catheter. 4. A review of Resident 125's admission Record indicated Resident 125 was admitted to the facility in September 2025 with multiple diagnoses including dementia (a condition that causes memory loss, also thinking and reasoning decline, that interferes with daily life), obstructive and reflux uropathy (blockage in the urinary tract preventing urine flow), and benign prostatic hyperplasia (enlargement of the prostate gland leading to urinary issues and difficulty emptying the bladder). A review of Resident 125's Minimum Data Set (MDS- federally mandated assessment tool), Bowel and Bladder, dated 9/30/25 indicated Resident 125 had an indwelling urinary catheter. A review of Resident 125's MDS, Bowel and Bladder, dated 12/29/25, indicated Resident 125 had an indwelling urinary catheter. A review of Resident 125's orders dated 9/24/25, 10/13/25, 11/25/25, 12/23/25, indicated order for Indwelling Urinary Catheter S/P (Status Post) TURP (Transurethral Resection of the Prostate-surgery to treat an enlarged prostate) and urinary retention (inability to completely empty the bladder). A review of Resident 125's Care Plan, initiated 9/24/25, revised 11/18/25 .Enhanced Barrier Precautions: Resident requires enhanced barrier precautions .due to the presence of indwelling device . ( .urinary catheter) not known to be infected or colonized with any MDRO . indicated Interventions . Place EBP notification/signage near resident room doorway to alert staff/visitors of precautions . initiated 11/18/25. During an observation on 1/6/26 at 9:04 a.m., observed Resident 125 in bed asleep with an indwelling catheter bag covered with blue bag. There was no sign at door that indicated EBP were needed in Resident 125's room. During a concurrent observation and interview on 1/6/26 at 10:33 a.m. with Certified Nursing Assistant (CNA) 7, CNA 7 confirmed that Resident 125 had an indwelling urinary catheter. CNA 7 confirmed there was no sign at door that indicated EBP and stated was not sure that EBP were needed. During an interview on 1/6/26 at 10:40 a.m. with Licensed Nurse (LN) 6, LN 6 acknowledged that Resident 125 had an indwelling urinary catheter and did not have EBP sign at door. LN 6 stated Resident 125 should be on EBP due to indwelling urinary catheter and should have had sign at door. LN 6 stated that there is a risk of spreading infection if there was no sign at door to indicate EBP needed. During an interview on 1/8/26 at 11:16 a.m. with the Director of Nursing (DON), the DON stated if resident had indwelling urinary catheter should be on EBP and had to have signage at the door indicating EBP needed. A review of the facility's Policy and Procedure (P&P) titled Enhanced Barrier Precautions, revised 12/25, indicated . Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO) to residents .Enhanced barrier precautions apply when: .A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to covered or contained .Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheostomies .Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE [Personal Protective Equipment] required .

Based on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one out of 37 sampled residents (Resident 42) when Resident 42 was suspected for elderly financial abuse by her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves) and was not investigated.This failure resulted in Resident 42 experiencing further financial abuse, and possible serious psychosocial harm.Findings:A review of Resident 42's clinical record indicated Resident 42 was admitted May of 2023 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), dementia (memory loss that interferes with daily functions), and need for assistance with personal care.A review of Resident 42's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/24/25, indicated Resident 42 was rarely/never understood.A review of the complaint letter forwarded by the Department of Justice, dated 7/23/25, indicated, [Resident 42] is currently residing at North Pointe Care Center .She was previously conserved by [resident 42's sister]. [Resident 42] was admitted to SNF [Skilled Nursing Facility] in May 2023. [Resident 42's sister] has not paid the share-of-cost of the facility since March 2024. Sutter County Public Conservator's office was able to access bank records which show [Resident 42's sister] withdrawing [Resident 42]'s full monthly income (minus $25/month for bank fees) .During a concurrent interview and record review on 1/7/26 at 10:12 a.m. with the Business Office Assistant (BOA), Resident 42's records were reviewed. The BOA confirmed that Resident 42's sister/responsible person (RP) had not paid Resident 42's share of cost (SOC- a specific monthly dollar amount some people must pay for healthcare services before Medi-Cal starts paying) from the time it started generating. The BOA explained that usually, the RP will send a check to the facility to pay the resident's share of cost. The BOA also stated she remembers calling Resident 42's sister every week or every other week, but she would not respond at all. The BOA stated she suspected Resident 42 was getting financially abused and that was when she told the Social Services Director (SSD) that Resident 42's sister was not returning any of their calls and had not paid Resident 42's share of cost for months already.During a concurrent interview and record review on 1/7/26 at 10:22 a.m. with the Business Office Manager (BOM), Resident 42's records were reviewed. The BOM confirmed that Resident 42's sister was the conservator upon her admission to the facility. The BOM also confirmed that Resident 42's share of cost had not been paid since March of 2024. The BOM stated she believed the conservator would handle the resident's money. The BOM also stated she reached out to the SSD on 4/22/25 through their internal communication system regarding their suspected financial abuse of Resident 42. The BOM explained that when they suspect financial abuse, they reach out to social services department first and they will be the ones who would report the suspicion. A review of the internal communication message sent by the BOM on 4/22/25 at 8:42 a.m. to the SSD indicated, I [BOM] was wondering if you [SSD] can do a financial abuse [report] for patients [Resident 42] .please.During an interview on 1/7/26 at 11:14 a.m. with the SSD, the SSD stated Resident 42's sister was originally her conservator and they could not reach Resident 42's sister for some time, so she reached out to the Sutter County's Public Guardian's Office about the issue on 1/30/25. The SSD also stated she did not suspect financial abuse at that time because all she knew was they could not contact Resident 42's sister and she had some remaining balances. The SSD explained that if there was suspicion of financial abuse, they would report it to Adult Protective Services, California Department of Public Health, and to the Ombudsman, then it would be investigated. The SSD confirmed there was no investigation done regarding Resident 42's case.A review of Resident 42's Social Service Note, dated 1/30/25, indicated, Writer [SSD] called Sutter County Public Guardians office (530) [PHONE NUMBER] and spoke with [Sutter County Public Guardians office staff] .Writer explained to him that writer has a resident within the SNF who is under a probate conservatorship through sutter county with a family member as the conservator, however we have not been able to reach the family member in some time, and writer would like to know if a referral would be appropriate in this instance .He [Sutter County Public Guardians office staff] stated that he was in court recently and the judge brought up residents [Resident 42] case as a referral for public guardians office, so they are actually already going to be starting the process of investigating and preparing to petition to transfer the conservatorship from resident's sister to the sutter county public guardians office .During an interview on 1/8/26 at 10:46 a.m. with the Administrator (ADM), the ADM stated their process, if there was a suspicion of any form of abuse was, he would get notified first, then they would report the suspicion, and they would do their own investigation. The ADM also stated that reaching out to the Sutter County's Public Guardian's Office regarding Resident 42's case was enough action on their part. The ADM further stated he was made aware about Resident 42's issue before the SSD reached out to the Sutter County's Public Guardian's Office but could not remember the exact date when.During an interview on 1/8/26 at 11:05 a.m. with the ADM, the ADM agreed that it was a red flag when Resident 42's conservator was not answering calls and was not paying Resident 42's share of cost for months. The ADM stated there was no evidence of fiduciary [elderly financial] abuse that was why they did not report Resident 42's issue. The ADM further stated the facility's policy was that all allegations of resident abuse should be thoroughly investigated. During a concurrent interview and record review on 1/8/26 at 12:46 p.m. with the ADM, Resident 42's records were reviewed. The ADM confirmed that Resident 42 started generating share of cost in March of 2024 and Resident 42's conservator did not pay any of it. The ADM stated that they tried to call Resident 42's conservator multiple times but could not reach her. The ADM further stated they received a letter on 5/15/25 from the Public Guardian's office which indicated that Resident 42's conservatorship was changed from her sister to the Public Guardian's Office and the facility started getting paid for Resident 42's share of cost in August of 2025.During an interview on 1/8/26 at 4:12 p.m. with the ADM, the ADM stated they did not investigate Resident 42's issue after they talked to the Public Guardian's office.During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated that all suspicion of abuse should be investigated thoroughly to prevent further abuse from happening to the residents.A review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2025, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Investigating Allegations .1. All allegations are thoroughly investigated. The administrator initiates investigations.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical restraints (physical devices, or equipment that restricted resident movement or ability to get out of bed including bed rails) for one of 37 sampled residents (Resident 149), when the facility did not:Obtain a physician's order for the use of bed rails; 2. Obtain approval from resident or resident's representative (RP) for the use of bed rails; 3. Conduct bed rail assessment prior to placing the quarter side rails and, 4. Develop a care plan to mitigate the risks for entrapment (being caught in or trapped).These failures placed Resident 149 at increased risk for complications of restraint use such as decline in functioning and potential to cause physical harm from entrapment. Findings:A review of Resident 149's admission Record indicated the facility admitted Resident 149 in 2023 with multiple diagnoses, which included Alzheimer's disease (disease characterized by a progressive decline in mental abilities), muscle weakness, and lack of coordination.A review of Resident 149's Order Summary Report contained physician order dated 8/15/25 which indicated Resident 149 was not capable of understanding rights and responsibilities.A review of Resident 149's clinical records contained a Bed Rail and Entrapment Risk Observation/Assessment, dated 5/16/25. The document indicated that bed rails were not currently in use and were not considered to be used. The medical conditions for the use of the bed rails which included the resident's physical mobility limitations, and safety concerns were blank.A review of Resident 149's Order Summary Report did not contain physician order for the use of bilateral bed rails.A review of Resident 149's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/10/25, indicated that the facility did not use any physical restraints, including bed rails while the resident was in bed or in chair.During an observation on 1/6/26 at 9:05 a.m., Resident 149 was observed sleeping in bed with both upper bed rails up. During an observation on 1/8/26 at 10:33 a.m., Resident 149 was observed sleeping in bed with both upper side rails up.During an interview on 1/9/26 at 8:40 a.m., the Director of Nursing (DON) stated that the facility utilized bed side rails to assist with mobility for some residents. The DON explained that prior to using bed side rails, nursing staff were to obtain physician's order for bed rails, obtain consent from resident or resident's RP while explaining the risks for using bed rails, and conduct screening for the safe use of bed side rails.During a concurrent observation and interview in Resident 149's room on 1/9/26 at 8:50 a.m., Resident 149 was sleeping in his bed. The DON validated that the resident had bilateral upper side rails up padded with blue cushioned pads. The DON explained the facility used bed side rails because Resident 149 was impulsive and was at high risk for falls.During a follow up interview and record review on 1/9/26 at 8:50 a.m., the DON stated there should be a physician's order and consent when the facility started using the bilateral side rails for Resident 149, but there was none. The DON acknowledged that no documented consent from Resident 149's RP for the use of bilateral side rails were found in the resident's clinical records. The DON explained that that bed side rail assessment dated [DATE] was not completed because the assessment indicated that no bed side rails were planned to be utilized. The DON stated there was no care plan with resident specific interventions addressing bed side rails developed. The DON stated that without proper documentation in place, the bed side rails were considered as physical restraints.A review of the facility's policy and procedure (P & P) titled, Physical Restraint Application, with revision date of 10/25, indicated, The purpose of this procedure is to provide safety.to the resident to prevent injury.when the resident has medical symptoms that warrant the use of restraints. The P&P explained that any device that has the effect on the resident of restricting freedom of movement.could be considered a restraint. The P&P indicated the process and directed staff to verify physician's order for the use of restraints and review the resident's care plan to assess for any special needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure two out of 37 sampled residents (Resident 13 and Resident 146) were assisted with nail care as part of his Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 13 and Resident 146 had long fingernails with blackish substance underneath. This failure had the potential for Resident 13 and Resident 146 to sustain skin injury and/or to acquire an infection and not achieve their highest practicable well-being.Findings:1. A review of Resident 13's clinical record indicated Resident 13 was admitted March of 2026 and had diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), muscle weakness, and need for assistance with personal care.A review of Resident 13's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 12/15/25, indicated Resident 13 was rarely/never understood. A review of Resident 13's MDS Functional Abilities, dated 12/15/25, indicated Resident 13 needed substantial/maximal assistance with showering/bathing herself and with personal hygiene and supervision or touching assistance with eating.A review of Resident 13's care plan, revised 9/16/25, indicated, ADL/Mobility: [Resident 13] is at risk for ADL/mobility decline and requires assistance related to fluctuating ADLs, mood problems, pain, behavior disturbance r/t [related to] schizophrenia .A review of Resident 13's care plan intervention, dated 9/14/25, indicated, Nails: Trim nails with bathing schedule.A review of the facility's shower schedule indicated Resident 13 was scheduled for shower or bathing every Wednesdays and Saturdays of the week.During a concurrent observation and interview on 1/6/26 at 10:56 a.m. with Resident 13, at the activity area, Resident 13 had long fingernails with blackish substance underneath. Resident 13 stated she wanted her fingernails to be cleaned and trimmed properly.During an observation on 1/6/26 at 12:32 p.m. of Resident 13, in Resident 13's room, Resident 13 was observed eating her lunch meal and still had long fingernails with blackish substance underneath.During a concurrent observation on 1/7/26 at 9:39 a.m. with Resident 13, in Resident 13's room, Resident 13 still had long fingernails with blackish substance underneath.During a concurrent observation and interview on 1/7/26 at 12:55 p.m. with Licensed Nurse (LN) 1, in Resident 13's room, LN 1 confirmed that Resident 13 had long fingernails with blackish substance underneath. LN 1 also confirmed that Resident 13 was able to eat on her own. LN 1 stated Resident 13's fingernails should be trimmed and cleaned to prevent Resident 13 from getting infection or getting skin injuries from her long fingernails.2. A review of Resident 146's clinical record indicated Resident 146 was initially admitted August of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), diabetes (elevated sugar in the blood), lack of coordination, and muscle weakness.A review of Resident 146's MDS Cognitive Patterns, dated 11/17/25, indicated Resident 146 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 146 had severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 146's MDS Functional Abilities, dated 11/17/25, indicated Resident 146 needed supervision or touching assistance with eating and was dependent with showering/bathing self and with personal hygiene.A review of Resident 146's care plan, revised 3/16/25, indicated, ADL/Mobility: [Resident 146] .has actual .is at risk for ADL/mobility decline and requiresassistance related to anticipated declines in condition due to disease process, behavioral symptoms, chronic disease progression, cognitive impairment,fluctuating ADLs, medical condition .Hygiene: Assist of .A review of the facility's shower schedule indicated Resident 146 was scheduled for shower or bathing every Wednesdays and Saturdays of the week.During a concurrent observation and interview on 1/6/26 at 10:03 a.m. with Resident 146, in Resident 146's room, Resident 146 had long fingernails with blackish substance underneath. Resident 146 stated he wanted his fingernails to be cleaned and trimmed properly.During an observation on 1/6/26 at 12:30 p.m. of Resident 146, in Resident 146's room, Resident 146 was observed eating his lunch meal and still had long fingernails with blackish substance underneath.During a concurrent observation and interview on 1/7/26 at 12:47 p.m. of Resident 146 with Certified Nurse Assistant (CNA) 5, in Resident 146's room, Resident 146 was observed eating his lunch meal and still had long fingernails with blackish substance underneath. CNA 5 confirmed the observations. CNA 5 stated Resident 146's fingernails should be trimmed and cleaned. CNA 5 stated staff should do nail care to every resident every day and especially during shower days. CNA 5 further stated nail care should be done to all residents to prevent possible skin tears or infection.During a concurrent interview and record review on 1/9/26 at 8:41 a.m. with LN 3, Resident 13 and Resident 146's clinical records were reviewed. LN 3 confirmed that Resident 13 and Resident 146 had no documented refusals of nail care. LN 3 stated CNAs should be doing nail care for residents who are not diabetic, and nurses should be doing nail care for all residents with diabetes. LN 3 further stated she would expect that all resident's nails would be trimmed and cleaned properly to prevent the risk of skin injury and infection.During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated she would expect that resident nail care would be done during shower days and every Sundays. The DON further stated all residents' fingernails should be trimmed and cleaned properly because of the risk of skin injury, hygiene issues, and possible infection. A review of the facility's policy and procedures (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 4/2025, indicated, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene ( .grooming .) .

Based on observation, interview and record review, the facility failed to ensure one out of 37 sampled residents (Resident 38) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P when Resident 38's foley catheter (a tube inserted through the urethra into the bladder to drain urine) bag was left on the floor.This failure had the potential for Resident 38 to develop infection and possible foley catheter complications.Findings:A review of Resident 38's clinical record indicated Resident 38 was admitted June of 2023 and had diagnoses that included dementia (memory loss that interferes with daily functions), neuromuscular dysfunction of bladder (the nerves and muscles in the urinary bladder don't work together properly), obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract), retention of urine (caused by a blockage or a failure of the bladder to squeeze hard enough to expel all of the urine), catheter use, and muscle weakness.A review of Resident 38's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/17/25, indicated Resident 38 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 2 out of 15 which indicated Resident 38 had severely impaired cognition. A review of Resident 38's MDS Bladder and Bowel Status, dated 11/17/25, indicated Resident 38 uses indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time).A review of Resident 38's active physician's order, dated 6/4/25, indicated, Indwelling Urinary (Foley) Catheter .related to .NEUROMUSCULAR DYSFUNCTION OF BLADDER .change catheter when dislodge. every 24 hours as needed.A review of Resident 38's care plan, revised 11/18/25, indicated, [Resident 38] has indwelling device and is At risk for complications with urinary system (FOLEY CATHETER) related to .indwelling catheter, urinary retention . A review of Resident 38's care plan intervention, revised 10/1/25, indicated, Indwelling Catheter: provide catheter care and empty catheter every shift and as needed.During an observation on 1/6/26 at 9:24 a.m. of Resident 38, in Resident 38's room, Resident 38 was observed lying on bed, awake, and was connected to a urinary catheter tubing attached to a urinary catheter bag. The urinary catheter bag was observed on the floor.During a concurrent observation and interview on 1/6/26 at 12:51 p.m. with Licensed Nurse (LN) 2, in Resident 38's room, Resident 38's urinary catheter bag was still on the floor. LN 2 confirmed the observation. LN 2 stated the urinary catheter bag should not be left on the floor because it may cause infection and to avoid urinary complications.During a concurrent observation and interview on 1/8/26 at 10:32 a.m. with Certified Nurse Assistant (CNA) 4, in Resident 38's room, Resident 38's urinary catheter bag was again on the floor. CNA 4 confirmed the observation. CNA 4 stated the urinary catheter bag should be hanging and off the floor to prevent possible back flow of the urine and risk for infection.During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated urinary catheter bags should always be hanging and off the floor because of the risk of infection and to prevent the urine from flowing back which could cause urinary complications.A review of the facility's P&P titled, Catheter Care, Urinary, revised 8/2025, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .2. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for 1 of 8 sampled residents when:Resident 130's oxygen tubing/nasal cannulas (a medical device connected to an oxygen source used to deliver supplemental oxygen directly into the airways) were not labeled with the date it was first used.This failure had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 130.Findings:A review of Resident 130's clinical record indicated Resident 130 was admitted in June of 2025 and had diagnoses that included chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems) and muscle weakness.A review of Resident 130's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/2130, indicated Resident 130 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 10 out of 15 which indicated Resident 130 had moderately impaired cognition.A review of Resident 130's active physician's orders indicated, . Oxygen- @ [at] 0.5-3 Liters/Min [lpm- unit of measurement for oxygen administration] via Nasal Cannula (Routine) (Medical DX [diagnosis] COPD/SOB [shortness of breath] and . Ipratropium- Albuterol Solution [inhalation medication] 0.5-2.5 3MG/ML (milligram/milliliter- units of measure) 1 application inhale orally via nebulizer [a machine that turns liquid medication into inhalable mist] mist three times a day for COPD . MD orders further indicated to, . Change humidifier bottle and tubing daily every night . and . Change nasal cannula every night every Wed [Wednesday] .During a concurrent observation and interview on 1/7/26 at 9:55 a.m. with Resident 130, in Resident 130's room, Resident 130 was observed using an oxygen concentrator at 3 lpm delivered via oxygen tubing/nasal cannula. Resident 130's oxygen tubing/nasal cannula was not labeled with the date when it was first used. On further observation, it was noted that Resident 130's nasal cannula connected to the oxygen tank on her wheelchair and the tubing connected to the nebulizer also did not have a label indicating when it was first used. Resident 130 confirmed that the oxygen tubing for the nebulizer, oxygen tank on the wheelchair and the oxygen concentrator were not labeled. Resident 130 was unable to confirm when the oxygen tubing was replaced last and could not recall when the nurses normally changed the oxygen tubing.During a concurrent observation and interview 1/7/26 at 9:57 a.m. with Licensed Nurse 9 (LN 9) in Resident 130's room, LN 9 confirmed that Resident 130's oxygen tubing/nasal cannulas (on the oxygen concentrator, the nebulizer on the side of the bed and on the oxygen tank on her wheelchair) were not labeled with the date it was first used. LN 9 stated, It [oxygen tubing/nasal cannula] should have been dated by whoever first opened it . since I do not know when that was, I will have to replace it now and date it . LN 9 further explained that oxygen tubing should be changed and labeled with date first used, every week to prevent infections.During an interview on 1/9/26 at 10:35 a.m. with the Director of Nursing (DON), when asked what her expectations were for labeling of oxygen tubing, the DON stated, Per our policy, the tubing is to be replaced every 7 days . I expect the nurse to label the tubing with date opened . The DON further stated that her expectation was that nurses change tubing for all oxygen delivery systems every seven days and label it with date, resident identifier and nurses' initials.A review of the facility's Policy and Procedure (P&P), the P&P titled, Departmental (Respiratory Therapy)- Prevention of Infection dated November 2025, indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection Control Considerations Related to Oxygen Administration: 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed .

Based on observation, interview, and record review, the facility failed to provide food in accordance with the physician's prescribed diet for one out of 37 sampled residents (Resident 146) when Resident 146 who was on 2 gram (gm/g- unit of measurement) low salt diet (a dietary restriction that limits the intake of salt to 2 grams for the whole day) received a salt packet during the 1/6/26 lunch meal.This failure had the potential to negatively affect Resident 146's medical condition and for Resident 146 not to achieve his highest practicable well-being.A review of Resident 146's clinical record indicated Resident 146 was initially admitted August of 2024 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), diabetes (elevated sugar in the blood), and hypertension (high blood pressure).A review of Resident 146's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/17/25, indicated Resident 146 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 146 had severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 146's MDS Nutritional Status, dated 11/17/25, indicated Resident 146 had therapeutic diet (specific meal plan prescribed by a doctor and planned by a dietitian to treat or manage a medical condition) while he was a resident in the facility. A review of Resident 146's MDS Functional Abilities, dated 11/17/25, indicated Resident 146 needed supervision or touching assistance with eating.A review of Resident 146's care plan, revised 3/16/25, indicated, Hypertension: [Resident 146] has a diagnosis of hypertension .Provide diet as ordered .A review of Resident 146's active physician's order, dated 5/29/25, indicated, 2 Gm Low Sodium [salt] diet .Minced and Moist texture .Moderately Thick consistency pureed fruits and veggies .A review of Resident 146's progress notes, dated 1/6/26, indicated, Resident [Resident 146] noted with +5lbs [increase of five pounds] in 1mo [one month] .No edema noted or SOB [shortness of breath] per nursing. Resident receives multiple meds [medications] that causes weight gain .Ongoing monitoring of PO [oral] intake and weight trends as needed.During a concurrent observation and interview on 1/6/26 at 12:14 p.m. with Resident 146, in Resident 146's room, Resident 146 was observed eating his lunch meal and there was a packet of iodized salt observed in Resident 146's meal tray. Resident 146's meal ticket was checked and indicated, Diet: 2g Na [salt]. Resident 146 stated he did not request the salt packet, and it was just served together with his meal.During a concurrent observation and interview on 1/6/26 at 12:16 p.m. with Certified Nurse Assistant (CNA) 1, in Resident 146's room, CNA 1 confirmed that Resident 146 was served with a salt packet in his lunch meal. CNA 1 stated nurses would check the meal tray, and CNAs would just pass them to the residents. CNA 1 further stated they provide salt packets to residents with 2g Na diet order.During a concurrent observation and interview on 1/6/26 at 12:25 p.m. with Licensed Nurse (LN) 1, in Resident 146's room, LN 1 confirmed that Resident 146 was served with a salt packet in his lunch meal even though his meal ticket indicated, Diet: 2g Na [salt]. LN 1 stated Resident 146 should not be provided with extra salt. LN 1 further stated Resident 146's salt intake should be limited to control his blood pressure or any cardiac issues he has. During an interview on 1/9/26 at 8:50 a.m. with the Registered Dietician (RD), the RD stated a resident who was on 2-gram Sodium diet should only have 2 grams of salt intake for the whole day. The RD also stated CNAs should be aware that Residents with 2g Na diet should not be provided with salt packet in their meal tray. The RD further stated she would expect Resident 146 to not be provided with salt packet in the meal tray because high salt intake could affect Resident 146's medical condition. During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated that the resident's prescribed diet should always be followed because the resident's medical condition would be affected and could get worse. A review of the facility's policy and procedures (P&P) titled, Therapeutic Diets, dated 10/2025, indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care .A review of the facility's P&P titled, DIET ORDERS, dated 2023, indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department.

Based on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of abuse in accordance with section 1150B of the Act for one out of 37 sampled residents (Resident 42) when Resident 42 was suspected for elderly financial abuse by her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves) and was not reported to the state agency, local ombudsman, adult protective services, and law enforcement officials.This failure resulted in a delayed investigation of the suspicion of Resident 42's financial abuse and placed Resident 42 at risk of experiencing further financial abuse, and possible serious psychosocial harm.Findings:A review of Resident 42's clinical record indicated Resident 42 was admitted May of 2023 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), dementia (memory loss that interferes with daily functions), and need for assistance with personal care.A review of Resident 42's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/24/25, indicated Resident 42 was rarely/never understood.A review of the complaint letter forwarded by the Department of Justice, dated 7/23/25, indicated, [Resident 42] is currently residing at [name of the facility] .She was previously conserved by [resident 42's sister]. [Resident 42] was admitted to SNF [Skilled Nursing Facility] in May 2023. [Resident 42's sister] has not paid the share-of-cost of the facility since March 2024. Sutter County Public Conservator's office was able to access bank records which show [Resident 42's sister] withdrawing [Resident 42]'s full monthly income (minus $25/month for bank fees) .During a concurrent interview and record review on 1/7/26 at 10:12 a.m. with the Business Office Assistant (BOA), Resident 42's records were reviewed. The BOA confirmed that Resident 42's sister/responsible person (RP) has not paid Resident 42's share of cost (SOC- a specific monthly dollar amount some people must pay for healthcare services before Medi-Cal starts paying) from the time it started generating. The BOA explained that usually, the RP will send a check to the facility to pay the resident's share of cost. The BOA also stated she remembers calling Resident 42's sister every week or every other week, but she would not respond at all. The BOA stated she suspected Resident 42 was getting financially abused and that was when she told the Social Services Director (SSD) that Resident 42's sister was not returning their calls and had not paid Resident 42's share of cost for months.During a concurrent interview and record review on 1/7/26 at 10:22 a.m. with the Business Office Manager (BOM), Resident 42's records were reviewed. The BOM confirmed that Resident 42's sister was the conservator upon her admission to the facility. The BOM also confirmed that Resident 42's share of cost had not been paid since March of 2024. The BOM stated she believed the conservator would handle the resident's money. The BOM also stated she reached out to the SSD on 4/22/25 through their internal communication system regarding their suspected financial abuse of Resident 42. The BOM explained that when they suspect financial abuse, they reach out to social services department first and they will be the ones to report the suspicion. A review of the internal communication message sent by the BOM on 4/22/25 at 8:42 a.m. to the SSD indicated, I [BOM] was wondering if you [SSD] can do a financial abuse [report] for patients [Resident 42] .please.During an interview on 1/7/26 at 11:14 a.m. with the SSD, the SSD stated Resident 42's sister was originally her conservator and they could not reach Resident 42's sister for some time, so she reached out to the Sutter County's Public Guardian's Office about the issue on 1/30/25. The SSD also stated she did not suspect financial abuse at that time because all she knew was they could not contact Resident 42's sister and she had some remaining balances. The SSD explained that if there was suspicion of financial abuse, they would report it to Adult Protective Services, California Department of Public Health, and to the Ombudsman. The SSD confirmed there was no report made regarding Resident 42's case.A review of Resident 42's Social Service Note, dated 1/30/25, indicated, Writer [SSD] called Sutter County Public Guardians office (530) [PHONE NUMBER] and spoke with [Sutter County Public Guardians office staff] .Writer explained to him that writer has a resident within the SNF who is under a probate conservatorship through sutter county with a family member as the conservator, however we have not been able to reach the family member in some time, and writer would like to know if a referral would be appropriate in this instance .He [Sutter County Public Guardians office staff] stated that he was in court recently and the judge brought up residents [Resident 42] case as a referral for public guardians office, so they are actually already going to be starting the process of investigating and preparing to petition to transfer the conservatorship from resident's sister to the sutter county public guardians office .During an interview on 1/8/26 at 10:46 a.m. with the Administrator (ADM), the ADM stated their process, if there was a suspicion of any form of abuse was, he would get notified first, then they would report the suspicion, and they would do their own investigation. The ADM also stated that reaching out to the Sutter County's Public Guardian's Office regarding Resident 42's case was enough action on their part. The ADM further stated he was made aware about Resident 42's issue before the SSD reached out to the Sutter County's Public Guardian's Office but could not remember the exact date when.During an interview on 1/8/26 at 11:05 a.m. with the ADM, the ADM agreed that it was a red flag when Resident 42's conservator was not answering calls and was not paying Resident 42's share of cost for months. The ADM stated there was no evidence of fiduciary [elderly financial] abuse that was why they did not report Resident 42's issue. The ADM further stated the facility's policy was to report all suspicion of any form of resident abuse including financial abuse. During a concurrent interview and record review on 1/8/26 at 12:46 p.m. with the ADM, Resident 42's records were reviewed. The ADM confirmed that Resident 42 started generating share of cost in March of 2024 and Resident 42's conservator did not pay any of it. The ADM stated that they tried to call Resident 42's conservator multiple times but could not reach her. The ADM further stated they received a letter on 5/15/25 from the Public Guardian's office which indicated that Resident 42's conservatorship was changed from her sister to the Public Guardian's Office and the facility started getting paid for Resident 42's share of cost in August of 2025.During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated that all suspicion of resident abuse should all be reported for it to be investigated thoroughly.A review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2025, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Reporting Allegations to the Administrator and Authorities .1. If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman .d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials .4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

Based on interview and record review, the facility failed to update and revise resident's care plans (documents that summarizes resident's needs, goals, and care/treatment) for one of 37 sampled residents (Resident 4), after the physician discontinued orders for resident's splint (a device to immobilize joint) and fluid restriction (means limiting person's intake of liquids due to health conditions).These failures increased the potential to result in confusion in the delivery of care and services to Resident 4 and the resident continued to receive care and treatment that was discontinued. A review of the admission Record indicated that the facility admitted Resident 4 in 2015 with multiple diagnoses, which included metabolic encephalopathy (brain disfunction, leading to confusion, memory issues, and personality changes), dementia (a progressive state of decline in mental abilities), muscle weakness, and contracture of muscle in right hand (a condition when tissue under the palm thickens and fingers are curled, which limits person's ability to use their hand).A review of Resident 4's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/29/2025, indicated that the resident had severely impaired cognitive skills (mental abilities, including remembering things, making decisions, concentrating, or learning) and limitations to upper extremities. The MDS indicated that Resident 4 was totally dependent on staff with all activities of daily living (ADLs - activities related to personal care).A review of the MDS dated [DATE], the section for special treatments, procedures, and programs indicated that a splint was applied to Resident 4.During an observation on 1/6/26 at 10:30 a.m., Resident 4 was in her bed, holding her hands close to her chest. Resident 4 had a splint (a device to support her right hand's fingers). No water was observed on resident's nightstand or bedside table.A review of Resident 4's flow sheets from 12/11/25 through 1/8/26 indicated that the splint was applied to resident's right hand every day.During a review of the Resident 4's care plan, initiated 11/27/24 with the last revision date of 12/23/25, the care plan indicated that Resident 4 required splinting to her right hand for 2 hours a day 7 days a week.A review of Resident 4's physician order indicated for splint to right upper extremity was discontinued on 12/2/25.A review of Resident 4's physician orders for diet dated 12/29/25 indicated that resident received pureed (pudding like texture) diet and her liquids were mildly thick consistency (like cream soup, used for residents with swallowing difficulties).A review of Resident 4's clinical records contained a flow sheet for daily fluid intakes from 12/11/25 through 1/8/26 indicating that the resident was on strict fluid restriction of 1.5 liters (unit of measurements) in 24 hours.A review of Resident 4's care plan initiated 4/2/24 with the last revision date of 12/23/25 indicated that the resident was at risk for altered nutrition related to dementia with inability to care for herself and fluid restriction. One of the care plan interventions indicated that the resident was on fluid restriction of 1.5 liters.A review of Resident 4's physician orders indicated that the physician ordered strict fluid restriction 1.5 liters on 7/13/24 and had discontinued the order on 10/31/25.During an interview on 1/8/26 at 8:30 a.m., with the Director of Nursing (DON), the DON stated that residents' care plans were required to be reviewed and revised after residents' change of condition and when the physician discontinued the order. The DON explained that the facility usually reviewed and revised residents' care plans every month to ensure the effectiveness of care plan interventions.During a concurrent interview and record review on 1/8/26 at 9:10 a.m., Resident 4's active orders and flowsheets for right hand splinting and fluid restriction were reviewed with Licensed Nurse (LN 2). LN 2 confirmed that the resident's flow sheets indicated the resident was on fluid restriction and splinting of her right hand. LN 2 stated, I don't see any physician's order for splinting and fluid restrictions.During an interview on 1/8/26 at 9:20 a.m., with Certified Nursing Assistant (CNA 8) in Resident 4's room, CNA 8 stated that Resident 4 was non-verbal and dependent on staff with feeding and ADLs. CNA 8 stated Resident 4 was on fluid restriction and explained that all fluids given with medications, meals, and in between meal were to be calculated and should not exceed what the physician ordered. CNA 8 stated she was not aware that the order for fluid restriction for Resident 4 was discontinued. CNA 8 uncovered Resident 4's right hand with splint on and stated that Restorative Nursing Assistants (RNA's) applied the splint in the morning and removed it 2 hours later.During an interview on 1/8/26 at 9:30 a.m., (RNA 1) explained that Resident 4 had her splint placed to her right hand every day and removed after 2 hours. RNA 1 stated that the therapy communicated to RNAs regarding new orders and when the orders were discontinued. RNA 1 stated she was not aware that the order for Resident 4's right hand splint was discontinued.During an interview and concurrent record review with Unit Manager (UM) on 1/8/26 at 9:38 a.m., UM stated that Resident 4's order for strict fluid restriction was discontinued on 10/31/25 and the order for splint was discontinued on 12/2/25. Upon reviewing the flow sheets for the resident's splint and fluid restriction, the UM acknowledged that the order for discontinuation of fluid restriction was not carried out. The UM verified that licensed staff did not revise or update Resident 4's care plans addressing resident's splint and fluid restriction. The UM agreed that not updating and/or not revising resident's care plans had the potential to provide inappropriate care to Resident 4.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 3/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated that care plan interventions were chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The policy indicated that the assessments of residents were ongoing, and care plans were to be revised as information about the residents and the residents' conditions changed.

Based on interview and record review, the facility failed to protect one out of 37 sampled residents' (Resident 42) right to be free from elderly financial abuse by a family member/legal representative when Resident 42 experienced financial abuse by her sister who was also her conservator (a court-appointed individual who manages the financial and/or personal affairs for someone unable to do so themselves).This failure resulted in Resident 42 experiencing financial abuse, and possible serious psychosocial harm.Findings:A review of Resident 42's clinical record indicated Resident 42 was admitted May of 2023 and had diagnoses that included metabolic encephalopathy (a condition where the brain does not receive enough nutrients or oxygen to function properly, leading to altered brain function), dementia (memory loss that interferes with daily functions), and need for assistance with personal care.A review of Resident 42's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/24/25, indicated Resident 42 was rarely/never understood.A review of the complaint letter forwarded by the Department of Justice, dated 7/23/25, indicated, [Resident 42] is currently residing at [name of the facility] .She was previously conserved by [resident 42's sister]. [Resident 42] was admitted to SNF [Skilled Nursing Facility] in May 2023. [Resident 42's sister] has not paid the share-of-cost of the facility since March 2024. Sutter County Public Conservator's office was able to access bank records which show [Resident 42's sister] withdrawing [Resident 42]'s full monthly income (minus $25/month for bank fees) .During a concurrent interview and record review on 1/7/26 at 10:12 a.m. with the Business Office Assistant (BOA), Resident 42's records were reviewed. The BOA confirmed that Resident 42's sister/responsible person (RP) has not paid Resident 42's share of cost (SOC- a specific monthly dollar amount some people must pay for healthcare services before Medi-Cal starts paying) from the time it started generating. The BOA explained that usually, the RP will send a check to the facility to pay the resident's share of cost. The BOA also stated she remembers calling Resident 42's sister every week or every other week, but she would not respond at all. The BOA stated she suspected Resident 42 was getting financially abused and that was when she told the Social Services Director (SSD) that Resident 42's sister was not returning their calls and had not paid Resident 42's share of cost for months.During a concurrent interview and record review on 1/7/26 at 10:22 a.m. with the Business Office Manager (BOM), Resident 42's records were reviewed. The BOM confirmed that Resident 42's sister was the conservator upon her admission to the facility. The BOM also confirmed that Resident 42's share of cost had not been paid since March of 2024. The BOM stated she believed the conservator would handle the resident's money. The BOM also stated she reached out to the SSD on 4/22/25 through their internal communication system regarding their suspected financial abuse of Resident 42. The BOM explained that when they suspect financial abuse, they reach out to social services department first and they will be the ones to report the suspicion. A review of the internal communication message sent by the BOM on 4/22/25 at 8:42 a.m. to the SSD indicated, I [BOM] was wondering if you [SSD] can do a financial abuse [report] for patients [Resident 42] .please.During an interview on 1/7/26 at 11:14 a.m. with the SSD, the SSD stated Resident 42's sister was originally her conservator and they could not reach Resident 42's sister for some time, so she reached out to the Sutter County's Public Guardian's Office about the issue on 1/30/25. The SSD further stated she did not suspect financial abuse at that time because all she knew was they could not contact Resident 42's sister and she had some remaining balances.A review of Resident 42's Social Service Note, dated 1/30/25, indicated, Writer [SSD] called Sutter County Public Guardians office (530) [PHONE NUMBER] and spoke with [Sutter County Public Guardians office staff] .Writer explained to him that writer has a resident within the SNF who is under a probate conservatorship through sutter county with a family member as the conservator, however we have not been able to reach the family member in some time, and writer would like to know if a referral would be appropriate in this instance .He [Sutter County Public Guardians office staff] stated that he was in court recently and the judge brought up residents [Resident 42] case as a referral for public guardians office, so they are actually already going to be starting the process of investigating and preparing to petition to transfer the conservatorship from resident's sister to the sutter county public guardians office .A review of the facility's transaction report indicated Resident 42 had an unpaid share of cost total of $15,594 from March 2024 to January 2025.During an interview on 1/8/26 at 10:46 a.m. with the Administrator (ADM), the ADM stated that reaching out to the Sutter County's Public Guardian's Office regarding Resident 42's case was enough action on their part. The ADM further stated he was made aware about Resident 42's issue before the SSD reached out to the Sutter County's Public Guardian's Office but could not remember the exact date when.During an interview on 1/8/26 at 11:05 a.m. with the ADM, the ADM agreed that it was a red flag when Resident 42's conservator was not answering calls and was not paying Resident 42's share of cost for months. The ADM stated there was no evidence of fiduciary [elderly financial] abuse that was why they did not report Resident 42's issue. The ADM also stated that when they reached out to the Public Guardian's Office regarding Resident 42's case, they were told it was a case were they would normally change the conservatorship. The ADM further stated the facility's policy was to protect all residents from any form of abuse including financial abuse. During a concurrent interview and record review on 1/8/26 at 12:46 p.m. with the ADM, Resident 42's records were reviewed. The ADM confirmed that Resident 42 started generating share of cost in March of 2024 and Resident 42's conservator did not pay any of it. The ADM stated that they tried to call Resident 42's conservator multiple times but could not reach her. The ADM further stated they received a letter on 5/15/25 from the Public Guardian's office which indicated that Resident 42's conservatorship was changed from her sister to the Public Guardian's Office and the facility started getting paid for Resident 42's share of cost in August of 2025.A review of the facility's transaction report indicated Resident 42 had an unpaid share of cost total of $21,412 from March 2024 to May 2025.During an interview on 1/9/26 at 9:13 a.m. with the Director of Nursing (DON), the DON stated that all residents in their facility should be free from any form of abuse.During a phone interview on 1/14/26 at 2:39 p.m. with an Adult Protective Services Supervisor (APSS), the APSS stated they received a referral from Sutter County Public Conservator's office about Resident 42's change of conservatorship. The APSS further stated that after Sutter County Public Conservator's office gained access to Resident 42's account, they had found fraudulent activities (intentional deception or unethical acts to gain an unauthorized benefit like money) in Resident 42's account. A review of the facility's policy and procedures (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2025, indicated, Residents have the right to be free from abuse .The resident abuse, neglect and exploitation prevention program consists of a facility -wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse .by anyone including, but not necessarily limited to: .f. family members; g. legal representatives .

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from verbal and physical abuse by Resident 2 for one of three sampled residents (Resident 1) when Resident 2, who had a history of verbal threats struck Resident 1 in the face.This failure resulted in Resident 2 striking Resident 1 causing lacerations to Resident 1's eyebrow, nose and cheek, caused pain, and had the potential for Resident 1 to experience emotional distress.Findings:A review of the admission Record indicated the facility admitted Resident 1 in May 2025 with multiple diagnoses which included dementia (a progressive state of decline in mental abilities).A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/11/25 indicated the resident was cognitively impaired (decline in mental ability).A review of Resident 1's care plan addressing cognitive impairment dated 9/25/25 indicated that resident had decreased ability to make self-understood and understand others and impaired decision making. The nursing measures directed staff to anticipate Resident 1's needs and meet them promptly.A review of Resident 1's care plan titled Injury, dated 9/10/25 indicated the resident had injury to his face as evidenced by lacerations to right eyebrow, abrasion with swelling on nose bridge area and discoloration on right periorbital area [tissues surrounding eye] with swelling d/t [due to] alleged abuse.During an observation in the presence of Licensed Nurse (LN 1) on 9/25/25, at 12:15 p.m., Resident 1 was sitting in wheelchair in the dining room getting ready to eat his lunch. Resident 1 was observed with swollen nose, dry scab on the bridge of the nose and on his right eyebrow. Resident 1's nose area and right periorbital (eye area) had large fading yellow-purplish bruises. During an interview on 9/25/25 at 12:15 p.m., Resident 1 was asked what happened to his face and the resident was not able to provide any details. Resident 1 was asked if he had a fall and injured himself or he obtained the injury when someone hit him, and the resident was not able to explain what happened.A review of Resident 1's clinical records contained a document titled, SBAR Summary for Providers [Situation, Background, Assessment, and Recommendation, a communication form] dated 9/10/25, at 9:47 a.m., informing resident's physician that the resident experienced a change in condition (COC) on 9/10/25 at 10 a.m. The COC document indicated, At approximately 09:30 [9:30 a.m.], resident reported to staff that another male individual allegedly struck him. Resident stated, he hit me because he said I was making noise, but I wasn't. The document indicated that Resident 1 had laceration [a tear or rip in the skin] on his right eyebrow measuring 2 cm (centimeters, unit of measurement) in width, 3 cm in length, and 0.5 cm deep, laceration[ to his nose 2 cm wide and 3 cm long, and laceration to cheek 1 cm wide and 2 cm long. The note indicated, Resident c/o [complained of] pain [sic] the bridge nose. The COC note indicated that the resident was sent to emergency department to be evaluated per physician order.A review of Resident 2's admission record indicated the facility admitted him in the spring of 2025 with multiple diagnoses including dementia, anxiety and depression.A review of Resident 2's MDS dated [DATE] indicated the resident was cognitively impaired. The MDS indicated that Resident 2 had behaviors of verbally threatening, screaming, and/or cursing at others, and had physical behaviors of pushing and hitting others. A review of Resident 2's care plan dated 3/4/25 indicated that resident had potential to demonstrate physical behaviors (can strike or hit) and verbal behaviors (by stating I will punch you r/t [related to] anger, dementia, depression, history of harm to others, poor impulse control. The care plan goal indicated, Will not harm self or others. The interventions included, Monitor/document/report to MD [Medical Doctor] of danger to self and others.When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress. A review of the nursing progress notes (NPN) indicated that Resident 2 had multiple episodes of aggressive behaviors toward Resident 1 who was his roommate.The NPN dated 8/3/25 at 12:36 p.m., indicated, Patient [Resident 2] is being really aggressive towards the roommates. He [Resident 2] told him [Resident 1] to get out of my property otherwise you will be responsible for consciences [sic].The NPN dated 8/4/25 at 8:42 a.m., indicated, Patient [Resident 2] exhibiting aggressive behavior with staff and roommates.The NPN dated 8/11/25 at 4 a.m., indicated, .resident was agitated and stated get him [Resident 1] out or I will hurt him.The NPN dated 8/20/25 at 7:59 a.m., and 1:48 p.m., contained communication notes to physician indicating that Resident 2 was 'Verbally aggressive and attempting to be physically aggressive towards roommate.pt [Patient, Resident 2] attempting to kick our [sic] roommate from room and cussing at him.Attempted to push roommate out of room and said Get that [expletives] out of here.The NPN dated 9/6/25 at 1:34 p.m., contained communication note informing physician that Resident 2 went to bathroom and after he finished, he attempted to smear the dirty toilet tissue on his roommate stating, I'm going to brown face you.A review of COC communication note dated 9/10/25 at 10 a.m., indicated, Therapy staff reported that [Resident 2] stated coming out of room Get that [expletives] out of my room.Entered both residents room.Assessed the roommate [Resident 1].Resident [2] was not present in the room.Resident [2] was located and assessed.Resident [2] is wearing ring on right hand.During an interview with LN 1 on 9/26/25 at 12:30 p.m., LN 1 described Resident 1 as non-ambulatory and requiring staff's assistance with transferring to and from wheelchair. LN 1 stated Resident 1 had yelling and screaming behaviors directed at staff during personal care, but no verbal or physical behaviors toward Resident 2 or other residents. LN 1 stated Resident 2 was ambulating independently. LN 1 stated Resident 2 had frequent behaviors of verbal aggression toward Resident 1 and other residents and required frequent staff's observation and redirection. LN 1 added, Apparently he did not like his roommate [Resident 1].During a continued interview with LN 1 on 9/26/25, commencing at 12:30 p.m., LN 1 stated Resident 1 and Resident 2 were assigned to him on 9/10/25 when the alleged abuse happened. LN 1 stated he was alerted by a Certified Nursing Assistant (CNA 1) that Resident 1 had bloody face, his nose and right eye were swollen and that the resident pointed towards his roommate's bed. LN 1 stated after he attended to Resident 1's facial lacerations, he went to talk to Resident 2 who was in the dining room. LN 1 stated Resident 2 could not provide any details what happened and denied hitting Resident 1. LN 1 mentioned that Resident 2 had a large ring on his right hand, but there was no blood or other markings on the resident's hands. Discussed that sharp edges of the ring could have caused lacerations to Resident 1's face when Resident 2 struck him and he could have walked to the bathroom and washed his hands and LN 1 agreed.During an interview with CNA 2 on 9/26/25, at 1 p.m., CNA 2 stated Resident 2 was observed being angry and yelling at the residents in the dining room on many occasions.During an observation on 9/26/25, at 1:13 p.m., Resident 2 was observed leaving the dining room and walking in the hall. Resident 2 was unstable and was holding onto the wall when he ambulated and a large bulky ring was observed on his right hand. Resident 2 stated he had trouble finding his room. When the resident was asked if he was getting along with other residents, Resident 2 replied, Not always.some of them are too noisy. When Resident 2 was asked about incident with his roommate (Resident 1) he did not provide any details. After a moment Resident 2 added, This is my home and I live alone. I don't need anyone in my room. During an interview with Physical Therapy Staff (PTS) on 9/26/25, at 1:17 p.m., PTS stated he worked with Resident 2 frequently and in order for the resident to participate in therapy the resident had to be in good mood. The PTS added, I have not seen anything physical, but he is verbally aggressive to other residents; I've seen on multiple occasions. The PTS stated that he was working with another resident in the morning on 9/10/25 when he met Resident 2 near nursing station 2. The PTS added, He seemed on the verge of being very angry, was loudly talking to himself. I heard him saying something like hurting my roommate.During an interview with CNA 1 on 9/26/25, at 1:45 p.m., CNA 1 stated that when she went to check on Resident 1 on 9/10/25 the resident was in bed. CNA 1 stated when she entered the resident's room, Resident 1 pointed to his face and said, look at my face. CNA 1 added that Resident 1's face was bloody, the face and nose were red and right side of the face was swollen.He pointed to his roommate's bed, closer to the door but did not say what happened. A review of the facility's 'Abuse Prevention Program,' with revision date of 8/2006 indicated, Our residents have the rights to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to .other residents.A concurrent interview and review of Resident 2's clinical record was conducted with Administrator (ADM) on 9/30/25, at 3:05 p.m. Upon reviewing nursing progress notes dated 8/3/25, 8/4/25, 8/11/25, 8/20/25, and 9/6/25 the ADM stated he was aware of Resident 2's multiple verbal aggressive behaviors toward Resident 1. The ADM added, [Resident 2's name] had history of threatening his roommate, but never done anything physical. The ADM agreed that Resident 2's verbal aggression and threatening placed Resident 1's safety at risk. The ADM confirmed that on 9/10/25 Resident 1 was found in his room with swollen bloody face and multiple facial lacerations. The ADM added, The incident happened, but we can't say for sure that it was [Resident 2] that hit [Resident 1], he might have injured himself. The ADM acknowledged that the facility was responsible for keeping all residents safe. When asked about interventions to keep Resident 1 safe, the ADM stated the staff were to provide snacks, redirect, and engage Resident 2 in activities. When asked if the interventions were effective, the ADM did not respond.A review of the facility's policy titled, Safety and Supervision of Residents, revised 7/2017, indicated, Resident safety and supervision.are facility-wide priorities.Safety risks.are identified on an ongoing basis.Resident supervision is a core component of the system approach to safety.The type and frequency of resident supervision may vary.Resident supervision may need to be increased when.there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to protect 2 of 6 sampled residents (Resident 2 and Resident 4) from abuse when: 1. Resident 1 pulled Resident 2's walker causing him to fall, and 2. Resident 3 punched Resident 4 on the face during an altercation. These failures resulted in Resident 2 sustaining a right intertrochanteric fracture (broken hip bone) and underwent hip arthroplasty (a surgery to replace the broken hip bone with an artificial implant) and Resident 4 had the potential to experience physical injury and emotional distress. Findings: 1.A review of Resident 1's admission record indicated he was admitted to the facility summer of 2024 with multiple diagnoses that included Dementia with agitation (impaired ability to remember, think, or make decisions). A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 6/20/24, indicated, he had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). His behavior assessment section indicated he exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred every 1 to 3 days. A review of Resident 1's care plan indicated, [Resident 1] has potential to demonstrate physical behaviors r/t [related to] Anger, Dementia, History of harm to others .Date Initiated: 06/21/2024 .will not harm self or others .Interventions included .Monitor/document report to MD [Medical Doctor] of danger to self and others .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress . A review of Resident 2's admission record indicated he was admitted to the facility spring of 2024 with multiple diagnoses that included Alzheimer's Disease (a brain disorder that affects memory, thinking, and behavior). A review of Resident 2's MDS dated [DATE], indicated, he had severe cognitive impairment. His functional status indicated Resident 2 had no limitation in range of motion on both upper and lower extremities. His MDS Significant Change in Status Assessment (post fall) dated 7/8/24, indicated he had developed a limitation in range of motion on his lower extremity. A review of Resident 2's Progress notes, dated 6/29/2024, indicated, While trying to enter the facility from the smoking area, pt [patient, Resident 1] and [Resident 2] were having a verbal disagreement then pt was aggressive towards [Resident 2]. pt pulled [Resident 2's] walker and caused him to fall on his back. [Resident 2] has skin tear on right elbow and pain on hip . A review of Resident 2's Nurse's notes, dated 6/29/2024, indicated, [name] radiology dept [department] could not give a eta [estimated time of arrival] when the x-rays will be done as no tech has been assigned at this time. Will transport to [name of hospital] . A review of Resident 2's Nurse's notes, dated 6/30/2024, indicated, [Hospital's name] called for an update resident admitted with rt [right] femur fx [fracture]. A review of Resident 2's Physician History and Physical, dated, 7/5/2024 indicated, Patient lives at a facility apparently per staff report patient had altercation with another resident took the patient's walker and pushed into the ground patient landed on his back did not strike his head. In the ED [ emergency department] x-rays revealing right intertrochanteric fracture underwent R hip arthroplasty on 7/1/24 . During a concurrent observation and interview on 7/10/24 at 12:36 p.m., Resident 2 was sitting on his wheelchair, eating lunch by the nurse's station. He stated he could not remember the incident and he could not remember why he was admitted to the hospital. He stated, he should go back to bed because his hip was hurting. During a concurrent observation and interview on 7/10/24 at 12:40 p.m., the Certified Nursing Assistant (CNA 1) stated Resident 1 was recently transferred to the behavior room where residents were monitored every 15 minutes. He stated, Resident 1 was in station 2 as he liked to walk around. CNA 1 was observed going to station 2 to look for Resident 1. Resident 1 was then seen coming in the door in station 2 from the backyard alone. CNA 1 pointed to where Resident 1 was and proceeded to going back to the behavior room. Resident 1 walked to his room and talked about his wife but at times was unable to maintain meaningful conversation. Resident 1 stated he could not remember the incident. During an interview on 7/10/24 at 1:28 p.m., the Licensed Nurse (LN1) stated, she was at the nurses' station when she heard screaming and argument between Resident 1 and Resident 2. Resident 2 was in his room and Resident 1 was coming in the door from the smoking patio. Resident 1 was standing in front of Resident 2 when Resident 1 pulled Resident 2's walker. Resident 1 picked Resident 2's walker and was about to hit him on his head and by that time, LN 1 stated, she ran towards them and stopped him. Resident 2 lost balance and fell . LN 1 stated, Resident 2 was on the floor, bleeding from right elbow and he was saying his leg hurt. LN 1 stated Resident 1 had behaviors, sometimes he could walk around quietly then suddenly if something upsets him, he will punch you. She further stated, Resident 1 gets aggressive at times; he would punch without saying anything. During a telephone interview on 7/10/24 at 3:57 p.m., the LN 2 stated, Resident 2 was standing on the doorway of his room when Resident 1 pushed the walker into him causing him to fall. LN 2 stated, she did not think he was trying to take Resident 2's walker. She stated, Resident 1 was upset, and he pushed Resident 2. LN 2 stated, it was just that one push and Resident 2 fell and by that time the staff were able to separate the residents. The LN 2 further stated, she has not seen Resident 1 being physically aggressive, but his son informed them that can be physically aggressive. She stated, they monitor both residents for behaviors that they noticed during the shift. She stated, we keep an eye on everyone not just these two residents. During a telephone interview on 7/12/24 at 1:09 p.m., the Director of Nursing (DON) stated, Resident 1 and Resident 2 were having a verbal disagreement in the hallway when Resident 1 pulled Resident 2's walker away from him that caused Resident 2's fall and he had a broken femur where he needed surgery for the fracture. The DON stated Resident 1 had behaviors and he had a care plan for the behavior. She also stated, Resident 1 had a monitoring for aggression but was not on every 15 minutes monitoring. The DON further stated, we try to monitor them [the residents] closely but sometimes it [altercations] can't be avoided. She stated, she expected the residents to be monitored closely to avoid these altercations from happening and if there was a care plan, she expected the staff to follow the care plan. 2. A review of Resident 3's admission record indicated, he was admitted to the facility winter of 2023 with multiple diagnoses that included Dementia, unspecified severity, without behavioral disturbance, mood disturbance and anxiety. His MDS, dated [DATE], indicated he had moderate cognitive impairment. A review of Resident 4's admission record indicated he was admitted to the facility summer of 2024 with multiple diagnoses that included Dementia, unspecified severity, with other behavioral disturbance. His MDS dated [DATE] indicated he had severe cognitive impairment. His behavior assessment indicated he exhibited both physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days. A review of Resident 4's care plan indicated the following: [Resident 4] has potential to demonstrate verbally aggressive behaviors r/t Dementia .Date Initiated: 04/30/2024 .[Resident 4] will not harm self or others through the review date interventions included: Monitor and Document observed behavior and attempted interventions in chart. When [Resident 4] becomes agitated: Intervene before agitation escalates; Guide away from source of distress . [Resident 4] has potential to demonstrate physical behaviors r/t [related to] Dementia .Date Initiated: 04/30/2024 .[Resident 4] will not harm self or others through the review date. Date Initiated: 04/30/2024, interventions included: When [Resident 4] becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation. A review of Resident 4's Nurse's notes, dated 7/9/24, indicated, Resident had a Peer to peer physical alteration [sic] with roommate. Staff heard yelling coming from the resident's room Get out of here and another No you get out of here. When the staff arrived to the room, they found the resident and roommate in front of each other and both had their hands up in the air toward each other . During a concurrent observation and interview on 7/10/24 at 12:11 p.m., Resident 4 was sleeping on his bed when a CNA came in to wake him up to ask him if he wanted to eat lunch. Resident 4 woke up and stated he wanted to eat lunch. Resident 4 then sat on his bed. He had a beard and mustache. When asked about the incident with his previous roommate, he stated, He hit me and he pointed on the right side of his face. He stated he could not remember the reason, but he punched me, I don ' t remember why .he's not here in the room now . There was no redness observed on his face. During a concurrent observation and interview on 7/10/24 at 12:30 p.m., Resident 3 was standing by his bed. Resident 3 stated, he was trying to open the cupboard and his previous roommate said it was his. Resident 3 stated, I told him it's mine, he swore at me, and he said f**** you .I punched him on the face .Yeah, I hit him on the right side of his face .He said f*** you .I ' m telling you that the clothes is mine. So I, told him the clothes is mine .I punched him right on his face .He had a beard .His face is scary. Resident 3 further stated, he was aggressive to me, he told me this is not yours; this is mine (referring to his clothes) . During an interview on 7/10/24 at 1:41 p.m., the LN 3 stated the Director of Staff Development (DSD) was the one who heard the screaming and saw both Residents in the room with both resident's arms up in front of each other looking like it's a striking pose. The LN stated, Resident 3 stated Resident 4 told him to get out of his room and that was when he punched Resident 4 on his face. During an interview on 7/10/24 at 2:00 p.m., the DSD stated she was in the hallway talking to one of the residents when she heard shouting, get out of here, the other resident was saying no, you get out of here, it was loud and shouting. The DSD then ran into the room and both residents were in the position trying to hit each other, there was a space in between them, and she stood in front of them. The DSD stated she told them to stop but they continued to try to hit each other, she then shouted for help. The DSD further stated, Resident 4 told her Resident 3 hit him but could not point exactly where he was hit. During a telephone interview on 7/12/24 at 1:09 p.m., the DON stated, both residents had behaviors. Resident 3 was territorial and aggressive and the same thing with Resident 4 who also had verbal aggression. The incident was not witnessed it was after they heard the commotion then they tried to stop the incident, and nobody witnessed how it happened. The DON further stated, she expected the staff to monitor residents closely to avoid these altercations from happening. If there was a care plan she expected the staff to follow it. A review of Facility policy titled, Resident-to-Resident Altercations, revised September 2022, indicated, 1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents . A review of Facility policy titled, Resident Rights, revised February 2021, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect . A review of Facility policy titled, Abuse Prevention Program, revised August 2006, Our residents have the right to be free from abuse .Our facility is committed to protecting our residents from abuse by anyone including .other residents .

Based on interview, and record review, the facility failed to protect one resident (Resident 1) in a census of 139 from physical abuse when the facility assigned Resident 1, known to have wandering behaviors, to a room with a resident (Resident 2) known to have aggressive and territorial behaviors. This failure resulted in Resident 2 physically attacking her roommate, Resident 1, in their room resulting in a physical injury. Findings: Resident 2 was admitted to the facility in July 2017 with diagnoses, which included [CONDITION(S)] (a serious mental illness that affects how a person thinks, feels, and behaves), dementia (impairment in memory, communication, and thinking), and persistent mood disorders (a mental health problem that primarily affects a person's emotional state). Review of Resident 2's care plan for behavioral symptoms, dated 7/14/18, indicated Resident 2 had alterations in her mood and behaviors as was evidenced by verbal and physical aggression, verbally threatening staff and residents, territorial behaviors (not wanting others in her personal space), and involvement in altercations with other residents as either the victim or the aggressor. The care plan indicated approaches to reduce the number of behaviors, which included, Remind resident to ask for help .Encourage resident to not use physical aggression to solve conflicts with peers .Monitor for safety as Resident has been a victim/aggressor of peer to peer altercations .Monitor for aggressive behavior .[name brand for olanzepine, an anti-psychotic medication] for Physical Aggression . Resident 1 was admitted to the facility in May 2019 with diagnoses, which included dementia, and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 1's care plan for behavioral symptoms, dated 5/14/19, indicated Resident 1 had alterations in her mood and behaviors as was evidenced by verbal aggression towards others, was impatient and would attempt to run into people with her wheelchair, and had exhibited aggressive behaviors. The care plan indicated approaches, which included, Monitor resident for safety d/t [due to] wandering behavior [occurs when a person suffering from dementia roams around and becomes lost or confused about their location] . Review of Resident 2's Medications Administration History (MAH) for July 2020, indicated the nurses were monitoring Resident 2 for behaviors of physical aggression, and were recording how often the behavior occurred daily on each shift. The MAH indicated Resident 2 exhibited physical aggression 55 times in the month of July 2020. Review of Resident 2's Event Report, dated 7/20/20, indicated Resident 2 was the aggressor in an altercation with her roommate, Resident 1, on that day. The Event Report indicated, The Resident Safety Monitor [RSM] heard yelling from [Resident 1 and Resident 2's room]. The RSM saw [Resident 2] with a cup and [Resident 2] threw it at [Resident 1] hitting her in the face and then hit [Resident 1] with an open hand in the face. Review of Resident 1's Event Report, dated 7/20/20, indicated Resident 1 was the victim in an altercation with her roommate, Resident 2, on that day in their room. The Event Report included a nursing assessment of Resident 1 after the altercation, which indicated Resident 1 had a scratch under her left eye that measured 1.5 centimeters (cm, a unit of measure) long. Review of a facility document titled VERIFICATION OF INVESTIGATION, dated 7/20/20, indicated that during an interview after Resident 2 threw a cup at Resident 1 and hit Resident 1's face with an open hand, Resident 2 stated, She [Resident 1] would not leave me alone. Review of Resident 1's nursing note, dated 7/20/20, indicated, S/P [status post [MEDICAL RECORD OR PHYSICIAN ORDER] .delayed injury found (hematoma [a more serious bruise that can cause pain and swelling]) w/c [which] measured 1x1 cm [1 cm by 1 cm] at the Right Upper Arm area. During an interview with Resident Safety Monitor (RSM) 1, on 3/3/21, at 2:25 p.m., RSM 1 stated she was the RSM that witnessed the altercation between Resident 1 and Resident 2 on 7/20/20. RSM 1 stated she heard screaming coming from the residents' room, and when she entered their room, she saw Resident 1 and Resident 2 in their wheelchairs sitting close to each other. Resident 2 threw a cup of coffee at Resident 1's face and began swatting at Resident 1's face. RSM 1 stated she heard Resident 2 yelling at Resident 1 to move away, and saw Resident 1 attempting to back away from Resident 2's space. RSM 1 stated Resident 2 had long finger nails, which probably caused the scratch under Resident 1's left eye. RSM 1 stated Resident 1 and Resident 2's beds were next to each other and Resident 1 had to enter Resident 2's space to exit the room. When asked if Resident 1 had wandering behaviors, RSM 1 stated Resident 1 was known for moseying around, and staff needed to look out for her. When asked if Resident 2 had physically aggressive behaviors, RSM 1 stated Resident 2 yelled a lot but this was the first time RSM 1 witnessed Resident 2 be physically aggressive toward other residents. During an interview with Licensed Nurse (LN) 1, on 3/9/21, at 3:45 p.m., LN 1 stated she was Resident 1 and Resident 2's nurse during the evening of their altercation on 7/20/20. LN 1 stated Resident 1 and Resident 2 shared a room and their beds were close to each other. When asked about Resident 2's aggressive behaviors, LN 1 stated Resident 2 got easily agitated and that staff could not keep an eye on her at all times. When asked what behaviors of physical aggression were the nurses monitoring in Resident 2, LN 1 stated Resident 2 would attempt to hit staff or other residents, she would yell, and she would point her finger at others and threaten them. When asked why it took two days to move Resident 1 to another room, LN 1 stated the facility decided to move Resident 1 to another room because Resident 2 continued to show aggressive behaviors towards Resident 1. When asked what Resident 2 was doing, LN 1 stated Resident 2 would point her finger at Resident 1 and threaten her. During a follow-up interview with LN 1 on 3/25/21, at 12:55 p.m., LN 1 stated nurses would monitor a resident, who was involved in a physical altercation, for three days to assess for delayed injuries. LN 1 stated she remembered Resident 1 had a scratch under her eye immediately after the physical altercation with Resident 2, and developed a hematoma on her arm. During an interview with the Director of Nursing (DON) on 3/25/21, at 4 p.m., the DON stated, when a resident was involved in a physical altercation, the nurses were expected to do a full body skin assessment on the resident to assess for injuries; the nurses would do a full body skin assessment each day for the following three days to monitor for delayed injuries. The DON stated Resident 1's full body skin assessments, which included the assessment immediately after the physical altercation and for the following three days, indicated Resident 1 had a scratch under her eye and a hematoma on her upper arm. The following represents the facilities corrective actions for this deficient practice: How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be affected by this deficient practice. All current residents will be assessed for potential of exhibiting territorial behavior and having potential to be involved in a resident to resident altercation. An audit was conducted by Social Service/DON/Designee on 11/20/2020 to identify residents who exhibited behavior of being territorial. There were 31 residents identified. The list of residents identified will be placed in the nurses station with the names of the residents who require monitoring for territorial behavior. The C.N.A. assigned to the resident will monitor every 30 minutes for territorial behavior towards other residents. The Care Plan and the nursing assistant point of care will include these behaviors and interventions will be documented. Compliance date 12/04/20 What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur; The DSD/DON/designee will in-service staff on the abuse policy to include all areas of the policy and reporting requirements. Staff will all be educated to immediately notify the abuse coordinator/Administrator of witnessed or suspected abuse. Special focus will be placed on resident peer to peer altercations, root cause, contributing factors, and care planning interventions. Nursing staff, department managers, safety monitors will be in-serviced by the DSD/DON/designee to monitor for residents who are territorial. The DSD/DON/designee will in-service licensed nurse on initiating and completing a complete and thorough investigation of all incidents and abuse allegations including peer to peer altercations to include root cause and appropriate interventions related to the residents individual needs and deficits and the importance of updating the care plan to include the interventions. The DON/designee will review all investigations for completeness and accuracy. The administrator/designee will sign off indicating completion, appropriate notifications and interventions to ensure there is not a repeat of the altercation and that compliance is sustained. Residents will be assessed for being territorial on admission, quarterly, or during change of condition and the list will be updated daily during the morning stand up meeting. The list of residents identified will be placed in the nurses station with the names of the residents who require monitoring for territorial behavior. The C.N.A. assigned to the resident will monitor every 30 minutes for territorial behavior towards other residents. The Care Plan and the nursing assistant point of care will include these behaviors and interventions will be documented. Residents with territorial behaviors will be identified by wearing a blue armband. Resident safety monitors will observe for territorial behaviors in hallways. Department Managers will monitor these residents during their daily room rounds. Compliance date 12/04/20 How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC must be integrated into the quality assurance system; Social Services/designee will track and trend any resident to resident altercations monthly to review with the QAPI team to determine if additional systematic approaches should be implemented. This will include time of day, location, other individuals involved, physical environment and other contributing factors. The Administrator/designee will report issues/concerns/trends of any other abuse allegations to the QAPI team for further recommendations and/or follow up. They will discuss monthly results and action items to ensure continued sustained compliance. Compliance Date 12/04/20

Based on observation, interview, and record review, the facility failed to ensure three residents (Resident 1, Resident 2, and Resident 3) in a census of 117 were free from physical abuse when the lack of supervision of Resident 1 resulted in the following: 1. Resident 1 hit Resident 3's arm while walking down a hallway, which caused a bruise on Resident 3's arm; 2. Resident 1 wandered into a resident's room (Resident 4), where Resident 4 swung her purse at Resident 1's face, scratching Resident 1's nose and above her left eye; and 3. Resident 1 wandered into Resident 2's room, pushed Resident 2 to the ground, and wrestled with her resulting in a skin tear to Resident 2's elbow. The failure to supervise Resident 1 resulted in harm to Residents 1, 2, and 3, and increased the potential to have a negative effect on their long-term psychosocial well-being. Findings: 1. Review of Resident 1's Face Sheet indicated she was admitted to the facility in the winter of 2018 with diagnoses, which included dementia with behavioral disturbances (cognitive decline with behaviors negatively affecting self and/or others). Review of Resident 3's Face Sheet indicated she was admitted to the facility in the spring of 2016 with diagnoses, which included dementia with behavioral disturbances. Review of Resident 1's care plan for behavioral symptoms, dated 5/24/19, indicated Resident 1 had symptoms of wandering and intrusiveness. Examples noted included, .in and out of other resident rooms and in other resident's personal space .Rummages through other resident personal belongings .verbally/physically aggressive .especially occurs when other residents yell at her .likes to clear the hallway when shes (sic) walking The care plan further indicated Resident 1 was involved in nine resident-to-resident altercations in the past 9.5 months as either the victim or the aggressor. The goal of the care plan was to Reduce the number of physical/verbal altercations, and long-term approaches included, Redirect resident when trying to go inside other people's room .Closer supervision when resident is displaying wandering behaviors .Redirect from cluttered areas .Provide activities of interest . Review of an Event Report in Resident 3's clinical record dated 5/29/20, at 6:05 p.m., indicated that at approximately 5:45 p.m. that day, as Resident 1 passed by Resident 3 in the hallway, Resident 1 hit Resident 3's right arm with her fist. The nursing assessment documented after the altercation revealed a bruise on Resident 3's arm where Resident 1 hit her. Review of a document titled, Verification of Investigation, dated 5/29/20, included a witness statement, which indicated, (Resident 3) was in her wheelchair in the hallway near room [ROOM NUMBER]. She was talking to me and suddenly (Resident 1) walked by and hit her on her right upper arm with close (sic) hand. Victim (Resident 3) did not do anything to provoke (Resident 1). The document indicated the causal or contributing factors were (Resident 3) in center of hallway attempting to communicate with nurse and unknowingly occluded walkway. Hit on the RUA (right upper arm) by (Resident 1) for being in (Resident 1)'s way, causing discoloration (bruising). Review of an interdisciplinary team (IDT) note for Resident 1 dated 6/1/20, at 10:16 a.m., indicated the IDT performed a root cause analysis (RCA) of the altercation and determined Resident 3 got into Resident 1's way, and that Resident 1 had a long history of aggressive behaviors. The IDT note indicated, Interventions: refer to SS (Social Services) department; continue monitoring for aggressive behaviors; refer to BMC (Behavior Management Committee) for med (medication) review. Review of a social services progress note for Resident 1 dated 6/1/20, at 1:40 p.m., indicated, (Resident 1) has a long history of aggressive and territorial behaviors. Resident becomes very impatient if peer is standing in way of where she is walking. 2. Review of Resident 4's Face Sheet indicated she was admitted to the facility in the spring of 2018 with diagnoses, which included dementia with behavioral disturbances. Review of Resident 4's care plan for behavioral symptoms dated 8/12/18, indicated Resident 4 became impatient with residents when they would enter her room and appeared to reach out towards her or her purse, was verbally aggressive, and would strike out. Review of an Event Report in Resident 1's clinical record dated 6/3/20, at 9:30 a.m., indicated Resident 1 entered Resident 4's room. A licensed nurse who was down the hall heard a commotion and witnessed Resident 1 stepping out of the room into the hallway. Resident 4 swung her purse and hit Resident 1 two times in the face. The licensed nurse's assessment noted a scratch above Resident 1's left eye, and a scratch on the bridge of her nose. A social services progress note for Resident 1 dated 6/3/20, at 2:41 p.m., indicated, (Resident 1) has very intrusive behaviors. Can be hard to redirect at times. Resident is unaware of safety cues and measures . Review of an IDT note for Resident 1 dated 6/4/20, at 9:25 a.m., indicated the IDT performed an RCA and determined Resident 1 entered Resident 4's room unwelcomed, and when Resident 1 refused to leave, Resident 4 swung her handbag at Resident 1's face causing scratches on Resident 1's face. The IDT note indicated, Interventions: Refer to SS dept (department) for psychosocial wellbeing; Tx (treatment) in place; monitor for other delayed injury as a result of incident; neuro-checks (frequent and ongoing assessments for [MEDICAL CONDITION]) initiated. 3. Review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility in the summer of 2018 with [DIAGNOSES REDACTED]. An Event Report in Resident 2's clinical record dated 9/6/20, at 5:45 p.m., indicated Resident 1 wandered into Resident 2's room. Resident 2 reported to the nurse that she was sitting on her bed when Resident 1 came over, pushed her to the ground, and sat on top of her. The document indicated a Certified Nurse Assistant (CNA) entered the room and witnessed Resident 1 sitting on top of Resident 2, and the two residents were grabbing at each other's arms. The nursing assessment documented after the altercation noted a skin tear on Resident 2's elbow. An IDT note for Resident 1 dated 9/8/20, at 9:40 a.m., indicated, Intervention: .Resident had a recent medication changes (sic) for anti anxiety. Encourage staff to redirect her when they see her going into other Residents room (sic). Refer to social services for psychosocial well being X (times) 72 hrs (hours). During an observation on 9/21/20, at 3 p.m., of Resident 1 wandering around Station 2, two staff members were sitting at the nurse's desk and one nurse was at the end of the hall at a medication cart. Resident 1 wandered in and out of two resident rooms. When Resident 1 wandered into the third room next to the nurse at the medication cart, Resident Safety Monitor (RSM) 1 redirected her out. During an interview with CNA 1 on 10/28/20, at 2:45 p.m., CNA 1 stated she witnessed the altercation between Resident 1 and Resident 2 on 9/6/20. CNA 1 stated, that day, she and another CNA were the only two staff members in the hallway when they heard screaming coming from Resident 2's room. CNA 1 stated she went to the room and witnessed Resident 2 on the ground, Resident 1 was sitting on top of her, and the two were grappling each other. CNA 1 stated Resident 1 was intrusive and staff would redirect her as needed. CNA 1 was unable to list any of Resident 1's activities of interest and stated the staff would generally just redirect residents. CNA 1 stated the dinner mealtime was a particularly hectic time of the day as staff were busy gathering residents to the dining room or to their rooms, and assisting residents with their meals. CNA 1 stated there were RSMs but it was just too hectic to monitor all the residents. During an interview with Licensed Nurse 1 (LN 1) on 11/11/20, at 11:10 a.m., LN 1 stated she witnessed the altercation between Resident 1 and Resident 4 on 6/3/20. LN 1 stated she saw Resident 1 exit Resident 4's room, and Resident 4 followed her out. Resident 4 swung her purse and hit Resident 1 in the face. LN 1 stated she told Resident 4 not to use her purse as a weapon, and stated the purse felt heavy. LN 1 stated Resident 4 was territorial, overprotective, and could get agitated and paranoid. LN 1 stated Resident 1 was a victim of aggression because she wandered into other residents' rooms and would lie in their beds. LN 1 stated staff would redirect Resident 1 when they noticed her wander into another resident's room. During an observation on 11/11/20, at 1 p.m., in a Station 1 hallway outside of room [ROOM NUMBER], Resident 1 was inside room [ROOM NUMBER] while a male resident (Resident 5) inside the room yelled repeatedly at Resident 1 to go back to her room. Resident 1 then sat down on bed A as the male resident moved behind her and continued to yell at her to go back to her room. The male resident moved in front of Resident 1, yelled at her to leave, grabbed her arm and lifted her up off the bed. Resident 1 then walked out of the room and down the hall. There were no staff present in the hallway. During an observation on 11/11/20, at 1:05 p.m., in a hallway in Station 1, Resident 1 wandered into room [ROOM NUMBER], grabbed a box of gloves and walked behind the curtain to bed C. After approximately one minute, Resident 1 walked out from behind the curtain holding a wheelchair footrest. As Resident 1 walked out into the hallway, a CNA walking by grabbed the footrest from Resident 1's hand and placed it back inside room [ROOM NUMBER]. Resident 1 then wandered into room [ROOM NUMBER] where she went to bed A, moved the pillow around, and walked back out.

Based on observation, interview, and record review, the facility failed to implement an intervention per a resident care plan for behavioral symptoms for 1 resident (Resident 1) in a sample of four when the staff did not redirect Resident 1 out of other residents' rooms or away from crowded areas. The failure to redirect Resident 1 resulted in physical harm to Resident 1, 2, and 3. Findings: Review of Resident 1's Face Sheet indicated she was admitted to the facility in the winter of 2018 with diagnoses, which included dementia with behavioral disturbances (cognitive decline with behaviors negatively affecting self and/or others). Review of Resident 1's care plan for behavioral symptoms dated 5/24/19 indicated Resident 1 had symptoms of wandering and intrusiveness. Examples noted included, .in and out of other resident rooms and in other residents personal space .Rummages through other resident personal belongings, .verbally/physically aggressive .especially occurs when other residents yell at her .likes to clear the hallway when shes (sic) walking The goal of the care plan was to Reduce the number of physical/verbal altercations, and long-term approaches included, Redirect resident when trying to go inside other people's room .Closer supervision when resident is displaying wandering behaviors .Redirect from cluttered areas .Provide activities of interest . The care plan further indicated Resident 1 was involved in nine resident-to-resident altercations in the past 9.5 months as either the victim or the aggressor. The altercations, where staff failed to redirect Resident 1, were the following: 1. On 5/29/20, at 5:45 p.m. Resident 1 was the aggressor in an altercation with another resident (Resident 3); 2. On 6/3/20, at 9:30 a.m. Resident 1 was the victim in an altercation with another resident (Resident 4); and 4. On 9/6/20, at 7:45 p.m. Resident 1 was the aggressor in an altercation with another resident (Resident 2). Review of an Event Report for Resident 1 dated 5/29/20, at 6:07 p.m., indicated that at approximately 5:45 p.m. that day, Resident 1 was walking in the hallway. A Certified Nurse Assistant (CNA) witnessed Resident 1 become agitated when Resident 3 was in her way. As Resident 1 lifted her fist up the CNA ran over but did not make it on time to stop Resident 1 from hitting the Resident 3's right arm with her fist. The Event Report included a nursing assessment documented immediately after the altercation, which revealed a bruise on Resident 3's arm where Resident 1 hit her. Review of an interdisciplinary team (IDT) note for Resident 1 dated 6/1/20, at 10:16 a.m., indicated, Interventions: refer to SS (Social Services) department; continue monitoring for aggressive behaviors; refer to BMC (Behavior Management Committee) for med (medication) review. Review of an Event Report for Resident 1 dated 6/3/20, at 9:30 a.m., indicated Resident 1 entered Resident 4's room. A licensed nurse down the hall heard a commotion and witnessed Resident 1 stepping out of the room into the hallway. Resident 4 swung her purse and hit Resident 1 two times in the face. The licensed nurse's assessment noted a scratch above Resident 1's left eye, and a scratch on the bridge of her nose. Review of an IDT note for Resident 1 dated 6/4/20, at 9:25 a.m., indicated, Interventions: Refer to SS dept (department) for psychosocial wellbeing; Tx (treatment) in place; monitor for other delayed injury as a result of incident; neuro-checks (frequent and ongoing assessments for [MEDICAL CONDITION]) initiated. An Event Report for Resident 1 dated 9/6/20, at 5:45 p.m., indicated Resident 1 wandered into Resident 2's room. A CNA entered the room and witnessed Resident 1 sitting on top of Resident 2, and the two residents were grabbing at each other's arms. The nursing assessment documented after the altercation noted a skin tear on Resident 2's elbow. An IDT note for Resident 1 dated 9/8/20, at 9:40 a.m., indicated, Intervention: .Resident had a recent medication changes (sic) for anti anxiety. Encourage staff to redirect her when they see her going into other Residents room (sic). Refer to social services for psychosocial well being X (times) 72 hrs (hours). During an interview with the Administrator (ADM) on 9/21/20, at 1:30 p.m., the ADM stated Resident 1 was very intrusive, wandered around and would grab items belonging to other residents and would walk away with the items. Resident 1 was very fast and would not always walk around people. The ADM stated the interventions included instructions to have staff redirect Resident 1 out of other residents' rooms and crowded areas. The ADM stated the staff would redirect Resident 1, but she was too fast. During an observation of Resident 1 on 9/21/20, at 3 p.m., in station 2, two staff were sitting at the nurse's desk and one nurse was standing at the end of the hall at the medication cart. Resident 1 wandered in and out of two resident rooms. When Resident 1 entered the third room next to the medication cart, Resident Safety Monitor (RSM) 1 redirected her out of the room. During an interview with CNA 1 on 10/28/20, at 2:45 p.m., CNA 1 stated she witnessed the altercation between Resident 1 and Resident 2 on 9/6/20. CNA 1 stated, that day, she and another CNA were the only two staff members in the hallway when they heard screaming coming from Resident 2's room. CNA 1 stated she went to the room and witnessed Resident 2 on the ground, Resident 1 was sitting on top of her, and the two were grappling each other. CNA 1 stated Resident 1 was intrusive and staff would redirect her as needed. CNA 1 was unable to list any of Resident 1's activities of interest and stated the staff would generally just redirect residents. CNA 1 stated the dinner mealtime was a particularly hectic time of the day as staff were busy gather residents to the dining room or to their rooms, and assisting residents with their meals. CNA 1 stated there were RSMs, but it was just too hectic to monitor all the residents. During an interview with Licensed Nurse 1 (LN 1) on 11/11/20, at 11:10 a.m., LN 1 stated she witnessed the altercation between Resident 1 and Resident 4 on 6/3/20. LN 1 stated she saw Resident 1 exit Resident 4's room, and saw Resident 4 swing her purse and hit Resident 1 in the face. LN 1 stated Resident 1 was a victim of aggression because she wandered into other residents' rooms and would lie in their beds. LN 1 stated staff would redirect Resident 1 when they noticed her wander into another resident's room. During an observation on 11/11/20, at 1 p.m., in a Station 1 hallway outside of room [ROOM NUMBER], Resident 1 was inside room [ROOM NUMBER] while a male resident (Resident 5) inside the room yelled repeatedly at Resident 1 to go back to her room. Resident 1 then sat down on bed A as the male resident moved behind her and continued to yell at her to go back to her room. The male resident moved in front of Resident 1, yelled at her to leave, grabbed her arm and lifted her up off the bed. Resident 1 then walked out of the room and down the hall. There were no staff present in the hallway. During an observation on 11/11/20, at 1:05 p.m., in a hallway in Station 1, Resident 1 wandered into room [ROOM NUMBER], grabbed a box of gloves and walked behind the curtain to bed C. After approximately one minute, Resident 1 walked out from behind the curtain holding a wheelchair footrest. As Resident 1 walked out into the hallway, a CNA walking by grabbed the footrest from Resident 1 hand and placed it back inside room [ROOM NUMBER]. Resident 1 then wandered into room [ROOM NUMBER] where she went to bed A, moved the pillow around, and walked back out.

Based on interview, and record review, the facility failed to take steps to prevent the occurrence of abuse for one of four sampled residents (Resident 1), when Resident 2 grabbed Resident 1's arm and caused a skin tear. This failure resulted in injury to Resident 1. Findings: Review of Resident 1's clinical record indicated the following documents: A Resident Face Sheet, undated, indicated Resident 1 was admitted to the facility in March of 2019, with a [DIAGNOSES REDACTED]. A Care Plan, dated 6/4/2020, indicated Resident 1 had a [DIAGNOSES REDACTED]. Review of Resident 2's clinical record indicated the following documents: A Resident Face Sheet, undated, indicated Resident 2 was admitted to the facility in May of 2019, with [DIAGNOSES REDACTED]. A Care Plan, dated 5/23/2019, indicated Resident 2 had a [DIAGNOSES REDACTED]. An addition to the care plan, dated 5/11/2020, indicated Resident 2 is territorial, never likes other residents coming into her room. An Interdisciplinary Team (IDT) progress note, dated 10/2/2020 at 9:20 a.m. indicated Resident 2 was involved in a peer to peer altercation as the aggressor by grabbing Resident 1's arm and causing a skin tear. The note further indicated Resident 2 was having delusional thoughts. In an interview with Licensed Nurse (LN) 1 on 10/12/2020 at 11:08 a.m., LN 1 stated Resident 2 was known to be territorial and get frustrated easily. In an interview with LN 2 on 10/12/2020 at 11:29 a.m., LN 2 stated Resident 1 could be very intrusive. LN 2 further stated Resident 1 was unable to remember which room or bed was hers, so was often found in other rooms and other resident beds. In an interview with LN 3 on 10/20/2020 at 2:46 p.m., LN 3 stated Resident 1 could be very aggressive, but usually only with other intrusive residents. LN 3 stated Resident 1 and Resident 2 were roommates at the time of the peer to peer altercation on 10/2/2020. In an interview with LN 4 on 10/23/2020 at 11:50 a.m., LN 4 stated Resident 2 had been known to scratch and grab at other staff and residents, but only when messed with. An interview was conducted with the Administrator and Director of Nurses (DON) on 10/27/20 at 11:22 a.m. The DON confirmed Resident 1 and Resident 2 were roommates prior to the altercation. The administrator stated it should be a priority to review behaviors of each resident prior to placing them as roommates. A review was conducted of a facility policy, Alleged Abuse and Elder Justice Act, undated. The policy indicated, It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property.

Based on interview and record review the facility failed to protect 1 of 4 residents (Resident 1) from abuse when staff placed a pillow case over Resident 1's head as a restraint to stop a behavior. This failure escalated Resident 1's agitation and caused psychosocial harm to a cognitively vulnerable resident. Findings: Review of the facility report faxed to the Department on 1/24/18, indicated a mandated reporter, on 1/24, observed three staff abuse Resident 1. Review of the facility document titled SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 1/24/18, indicated 3 CNAs (Certified Nursing Assistants 1, 2, and 3) called LN (Licensed Nurse 1) to room as witness for care for (Resident 1) (with) hx (history) of resistance to care. CNA placed pillowcase over head to protect them from (Resident 1) spitting on them . Review of the facility document titled Record of Admission, revealed Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident 1's medical record document titled Mood/ Behavior/ Psychosocial Wellbeing indicated on 11/30/17 in the column Resident Problems/ Concerns Res. (Resident 1) refused shower, striking out, hitting, kicking, spitting, scratch staff. Review of Resident 1's medical record document titled Non Pharmacologic Interventions for (MONTH) (YEAR) indicated under Behavior, spitting out meds (medications). Review of Resident 1's medical record document titled Medication Record indicated the following: - 1/6/18 Resident non compliant (with) x-ray done, spitted out (sic) on x-ray tech, tried X3 (three times), MD notified. Review of Resident 1's medical record document titled Nurses Medication Notes indicated the following: - 1/11/18, 6:00 a.m., Refused all meds x3. Resident spitted (sic) out and wiped mouth (with) blanket, striking - 1/16/18, 6:00 a.m., Refused all meds x3, striking, spitted (sic) out and wiped mouth off (with) blanket - 1/17/18, 6:00 a.m., Refused all meds x3. Resident spitted (sic) meds out and wiped (with) blanket Review of Resident 1's medical record document titled Progress Notes, dated 1/24/18 at 9:01 a.m. and signed by the Director of Nursing, indicated Unusual Occurrence (sic): On 1/24/18 AM (morning) shift resident was soiled (with) urine/feces, Three CNA staff members went to change her secondary to her combative behaviors during care, along (with) spitting. The CNA ' s (sic) were trying to shield themselves from her spit, and placed a pillow case over her head, using the pillow case as a spit shield .Staff instructed to use face mask instead to prevent to (sic) possibility of psychosocial-emotional distress. During an observation on 2/8/18 at approximately 1:35 p.m., Resident 1 was lying in bed, unable to answer questions. Resident 1 was observed to have increased agitation with surveyor in the room, and calmed some with familiar staff redirecting. During an interview on 2/8/18 at 2:04 p.m., the Occupational Therapist (OT) stated on 1/24/18, she was in the restroom assisting another resident. Upon exiting the restroom, three CNAs (CNA 1, 2 and 3) and one Licensed Nurse (LN) 1 were quickly assisting Resident 1 to the restroom and asked for help as Resident 1 had pulled her pants down making walking to the rest room difficult. The OT stated she looked down to pull up Resident 1's pants and as the OT looked up, a pillow case was completely pulled over Resident 1's head. The OT further stated, .one of the CNAs explained it was 'because she spits'. The OT additionally added the pillowcase was then pulled off Resident 1's head. The OT indicated she completed a facility report regarding the incident. Review of the facility provided written statement of CNA 1, dated 1/30/18, indicated the day of the incident with Resident 1, the following occurred: - CNA 1 was walking in the hallway and was asked by CNA 2 and CNA 3 for assistance to help change Resident 1. - CNA 1 went to get the nurse and entered Resident 1 ' s room - Resident 1 was taken to the bathroom after the therapist and another resident (Resident 2), left the bathroom. - Resident 1 changed her mind and started moving towards her bed spitting, hitting kicking resident was very combative aggressive, so I hold her hands and my co-workers change her. It happen so fast that I couldn ' t figure out who put the pillow case .(sic) Review of the facility provided written statement of CNA 2, dated 1/30/18, indicated the day of the incident with Resident 1, the following occurred: - CNA 2 was assisted by CNA 1 and CNA 3 to change Resident 1. - One of the CNAs called the nurse in to Resident 1 ' s room. - There was a therapy lady with Resident 2 in the room. CNA 1 approached Resident 1 to come to the bathroom. - Resident 1 followed to the bathroom, but as soon as we tried to change, (Resident 1) was very combative and tried to spit, kick and bite. We all tried our best but it couldn ' t work, so asked (therapist) to help us. It happened so fast that someone put pillow case to protect from spitting .Later resident threw the pillow case on the floor. (sic) Review of the facility provided written statement of CNA 3, dated 1/30/18, indicated the day of the incident with Resident 1, the following occurred: - CNA 3 was in the hallway and was asked by CNA 1 and CNA 2 for assistance to help change Resident 1. - Prior to entering the room, we asked a licensed nurse to accompany us and witness what we were doing. - First we tried to usher (Resident 1) to use the bathroom. When (Resident 1) resisted, I held her hands and the other two CNAs tried to change her. She started spitting on us so one of the two CNAs put a pillow case on her. During a telephone interview on 2/9/18 at 10:00 a.m., LN 1 confirmed her written statement of the incident on 1/24/18, indicating CNA 1 placed the pillow case over Resident 1 ' s head. LN 1 further stated, .didn't think the pillow case over the head was OK .The resident was more agitated with the pillow case on her head. During a telephone interview with the ADM on 2/15/18 at approximately 9:30 a.m., the ADM stated Resident 1 had a history of [REDACTED]. When the Department asked if protective masks were available for the staff, the ADM stated, not currently. Review of the facility provide policy titled Alleged Abuse and Elder Justice Act last revised (MONTH) 2011, stipulated Policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injury of unknown source, misappropriation of resident's property and elder act . It is the policy of this facility to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property .Training . The facility shall provide employees, through orientation and educational opportunities strategies to prevent mistreatment, neglect and abuse. Training will occur on topics related to abuse prevention such as .Appropriate interventions to deal with aggressive and/or catastrophic reaction of residents.

Based on interview and record review, the facility failed to report a change of condition to the physician when one of three sampled residents (Resident 1) had an unwitnessed fall with new onset right lower leg pain on 1/4/19. This failure resulted in the neglect of Resident 1's need for care and treatment for [REDACTED]. Findings: According to Resident 1's Face Sheet, the document noted she was admitted in 2013 with [DIAGNOSES REDACTED]. break in a bone). A review of the clinical record for Resident 1 included the following documents: A Minimum Data Set (MDS, an assessment tool) dated 9/2/18, indicated Resident 1, Is rarely/never understood, and the Brief Interview for Mental Status (BIMS) should not be attempted. The MDS also described Resident 1 as total dependence for transfer and toileting, and limited assistance for locomotion on the unit in a wheelchair. A Physician order [REDACTED]. The document included an order, dated 12/19/13, for monitoring Resident 1 every shift for signs and symptoms of pain using a 0- 10 pain scale. An Event Report, created 1/4/19 and edited on 1/8/19 by Unit Manager (UM) 1, reflected Resident 1 had an unwitnessed fall on 1/4/19 at 11:38 p.m. The document reflected Resident 1 as having, Moderate Pain - Distressing, Miserable, in the lower extremities. The document further indicated UM 1 was unable to complete range of motion (ROM, the normal amount of movement within a joint) with Resident 1. The Event Report contained notification guidelines which indicated; Notify MD (doctor of medicine)/NP (nurse practitioner) immediately by phone or beeper for any of the following . Hip/Joint pain with palpation or ROM. The Event Report reflected Resident 1's physician was notified of the fall on 1/5/19 at 1:40 p.m. A Falls Care Plan, dated 1/4/19 and written by UM 1, included an intervention to, Notify MD/RP. A Pain Assessment in Advanced Dementia Scale (PAINAD, a pain assessment scale based on observation of several resident behaviors) report, completed by UM 1 on 1/4/19 at 11:47 p.m., reflected Resident 1 as having, Moderate Pain, and UM 1 scored the pain at 6 points out of a 10 total possible (1-3= mild pain, 4-6= moderate pain and 7-10=severe pain). A Fall Risk Assessment, dated 1/4/19 at 11:37 p.m. by UM 1, indicated Resident 1 had a, Change in Condition - Fall. A nursing progress note, dated 1/5/19 and entered at 1:45 a.m. by Licensed Nurse (LN) 1, indicated Resident 1 had an unwitnessed fall out of bed at 11:00 p.m. and there was no apparent injury at the time. A Medication Administration History, dated 1/1/19 - 1/31/19, reflected Resident 1 had no pain on all of the 3 days prior to the fall (1/1/19 - 1/3/19) as indicated by a score of, 0, on each shift, each day. The document also indicated Resident 1 had no pain on 1/4/19 prior to the fall. The document reflected Resident 1 was given an as needed dose of pain medication ([MEDICATION NAME]- a mild pain reliever) on 1/4/19 at 11:56 p.m. by LN 1. An Event Report, completed 1/7/19 by LN 2, indicated Resident 1 had new onset right lower leg pain at 8:40 a.m. The document also indicated Resident 1 was, yelling out her leg hurts, and LN 2 rated Resident 1's pain at, 10/10. The document reflected Resident 1's leg was, swollen with discoloration. The document indicated LN 2 spoke to the Physician Assistant (PA) 1 at 9:53 a.m. and received an order for [REDACTED]. A nursing progress note, dated 1/7/19 at 9:53 a.m. by LN 2, indicated LN 2 spoke with PA 1 and received an order for [REDACTED]. A nursing progress note, dated 1/7/19 at 11:07 a.m. by LN 2, reflected the x-ray was completed and the results indicated Resident 1 had an acute tibial fracture. LN 2 notified PA 1, and was given an order to send Resident 1 to the General Acute Care Hospital (GACH) emergency room for further evaluation. A GACH ED (Emergency Department) Triage Note, dated 1/7/19 at 12:55 p.m., described Resident 1 as having significant swelling and bruising of the right lower leg. A GACH radiology report, dated 1/7/19 at 5:08 p.m., confirmed the acute fracture of Resident 1's right tibia. An Orthopaedic (branch of medicine dealing with the treatment of [REDACTED]. A nursing progress note, dated 1/8/19 at 3:21 p.m. by UM 1, indicated Resident 1 had an unwitnessed fall at 10:30 p.m. on 1/4/19. The document reflected Resident 1, used non-verbal signs to identify pain in the right leg, and there were no apparent injuries. PRN pain medication (a medication taken as needed) was given. In a telephone interview on 1/25/19 at 3:45 p.m., UM 1 stated the process for falls, witnessed or unwitnessed, included the nurse assessing for any obvious injuries and then staff helped the resident back into the bed or wheelchair. UM 1 stated nurses immediately call the doctor, then the family or responsible party (RP). UM 1 stated all unwitnessed falls also get neuro checks (a visual, verbal, physical, mental and emotional response assessment to determine whether head injury has occurred). UM 1 stated he was working at the time of Resident 1's fall, and completed some of the fall paperwork to help the night nurse. In an interview, on 2/27/19 at 2:27 p.m., LN 2 stated on 1/7/19 Resident 1 was self-propelling in her wheelchair out of the dining room when she grabbed her right leg and moaned in pain. LN 2 stated she did not observe any swelling or bruising. LN 2 stated Resident 1 normally had full ROM or close to it. In an interview, on 2/27/19 at 2:45 p.m., LN 3 stated she observed Resident 1 screaming, pain, pain!, on 1/7/19. LN 3 stated the nurse could not palpate Resident 1's leg and she was unable to assess or do ROM. LN 3 stated Resident 1's right leg was swollen, with bruising. LN 3 further stated after an unwitnessed fall nurses were to do an assessment, check for pain, start neuro checks, notify the doctor and family or RP and complete documentation. LN 3 stated if she could not have done ROM with Resident 1 after the unwitnessed fall, she would have called the doctor immediately. LN 3 stated it was the facility policy to call the doctor immediately when a fall occurred, witnessed or unwitnessed. In an interview, on 2/27/19 at 3:11 p.m., UM 1 verified the notation on Resident 1's Event Report concerning the fall on 1/4/19 indicated Resident 1 was in, moderate pain- distressing, miserable. UM 1 denied writing the documentation and stated he, may have hit the wrong key. UM 1 stated when Resident 1 fell , he jumped on the computer to help the night nurse complete the paperwork. UM 1 stated he believed LN 1 called the doctor. UM 1 was unable to explain why he documented the physician was notified of the fall on 1/5/19 at 1:40 p.m. and the family was notified on 1/5/19 at 11:41 a.m., but states he did not make the calls. UM 1 stated phone calls to the doctor or family are reflected in the nursing progress note, and confirmed there was no progress note in Resident 1's EMR (electronic medical record) that reflected the calls were made. UM 1 stated the doctor and family are notified immediately when a fall occurs. UM 1 confirmed Resident 1 did not have any chronic right leg pain, and he was not able to complete ROM with Resident 1 after the fall. UM 1 agreed that if someone fell , witnessed or unwitnessed, and was in pain and could not do ROM, the doctor and RP should be called immediately. UM 1 also agreed, as a Unit Manager, he should have made sure the paperwork and the physician and RP notifications were completed. In an interview, on 2/27/19 at 3:42 p.m., the DON stated it was his expectation the nurses notify the physician and family immediately after a fall. The DON further stated he expected his Unit Managers to ensure incident paperwork was completed. The DON agreed UM 1 should have called the doctor and RP immediately after Resident 1's fall. In a telephone interview, on 2/28/19 at 4:10 a.m., LN 1 stated she was not sure how she learned of Resident 1's fall on 1/4/19, but maybe she heard Resident 1 calling out. LN 1 stated Resident 1 was found on the floor lying next to her bed. LN 1 stated Resident 1 said her legs were hurting her and she gave her some pain medication, after which, Resident 1 quickly fell asleep. LN 1 stated Resident 1 had no visible injuries and could do ROM, but was complaining of leg pain at, maybe a 5 out of 10. LN 1 confirmed Resident 1 did not normally have leg pain. LN 1 stated after a fall the nurse assessed for pain, level of consciousness, ROM, care planned and called the doctor and family to notify them of the fall. LN 1 stated she did not remember if she called the doctor or family to report Resident 1's fall, but stated that if she had, it would have been written in Resident 1's progress note. In a telephone interview, on 2/28/19 at 4:15 p.m., Certified Nursing Assistant (CNA) 1 stated she worked on Resident 1's hallway on 1/4/19. CNA 1 stated she found Resident 1 lying on her back next to her bed between 10:30 p.m. and 11:30 p.m. CNA 1 stated Resident 1 was complaining of leg pain. CNA 1 stated she called out for the nurse. CNA 1 stated UM 1 and LN 1 assessed Resident 1 and there was no bruising or swelling at that time. CNA 1 stated when they picked up Resident 1 and put her back into bed, Resident 1 yelled out in pain. CNA 1 stated she said, You guys should send her out. CNA 1 stated UM 1 and LN 1 replied Resident 1 was always complaining of pain in her right leg. CNA 1 stated LN 1 gave Resident 1 some pain medication, but Resident 1 continued to complain of pain for an hour or two. CNA 1 stated in the morning when she tried to dress Resident 1, Resident 1 yelled out in pain. CNA stated she left Resident 1 in her gown for the day to avoid causing her more pain with dressing. In a telephone interview, on 3/1/19 at 10:20 a.m., PA 1 stated he did not see a provider note in the system for Resident 1 on 1/4/19. PA 1 stated normally staff called the physician and asked for guidance when a fall occurred. PA 1 stated if staff had called the physician and notified him of a fall, it would be noted in the system (EMR). PA 1 stated the first note in the system concerning Resident 1's fall was on 1/7/19 at 10:53 a.m. in reference to new onset pain, and PA 1 ordered the right lower leg x-ray. In a telephone interview, on 3/14/19 at 9:45 a.m., the Medical Records Director (MRD) stated if a report were created in the EMR it would include the names of anyone that worked on the document. The MRD stated the Event Report, created on 1/4/19 and edited on 1/8/19 by UM 1 for Resident 1's fall, had only UM 1's name on it. A review of the EMR Work History for Resident 1's Fall Event Report, provided by the MRD on 3/14/19, confirmed UM 1 was the individual that created and edited this document. No other staff member edited this document. A review of the facility's Change in a Resident's Condition or Status policy, dated (MONTH) 2013, stipulated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The policy further stipulated a significant change as one that, Requires interdisciplinary review and/or revision to the care plan.

An unannounced visit was made to the facility on [DATE] to initiate an investigation of Complaint #CA 939. As a result of the investigation, the Department determined that the facility failed to:1. Identify a possible [MEDICAL CONDITION] infection ([MEDICAL CONDITION]-a contagious bacterial infection) and follow the facility's policy for testing Resident 1 for [MEDICAL CONDITION]. timely and notifying Resident 1's physician when she started having frequent loose stools.2. Identify and effectively monitor individual risks for pressure ulcers and implement preventive measures to relieve pressure from vulnerable areas.3. Ensure early detection of skin changes and institute treatment prior to development of a stage III pressure ulcer.4. Ensure the plan of care to monitor skin condition following diarrhea was implemented. The failures placed Resident 1 at risk of further skin breakdown, increased pain, the need for operative intervention, local or systemic infection, prolonged bed-rest, delayed healing, and death.Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's quarterly Minimum Data Set (MDS-a standardized assessment tool) dated 9/1/11 indicated her cognitive level was severely impaired and she needed extensive assistance with her Activities of Daily Living (ADLs-e.g. dressing, bathing, toileting). The MDS described Resident 1 as being incontinent of both bowel and bladder. She was documented to be resistive to care and frequently refused to eat or take fluids. On her admission to the facility, Resident 1's weight was 137 pounds (lbs.). An Initial Braden Scale for Predicting Pressure Sore Risk dated 6/8/11 listed Resident 1 as a 17 - indicating she was a low risk for developing pressure ulcers (a score of 12 or below indicated a high risk for developing a pressure ulcer). The Braden Scale included a section related to nutritional status. The score assigned by staff indicated her nutritional status was adequate from 6/08/11 through 6/29/11. The next Braden assessment dated [DATE] indicated her nutritional status was very poor. Insufficient fluid intake and inadequate nutrition can contribute to development of pressure ulcers. An Initial Nutritional assessment dated [DATE] indicated Resident 1's nutritional needs included receiving 1700 calories and 1530-1840 milliliters of fluids a day (30 milliliters is equal to one fluid ounce). During Resident 1's stay at the facility, she tested positive for the infection [MEDICAL CONDITIONS] on 6/20/11 and then again on 7/18/11. [MEDICAL CONDITION] is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. The associated diarrhea can compromise skin integrity and contribute to the development of pressure sores.A Care Plan for [MEDICAL CONDITION] dated 6/28/11 indicated Resident 1's [MEDICAL CONDITION] infection had the potential for dehydration and impaired skin integrity secondary to diarrhea. Interventions included monitoring for skin breakdown.A Care Plan for Dehydration dated 6/28/11 indicated Resident 1 was at risk for dehydration because of her dementia, having [MEDICAL CONDITION], and that she was receiving a diuretic ([MEDICATION NAME]). Interventions included monitoring for signs of insufficient fluid intake such as: cracked lips. The staff was also to watch for abnormal laboratory values.Review of Resident 1's CNA-ADL (Certified Nursing Assistant - Activities of Daily Living) Tracking Form from August 22 through August 31 2011 (10 days) indicated the following: Resident 1 had a poor appetite for 20 meals and refused 4 meals out of a total of 27 meals. The Resident's average daily fluid intake was only 718 ml (ml. = milliliter). The Resident had 38 bowel movements. The average daily bowel movement frequency per day from 8/01/11 to 8/07/11 was 1; 08/08/11 to 8/14/11 was 1.3; 8/15/11 to 8/20/11 was 2; 8/21/11 to 8/31 was 3.9. Review of Resident 1's CNA-ADL Tracking Form for September 2011 indicated the following: Between 9/1/11 and 9/20/11 (20 days, 60 meals), the Resident refused 25 meals and had a poor appetite for 29 meals for a total of 54 meals. Between 9/1/11 and 9/20/11 (20 days) the Resident's average daily fluid intake was 754 ml. Between 9/1/11 and 9/20/11 (20 days) the Resident had 91 bowel movements. The average daily bowel movement frequency per day from 9/1/11 to 9/10/11 was 3.2 and from 9/11/11 to 9/20/11 was 4.6. However, there was no documented evidence of physician notification of the increased frequency of bowel movements to ensure early detection of [MEDICAL CONDITION] until 9/16/11. Review of the Weekly Summaries (a document the licensed nurses use to update and summarize the Resident's status) dated 8/18 through 9/15/11, indicated the space where bowel frequencies were supposed to be written was blank.Review of Resident 1's Nurses Note on 8/25/11 indicated she had developed a reddened area on her perineum (The external region between the vulva and the anus in a female). A physician order [REDACTED]. chair as she became less active or efforts to ensure her position was frequently changed when she was sitting in the chair for extended periods during the day. The Braden Scale for Predicting Pressure Sore Risk dated 9/2/11, indicated Resident 1 was now listed as a 14, a moderate risk for developing a pressure ulcer due to an increase in skin exposure to moisture, going from occasionally moist to often moist. The report also indicated Resident 1 went from having adequate nutrition to very poor nutrition on the scale. At the same time there were no updates on Resident 1's Nutritional Status Care Plan (last entry was 8/12/11) and no care plan had been implemented for the higher risk for pressure ulcers.Nurses Notes dated 9/7-9/8/11 indicated Resident 1's buttocks were now reddened and being treated with the [MEDICATION NAME] cream that had been prescribed for the perineum area on 8/25/11.A Nurses Note dated 9/10/11, indicated Resident 1 had developed an open area to her left butt cheek. The note indicated Resident 1 was complaining of moderate pain (6 out of 10, where 10 is the worst pain). The Pain Management tool documented Resident 1's pain was in the left buttock cheek. A Wound/Skin Healing Record dated 9/10/11 indicated the original stage of the pressure ulcer (when the facility first discovered the pressure ulcer) was a stage III with a measurement of 4.0 by 2.5 centimeters (cm - 1 inch =2.5 centimeters) with a depth of 0.2 cm. (A stage III pressure ulcer is when there is full thickness skin tissue lost). The facility failed to assess Resident 1's buttock area and notify the medical doctor before the lesion had progressed to stage III.A stool microbiology report dated 9/16/11 indicated Resident 1 tested positive for [DIAGNOSES REDACTED].A Wound Nurse note dated 9/20/11 indicated risk factors for delayed wound healing included active [MEDICAL CONDITION].The Medication Administration Record [REDACTED]. Resident 1's pain during the 5 times she was medicated was described as 6 out of 10. (The Pain Monitoring Tool indicated a score of 5-7 represented moderate pain). Resident 1's Weight Record dated 9/11/11 indicated her weight at 114 lbs. (a weight loss of 5 lb. in 2 weeks and 23 lbs. since admission). A Dietary Progress Note dated 9/13/11 revealed the Registered Dietitian (RD) had assessed Resident 1 and had indicated the resident's lips were dry and she was worried about her being dehydrated. Her plan was to suggest the licensed staff get an order for [REDACTED]. in 3 months. Resident 1 continued to refuse food and fluids despite documented facility efforts to encourage adequate fluids and nutritional meals and snacks.A Blood Chemistry Report (blood tests to assess a wide range of conditions and the function of organs.) ,dated 9/14/11, revealed the following:BUN was 30 which was elevated and outside of normal range (normal is 5-26) (last BUN was normal at 22 on 8/9/11). Sodium was 149 which was elevated and outside the normal range (normal is 135-145) (last Sodium was 137 on 8/9/11). [MEDICATION NAME] (protein level) had decreased to 14 which was outside the normal range (normal is 18-38) (previous [MEDICATION NAME] level was 20). After looking at the Blood Chemistry labs of 9/14/11 the RD stated, She was dehydrated.A Blood Chemistry Report for Resident 1 dated 9/21/11 listed her BUN had increased from 30 to 37 which was high and outside the normal range. Resident 1's Sodium had increased from 149 to 151 which was high and outside the normal range. Resident 1's Chloride had increased from 110 to 112 which was high and outside the normal range, and her [MEDICATION NAME] was 15, which was still low and outside the normal range.A physician order [REDACTED].A hospital note dated 9/21/11 for Resident 1 indicated the following labs:Sodium 147 (H), Chloride 111 (H), BUN 41 (H), [MEDICATION NAME] 2.6 (H), White Blood Count 12.7 (H) Red Blood Count 5.14 (H). The hospital evaluation dated 9/21/11 indicated because of Resident 1's elevated [MEDICATION NAME] of 2.6, and her BUN of 41 and Sodium of 147, she was dehydrated. Resident 1 was given 1000 ml. (one quart or approximately 20% of Resident 1's blood volume) of intravenous normal saline while in the hospital and then was transferred back to the facility.Review of the facility's policy titled [MEDICAL CONDITION] dated 12/2008 under Policy Interpretation and Implementation: Contact Precautions-Residents with diarrhea associated with [MEDICAL CONDITION] (i.e., residents who are colonized and symptomatic) will be placed on contact precautions for the duration of the illness. Residents at High Risk-Resident considered at high risk of developing symptoms with [MEDICAL CONDITION] includes those with advancing age .previous gastrointestinal illness caused by [MEDICAL CONDITION]. When residents with these risks have symptoms of diarrhea (i.e. three loose stools in twenty-four hour period), [MEDICAL CONDITION] should be considered as a cause. Residents with previous infection who develop diarrhea should be evaluated as soon as practical. Assessment of Resident for Dehydration-Any Resident with diarrhea shall be assessed for dehydration regularly. The facility did not document evidence of an assessment of Resident 1 regularly for dehydration.In an interview with the Director of Nurses 1 (DON) on 2/2/12 at 11:15 a.m., she stated Resident 1 was originally a low risk for getting a pressure ulcer. She also stated a care plan for pressure ulcer was not written until 9/10/11 when her pressure ulcer (stage III) had been first discovered. In a follow-up interview with the DON on 2/3/12 at 1:30 p.m., she stated the facility did not update the residents care plans for pressure sores if the residents went from low risk to moderate risks. (Resident 1 went from low risk at admission 6/8/11 to moderate risk on 9/2/11 and the stage III pressure sore was discovered on 9/10/11). She also stated, when asked what was causing Resident 1's skin to become irritated starting on 8/25/11, I assume it was from the diarrhea, from the [MEDICAL CONDITION]. In an interview with the Nurse Consultant on 2/2/12 at 1:30 p.m., she stated Resident 1's skin was irritated from having diarrhea and that is why she was ordered the [MEDICATION NAME] cream on 8/25/11 and why the resident's bottom was reddened. She also stated the staff had not discovered Resident 1's pressure ulcer until it was a stage III. She stated, They (the facility) should have found it (the pressure sore) at a stage II but didn't.In an interview with Certified Nursing Assistant (CNA) 1 on 2/3/12 at 12:50 p.m., she stated the CNA staff writes in a bowel book if the residents are having frequent stools.In an interview with Licensed Nurse (LN) 1 on 2/3/12 at 1:15 p.m., when asked about checking residents' bowel movements, he stated that if the residents had frequent stools that are smelly they would notify the resident's physician.In an interview with LN 2 on 2/7/12 at 2:15 p.m., she stated she remembered Resident 1 and remembered that her skin was irritated and that she had frequent stools. She also stated the licensed staff were supposed to look at the ADL form the CNAs had fill out each shift but sometimes the licensed staff were too busy to do this. She stated the nurses should have been aware of Resident 1's frequent stools and that the licensed nurses were supposed to be checking the residents' skin on a twice weekly basis with their baths.In an interview with CNA 2 on 2/7/12 at 2:35 p.m., she stated she remembered taking care of Resident 1 in August of 2011. She stated she remembers Resident 1 having diarrhea and smelly stools. She stated she notified the charge nurse when this happened and wrote this in the Bowel Book. In an interview with LN 2 on 2/7/12 at 3:05 p.m., after showing her documentation that the Resident had four stools on 8/23/11 during the PM shift in which LN 2 was in charge, she stated. I should of told someone about this and she (the resident) should have been tested (for [MEDICAL CONDITION]). I didn't do it.In an interview with LN 4 on 2/24/12 at 2:45 p.m., she stated she had taken care of Resident 1 in the past. When shown the ADLs for 8/24/11, which documented that Resident 1 had 4 stools during the evening shift, she stated she could not remember if anyone had told her about the stools. When asked about the Weekly Summaries she had filled out for Resident 1 leaving the slot for frequency of bowel movements empty, she stated, I did not fill out the frequency, I should have. Between 8/23 and 9/10 there was no documented evidence that the frequent loose stools was addressed by the licensed nursing staff. In an interview with DON 2 on 11/30/12 at 10:30 a.m., she stated after reviewing Resident 1's clinical records, that residents with stage III pressure ulcers can experience pain from the wound itself and also from the dressing changes. She stated that Resident 1's need to start using a narcotic pain medication on 9/10/11 was probably due to her developing the Stage III pressure ulcer.The Department determined that the facility failed to:1. Identify a possible [MEDICAL CONDITION] infection ([MEDICAL CONDITION]-a contagious bacterial infection) and follow the facility's policy for testing Resident 1 for [MEDICAL CONDITION]. timely and notifying Resident 1's physician when she started having frequent loose stools. 2. Identify and effectively monitor individual risks for pressure ulcers, implement preventive measures to relieve pressure from vulnerable areas.3. Ensure early detection of skin changes and institute treatment prior to development of a stage III pressure ulcer.4. Ensure the plan of care to monitor skin condition following diarrhea was implemented.These violations presented either (1) imminent danger that death or serious harm to the Residents or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to Residents or residents of the long term health care facility would result therefrom.

The following citation was written as a result of an unannounced visit on 12/21/10 for the investigation of complaint number CA 279. The Department determined the facility failed to provide adequate supervision or interventions to prevent Resident 1 from falling on 12/14/09, resulting in a right hip fracture and from falling on 1/22/10, resulting in a left hip fracture. These failures resulted in two unnecessary surgeries with their inherent risks and the potential to impede his ability to walk. Resident 1 was admitted to the facility on [DATE]. He had [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS - an assessment tool), dated 8/20/09, described Resident 1 as having long term and short term memory problems and modified cognitive abilities. The MDS indicated Resident 1 " required supervision " to walk, but " no physical help from staff. " He was described as having " wandering " behaviors. Resident 1 was readmitted to the facility on [DATE] after hospitalization for a fracture of his right hip following a fall on 12/14/09. This resulted in right hip replacement surgery on 12/16/09. Resident 1 was observed and interviewed on 12/23/10 at 12:20 p.m. He was sitting in a wheelchair in the dining room eating lunch independently. Resident 1 stated, " Yes, I broke my hip. " When asked about the pain, Resident 1 stated, " Yes, sharp pain. " A Fall Risk Assessment, dated 8/12/09, listed Resident 1 ' s score as 10. A note on the line for Total Score indicated " Total score of 10 or above represents HIGH RISK. " Resident 1 fell 14 times between admission on 8/12/09 and his transfer to the hospital on [DATE] for the fracture of his right hip. After readmission to the facility on [DATE], Resident 1 fell 2 more times and was transferred to the hospital on [DATE] for a fracture of his left hip. On 8/15/09 Resident 1 had an un-witnessed fall in the front yard of the facility. An Interdisciplinary Team (IDT) note, dated 8/17/09, included no recommended interventions to prevent further falls. A care plan titled Fall, dated 8/17/09, listed under problems/concerns: " Wandering; Unsteady gait; Poor safety awareness; Wanders without regard to fatigue; and (Resident) sits down on the ground. " The goal was " Have no fall or injury daily x 3 months. " Under Approach/Interventions were listed: " Out of bed as tolerated; Assist with all transfers or ambulation; Provide adequate lighting; Monitor resident location with visual check every 2 hours (as needed); Assist in reorientation to room and facility with verbal cues; Encourage group activities and attempt to keep occupied; (Encourage) to call nurse for help; Monitor for sedation, dizziness, unsteady standing/sitting balance; Report to (Medical Doctor (MD)); Inform MD and family if with incident of fall/injury; Encourage (Resident) to take rest periods (as needed). On 8/18/09 Resident 1 had an un-witnessed fall in a resident room. An IDT note, dated 8/19/09, concluded " continue to observe. " The Fall care plan, dated 8/17/09 and updated 8/18/09, included the following item: " Re-approach (resident) when refuses rest periods. " The care plan was not modified with additional approaches or interventions. On 8/20/09 Resident 1 had an un-witnessed fall beside his bed. An IDT note, dated 8/21/09, indicated their recommendation was to continue current plan of care. Resident 1 had a physician's order [REDACTED]. On 8/28/09 Resident 1 had two un-witnessed falls that resulted in an abrasion on the back of his head. An IDT note, dated 8/31/09, recommended RNA work with the resident " for 3 months for balance ...and quiet time from 2-3:30. " On 9/14/09 Resident 1 had a fall from catching his foot on a door. An IDT note, dated 9/14/09, did not include any recommendations or changes in care. A new care plan titled Fall, dated 9/15/09, included the following Problems: " Fall risks due to (history) of falls; Unsteady gait; Poor safety awareness; Forgetful and confused; Wanders throughout facility; Not able to remember how to use call light, (Diagnosis) Alzheimer ' s, Parkinson ' s; At risk for additional falls due to above; Resident sits down on floor/ground; (Resident) with poor safety awareness. " Under Goals was listed, " Will have no decline in ADLs due to falls. " Under Interventions was listed: " Assess needs as not able to use call light; Provide non-skid footwear; When restless, assist (resident) to lay down or sit in chair; Offer food and/or fluids when indicated. Keep environment consistent and alert resident to any changes. Pain management as needed. Assist to use commode as needed. Rehab services as ordered. " On 9/20/09 Resident 1 had an un-witnessed fall in the hallway. An IDT note, dated 9/21/09, concluded the resident was fatigued and would assist the resident to bed when he was fatigued. The Fall care plan, dated 9/15/09 and updated 9/20/09, included the following: " Remind (resident) to take rest periods (as needed) fatigue. " On 10/2/09 Resident 1 had an un-witnessed fall and was found in a resident room. He sustained skin abrasions. On 10/4/09 Resident 1 had an un-witnessed fall on the ramp between the two wings. He complained of severe neck and back pain and went to the emergency room for evaluation. An IDT note, dated 10/5/09, addressed his falls on 10/2/09 and 10/4/09. A PT evaluation was recommended. The Fall care plan, dated 9/15/09, was updated on 10/5/09 to include " PT evaluation for possible merriwalker (an enclosed walker with a seat (due to) unsteady shuffling gait and increased falls. " A PT evaluation, dated 10/6/09, recommended therapy 5 days a week for 2 weeks. PT was re-ordered until it was discontinued on 12/1/09. On 10/21/09 Resident 1 had an un-witnessed fall in the hallway. The Post Fall/Trauma report, dated 10/21/09, indicated Resident 1 ' s pants were wet and he was trying to toilet himself. Under Interventions Used Prior to Fall the report included " (wheelchair). " Under the heading Post Fall Investigation Summary Recommendations and Interventions the following items were checked: " Toileting schedule; Transfer pole in bathroom; Bed/chair alarm; (Wheelchair) positioning; Safety cues/reinforcement/reminder. " An IDT note, dated 10/22/09, included " Noted with functionally (sic) decrease; ADL ' s, ambulation, gait unsteady " and recommended " Refer to PT for ambulation ...resident reminded to ask for assistance ...continue to observe. " The Fall care plan, dated 9/15/09, and updated on 10/22/09, indicated " (Resident) to ask for assistance regarding ADLs and transfers. " A Fall Risk Assessment, dated 10/31/09, indicated a total score of 10 for Resident 1 ' s risk. Section B, titled History of Falls, had " 0 " entered, indicating " No falls. " Section E, titled Gait/Balance, had " 0 " entered, indicating " Gait/Balance normal. " The Assessment indicated " Total score of 10 or above represents HIGH RISK. " On 11/4/09 Resident 1 had a fall in his room. He slipped after standing up independently. The Post Fall/Trauma report, dated 11/4/09, indicated he hit the back of his head. No interventions were documented as having been in place prior to the fall. " Ambulatory " was entered under Other. Under Post Fall Investigation Summary Recommendations, the report indicated, " Requires (wheelchair) (with) lap buddy for rest period. He is non-compliant with rest period in bed. " The IDT review, dated 11/5/09, included " Resident noted with decline in functional ability, (with) poor safety awareness and abnormal posture in (wheelchair). Will refer to PT for (wheelchair) positioning and abnormal gait. " The Fall care plan, dated 9/15/09, and updated on 11/5/09 indicated " Refer (to rehab) for positioning. " On 11/7/09 Resident 1 had a witnessed fall in the dining room. After standing, he fell to one knee. The IDT note, dated 11/9/09, recommended, " Will put a (wheelchair) alarm on (resident) while (up) in (wheelchair). " The Fall care plan, dated 9/15/09, was not updated following this fall. An Occupational Therapy document titled Functional Maintenance Program, dated 11/18/09, indicated, " (Patient) has progressed to be able to walk the entire distance of the building before fatiguing. He may need a reminder to sit and rest ...during activities at least once in the (morning) and more often in the afternoon as he does get tired and is then at risk of falling. He no longer has a (wheelchair) assigned to him. " The second page of the document was titled Bowel and Bladder Training Program. This indicated Resident 1 " is able to hold his urine for up to 3 to 4 hours without accident. He does best on the shift that routinely asked him every hour if he needed to use the toilet. " Resident 1 had a physician's order [REDACTED]. On 12/9/09 Resident 1 had an un-witnessed fall in the hallway. The Post Fall/Trauma report, dated 12/9/09, under the heading Interventions Used Prior to Fall, indicated Resident 1 was " ambulatory. " Under the heading Post Fall Investigation Recommendations, the report indicated, " Provide rest periods. " The IDT note, dated 12/10/09, did not include any recommended interventions to prevent further falls. The Fall care plan, dated 9/15/09, was not updated following this fall. physician's order [REDACTED]. A Fall Risk Assessment, dated 12/10/09, indicated a total score of 16 (HIGH RISK). On 12/14/09 Resident 1 had a witnessed fall and complained of right hip pain. On 12/15/09 a right hip fracture was confirmed. This resulted in right hip replacement surgery. The Fall care plan, dated 9/15/09, was updated on 12/14/09 to include " Remind (resident) to not push other residents (in wheelchairs) (due to) impaired balance. " A transfer form, dated 12/15/09, indicated Resident 1 was transferred to the general acute care hospital for treatment of [REDACTED]. A Fall Risk Assessment, dated 12/15/09, indicated a total score of 19 (HIGH RISK). Resident 1 was readmitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. An admission MDS, dated [DATE], described Resident 1 as not walking in the week prior to the assessment and self-performance of activities of daily living were described as " deteriorated. " Resident 1 ' s physician's order [REDACTED]. A Fall Risk Assessment, dated 12/19/09, indicated a total score of 12 (HIGH RISK). Under Section E, Gait/Balance, " (Not applicable) - not able to perform function " was marked. A care plan titled Fall/Injury Potential, dated 12/20/09, listed the following under the heading Problems/Concerns: Altered mobility; Poor safety awareness; History of falls; Impaired cognition/communication; Gait/balance impaired; and Increased weakness. The plan included the following under the heading Approaches or Interventions: Cue resident and reorient; Provide safe, secure environment clutter free pathways, well-lit room, dry floor; Use simple direction to establish consistent routine; Monitor change in level of alertness, increasing lethargy; Keep assistive device within reach; Provide non-skid shoes as needed. There were no alarms to alert staff of unassisted transfer checked off as interventions in the care plan. A Nurse ' s Note, dated 1/14/10, indicated, " Returned from MD appointment with full weight bearing and full activities as tolerated status. " On 1/20/10 Resident 1 had an un-witnessed fall in his room. A Post Fall/Trauma report, dated 1/20/10 at 7 p.m., indicated, " Resident found on the floor on his left side next to his bedside. Un-witnessed fall, he verbalized that he wanted to go to bed, prior to incident he was sitting on his wheelchair in his room. " Resident 1 was assessed to have no hip injury, but did have an abrasion on his left elbow. The section titled Interventions Used Prior to Fall listed 23 possible interventions. None were checked and only " Wheelchair " was written on the line next to the title Other. Review of physician's order [REDACTED]. On 1/22/10 Resident 1 had an un-witnessed fall in his room. A Post Fall/Trauma form, dated 1/22/10, indicated Resident 1 fell when he attempted to transfer himself from his wheelchair to his bed independently. Resident 1 had a hip x-ray on 1/26/10. The report indicated, " There is a left intertrochanteric fracture (hip fracture). " The report included, " Osteoporosis (weakened bones) is present. " An interview was conducted with Certified Nurse Assistant (CNA) 2 on 12/30/10 at 2:45 p.m. He stated Resident 1 sometimes tried to stand, picking himself up from his chair. Before his second hip fracture he stood on one foot. CNA 2 stated, " He ' s not walking at all now. " An interview was conducted with Licensed Nurse (LN) 1 on 12/30/10 at 2:50 p.m. She reviewed the Post Fall/Trauma form, dated 1/22/10, which she had written and stated at the time of the fall " there was no alarm " in use for Resident 1 to alert staff when he stood up from his chair. An interview was conducted with CNA 1 on 2/9/11 at 4:30 p.m. She stated Resident 1 can stand, holding on to a transfer pole, turn around, and sit down. She stated Resident 1 did " no walking. " The facility policy titled Clinical Guideline: Falls Management was reviewed. The following directions were included in the policy: " Following a resident ' s fall ...Appropriate interventions are implemented. (See optional Resource for Resident Interventions to Prevent Falls attached) ...The IDT review the ...Post Fall/Trauma and makes additional recommendations. " The policy attachment titled Team Resource For Resident Interventions to Prevent Falls included the following: " Falls with Cognitively Impaired Residents " : Toileting programs, schedule; Ask families to make an activity basket, memory book, photo albums; Restorative programs - exercises, ambulation; Appropriate footwear; Alarms (TABS, chair, bed) - to alert staff to changes of position. " Falls for Ambulatory Residents " : Monitor, remind resident appropriate use of assistive devices; Appropriate footwear; Remind, monitor residents ability to maneuver change in flooring (ex. carpet to tile). " Residents with Multiple Falls " : Trending of falls for the individual - time of day, reason for fall, location of fall, etc.; Consider room change to move resident closer to the nurses ' station; Keep resident in view during high risk times if possible; Refer to therapy; Discuss at stand up, grand rounds, with interdisciplinary team; Restorative program - ambulation; Have staff members from each shift come up with individual interventions for residents with frequent falls; Discuss reasons for falls with direct care givers; Routine monitoring for implementation of interventions; Involve Recreation for activity interventions: Tai Chi/exercise/movement groups for frequent falls, favorite TV programs, radio shows for high-risk times Hydration group - activity during risk times; Assess medical condition/medication as possible causal factors; Example: Blood sugar fluctuations, blood pressure fluctuations, orthostatic (drop in blood pressure upon rising), Urinary Tract Infection or other infection process; Timing of medications in relation to falls; Assess need for restraint - least restrictive; Evaluate need for high/low bed. An interview was conducted with the Director of Nurses on 12/23/10 at 3 p.m. She stated after falls, the RN assesses the patient and notifies the MD and responsible party. The IDT does a root cause analysis within 72 hours and makes recommendations. After reviewing Resident 1 ' s clinical record, she stated, " The IDT didn ' t recommend new interventions after each of his falls to prevent more falls. " The Department determined the facility failed to provide adequate supervision or interventions to prevent Resident 1 from falling on 12/14/09, resulting in a right hip fracture and from falling on 1/22/10, resulting in a left hip fracture. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom.