Every finding on record at Oakwood Healthcare Center

Based on observation, interview and record review, the facility failed to implement care planned interventions to prevent further falls and injuries for seven of seven residents sampled for care planned fall interventions. (Residents 1, 2, 3, 4, 5, 6, and 7) These failures had the potential for the residents to continue to fall and sustain injuries and not attain or maintain their highest practical level of physical, emotional, and psychosocial well-being.Findings:A review of the facility's policy titled, Resident Safety, Revised [DATE], indicated, To provide a safe and hazard free environment.The Interdisciplinary team (IDT, group of people within a facility of different disciplines that meet to determine and strategize facility and resident needs and issues to implement in a variety of means) members will assess the resident's safety risk.when there is a change of condition or if an accident or incident occurs that involves the resident's safety.a Resident-centered care plan will be developed to mitigate safety risk factors.A review of the facility's policy titled, P-NP04 Person-Centered Care Planning, Revised [DATE], indicated, Person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident's life.Interventions are actions, treatments, procedures, or activities designed to meet an objective.Objective is a statement describing the results to be achieved to meet the resident's goals.The care plan must include the minimum healthcare information necessary to properly care for each resident.It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary.The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs.The comprehensive care plan must describe the following:.The services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.A review of Resident 1's medical record indicated that Resident 1 was admitted on [DATE] with diagnoses that included Fracture of Unspecified part of Neck of Right Femur with Surgical Intervention (Hip Fracture), Osteoporosis, Rheumatoid Arthritis (RA, Autoimmune disease where your immune system attacks the lining of joints), and Contractures of Right and Left Hands (permanent tightening and shortening of muscles, tendons, skin, and connective tissue causing stiffness, and restricting movement).A review of Resident 1's medical record document titled, At Risk for Falls; Care Plan Report, indicated, The resident is at risk for falls.Interventions: Bilateral landing pads [fall mat/cushions on the floor] to prevent serious injury, Check range of motion [ability to move arms and legs] QS [every shift]/ as indicated per facility fall protocol, follow facility fall protocol.During a concurrent observation and interview on [DATE] at 3:00 pm, with Licensed Nurse (LN) C in Resident 1's room to observe for intervention measures utilized. LN C confirmed there is only one fall mat present, instead of two, and the one was shoved under the bed. LN C stated they were not aware of the facility's fall protocol and would need to see a policy to review. A review of Resident 2's medical record indicated that Resident 2 was admitted on [DATE] with diagnoses that included, Pancreatic Cancer, Diabetes Mellitus (DM, disease with persistently high levels of blood sugar dysregulated by the pancreas), and Dementia (brain disorder with loss of memory and thinking abilities).A review of Resident 2's at Risk for Falls Care Plan Report was conducted. The interventions included, Bilateral [both sides of the bed] landing pads in place, floor mat right side of bed for safety, Check range of motion (ROM) per facility fall protocol, Neuro checks x (Freq) (Frequency), Follow facility fall protocol.During a concurrent observation and interview on [DATE] at 1:30 pm, with LN C in Resident 2's room. Resident 2's room was observed for placement of fall mats. LN C confirmed there was only one fall mat present, instead of two, and bilateral mats were not present. The Neuro check intervention was suppose to identify the frequency per facility policy, but no frequency was listed. LN C stated they are unaware of the facility fall protocol and would need to review a policy to ensure it was being adhered to.A review of Resident 3's medical record indicated that Resident 3 was admitted on [DATE] with diagnoses that included, Wedge Compression Fracture of T9-T10 Vertebra (Spine fracture), DM, and Parkinson's Disease (brain disorder causing progressive degenerative nervous system damage).A review of Resident 3's At Risk for Falls Care Plan Report was conducted. Interventions included, Non-skid strips to the bathroom floor, Anti-roll back device on the wheelchair (prevents the wheelchair from tipping over backwards), Dycem (Non slip material used to grip objects and stabilize slippery surfaces without sticky adhesive) to be added to the wheelchair cushion, fall mat next to bed for safety, follow facility fall protocol.During an observation and interview on [DATE] at 4:00 pm, was conducted with LN B in Resident 3's room. Resident 3's wheelchair was examined for a Dycem pad. The Dycem was found under the wheelchair's seat cushion, instead of on top of the cushion. The fall mat was not present beside the resident's bed and the non-skid strips were not on the bathroom floor. LN B confirmed the improper positioning of the Dycem, the lack of fall mat presence, and the lack of non-skid strips in the bathroom. LN B confirmed they were not familiar with the specific facility Fall Protocol and would need to review a policy or written process.A review of Resident 4's medical record indicated that Resident 4 was admitted on [DATE] with diagnoses that included, Dementia, Major Depressive Disorder (MDD, clinical mood disorder with persistent feelings of sadness, and loss of interest), and Altered Mental Status (AMS, sudden or progressive change in person's thinking, alertness, and awareness).A review of Resident 4's At Risk for Falls Care Plan Report, was conducted. Interventions included, anti roll back device to wheelchair, Bilateral landing pads to prevent serious injury, Neuro-checks x (FREQ), and Follow facility fall protocol.A concurrent observation and interview on [DATE] at 2:00 pm, was conducted with LN A in Resident 4's room. Resident 4's room was observed for placement of fall mats, and the wheelchair for an anti-roll back device. LN A confirmed there was one fall mat present, bilateral mats were not present, and there was no anti-roll back device attached to Resident 4's wheelchair. LN A confirmed the Neuro- check intervention should include an actual frequency of time that they were to be performed. LN A stated they are unaware of the facility fall protocol and would need to review a policy to ensure it was being adhered to.A review of Resident 5's medical record indicated that Resident 5 was admitted on [DATE] with diagnoses that included, Hemangioma of Intracranial Structures (A tangle of abnormal, thin-walled blood vessels), Cerebral Ischemia (blockage in an artery restricting oxygen blood flow resulting in damage to brain tissue), and Encephalopathy (brain disease, damage, or malfunction).A review of Resident 5's At Risk for Falls Care Plan Report, was conducted. Interventions included, Monitor, anti-roll back device to wheelchair, Dycem to wheelchair seat for safety, Floor mats next to bed for safety, Neuro-checks x (FREQ), and Follow facility fall protocol.During a concurrent observation and interview on [DATE] at 4:00 pm, with LN A in Resident 5's room. Resident 5's room was observed for placement of fall mats, the wheelchair for an anti-roll back device, and Dycem placement on the wheelchair seat. LN A confirmed there were no fall mats present, no anti-roll back device attached to the wheelchair, and no Dycem placed on the seat of Resident 5's wheelchair. LN A confirmed the Neuro- check intervention should include an actual frequency of time to be performed, and was blank. LN A stated they are unaware of the facility fall protocol and would need to review a policy to ensure it was being adhered to.A review of Resident 6's medical record indicated that Resident 6 was admitted on [DATE] with diagnoses that included, Psychosis (mental health dysfunction where one loses touch with reality), Essential Hypertension (high blood pressure), and Dementia.A review of Resident 6's At Risk for Falls Care Plan Report, was conducted. Interventions included, Bilateral landing pads to prevent serious injuries, Check range of motion, a number of times was to be specified, daily, Follow facility fall protocol.During a concurrent observation and interview on [DATE] at 4:00 pm, with LN A in Resident 6's room. Resident 6's room was observed for placement of bilateral landing mats. LN A confirmed there was only one landing mat present by the bedside. LN A confirmed the range of motion intervention should include an actual number of times daily this was to be performed, but was left blank. LN A stated they are unaware of the facility fall protocol and would need to review a policy to ensure it was being adhered to.A review of Resident 7's medical record indicated that Resident 7 was admitted on [DATE] with diagnoses that included, Lung Cancer, Chronic Obstructive Pulmonary Disease (COPD, long term lung disease caused by lung damage making it difficult to breathe), and Acute and Chronic Respiratory Failure with Hypoxia (sudden worsening of long-term oxygenation problem).A review of Resident 7's At Risk for Falls Care Plan Report was conducted. Interventions included, Reacher [a device to grab objects that can't be reached] will be provided, Consider bed/chair alarm per policy, and Follow facility fall protocol.During a concurrent interview and record review on [DATE] at 4:00 pm, with the Administrator (Admin) via email, Admin confirmed Resident 7 was deceased as of [DATE], and there was no documentation to support that a Reacher was provided to Resident 7, and added that bed/chair alarms are not utilized in the facility and would not be used nor considered. During a concurrent interview and record review on [DATE] at 4:30 pm, with Admin via email, the facility policy titled, FA01 Fall Management Program, revised [DATE], was reviewed. Admin confirmed there is not a policy nor written process for what the facility's Care Plan interventions referred to as Facility Fall Protocol, stating it is a component of the Fall Management program policy. Admin confirmed there are no specific intervention components (such as ROM) listed in the Fall Management Program policy. Additionally, interventions need to be specific to number of times needing to be performed if it is addressed in the care plan. Interventions, including devices, listed in care plans need to be provided and monitored.

Based on interview, record review, and policy review, the facility did not ensure that one of three residents sampled for neglect (Resident 1), was provided with treatments and monitoring to a wound on his scalp as ordered by the physician, and the wound was found to be infested with maggots (fly larva).The nursing staff's neglect in treating Resident 1's wound had the potential for infection, discomfort, embarrassment and humiliation to Resident 1.Findings:Review of a facility policy titled, Abuse Prevention and Management, revised 5/30/26, defined neglect as .failure to provide.services necessary to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress.Review of the National Library of Medicine (a nationally recognized resource for healthcare providers) website titled, Maggot Infestation: Various Treatment Modalities - PMC dated 3/30/18 indicated that at skin temperature fly eggs can hatch in 8-12 hours and that within 24 hours grow to about 7-8.5 millimeters (about the width of the top of a pencil eraser).Review of an article written by, Termite Management Services, dated 2/6/20, indicated when a fly lays eggs, the maggots remain in the egg laying site for three to five days to feed before moving to a new location.Review of the document titled, Myiasis, dated 2/23/24, located on the Centers for Disease Control and Prevention (CDC), indicated myiasis is a parasitic infection of maggots in human tissue. The document indicated that maggots could move deeper into the body, causing severe damage.Review of Resident 1's medical record indicated that he was admitted to the facility on [DATE] with diagnoses that included cancer and a cancerous wound to the top of his head.Review of Resident 1's Comprehensive Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 5/27/26, and completed by Minimum Data Set Nurse (MDS Nurse) showed a score of 5 of a possible 15, which indicated Resident 1 had a poor memory.During a phone interview on 7/24/26 at 10:26 am, Certified Nursing Assistant (CNA) A indicated that he was turning Resident 1 when he saw maggots on Resident 1's pillow. CNA A indicated that he then looked at the top part of the back of Resident 1's head and saw maggots going in and out of Resident 1's scab and crawling through his hair.During an interview on 7/24/26 at 11:13 pm, the Infection Control nurse (IP) indicated that on the evening of Saturday 7/18/26 she received a call from Licensed Nurses (LN B) and LN C and that they told her that Resident 1 had maggots in his head wound. The IP confirmed that wounds should not develop maggots.During an interview on 7/24/26 at 11:53 am, Wound Care Nurse (WCN) indicated that he worked the AM shift on Fridays and Saturdays and had completed a dressing change Resident 1's head wound earlier in the day on Saturday 7/18/26, the day the maggots were discovered, and had not seen any maggots.During a phone interview on 7/24/26 at 1:50 pm, LN B indicated that she worked 8-hour shifts and her shifts ended at 10:30 pm. LN B indicated that after 9:00 pm, a CNA told her that she should go look at the wound on Resident 1's head. LN B indicated that she did and that there were a couple of dozen maggots on his head and on his pillow. LN B indicated that there was no dressing covering the wound on the back of Resident 1's head. LN B indicated that she had not seen the maggots earlier in the shift.During a phone interview on 8/4/26 at 1:14 pm, LN C indicated that a CNA told him to come look at Resident 1's head wound and when he looked there were maggots in and around the wound.Review of Resident 1's Medication Administration Record (MAR) for the month of July 2026 for the dates of Wednesday 7/15/26 to Saturday 7/18/26, indicated that Resident 1 had physician's orders (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) for cleaning his head wound and changing the dressing every day. Resident 1 also had physician's orders to monitor (look at under the bandage) the back of his head every shift (AM, PM, and night shift) for any changes and notify the physician if there were any changes. From Wednesday 7/15/26 to Saturday 7/18/26, there was documentation on Resident 1's MAR that reflected eight LNs electronically signed that they had monitored Resident 1's head wound. No progress notes (a healthcare professional's written record of an observation, the care given, and how the patient responded) from those dates indicated that any of the eight nurses noticed any changes in Resident 1's head wound or that they noticed any maggots.During an interview on 8/5/26 at 3:00 pm, the Director of Nursing (DON) confirmed that there should not be maggots in residents' wounds and that nursing staff should have noticed that there was a change in Resident 1's head wound before there were maggots in it.

Based on interview, record review, and policy review the facility failed to ensure each authorized individual had their own credentials and password to access resident electronic medical records (EMRs) when one of three residents sampled (Resident 1) when Licensed Nurse (LN) D gave LN B her credentials and password to login to Resident 1's EMR and document under her name.This failure had the potential for unauthorized users to access Resident 1's EMR and violate his right to have his medical information private and safeguarded. Findings:Review of a facility policy titled, Electronic Protected Health Information Security revised 12/1/12, indicated A. Facility Staff will be assigned unique user log-in information to access the electronic record keeping system. i. Facility Staff will be advised not to share their passwords with other employees.During a phone interview on 7/24/26 at 1:50 pm, LN B indicated that she was working as registry nurse at the facility (temporary staffing agency) on Saturday 7/18/26, and had not been provided with her own login for the EMRs. LN B confirmed she used LN D's password and log-in information to document the care she had provided to Resident 1 that day.During a phone interview on 8/5/26 at 1:14 pm, LN D confirmed that on Saturday 7/18/26 she worked and that LN B did not have a logon to access the EMRs. LN D indicated that she allowed LN B to use her logon and that it was not uncommon for registry staff to not have a logon for their shifts at the facility. LN D indicated that the documentation LN B had done for the change in condition for Resident 1, was done hours after LN D had already left the facility for the day around 5:00 pm.Review of Resident 1's medical record titled, eINTERACT Change in Condition Evaluation dated 7/18/26 at 10:58 pm, indicated that it was electronically signed by LN D, when she was not in the facility, and Resident 1 was under the care of LN B.Review of Resident 1's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of July 2026, for the day of Saturday 7/18/26, indicated LN D's electronic signature was used for the care that LN B had provided.During an interview on 8/5/26 at 3:00 pm, the Director of Nursing (DON) confirmed that nursing staff should not give other nurses' their logins, credentials or passwords to access the EMRs.

Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH), potential abuse and unusual occurrences for two of three sampled residents who had falls with major injuries (Resident 1 and 2) when, Resident 1 fell and broke her wrist and Resident 2 fell and broke her hip and the facility had not notified CDPH.This failure had the potential of creating an unsafe environment for residents where conceivable abuse or unusual occurrences go unreported to appropriate authorities resulting in significant physical harm and emotional suffering to residents affected without being properly investigated.During a review of the facility's policy and procedure titled, P-AP12 Unusual Occurrence Report, dated Revision 5/30/24, the policy indicated, The facility reports the following events by phone and in writing to the appropriate State or Federal agencies.Other Occurrences.Major Accidents.Allegations of abuse.A review of Resident 1's medical record indicated that Resident 1 was admitted [DATE] with diagnoses that included Nondisplaced Fracture of Greater Trochanter of Right Femur with Subsequent Encounter for Closed Fracture (Hip Fracture with surgical intervention), Breast Cancer, and Osteoporosis (progressive disease that weakens bones).A review of Resident 1's medical record document titled, Progress Notes, dated 6/5/26 at 07:18 am, indicated that Resident 1 experienced an unwitnessed fall in [their] room. Resident with right wrist not in alignment sent to [acute hospital] to evaluate and treat.A review of Resident1's medical record document titled, XR (Xray) Wrist Limited 2 VW (view) Right, dated 6/5/26, indicated, Distal Radial and Ulnar Fracture (wrist fracture) diagnosed, which required a closed reduction hospital intervention (procedure to set a broken bone without cutting skin open).During an interview on 6/17/26 at 10:25 am, with Resident 1, in Resident 1's room while sitting in their wheelchair, Resident 1 stated, I fell and broke my wrist. I was sent to the hospital and have to wear this cast.During a concurrent interview and record review on 6/18/26 at 4:30 pm, with Administrator (Admin) and Director of Nursing (DON) in the DON's office, a document titled, TX Result Report (fax report), along with an Unusual Incident/Injury Report regarding Resident 1's fall, dated 6/5/26, was reviewed. The report indicated that on 6/5/26 at 14:36 (2:36) pm, the facility attempted to fax CDPH a copy of an Unusual Incident/Injury Report regarding Resident 1's fall. The fax report indicated that there was No Ans (No Answer), confirming the fax was not successfully sent nor received because it was faxed to CDPH's telephone number instead of CDPH's fax number. Thus, the faxed report of Injury/Accident was never received by CDPH. The DON confirmed she did not call to confirm the fax number for CDPH, nor did she check the confirmation status of the fax after sending it. The Admin confirmed the fax report reflected the status of No Answer, and verbalized understanding that this meant the fax regarding the injury/accident report for Resident 1, was not received by CDPH and stated that should have been checked for confirmation of successful completion but was not. A review of Resident 2's medical record indicated that Resident 2 was admitted on [DATE] with diagnoses that included Fracture of Unspecified part of Neck of Right Femur with Surgical Intervention (Hip Fracture), Osteoporosis, Rheumatoid Arthritis (RA, Autoimmune disease where your immune system attacks the lining of joints), and Contractures of Right and Left Hands (permanent tightening and shortening of muscles, tendons, skin, and connective tissue causing stiffness, and restricting movement).A review of Resident 2's medical record document titled, Progress Note, dated 6/9/2026 at 11:15 am, indicated that resident 2 had an unwitnessed fall, resident was lying on the floor on the right side of the bed in resident room.right hip 7/10 [pain].Resident had noted external rotation on the right leg and shortening (hip misalignment).Resident was transferred to the ED [Emergency Department].A review of Resident 2's medical record document titled, XR Hip 2-3 VW Right XR Pelvis 1 VW , dated 6/9/26, indicated, Fracture deformity is noted of right femoral neck (hip fracture) diagnosed, which required hospital surgical intervention.During an interview on 6/17/26 at 8:45 am, with Resident 2, in Resident 2's room while they are lying in bed, Resident 2 stated, I fell out of bed reaching for something. I went to the hospital, they did surgery. I am recuperating.During an interview on 6/18/26 at 4:30 pm, with DON and Admin, in DON's office, DON and Admin confirm CDPH was not notified of Resident 2's accident/injury which resulted in a right broken hip.

Based on interview and record review, the facility failed to provide food that is palatable (refers to the taste and/or flavor of the food), attractive, and nutritious for two of five sampled residents (Residents 2 and 4) who complained of food being cold.This had the potential for all residents to receive an inadequate amount of nutrition required to aid in the recovery from illness or injury or maintain a healthy body weight.A review of a facility policy titled, Menu Operational Manual Policy, revised 04/01/2014, indicated the Dietary Manager will develop menus in collaboration with the Dietitian. Menus are to be designed in consideration of resident preferences, Dietary Department resources, and seasonal availability of food.A record review of monthly Resident Council Meeting minutes from 2/12/24 and 2/24/26, included complaints/concerns regarding food including not being cooked properly (under or overcooked), no condiments (salt, pepper, ketchup, mustard etc.) provided, and no alternative menu items were available.During an interview on 3/3/26 at 1:30 pm, Resident 2 stated her food was cold by the time it gets to her and arrives very late.During an Interview on 3/4/26 at 12:20 pm, Resident 4 stated there was not enough staff during lunch, meals are frequently late and food is rarely warm.A test tray was requested on 4/21/26 at 12:50 pm. Surveyor tasted food items in the presence of the Corporate Certified Dietary Manager (CDM) C. The entree was meatballs and were pale in color and lukewarm (barely warm). green peas which were lukewarm and pasta that was tough, bland in flavor and lukewarm. CDM C had not requested a meal tray to test for herself.During an interview on 4/21/26 at 1:05 pm, CDM C and the Registered Dietician (RD), both confirmed that neither of them had tested any food that was served to the residents or completed audits of meal temperatures and taste, from January to March 2026.

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service in a safety manner when:1. [NAME] F did not obtain and document the internal temperature of three of five chicken breast patties prior to serving to residents.2. [NAME] F did not wear gloves when assisting with the plating (putting food on the plate to be served) of a resident's lunch.3. Dietary Aide (DA) placed food in a plastic storage bag with their bare hands.These failures had the potential to result in food contamination which could cause illness for all residents who received food prepared from the facility kitchen. A review of the facility's policy titled, P-D516 Food Temperatures with the effective date of 11/14/2025 indicated, 3. Where To Record Temperature: a. Record the reading on Food Temperature Log at the beginning of the tray line making sure to take the temperature of each pan of product before serving.1. During the lunch meal plating observation 4/21/26 at 11:45 am, five raw chicken patties were on a plate being prepared to fry. The chicken patties were individually fried then placed in covered pan while waiting to be served and no internal temperature was taken.During an interview on 4/21/26 at 1:02 pm, with [NAME] F after the chicken patties were served to the residents, [NAME] F confirmed he had not taken the temperatures of three of the five chicken patties that were served. [NAME] F stated all cooked food should be verified to have a safe internal temperature before serving.During an interview on 4/21/26 at 1:21 pm, Corporate Certified Dietary Manager (CDM) C, confirmed the expectation was to have internal temperatures taken and recorded of all cooked food before serving to residents to ensure the food has reached a safe temperature and avoid food borne illnesses.In an email dated 4/21/26 at 5:06 pm, to the Administrator (ADM), requesting competency evaluations for [NAME] E and [NAME] F, ADM responded neither competencies could be found.2. During a lunch meal observation on 4/21/26 at 12:45 pm, [NAME] E handed a resident plate to [NAME] F to add on a piece of fish. [NAME] F took the plate with his bare hands, used tongs to place the fish onto the plate, then placed the lid on plate without wearing gloves and handed the plate back to [NAME] E. During an interview on 4/21/26 at 1:02 pm, [NAME] F confirmed that gloves are required when handling food and resident meal plates. [NAME] F stated he was in a hurry and forgot to put on gloves when he put the fish on the resident's plate. During an interview on 4/21/26 at 1:47 pm, CDM C confirmed that all kitchen staff are required to wear gloves when handling and plating food. 3. During the lunch meal observation on 4/21/26 at 12:47 pm, DA was putting an onion into a plastic storage bag with her bare hands. DA dropped the onion on the cart and used her bare hands to pick up the onion and put it in the plastic bag.During an interview on 4/21/26 at 1:07 pm, DA acknowledged that gloves should be worn when handling food and confirmed she had forgotten to wear them when putting the onion in a plastic storage bag. DA confirmed the onion she touched without gloves was placed in the refrigerator for use in resident food. During an interview on 4/21/26 at 1:47 pm, CDM C confirmed that all kitchen staff are required to always wear gloves when handling any food, whether it be cooked or raw.

Based on interview and record review, the facility failed to ensure sufficient nursing staff were available to meet residents' care needs when:1. Five of five sample residents (Residents 1-5) reported long delays with Certified Nursing Assistants (CNAs) answering call lights and not getting scheduled showers.2. Resident council meetings and resident grievances identified call light response delays during January-March 2026.3. Acuity (complexity and intensity rather than just resident numbers) levels for residents were not considered when scheduling CNA staff on Nursing Station 2.This resulted in missed showers, resident care needs not being met, and residents felt unsafe and disrespected.Findings:1. During an interview on 3/3/26 at 1:30 pm, Resident 2 stated call lights were not answered in reasonable time and has waited 30-40 minutes on the toilet for CNA assistance on Nursing Station 2. Resident 2 stated this caused pain/redness to her legs and bottom. Resident 2 explained CNA staffing on her Nursing Station 2 was three CNAs three days in a row, 3/1-3/3/26. Resident 2 stated there is usually a minimum of four CNAs scheduled and felt five were needed due to so many residents on Hoyer lifts (a mechanical lifting device) to transfer which required two staff. Resident 2 stated delays in assistance feels scary. Resident 2 stated last night staffing was three CNAs. Resident 2 stated she observed a CNA using a Hoyer lift (a mechanical lifting device requiring 2 staff to transfer residents with limited mobility safely between from bed to wheelchair) alone which was not safe. During an interview on 3/3/26 at 1 pm, Resident 1 stated one occasion CNA response was delayed, causing her to yell from room for assistance. Resident 1 stated facility can be short staffed at times, having only 3 CNA staff on Nursing Station 2. Resident 1 stated sometimes there are not enough staff to facilitate smoking breaks for residents. During an interview on 3/4/36 at 1:47 pm, Resident 3 stated she was frustrated with the care provided. Resident 3 stated there are frequent CNA call-offs, and she believes there are not enough CNAs available. She reported that CNAs do not treat all residents the same and stated her roommate requires multiple CNAs for Hoyer lift transfers while she sometimes does not receive assistance when needed. Resident 3 stated she often tries to complete tasks herself but is unable to do so safely. Resident 3 further reported that items are sometimes left blocking the bathroom doorway, and she recalled having to move a dirty brief out of the way to access the bathroom.During an interview on 3/4/26 at 12:20 pm, Resident 4 stated she often must wait a long time to change their incontinence brief, explaining that it depends on staffing and that there were not enough staff available. Resident 4 stated the delays make her feel uncared for and increase her anxiety. Resident 4 stated that CNAs appear to be rushed and do not always leave her feeling completely clean after care. Resident 4 further stated that meals frequently arrive late and are rarely warm. She stated there is not enough CNAs during lunchtime, as CNAs are busy getting residents up, dressed, and transferred using Hoyer lifts.During an interview on 3/4/26 at 12:50 pm, Resident 5 stated she does not believe there are enough CNAs available. Resident 5 stated she often missed her Saturday shower and missed her scheduled shower today. Resident 5 stated CNAs appear stressed and rushed. She stated she feels bad for the CNAs because they work very hard, but due to staffing she does not always receive the care she needs. Resident 5 further stated she is not receiving enough physical or emotional care, and it takes a long time for CNAs to assist her out of bed. She reported CNAs appear rushed and quickly move to the next resident, and she feels neglected and disrespected.During an interview on 3/3/26 at 12:00 pm, CNA G stated that on recent shifts there were three CNAs assigned to the station, and several residents required Hoyer lift assistance. CNA G stated with this level of staffing we can only do so much. CNA G stated that showers may not always be completed due to workload. CNA G stated the corporation had approved five CNAs for Station 2, and that level of staffing occurred only once, and staffing typically remained at three or four CNAs.During an interview on 3/4/26 at 2:40 pm, CNA B stated the facility was often short-staffed due to call-offs, and staff who call off are not always replaced. CNA B reported residents frequently complain about call light response times.In an interview on 3/4/26 at 2:50 pm, CNA C stated she previously worked the morning shift and transferred to the evening shift because mornings were too busy and assignments were difficult to complete. CNA C stated that when care was completed late, residents sometimes refuse showers which caused showers to be refused or missed.In an interview on 3/4/26 3 pm, CNA D reported that during the morning shift there were initially three CNAs assigned, but one aide left early due to illness, leaving two CNAs for a period of time. CNA D stated the shift was very difficult due to the low staffing level. CNA D stated that showers were not completed and some residents were left wet because CNAs were unable to reach everyone in a timely manner. CNA D stated that four CNAs per station were considered manageable which rarely occurs.2. A review of a Resident/Grievance report dated 2/15/26, indicated Resident 5 reported that a CNA B was not cleaning her thoroughly during personal hygiene care. Resident 5 requested another CNA. A Licensed Nurse on the evening shift informed Resident 5 that she would have to wait for assistance due to the CNAs being busy and would go find a CNA to assist her and never came back.A review of a Resident/Grievance report dated 2/28/26, Resident 2 reported that she had to wait 25 minutes for her bathroom call light to be answered. Resident 2 indicated that on two other occasions when she had initiated her call light, she saw two CNAs walk past her room and did not respond to her request for assistance.A review of Resident Council Meeting Minutes indicated:-On 2/12/26 at 2:30 pm, nine residents attended the meeting and it was reported that call light wait times were at 45 minutes for all nursing shifts.-On 2/24/26 at 2:30 pm, seven residents attended the meeting and it was reported that call light wait times were at 45 minutes for all nursing shifts. CNAs take lunch breaks two at a time and this does not allow enough direct care staff to assist residents.-On 3/10/26 at 2:30 pm, the meeting was attended by nine facility residents who indicated CNAs take lunch breaks two at a time and this does not allow enough direct care staff to assist residents. CNAs assigned to a particular nursing station does not answer call lights while covering for another CNA while on lunch break.3. A review of a mechanical lift (Hoyer) list of residents updated 1/13/25 indicated that on Nursing Station 2 there were 18 dependent residents that required the Hoyer lift. At Nursing Station 1 there were 10 residents listed, for a total of 28 residents who required the Hoyer lift device in the facility.A review of a Bed Bath shower report dated from 1/31/26-3/9/26 for four residents on Nursing Station 2 indicated:-Resident 3's shower schedule days were Wednesday and Saturday on evening shift, she refused showers nine times from 1/31-3/7/26. The showers were offered on the day shift, not the evening shift.-Resident 2's shower schedule days were Wednesday and Saturday on evening shift, she refused her showers seven times from 2/4-3/7/26. The showers were offered on the day shift, not the evening shift.-Resident 4's shower schedule days were Tuesday and Friday on day shift. She refused shower 12 times from 2/3-3/6/26.-Resident 5's 4's shower schedule days were Wednesday and Saturday on day shift. She refused showers seven times from 2/4-3/7/26.A review of the Nursing Staffing Assignment and Sign in Sheets indicated:-On 2/17/26, Nursing Station 2 shift 2:30 pm-10:30 pm, indicated three scheduled CNAs.-On 2/2826, Nursing Station 2 shift 6:30 am-2:30 pm three scheduled CNAs, and shift 2:30 pm-10:30 pm, three scheduled CNAs.-On 3/1/26, Nursing Station 2 shift 6:30 am-2:30 pm three scheduled CNAs.-On 3/2/26, Nursing Station 2 shift 6:30 am-2:30 pm three scheduled CNAs. Shift 2:30 pm-10:30 pm, three scheduled CNAs.During a concurrent interview and record review on 4/21/26 at 11:38 am, the Director of Staff Development (DSD) reviewed staffing schedules and shower documentation for February and March 2026 for Station 2. DSD confirmed that Station 2 had the most Hoyer lifts which meant a higher level of resident acuity and more complex residents with behaviors. DSD confirmed during those months, often they only had three CNAs for Nursing Station 2 when it required four, and now they try to schedule five CNAs. DSD stated they now include acuity in their calculation of needed staff on Station 2 due to the large number of dependent residents that required transfers with Hoyer lifts. DSD stated the Day and Evening shifts should have four CNAs and night shift should have 2. DSD confirmed showers were identified as being refused and missed. DSD stated they have started adding shower CNAs to assist with the workload. DSD confirmed issues with resident showers not happening and resident refusals due to being offered too late.

Based on observations, interviews, and record reviews, the facility did not identify or implement interventions to ensure the residents were free from accidents or hazards when:1.An unlocked crash cart (a mobile cart that contained lifesaving equipment and medication) was stored in the communal dining room (a large room where residents met to eat meals, participate in activities, or watch TV); and2.Facility nurses did not check two out of two crash carts every night to ensure that needed supplies were available and not expired.This resulted in residents and visitors having access to the contents of the crash cart and had the potential to impact resident safety or cause a delay in life sustaining care.Findings:1.A review of the facility's policies and procedures (P&P) titled, Resident Safety, dated [DATE], indicated, the purpose of the P&P was to ensure residents had a safe and hazard free environment. The P&P indicated that when an unsafe situation was identified, it would immediately be reported to their supervisor.During a concurrent interview and observation on [DATE] at 12:00 pm, with the facility's Infection Preventionist (IP), the crash cart located in the communal dining room was observed. The crash cart was located next to the door, covered with a red cloth cover that was not secured closed and there was no lock. There were residents in the communal dining room waiting for lunch to be served, and no staff were present. Some items located on the crash cart that could be harmful to residents were normal saline (salty, sterile water), an oxygen tank (supplemental oxygen provided to someone who had difficulty breathing on their own), iodine swab sticks (used as first aide to sanitize cuts and scrapes), and Yankauers (a long, hard plastic devise used to suction fluids out of the mouth and throat). Upon leaving the communal dining room, a resident wheeled themselves to the dining table that was within arms reach of the crash cart. IP confirmed the contents of the crash cart were available to residents and stated, that's why we are trying to get a new one that locks.During an interview on [DATE] at 12:28 pm, Director of Nursing (DON) was asked why the facility had one crash cart that was locked and one crash cart that could be accessed by residents. DON could not verbalize a reason and confirmed, the contents of the crash cart in the communal dining room were accessible to the residents and posed a risk to the safety of the residents.During an interview on [DATE] at 3:45 pm, the facility's Administrator (Admin) stated, I am not aware why the crash cart is unlocked and the expectation is the crash cart is to be locked.2.A review of the facility's P&P titled, Medical Emergencies-Code Blue, dated [DATE], indicated there was a signed Emergency Checklist that indicated the crash cart was ready for use.During a concurrent interview, observation, and record review, on [DATE] at 12:00 pm, with the facility's IP, the crash cart located in the communal dining room was observed. The crash cart had a binder that contained untitled documents dated [DATE] through [DATE]. IP indicated the documents were a check list that the night nurses utilized to check the crash carts, every night, to ensure all the supplies were present and nothing on the crash carts were expired. IP reviewed the untitled document on the crash cart located in the communal dining room and confirmed, the night nurses did not document an inspection of the crash cart on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], and [DATE] through [DATE]. IP confirmed, the crash cart contained four packages of Povidone-Iodine Swabsticks (used to treat cuts or to sanitize skin) that expired [DATE] and there were no boxes of gloves located on the crash cart.During a concurrent interview, observation, and record review, on [DATE] at 12:15 pm, with the facility's IP, the crash cart located near Station 2 was observed. The crash cart had a binder that contained untitled documents dated [DATE] through [DATE]. IP conf there was no documentation present in the binder that indicated the night nurses had documented an inspection of the crash cart on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], and [DATE] through [DATE]. IP confirmed there was no document in the binder that indicated that night nurses had started a document for [DATE] and confirmed there was no documentation for [DATE].During an interview on [DATE] at 12:28 pm, DON confirmed that it was the DONs responsibility to ensure the night nurses were monitoring the crash carts for expired supplies, needed equipment, and were documenting the crash cart inspections nightly. DON was asked when the last time DON had reviewed the night nurse's crash cart documentation binders and the DON stated, I have not checked recently.

Based on observation, interview, and record review, the facility failed to ensure that a resident who entered the facility without pressure injuries (PIs, bed sores) did not develop PIs, develop care plans related to the PIs, identify heel PIs, and manage PIs in one of three residents sampled for PIs (Resident 1) when:1. Facility nursing staff failed to recognize a PI on Resident 1's coccyx (the small, triangular bone at the very bottom of the spine) until it was a stage 2 PI (partial-thickness skin loss with exposed dermis [the middle layer of the skin]).2. A specialized mattress was not obtained for Resident 1 until 11 days after her coccyx PI was discovered.3. Facility nursing staff failed to recognize the development of PIs on Resident 1's heels until her family told staff that Resident 1's heels were hurting.4. No change in condition assessment (documentation completed in a patient's chart after an unexpected change in the patient's physical or mental state occurs, documentation includes specific observations, the assessments of the patient performed, and any actions taken, completed to ensure a clear record for communication and follow-up) was completed for Resident 1's coccyx PI.5. No care plan (a document that outlines a patient's health care needs and the actions and interventions required to address them) was developed for Resident 1's coccyx PI until 8 days after it was discovered.6. The Registered Dietitian (RD is a food and nutrition expert who has completed schooling, supervised practice, and passed a national exam) was not notified that Resident 1 had any PIs until 3/12/26, 10 days after the discovery of Resident 1's coccyx PI, and 7 days after the discovery of the PIs on her heels, and a non-dairy nutrition fortification shake to help with PI wound healing was not obtained until 23 days after the discovery of Resident 1's coccyx PI.These failures had the potential to delay wound healing, lead to infections, and pain for Resident 1.Findings:Review of the National Pressure Injury Advisory Panel NPIAP (a nationally recognized professional resource for the staging and treatment of pressure injuries a global driver of quality improvement and patient safety in healthcare), website document webpage titled, Pressure Ulcer/Injury: Definitions and Etiology https://internationalguideline.com/etiology published February 2025, indicated that other names for pressure injuries include bedsores, decubitus ulcers, pressure sores and pressure ulcers.Review of the National Pressure Injury Advisory Panel's website document titled, NPIAP Pressure Injury and Stages, at https://npiap.com, dated September 2016 indicated;Stage 1 pressure injury: non-blanchable (skin redness or discoloration that does not fade or turn white when pressure is applied) erythema (reddening of the skin), which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes.Stage 2 pressure injury: partial-thickness skin loss with exposed dermis (the middle layer of the skin). The wound bed is visible, pink, or red, moist and may also present as an intact or ruptured serum-filled blister (a raised pocket of skin filled with fluid, caused by skin injury from friction [rubbing], heat, or certain diseases. Adipose [fat] is not visible, and deeper tissues are not visible. Granulation tissue may be visible [a type of new, temporary tissue that forms during the wound healing process]). These injuries commonly result from adverse microclimate (temperature and moisture on the skin), and shear in the skin (injury that occurs when skin layers are pulled in opposite directions, damaging tissues, and blood vessels beneath the skin).Unstageable Pressure Injury: Obscured (hidden or difficult to see) full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (thick stringy yellow or gray dead tissue or eschar (black, brown, or tan scab-like dead tissue attached firmly to the wound). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.Review of Resident 1's health record indicated that she was admitted to the facility on [DATE] with diagnoses which included vertebral fractures (breaks in the bones of the spine).Review of Resident 1's Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents), dated 2/17/26, indicated a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 7 out of 15 indicating poor decision making ability.Review of Resident 1's wound care physician consultation dated 3/9/26, completed by the Wound Care Physician (WCP), confirmed that Resident 1 had a stage 2 PI on her coccyx, a stage 2 PI on her left heel, and an unstageable PI on her right heel.1. Review of a facility policy titled, Pressure Injury Prevention revised 6/27/24 indicated 5. Staff will observe for any signs of potential or active pressure injury daily.During a phone interview on 3/12/26 at 4:01 pm, with Licensed Nurse (LN B), LN B indicated that she discovered Resident 1's stage 2 coccyx PI on 3/2/26 and that Resident 1 had been admitted to the facility with no PIs. LN B indicated that PIs do not happen overnight.During a concurrent interview and record review on 3/13/26 at 4:00 pm, with the Director of Nursing (DON), reviewed Resident 1's record titled Skin Check dated 2/24/26 and completed by LN D, the DON acknowledged that there was no mention of a PI on Resident 1's coccyx. Review of Resident 1's record titled N Adv - Long Term Care Evaluation dated 3/4/26 and completed by LN E, the DON acknowledged that the evaluation did not mention PIs on Resident 1's heels. Review of Resident 1's record titled, eINTERACT SBAR Summary for Providers dated 3/5/26 and completed by LN E, the DON acknowledged that this evaluation, done just one day later, indicated that Resident 1 had developed PI wounds on her heels. The DON indicated that this was due to poor assessment skills.2. Review of a facility policy titled, Pressure Injury Prevention revised 6/27/24 indicated 3. Implemented interventions identified in the plan of care which may include, but are not limited to, the following: a. Pressure redistributing devices for bed and chair.During an interview on 3/12/26 at 4:01 pm, with Licensed Nurse (LN B), LN B confirmed that Resident 1 admitted to the facility with no PIs and that she discovered a new stage 2 PI had developed on Resident 1's coccyx on 3/2/26. And that she had put in a request for a low air loss mattress (LAL - a specialized medical mattress designed to prevent and treat pressure ulcers by using inflatable air cells that continuously circulate air, allowing a small amount of air to escape through tiny holes in the mattress that helps keep skin cool and dry) for Resident 1 but she did not know if it was documented.During review of Resident 1's records titled, Orders Summary 2/13/26 to 3/13/26 showed no record for an LAL ordered by LN B was found.Review of Resident 1's record titled, N Adv - Clinical Assessment dated 2/13/26, completed by LN B, indicated that Resident 1 admitted to the facility with no pressure ulcers.Review of Resident 1's record titled, N Adv - Skin Check dated 3/2/26, completed by LN B, indicated a new stage 2 pressure ulcer was found on Resident 1's coccyx with moisture associated skin damage (moisture associated skin damage caused from prolonged exposure to moisture) on her buttocks.During an interview on 3/26/26 at 12:22 pm, with LN A, LN A indicated that on 3/12/26 she looked at Resident 1's skin and ordered a LAL mattress for Resident 1. LN A indicated that the mattress that Resident 1 had before was a standard medical grade mattress, and that this kind of mattress has some pressure relieving qualities but that it was not the mattress that Resident 1 needed.Review of Resident 1's record titled, Order Details (Physician's Order - written instructions from a doctor detailing specific treatments, medications, or tests for a patient) dated 3/13/26, ordered by the Physician (MD), indicated that a LAL was ordered on 3/13/26, 11 days after the discovery of Resident 1's coccyx PI.During a concurrent interview and record review on 3/13/26 at 4:00 pm, with the DON, reviewed Order Details and the DON acknowledged that the Physician's Order for the LAL for Resident 1 was obtained on 3/13/26.3. Review of a facility policy titled, Skin Integrity Management revised 6/28/24 indicated, The facility will identify, evaluate, and intervene to prevent further pressure injury and/or heal pressure ulcers and any other skin integrity conditions.Review of a facility policy titled, Skin Integrity Management revised 6/27/24 indicated, b. A Licensed Nurse will complete the skin evaluation weekly.During a concurrent interview and record review on 3/26/26 at 11:19 am, with LN E, LN E indicated that she completed one of Resident 1's weekly summaries on 3/4/26 but did not actually check Resident 1's heels stating, I guess I missed it, sometimes we miss things. LN E explained that the facility has the nursing staff complete the N ADV Skin Check and the N ADV Long Term Care Evaluation. LN E explained that these two assessments are very time consuming and make it difficult to recognize an issue because one includes specific areas of the skin to follow up on from the previous week where there was for example a PI, bruise, or skin tear and another assessment does not indicate a specific area to focus on. LN E indicated that having two redundant assessments made it difficult to recognize Resident 1's heel PIs. LN E indicated that there has been no consistency in how the facility wants them to do things because there has been so much change in the leadership of the facility.Review of Resident 1's change in condition evaluation titled, eINTERACT SBAR Summary for Providers dated 3/5/26 at 2:28 pm, written by LN E indicated that Resident 1 had developed discoloration to the right heel and small open area to left heel measuring 1cm x 1cm (centimeters, a unit of measure, 2.5 cm equals about an inch).During an interview on 3/26/26 at 2:48 pm, with the facility administrator (ADM), Corporate Resource Nurse (CRN), and Regional [NAME] President of Operations (RVPO), the ADM, CRN, and RVPO acknowledged that having two redundant assessments which were not due to be completed at the same time, made recognition of Resident 1's heel PIs difficult.4. Review of a facility policy titled, Pressure Injury Prevention revised 6/27/24 indicated 1. Complete a skin risk evaluation.when there is a significant change in condition.During an interview on 3/26/26 at 10:30 am, with the Minimum Data Set Nurse (MDS - a nurse who completes federally mandated assessments that measure the health status in nursing home residents), the MDS nurse confirmed that there was not a change in condition MDS assessment completed for Resident 1 related to her PIs, that they were just monitoring Resident 1 right now, and that there was an option to not do the change in condition on her at that time.During an interview on 3/26/26 at 2:48 pm, with the CRN, the CRN confirmed that the significant change in condition MDS (SCOC) assessment was not optional and if Resident 1's PIs had not healed within 14 days after discovered, an SCOC MDS should have been completed.5. Review of a facility policy titled, Skin Integrity Management revised 6/27/24 indicated, 5. Review the resident's care plan and update as necessary.Review of Resident 1's record titled, Care Plan dated 3/10/26, indicated that it was not updated to include Resident 1's stage 2 coccyx PI until 3/10/26, 8 days after this PI was discovered, and was not updated to include Resident 1's PIs to her heels until 3/10/26, 5 days after these PIs were discovered.During an interview on 3/13/26 at 4:00 pm, with the DON, the DON confirmed that the care plans for Resident 1's PIs should have been developed right away after their discovery so that a plan was put into place for the interventions necessary to promote healing of Resident 1's PIs.6. Review of a facility policy titled, Skin Integrity Management revised 6/27/24 indicated, d. The dietary needs of the Resident will be evaluated by the registered dietitian upon any significant change in condition.Review of a facility policy titled, Evaluation of Weight and Nutritional Status revised 1/30/25 indicated, 1. The Facility will maintain an acceptable nutritional status for residents per professional standards by: c. Implementing interventions for maintaining or improving nutritional status that are consistent with resident needs.During an interview with the Registered Dietitian (RD) on 3/26/26 at 9:57 am, the RD indicated that she was not notified of Resident 1's PIs until 3/12/26, 10 days after Resident 1's coccyx PI was discovered, and 7 days after the discovery of Resident 1's heel PIs were discovered. The RD indicated that she ordered health shakes 3 times per day to be added to Resident 1's meals on 3/12/26 but that on 3/17/26 she was told by nursing that Resident 1 does not consume dairy products and that they were trying to order Resident 1 a non-dairy health shake. The RD indicated that she was told that the non-dairy health shake that she suggested was not in the facility's ordering system. The RD confirmed that as of 3/26/26, 24 days after the discovery of her first PI, Resident 1 had still not gotten the non-dairy health shakes.Review of Resident 1's record titled, Nutrition/Dietary Note dated 3/12/26, and written by the RD indicated, Recommend add Health shake TID (3 times per day) with meals.During an interview on 3/26/25 at 2:48 pm, with the RVPO, the RVPO confirmed that the facility went out and purchased the non-dairy health shake that afternoon and that Resident 1 had gotten the first of her non-dairy health shakes that day.

Based on interview and record review the facility did not maintain complete documentation for six out of six sampled residents (Residents 1, 2, 3, 4, 5, and 6) when Licensed Nurse (LN) B did not sign the medication administration record (MAR) when administering medication.This failure had the potential for medication errors, residents to receive a double dose of medication, and a decline in resident health status.Findings:A review of the facility's policies and procedures (P&P) titled, Medication Administration, revised 6/26/25, indicated, the person who administered medication would document the date and time of the medication in the resident's medical record.A review of the facility's P&P titled, Completion and Correction, revised 1/1/12 indicated, the resident's medical records would include professional documentation that was complete and accurate.A review of Resident 1's Face Sheet, dated 12/27/17, indicated admission to the facility on [DATE] with the diagnosis of anxiety (feelings of fear, worry, or nervousness). Resident 1 was not their own responsible party (RP, decision maker).A review of Resident 1's Physician's order, dated 10/14/25, indicated the Physician prescribed Xanax (a medication that treated anxiety) 0.5 milligrams (mg), one tablet every six hours as needed for anxiety. (Receiving too much Xanax can cause breathing to slow or stop)A review of Resident 2's Face Sheet, dated 4/4/18, indicated Resident 2 was admitted to the facility on [DATE] with the diagnosis of muscle spasms (the muscles become tight, similar to cramping, and can be very painful). Resident 2 was their own RP.A review of Resident 2's Physician order, dated 2/9/25, indicated the Physician prescribed oxycodone-acetaminophen (a narcotic pain medication, also called Percocet) 5-325 mg, give one tablet for moderate pain (pain that interfered with daily life but was tolerable) every six hours as needed. (Receiving too much Percocet can cause severe sleepiness and breathing to slow or stop)A review of Resident 3's Face Sheet, dated 1/12/21, indicated, admission to the facility on 1/12/21 with the diagnosis of Parkinson's disease (brain disorder that caused muscles to shake and become stiff and caused pain) with dyskinesia (uncontrolled movement of the body). Resident 3 was their own RP.A review of Resident 3's Physician order, dated 2/9/25, indicated the Physician prescribed Norco (a narcotic pain medication) 5-325 mg, give two tablets for severe pain every six hours, as needed. (Receiving too much Norco can cause severe sleepiness and breathing to slow or stop.)A review of Resident 4's Face Sheet, dated 6/24/14, indicated admission to the facility on 6/24/14 with the diagnosis of chronic pain syndrome (pain that was ongoing and lasted for three to six months or longer). Resident 4 was their own RP.A review of Resident 4's Physician order, dated 2/9/25, indicated the Physician prescribed hydroco/APAP (Norco) 5-325 mg, give half a tablet for moderate pain and 1 whole tablet for severe pain every four hours as needed.A review of Resident 5's Face Sheet, dated 7/18/24, indicated admission to the facility on 7/18/24 with the diagnosis of chronic pain. Resident 5 was their own RP.A review of Resident 5's Physician order, dated 2/12/26, indicated the Physician prescribed Percocet 10-325 mg, one tablet every six hours as needed for moderate pain.A review of Resident 6's Face Sheet, dated 3/14/17, indicated admission to the facility on 3/14/17 with the diagnosis of chronic pain syndrome. Resident 6 was their own RP.A review of Resident 6's Physician order, dated 6/29/24, indicated the Physician prescribed Norco 10-325 mg, one tablet every six hours as needed for moderate to severe pain.During an interview on 3/12/26 at 8:02 am, LN A confirmed, when a controlled substance (medication such as Xanax, Percocet, and Norco, was highly addictive or dangerous and was managed by the government) was administered to a resident, the LN was required to sign the medication out on the narcotic sign out sheet (a hand written log that indicated which resident received a controlled substance that included the residents name, the date and time the controlled substance was given to the resident, and included the LN's initials) and the MAR (medication administration record). LN A stated, the narc book [another term used for narcotic sign out sheets] and MAR should match and if the MAR isn't signed, there is the potential for the medication to be given twice.During a concurrent interview and record review on 3/12/26 at 8:47 am, with Director of Nursing (DON), Resident 1's MAR and the narcotic sign out sheets, dated 10/20/25 and 10/21/25 were reviewed. DON confirmed, the narcotic sign out sheets indicated that LN B administered one tablet of Xanax 0.5 mg to Resident 1 on 10/20/25 and 10/21/25 at 3:00 pm and 9:00 pm. DON stated [LN B] did not sign it out on the MAR.During a concurrent interview and record review on 3/12/26 at 10:18 am, with DON, Resident 2's MAR and the narcotic sign out sheet dated 10/20/25 was reviewed. DON confirmed, the narcotic sign out sheet indicated, LN B administered one tablet of Percocet 5-325 mg to Resident 2 at 9:00 pm. DON stated it was not signed out on the MAR.During a concurrent interview and record review on 3/12/26 at 10:25 am, with DON, Resident 3's MAR and the narcotic sign out sheets, dated 10/20/25 and 10/21/25 were reviewed. DON confirmed, the narcotic sign out sheets indicated that LN B administered two tablets of Norco 5-325 mg to Resident 3 on 10/20/25 and 10/21/26 at 3:00 pm and 9:00 pm. DON confirmed the medications were not signed out on the MAR. DON stated, [LN B] should have signed both the MAR and the narc book. Not signing the MAR could cause medication errors by providing residents a double dose [giving the medication twice] or by giving the medication too early.During a concurrent interview and record review on 3/12/26 at 10:32 am, with DON, Resident 4's MAR and narcotic sign out sheets, dated 3/3/26 and 3/4/26 were reviewed. DON confirmed, the narcotic sign out sheets indicated that on 3/3/26 at 3:45 am and on 3/4/26 at 4:30 am, LN B administered one tablet of Norco 5-325 mg to Resident 4 and LN B did not sign the medications out on the MAR.During a concurrent interview and record review on 3/12/26 at 10:39 am, with DON, Resident 5's MAR and narcotic sign out sheet dated 3/4/26 was reviewed. DON confirmed, the narcotic sign out sheet indicated that LN B administered one tablet of Percocet 10-325 mg to Resident 5 at 4:30 am, and did not sign the medication out on the MAR.During a concurrent interview and record review on 3/12/26 at 10:39 am, with DON, Resident 6's MAR and narcotic sign out sheet, dated 3/4/26 was reviewed. DON confirmed, the narcotic sign out sheet indicated that LN B administered one tablet of Norco 10-325 mg to Resident 6 at 6:00 am and did not sign the medication out on the MAR.During an interview on 3/12/26 at 11:42 am, the facility's Administrator confirmed that LN B did not document medication administered to the residents in the MAR.

Based on observation and interviews, the facility failed to ensure three of four shower rooms were maintained in a clean and homelike environment.These failures had the potential to expose all residents who receive shower services to conditions that are not safe, clean and comfortable.During an observation on 2/20/26 at 9:44 am, of three of four shower rooms, two Shower Rooms in Station 1, had a dark black substance along the floor-to-wall seams and within the corners of the shower stall. The discoloration was concentrated along the grout lines and caulked joints. One of the shower rooms in Station 1 had six (6) 4 inch by 4 inch wall tiles missing from the wall surface beside and beneath the shower faucet handle mounted on the wall. The exposed surface beneath the missing tiles contained a brown and black substance.During an observation on 02/20/26 at 11:11 am, shower room in Station 2 had black substance throughout floor seams where wall meets the floor and in the corners of the shower stall. The affected area extended along the perimeter of the shower floor. The grout lines were visibly darkened and uneven in coloration with gray and black staining noted across multiple areas of the floor. Several tiles showed cracks and signs of wear.During a concurrent observation and interview with Administrator (Admin), on 2/20/26 at 1:57 pm, in Shower room [ROOM NUMBER] located in Station 1, when asked about the discolored area along the floor seams and the area by faucet in the shower wall missing six (6) 4 by 4 tiles, Admin acknowledged discoloration and the tiles of shower wall missing. Admin stated that it has been requested to be repaired. Admin acknowledged and confirmed area exposed by missing tiles having brown and black substance covering the area. Admin acknowledged area is uncleanable, Admin stated, the expectation is for a resident to be showered in an area that is in good condition and is a home like.

Based on observation, interview, and record review, the facility failed to ensure seven Nurse's Aides (NA, in training not certified by state) were state certified prior to hiring and were competent to provide direct resident care independently.This had the potential for all residents not to have their care needs met and at risk for injury and harm when seven uncertified Nurse's Aides provided direct resident care and were not deemed by the State of California to be competent to provide direct resident care. Refer to 837.Findings: A review of the Nursing Assistant Job Description (undated) indicated, uncertified Nursing Assistants are expected to provide routine daily nursing care and services in which the nursing assistant has received clinical instruction and demonstrated competence. Job description stated, General duties and responsibilities (Direct resident care) cannot be performed until theory and competency skills are accomplished. NA qualifications include currently enrolled in Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification approved by the California Department of Public Health (CDPH) and nursing assistants need to maintain clinical competency while enrolled in a NA certification class. A review of Facility 3's records indicated it did not have a CDPH approved NATP program. A record review of active Certified Nursing assistant (CNA)/NA list (undated), indicated Facility 3's Nurse's Aide Training Program (NATP) graduation list (undated), employee files, and the California State Board for Certified Nursing Assistants registry on 1/8/2025, indicated: NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 11/19/2025. On 10/21/2025 NA 1 was assigned to residents in Rooms 33-37 to orient with CNA 4 from 2:30 pm to 10:30 pm. On10/22/2025 NA 1 was assigned to residents in Rooms 38-41 to orient with CNA 5 from 2:30 pm to 10:30 pm. On 10/23/2025 NA 1 was assigned a resident assignment unpaired with a CNA from 2:30 pm to 10:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/22/2025 NA 2 was assigned to residents in Rooms 33-37 to orient with CNA 6 from 6:30 am to 2:30 pm. On 10/23/2025 NA 2 was assigned to residents in Rooms 42-45 to orient with CNA 7 from 6:30 am to 2:30 pm. On 10/26/2025 NA 2 was assigned to residents in Rooms 1-10 to orient with CNA from 6:30 am to 2:30 pm. NA 3 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/24/2025 NA 3 was assigned to residents in Rooms 46-50 to orient with CNA 4 from 2:30 to 10:30 pm. On 10/25/2025 NA 3 was assigned to residents in Rooms 1-9 to orient with CNA 8 from 2:30 pm to 10:30 pm. On 11/17/2025 NA 3 was assigned to provide 1:1 (direct resident observation) for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 1/18/2025 NA 3 was assigned to provide 1:1 care for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. NA 4 was hired on 6/13/2025 and remains uncertified to date (1/13/2026). On 11/17/2025 NA 4 was assigned to a unit to work independently unpaired with specific CNA from 2:30 pm to 10:30 pm. On 11/18/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/22/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 5 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and remained uncertified until their resignation on 12/8/2025. On 11/18/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/19/2025 NA 5 was assigned to provide 1:1 for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 11/22/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/23/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 6 was hired on 11/10/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026). NA 7 was hired on 11/20/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026). A record review of Facility 3's December 2025 Schedule for 2:30 pm to 10:30 pm, had no listing of NA 6 or NA 7, however NA 6 and NA 7 were observed on 12/29/2025 at 2:15 pm at Facility 1 and interviewed on 12/29/2025 at 2:23 pm. During interviews with NA 6 and NA 7 on 12/29/2025 at 2:23 pm, NA 6 and NA 7 both stated they had recently graduated NATP at Facility 2 and are working as NAs at Facility 3 until they become certified as CNAs. NA 6 and NA 7 both stated, today is my first day. During interview with Director of Staff Development (DSD 1) on 12/5/2025 at 11:40 am, DSD 1 (works at Facility 3) stated Facility 2 interviews and hires 5 NA students per Nurse's Aide Training Program (NATP) cycle during the application process at Facility 2. DSD 1 explained the NATP was conducted through Facility 3 off campus. DSD 1 stated Facility 3 does not have an approved NATP and was not a clinical training site. DSD stated their knowledge of the NATP was very minimal. DSD 1 stated graduated Nurse's Aides can do everything a CNA can do except operate machinery like the Hoyer lift. DSD 1 stated the NAs can do one on one care, go to appointments with residents, and pretty much everything a CNA can do. During an interview with the Scheduler on 12/5/2025 at 11:46 am, Scheduler stated, NAs are scheduled to work full time and are filled into a CNA rotation slot in advance so they can transition into the CNA position already with their schedule.During an interview with Account Payable/Payroll Clerk (AP, time sheet verification technician) on 12/5/2025 at 12:08 pm, AP stated NAs in training (recently graduated NAs) are employees at Facility 3. During an interview with NA 4 on 12/8/2025 at 10:15 am, NA 4 stated their role as an NA was to assist CNAs with tasks such as transferring (mobilizing) and providing one-on-one care to residents. During an concurrent interview with NATP Instructor (NATP-I from Facility 2) and DSD 2 from Facility 2 on 12/23/2025 at 2 pm, NATP-I stated, uncertified NAs are not supposed to do direct resident care (hands on care) without the supervision of a CNA or licensed nurse until they are certified. NATP-I stated NAs are allowed to do direct resident care with a CNA present and are deemed NAs in training until they are certified at Facility 2. NATP-I and DSD 2 stated they were unaware that NA graduates were not permitted to work at Facility 1 or Facility 3 prior to becoming state certified. During an interview with CNA 3 on 12/29/2025 at 1:35 pm, CNA 3 stated NAs are allowed to feed residents. During an interview with NA 6 on 12/29/2025 at 2:20 pm, NA 6 stated they just graduated from NATP class at Facility 2 and it was their first day working at Facility 3. NA 6 was scheduled for the 2:30 pm to 10:30 pm shift. Assignments sheets requested from the Scheduler and were not provided for this date. During an interview with NA 7 on 12/29/2025 at 2:23 pm, NA 7 stated they recently graduated from the NATP through Facility 2 and were picked to work at Facility 3. A record review of Facility 2's December 2025 Schedule for 2:30 pm to 10:30 pm had no listing of NA 6 or NA 7. During an interview with NA 3 on 12/30/2025 at 11:09 am, NA 3 stated they performed direct resident care including touching and changing residents with CNA supervision. They stated their job duties changed following an incident in which a resident fell because of an NA using a Hoyer lift unsupervised by certified or licensed staff. They stated NAs are no longer allowed to provide direct resident care touching residents. NA 3 stated at first things got confusing, we were not sure what we could and couldn't do. NA 3 stated at that time they were unaware of who the DSD was.NA 3 stated the facility has not assessed skill competencies or provided orientation during their work as an NA. During an interview with Interim Administrator (IA) on 12/30/2025 at 12 pm, IA stated they have been working at Facility 3 since 11/11/2025 and they have recently ceased using uncertified NAs at the Facility 3 until the matter of training and competence is resolved. During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations.

Based on interview and record review the Governing Body (GB) failed to provide oversight for the Administrator to ensure seven Nurse's Aides (NA, in training not certified by state) were state certified and had the competencies required prior to providing care to residents independently.This had the potential to put all residents at risk of injury and harm and to not receive quality of care when seven NAs were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.Findings: A record review of the Operations Manual Administrative Policies dated 6/4/24, indicated the purpose was to ensure proper and lawful oversight of the facility. GB was responsible for appointing a facility administrator. GB was legally responsible for establishing and implementing policies and procedures regarding the management and operation of facility. The GB was responsible for providing Administrative Services who develop policies and procedures for the management and operation of the facility. A review of the Nursing Assistant Job Description (undated) indicated, uncertified Nursing Assistants are expected to provide routine daily nursing care and services in which the nursing assistant has received clinical instruction and demonstrated competence. Job description stated, General duties and responsibilities (Direct resident care) cannot be performed until theory and competency skills are accomplished. NA qualifications include currently enrolled in Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification approved by the California Department of Public Health (CDPH) and nursing assistants need to maintain clinical competency while enrolled in a NA certification class. A review of Facility 3's records indicated it did not have a CDPH approved NATP program. A record review of active Certified Nursing assistant (CNA)/NA list (undated), indicated Facility 3's Nurse's Aide Training Program (NATP) graduation list (undated), employee files, and the California State Board for Certified Nursing Assistants registry on 1/8/2025, indicated: NA 1 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and became certified on 11/19/2025. On10/21/2025 NA 1 was assigned to residents in Rooms 33-37 to orient with CNA 4 from 2:30 pm to 10:30 pm. On10/22/2025 NA 1 was assigned to residents in Rooms 38-41 to orient with CNA 5 from 2:30 pm to 10:30 pm. On 10/23/2025 NA 1 was assigned a resident assignment unpaired with a CNA from 2:30 pm to 10:30 pm. NA 2 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/22/2025 NA 2 was assigned to residents in Rooms 33-37 to orient with CNA 6 from 6:30 am to 2:30 pm. On 10/23/2025 NA 2 was assigned to residents in Rooms 42-45 to orient with CNA 7 from 6:30 am to 2:30 pm. On 10/26/2025 NA 2 was assigned to residents in Rooms 1-10 to orient with CNA from 6:30 am to 2:30 pm. NA 3 was hired on 9/5/2025, graduated from NATP 10/17/2025, and became certified on 11/19/2025. On 10/24/2025 NA 3 was assigned to residents in Rooms 46-50 to orient with CNA 4 from 2:30 to 10:30 pm. On 10/25/2025 NA 3 was assigned to residents in rooms 1-9 to orient with CNA 8 from 2:30 pm to 10:30 pm. On 11/17/2025 NA 3 was assigned to provide 1:1 (direct resident observation) for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 1/18/2025 NA 3 was assigned to provide 1:1 care for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. NA 4 was hired on 6/13/2025 and remains uncertified to date (1/13/2026). On 11/17/2025 NA 4 was assigned to a unit to work independently unpaired with specific CNA from 2:30 pm to 10:30 pm. On 11/18/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/22/2025 NA 4 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 5 was hired on 9/5/2025, graduated from NATP on 10/17/2025, and remained uncertified until their resignation on 12/8/2025. On 11/18/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/19/2025 NA 5 was assigned to provide 1:1 for room [ROOM NUMBER] from 2:30 pm to 10:30 pm. On 11/22/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. On 11/23/2025 NA 5 was assigned to a unit to work independently unpaired with a specific CNA from 2:30 pm to 10:30 pm. NA 6 was hired on 11/10/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026). NA 7 was hired on 11/20/2025, graduated from NATP on 12/19/2025, and remains uncertified to date (1/13/2026).During interview with Director of Staff Development (DSD 1) on 12/5/2025 at 11:40 am, DSD 1 (works at Facility 3) stated Facility 2 interviews and hires 5 NA students per Nurse's Aide Training Program (NATP) cycle during the application process at Facility 2. DSD 1 explained that the NATP was conducted through Facility 2 (had an approved CDPH NATP) off campus. DSD 1 stated Facility 3 does not have an approved NATP and was not a clinical training site. DSD stated their knowledge of the NATP was very minimal. DSD 1 stated graduated Nurse's Aides can do everything a CNA can do except operate machinery like the Hoyer lift. DSD 1 stated the NAs can do one on one care, go to appointments with residents, and pretty much everything a CNA can do. During an interview with the Scheduler on 12/5/2025 at 11:46 am, Scheduler stated, NAs are scheduled to work full time and are filled into a CNA rotation slot in advance so they can transition into the CNA position already with their schedule.During an interview with Account Payable/Payroll Clerk (AP, time sheet verification technician) on 12/5/2025 at 12:08 pm, AP stated NAs in training (recently graduated NAs) are employees at Facility 3. During an interview with Interim Administrator (IA) on 12/30/2025 at 1:35 pm, IA stated they have been working at Facility 3 since 11/11/2025. IA stated Facility 3 has stopped NAs working at the facility until the matter of training and competence was resolved. During an interview with the Governing Body (GB), with the [NAME] President of Operations (VPO), Regional Administrator (RA), and Chief Clinical Officer (CCO) on 1/14/2026 at 1:35 pm, VPO explained they were responsible for oversight of Facility 1, 2 and 3, Facility 2 was the only site that had an approved NATP program. VPO stated the GB assists the Administrators and Director of Nursing at each facility to create policies and procedures to operate each of the three facilities. VPO stated the Governing Board meets with each facility quarterly. VPO stated they attended their first Governing Board meeting yesterday 1/13/2026, due to a change in leadership in early December 2025. VPO stated Facility 1 and 3 was not approved to have a NATP because it had a history of regulatory compliance issues. VPO agreed that NAs should not be feeding and changing residents. VPO stated they have reviewed the NA job description and have decided to revise the job description and hiring processes to ensure NAs do not provide direct resident care before they are certified by CDPH. VPO stated the Administrators and GB were ultimately responsible for ensuring the NATP program and hiring NAs at each Facility 1, 2, and 3 followed federal and state regulations.

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) was free from physical and verbal abuse when Resident 2 yelled profanity and was swinging at Resident 3 in the hallway. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, anger, and the potential for negative clinical outcomes.Findings: The facility's policy revised 5/30/24, titled Abuse and Prevention Management, was reviewed and indicated the purpose of this policy is to address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment, including freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat medical symptoms. This facility's policy also indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention systems to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment. The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the facility's abuse prevention, screening, and training program policies. The facility's policy revised 5/30/24, titled Abuse and Prevention Management, was reviewed and indicated Abuse is defined as the willful, deliberate infliction of injury.intimidation.resulting physical harm, pain or mental anguish. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability. Mental abuse, emotional abuse, and psychological abuse, are defined as, but not limited to, verbal or non-verbal conduct that causes humiliation, intimidation, fear, shame, agitation, or degradation. During a review of Resident 2's record titled, admission Record, indicated Resident 2 was admitted the facility on 1/12/21 with diagnoses that included vascular dementia, (a decline in thinking, memory and daily function) with agitation (restless, upset or irritable), chronic obstructive pulmonary disease (COPD, a progressive lung condition), heart failure (the heart cannot pump enough blood to meet the body's needs), dysphagia (difficulty swallowing), anxiety (a feeling of worry, fear, unease and dread), glaucoma (progressive eye disease caused by too much pressure that can lead to vision loss), major depressive disorder (persistent feelings of sadness, hopelessness and loss of interest), and polyneuropathy (many damaged nerves causing tingling, numbness, weakness and pain). During a review of Resident 2's record titled, Minimum Data Set, (MDS, a resident assessment), dated 10/3/25, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 3 of 15. This score indicated a severe cognitive (ability to think, reason and make decisions) impairment. During an interview on 12/16/25 at 9:40 am, Resident 2 shouted, I don't remember, get out of here. Just pick up the covers and then you can leave. During an interview on 12/16/25 at 9:42 am, Certified Nurse Assistant (CNA) E stated, I heard [Resident 2] did not sleep much last night. [Resident 2] does have behaviors; we all check on her a lot. During an interview on 12/16/25 at 10:03 am, Activity Assistant (AA) stated, I know [Resident 2] very well. I think she has a great spirit, and she can be loving and funny. [Resident 2] does get aggressive; I can tell a difference in her behaviors lately. She is more confused. During an interview on 12/16/25 at 10:15 am, Activity Director (AD) stated, Oh, I know [Resident 2]. She is having a lot of behaviors lately. I heard she is not taking her medicine, she thinks it is for someone else. I did hear [Resident 2] waved her hands at [Resident 3], but I don't know if she hit her. During a review of Resident 3's record titled, admission Record, indicated Resident 3 was admitted the facility on 1/12/21 with diagnoses that included diabetes (too much sugar in the blood), anxiety, heart disease, Bi-polar disorder (a mental health condition causing severe mood swings), depression, high blood pressure, stage 4 chronic kidney disease (severe damage to the kidneys when they can no longer filter blood effectively), Nicotine use (smoking tobacco or cigarettes), and neuralgia (severe burning, stabbing, and shocks of pain from damaged nerves.) During a review of Resident 3's MDS, dated [DATE], indicated Resident 3 had a BIMS score of 15 of 15. This score indicated Resident 3 has no cognitive impairments and could make her own decisions. During an interview on 12/16/25 at 9:25 am, Licensed Nurse (LN) H stated, I know about the incident with [Resident 2]. She is confused, and she has behaviors, and just yells at times. She likes to block the hallways. She will not always take her medicine. [Resident 2] gets very defensive. [Resident 3] said [Resident 2] hit her. From what I understand [Resident 3] had no red marks or bruising on her mouth, and the video showed [Resident 2] waving her hands at her. During an interview on 12/16/25 at 9:30 am, LN C stated, I was here that day and I am the one who reported it immediately. I was at the cart in front of the nurses' station, and [Resident 3] came to see me, she was by room [ROOM NUMBER], and [Resident 2] was headed to the therapy room. I would say they just crossed paths. [Resident 3] said that [Resident 2] hit her in the face, but I did not see that. I wrote it down and I reported it. [Resident 3] is alert and oriented, but she also exaggerates. I know they don't like each other. She also said [Resident 2] called her a name. I don't doubt that because she does have behaviors. [Resident 3] was really mad because she called her a bad name. I reported it to the administrator. I think [Resident 3] was more mad than upset. I don't know for sure if it happened, but I report what I'm told. [Resident 2] can be very intimidating because she's unpredictable and she's very strong. This just all happened so fast, they have a history of arguing. During an interview on 12/16/25 at 9:42 am, Resident 3 stated, Yes, I remember the incident with [Resident 2]. I asked her nicely if she could move so I could get by. She called me a profanity name and hit me in the mouth. She did not hit me hard, but it is on video. She was waving and swinging her hands all around. I was in the hall; it was very embarrassing. No, I am not scared of her, I knew not to hit her back, but they need to keep her out of the halls where it is crowded. [Resident 2] has cussed at me before but never hit me. They say she is confused, but I think she knows what she is doing. I am not as mad as I was, it just gets frustrating. During an interview on 12/16/25 at 10:05 am, AA stated, I would describe [Resident 3] as sticking to herself, she likes to keep to herself. She can get inpatient waiting on staff to go smoke, but other than that, she is very friendly. During an interview on 12/16/25 at 10:18 am, AD stated, [Resident 3] likes to stay to herself and near the nurse's station, she enjoys the gossip from the staff. During an interview on 12/16/25 at 10:45 with the Director of Nursing (DON), DON stated, The problem is we could not see a clear view on the video of [Resident 2] hitting [Resident 3]. We could see [Resident 2] waving her hands close to [Resident 3]'s face and all around but if she did hit her it was not hard, maybe a light swat. During an interview on 12/16/25 at 10:50 am, the Admin stated, I was told [Resident 2] did not hit [Resident 3]. I confirm if [Resident 2] called [Resident 3] a profanity that is a type of verbal abuse.

Based on observations, interviews, and record reviews, the facility failed to ensure the environment was free from hazards when they did not follow their laundry policies and procedures (P&P) and did not provide Laundry Tech (LT) A with required competencies (training and education). This had the potential to contribute to smoldering (burn slowly with smoke but no flames) laundry that was discovered in a laundry bag.Findings: A review of the facility's P&P titled, Laundry-Sorting, Washing and Drying, revised 1/1/12, indicated, dryers would be unloaded after the drying cycle was complete. The P&P indicated, to remove grease and stains, when needed, kitchen and housekeeping laundry would be pre-soaked in degreaser (a chemical that broke down grease and oil) or detergent, prior to washing. A review of the undated Laundry Tech, job description, indicated the LT would maintain a safe working environment. A review of the Full NFIRS v1.0 (fire department report), dated 12/1/25, indicated, the fire department arrived at the facility on 12/1/25 at 2:54 am due to facility staff smelling smoke in the laundry room. The fire department report indicated that the fire department captain felt heat coming from a laundry bag and relocated the laundry bag to the parking lot. The fire department report indicated that when the fire captain opened the laundry bag, the smoldering laundry ignited with flames, and the fire was immediately put out. During an interview on 12/12/25 at 11:32 am, the facility's previous Environmental Services Manager (PEVSM) stated, the drying cycle had a cooling period (switching from hot air to cool air) and when I came in the next day [12/2/25], the dryers didn't work. I found out the fire department had turned the breakers [an automatic safety switch] off. Once the dryers were turned back on, I had to reach out to [LT A] because the dryer timer indicated there was 20 minutes left on the [dryer] cycle. [LT A] told me she took the laundry out before the dryer was done and I educated her that you can't do that, it's too hot, and when you put it in a bag it could smolder. During an interview on 12/12/25 at 12:14 pm, LT B described the different washing machine cycles and stated that the washing machine chemicals were preset and dispensed for each cycle. Kitchen rags with grease, we pre-wash. LT B could not verbalize if the prewash cycle contained a degreaser or detergent and stated, we haven't been pre-soaking kitchen laundry, there is a pre-rinse cycle [prewash] built into the laundry cycle. During an interview on 12/12/25 at 2:13 pm, the Regional Operations Manager (ROM, oversaw the company that supplied the facility's washing machines) stated that all washing machine cycles start with a pre-wash. It's just warm water to remove chunky [food particles or residue from bowel movements] things that might come from patients. ROM confirmed, no detergent or degreaser was utilized during the washing machine's pre-wash cycle. During a concurrent observation and interview on 12/12/25 at 2:58 pm, located in the facility's laundry room, LT A was observed removing laundry from plastic bags and placing the laundry directly into the washing machine. LT A confirmed the laundry was housekeeping's, LT A had not performed a pre-soak per the facility's P&P, and was not aware of the P&P regarding washing kitchen and housekeeping's laundry. LT A stated no training had been provided. I was hired in August as a housekeeper and moved to laundry. LT A indicated, on 11/30/25, at the end of the shift (approximately 7:00 pm), prior to the dryer completing its entire cycle, LT A had removed the kitchen laundry from the dryer, immediately put the hot laundry in a laundry bag, and placed it near the door inside of the laundry room. LN A confirmed, having knowledge that the fire department had discovered a laundry bag that contained smoldering laundry and stated, I was thrown in, not aware of drying and cooling times until it happened. LT A could not verbalize when they transitioned from being a housekeeper to an LT and stated, We never do whole [drying] cycle and cool down. It went straight from the dryer to the plastic bag. I don't ever remember doing or signing competency forms, I was just thrown in. A review of LT's employee file indicated LT's hire date was 8/19/25. There was no documentation that indicated when LT A transitioned from housekeeper to LT. During a concurrent interview and record review on 12/12/25 at 3:19 pm, with Maintenance Supervisor (MS), LT A's Laundry Competency check list, dated 8/20/25 was reviewed. MS stated, I went down the [competency] list with her today. MS confirmed, the date on LT A's competency form indicated LT A's competency checklist was performed on 8/20/25 not 12/12/25. During a concurrent interview and record review on 12/12/25 at 3:35 pm, with Payroll (PR), LT A's Laundry Competency check list, dated 8/20/25 was reviewed. PR stated, it was given to me today. PR confirmed, PR placed the competency form into LT A's employee file on 12/12/25. During an interview on 12/16/25 at 9:55 am, PEVSM stated, [LT A] transitioned from housekeeping to laundry in September. I don't remember doing competencies with [LT A], if I did, I would have given it to PR. During an interview on 12/16/25 at 10:06 am, Administrator stated, [LT A's] competency was done Friday, 12/12/25, not 8/20/25.

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1 was rushed by Certified Nursing Assistant (CNA) F and spoken to with a demeaning tone and attitude.This failure resulted in Resident 1 feeling angry, helpless and emotionally stressed and had the potential to result in embarrassment and neglect which could result in negative clinical outcomes.Findings: The facility's policy revised 8/2025, titled, Residents' Rights, was reviewed and indicated employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights. The facility's policy revised 3/2017, titled, Quality of Life-Dignity, was reviewed and indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. All residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity is prohibited. The staff shall promote dignity and assist the residents as needed by promptly responding to the residents' request for activities of daily living (ADLs are activities related to personal care. ADLs include bathing, dressing, getting in and out of bed or a chair, walking, toileting, and feeding) assistance. During a review of Resident 1's record titled admission Record, indicated Resident 1 was admitted the facility on 11/12/25 with diagnoses that included cellulitis of perineum (area of the body located between and anus and private areas with infection of the skin causing redness, pain, and swelling), rectal abscess (painful pus filled pocket near your anus or rectum, like a deep pimple or boil), hyponatremia (low sodium level in the blood), dysphagia (difficulty swallowing), glaucoma (progressive eye disease caused by too much pressure that can lead to vision loss), bilateral osteoarthritis of knee and hip (the joints smooth cartilage wears down, causing stiffness, pain, swelling and decreased movement), bilateral hearing loss (hard of hearing in both ears), hypokalemia (low potassium level in the blood), high blood pressure, and a history of falling. During a review of Resident 1's record titled, Minimum Data Set, (MDS, a resident assessment), dated 11/19/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 9 of 15. This score indicated a mild cognitive (ability to think, reason and make decisions) impairment, but was her own responsible party (RP) and was capable to make her own decisions. MDS, section GG indicated Resident 1 was totally dependent on facility staff for toileting to complete this activity. During an interview on 12/16/25 at 9:02 am, Resident 1 stated, Yes, I remember the incident. I remember it was a long night, and I have requested [CNA F] does not come back in my room. [CNA F] did not physically hurt me, she just told me she could not keep coming in here, and I did need help that night. She acted like she was in a hurry and did not want to help me. You know, you can tell when someone doesn't want to help you. I reported [CNA F] for not being nice. I just felt helpless and I was kind of mad at the time, but not now. She just emotionally hurt me. During a interview on 12/16/25 at 12:30 pm, CNA F stated, I was in [Resident 1]'s room every 45 minutes to an hour. She had diarrhea that night, and I did help her. [Resident 1] is very hard of hearing and doesn't wear her hearing aids at night, so you do have to raise your voice, or she cannot hear you. During a concurrent interview and record review on 12/16/25 at 1:30 pm, the Director of Nursing (DON) confirmed she had verbally counseled CNA F on 11/28/25 related to resident rights, working too many hours, and on dignity and respect. DON stated, I confirm [CNA F] did not provide kindness during care for [Resident 1] which violated her rights for dignity and respect. During an interview on 12/16/25 at 1:45 pm, the administrator confirmed CNA F had no self-awareness of her attitude, she was very task focused and needed additional training on dignity and respect for resident care.

Based on observation, interview and record review, the facility failed to ensure that staff consistently implemented the physical mobility care plan for one of three sampled residents (Resident 1) when Resident 1's care plan indicated that she would be transferred using a Hoyer lift (a mechanical lifting device), and staff were not consistently using the Hoyer lift and transferring her with two people lifting her up by her arms. This had the potential for Resident 1 to sustain injuries from staff not using the Hoyer lift and negatively impact her ability to attain or maintain her highest practicable level of emotional and physical well-being. Findings:A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, indicated a care plan would be developed for each resident that included standards for meeting safety and health care needs.During a review of Resident 1's medical record indicated that Resident 1 was admitted to the facility on [DATE] with a diagnoses that included Parkinson's disease (a neurological disorder leading to movement issues like tremors, stiffness, and balance problems), schizophrenia (a brain disorder that disrupts how people interpret reality) and dementia (a decline in mental ability, including memory, thinking and behavior that is sever enough to interfere with daily life). Resident 1 has a Responsible Party (RP - decision maker) who makes decisions for them. On 10/10/25 the facility reported to the California Department of Public Health (CDPH) that Resident 1 was found to have a broken left pinky toe and they were unsure how it occurred. During a review of Resident 1's Physical Mobility care plan dated 12/13/22, indicated Resident 1 had limited physical mobility and was dependent on staff for care. An update to the care plan was added on 10/10/25 and reflected that Resident 1 was non-ambulatory (unable to walk or stand) and dependent on a Hoyer lift for transfers. During a review of Resident 1's most recent Minimum Data Set (MDS, a resident assessment) dated 9/26/25, Resident 1 was dependent (helper does all of the effort) for showering/bathing and for chair to bed transfers. A review of a handwritten note by CNA A dated 12/1/25, was provided by Medical Records. CNA A had written that on 10/6/25 Resident 1 had been transferred with two staff members and had not included that the Hoyer lift had been used. During a review of a health status note dated 10/10/25 at 11:09 am, Registered Nurse (RN) A documented that there was a bruise discovered on Resident 1's left top of the foot that was yellow in color with blotchy red and purple bruising. Resident 1 stated someone stepped on my foot and that it was painful. RN A documented that Resident 1 was non-ambulatory and had foot drop (where the feet point downward from contracted muscles). An x-ray was ordered. During a review of a health status note dated 10/10/25 at 2:34 pm, RN A documented that the x-ray results for Resident 1 had been received and Resident 1 had an acute fracture on the left pinky toe. During an observation and interview on 11/6/25 at 10:02am, with Resident 1, Resident 1 was lying in bed with foot board (a device that keeps blankets from touching the feet) in place. When Resident 1 was asked how she broke her pinky toe, Resident 1 stated that her sister stepped on her toe.During an interview on 11/6/25 at 2:22 pm, with the Director of Nursing (DON), the DON confirmed that Resident 1 was found with a bruise and fractured left pinky toe on 10/10/25 and the facility had not known how that happened. The DON confirmed that Resident 1 required a Hoyer lift to transfer from bed to chair. During an interview on 11/12/25 at 11:06 am, with CNA B, CNA B stated that sometimes they will transfer Resident 1 with just two people by lifting Resident 1 under the arms instead of using a Hoyer lift, it just depends on how the resident is feeling. During an interview and concurrent care plan review on 11/13/25 at 3:25 pm, with Licensed Nurse (LN), the LN confirmed Resident 1 is a Hoyer lift. During an interview on 11/13/25 at 3:32 pm, with CNA C, CNA C stated that Resident 1 is a 2-person transfer (where 2 staff lift her under her arms) but they will use a Hoyer lift if Resident 1 is really struggling to get up. During an interview on 11/13/25 at 3:37 pm, with CNA A, CNA A stated that she got Resident 1 up and out of bed for a shower on 10/6/25, using another CNA to help lift her and had not used the Hoyer lift.

Based on observation, interview, and record review, the facility failed prevent an avoidable fall with injuries when staff had not correctly used a Hoyer lift (a mechanical device with a sling that has straps which are to be securely attached to the device used to lift and carry a resident to a desired location. This lift requires two staff for a safe transfer, one to operate the lift and one to guide the resident), for one of five sampled residents (Resident 1) when:1a. Staff had not ensured the straps on the Hoyer lift were secure and the sling straps came off and dropped Resident 1 onto the floor.1b. While one staff operated the Hoyer lift, the second staff had not stood by and guided Resident 1 during the transfer.1c. Staff placed Resident 1 in a Hoyer sling that had damaged straps which were rigid and stiff and should not have been used.1d. Staff placed Resident 1 in a Hoyer sling that was not previously identified to be the correct size for her. The cumulative effects of these failures caused Resident 1 to fall out of the Hoyer lift on to the metal leg of the lift and onto the floor. Resident 1 sustained four broken bones in her lower back and pelvis (the large bony structure near the base of the spine), severe back pain with an increased need for narcotic pain medication, the need for supplemental oxygen use (extra air breathed in by a tube in the nose), and a hospital stay. Findings: 1a. A review of the facility's policy and procedure (P&P) titled, Fall Management Program, revised 3/13/21, indicated, the purpose of the P&P was to provide residents a safe environment that minimizes complications associated with falls.A review of the admission Record, dated 8/15/20, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of fusion of spine, cervical region (a surgical procedure where two bones in the neck are joined together to stop them from moving) and low back pain. A review of the Physician's Order, dated 8/25/23, indicated, Resident 1 could make their own decisions. A review of the Minimum Data Set (MDS, a resident assessment tool), dated 8/21/25, indicated a Brief Interview of Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 1 scored 15 out of 15 which indicated good memory. The MDS indicated Resident 1 had limited movement of both legs, and Resident 1 was dependent on two facility staff for transfers from the bed to the wheelchair, bathroom, and shower. A review of the, Post Fall Evaluation, dated 10/29/25, written by Licensed Nurse (LN) A indicated, Certified Nurse Assistant (CNA) B and Nurse Assistant (NA, an uncertified nurse assistant who is still in training) D attempted to transfer Resident 1 from the bed to the wheelchair and witnessed both lower sling straps (closer to the legs) dislodge from the mechanical lift. Resident 1 fell to the floor next to the bed and landed on her back. A review of the hospital's, History and Physical, dated 10/29/25, indicated, Resident 1 was brought into the emergency room by ambulance due to a three-to-four feet fall from a mechanical lift, landing on her backside.A review of the medical imaging report done at the hospital titled, CT [rotating x-ray machine] Abdomen [belly area] Pelvis [hip area] dated 10/29/25, indicated, Resident 1 had acute (sudden) fractures of the right sacrum (bone that connects the spine to the pelvis), right L5 transverse process fracture (last bone in the spine, just above the sacrum), right inferior pubic ramus fracture (a bone that points down from the pelvis), and a fractured coccyx (tailbone).During a concurrent observation and interview on 10/31/25 at 9:43 am, Resident 1 was observed in bed, lying on her back, and wearing a nasal cannula (oxygen tube that fits into the nose). Resident 1 confirmed falling from the mechanical lift on 10/29/25 and stated, I was getting up into the wheelchair and the sling gave way. It looked like the sling detached from the Hoyer [the brand name of the mechanical lift that was used]. I don't feel like I slipped out, I fell straight down. During the interview, Resident 1 appeared to become short of breath while talking and paused in between sentences. Resident 1 confirmed, CNA B and NA D transferred her using the Hoyer lift when she fell and stated, [CNA B] and [NA D] got me into the Hoyer. Resident 1 became tearful and stated, I can't lift my body more than two inches off the bed. The pain is excruciating and sharp. Resident 1 described excruciating pain as a ten-out-of-ten, where ten was the worst pain ever. Resident 1 attempted to raise the upper half of her body off the bed, cried out in pain, and stated, see, I can't do anything. Resident 1 stated, I'm upset because I was able to leave weekly to visit my husband and now I can't go anywhere. It's the holidays, I can't go home to visit or celebrate the holidays. Resident 1 became teary eyed and stated, I have to cancel my mammogram [test to detect early warning signs of breast cancer], my DMV [Department of Motor Vehicles] appointment, all my appointments are cancelled. During an interview on 10/31/25 at 11:47 am, CNA B confirmed assisting with a transfer, utilizing the Hoyer lift. CNA B stated, I saw her fall, she just went straight down, she didn't slip out of the sling, she fell straight down. I thought the sling broke, but it didn't, the lower straps weren't on the Hoyer, and they came off at the same time.During an interview on 10/31/25 at 12:04 pm, Director of Staff Development (DSD), stated, I went to the room [after being alerted of the fall], and I observed the top loops hooked to the Hoyer, but not the bottom loops.During an interview on 10/31/25 at 1:06 pm, NA D confirmed assisting with Resident 1's Hoyer lift transfer, and witnessed Resident 1's fall. NA D stated, I was the one who used the Hoyer, when I pulled the Hoyer out [away from bed], I swung the Hoyer around, both lower straps fell off. She [Resident 1] landed on her back and onto the leg of the Hoyer. I'm not sure how the straps came off. Both straps came off at the exact same time.During an interview on 10/31/25 at 1:30 pm, with the facility's Director of Nursing (DON) and Administrator (Admin), DON stated, I thought the sling broke, but it didn't. I looked at it myself. Admin confirmed the sling did not break and stated, I did look at the sling, it was fine.During a concurrent interview and record review on 10/31/25 at 2:13 pm, with DSD, CNA B's Corrective Action Memo written by the DSD and dated 10/31/25, regarding Resident 1's fall with injuries, was reviewed. The section titled, Employer's Statement indicated, This disciplinary action is regarding safety and safe handling of residents. CNA [CNA B] did not have a second CNA present during mechanical lift transfer. DSD indicated that it was an unsafe practice to use an NA instead of a CNA when using the Hoyer lift to transfer residents. DSD indicated that an NA should never be the substitute for another CNA when using the Hoyer lift.During a concurrent interview and record review on 10/31/25 at 2:15 pm, with DSD, NA D's Corrective Action Memo dated 10/31/25, regarding Resident 1's fall, was reviewed. DSD confirmed, corrective action was taken against NA D for, This disciplinary action is regarding safety, scope of practice [list of care that can legally be provided] and safe handling of residents. The level of competence has not been exhibited during event of patient transfer with mechanical lift the level of competency was not exhibited for safe handling of resident during transfer, and the scope and practice of NA was not exhibited or adhered to. A review of the care plan titled, ADL (activities of daily living, examples include but not limited to dressing, transfers, eating) dated 3/18/24, indicated, Resident 1 required the assistance of two staff members for mechanical lift transfer and that care would be provided by CNAs, Licensed Nurses, Registered Nurses, and Restorative Nursing Aides. NA was not listed on the care plan. A review of the hospital's, Discharge Summary, dated 10/30/25, indicated, Resident 1 was being discharged from the hospital, was in a considerable amount of pain (a great degree of physical suffering), and required strong narcotic pain relief. The Discharge Summary indicated, [Resident 1] required supplemental oxygen, likely due to chronic debility [long term physical strength] and need or strong pain relief (a side effect of strong pain medication was breathing less, which could cause the need for supplemental oxygen). During an interview on 11/5/25 at 2:55 pm, Licensed Nurse (LN) A stated, [Resident 1] didn't wear oxygen before the fall. She was low, 88 percent (%) [normal oxygen saturation levels (oxygen level in the blood) are around 90 to 100%] at the hospital and she has a low pain tolerance. [Resident 1's] MS Contin [generic name morphine sulfate, a strong narcotic pain medication] and Percocet [a strong narcotic pain medication] were increased after the fall.A review of Resident 1's Physician's Order, dated 10/30/25, after the fall, indicated a new order for, Oxygen at 1 liter [a unit of measure] per nasal cannula to keep oxygen saturation at or above 88%, every shift.A review of the, Order Summary Report, dated 10/28/25, indicated on 7/14/24 (before the fall), Resident 1 had an order for Morphine Sulfate ER (extended release), 15 milligrams (mg, a unit of measure) one tablet, by mouth two times a day for chronic pain. A review of the, Order Summary Report, dated 11/5/25, indicated on 10/31/25 (after the fall), Resident 1's Physician increased her Morphine Sulfate ER, 15 mg to two tablets, twice a day for pain management.A review of the, Order Summary Report, dated 10/28/25, indicated on 5/21/25 (before the fall), Resident 1 had an order for Percocet, 10-325 mg give one tablet by mouth three times a day for chronic pain. A review of the, Order Summary Report, dated 11/5/25, indicated on 10/31/25 (after the fall), Resident 1's Physician increased her Percocet 10-325 mg to one tablet every 6 hours as needed for severe pain (7-10 out of 10 on the pain scale). 1b. A review of the CNA Nursing Assistant Certification, (training book, utilized by the NA during the CNA training program) with the copywrite (year it was published) of 2020, indicated, that one nursing assistant would operate the mechanical lift and the second nursing assistant would care for the residents during the transfer (utilizing their hands or the straps on the sling to guide and stabilize the residents). The training book indicated that when the resident was lifted in the air, the resident would be facing the operator of the mechanical lift during the transfer. During an interview on 10/31/25 at 11:47 am, CNA B stated, I was furthest away from the door, [NA D] was on right side of the bed, closest to the door. I wasn't paying attention to the hooks during the transfer. During an interview on 10/31/25 at 12:04 pm, DSD stated, It is my expectation, that when there is a CNA and a NA performing a Hoyer lift transfer, the CNA controls the Hoyer and the other CNA is the spotter [guiding the resident], hands on, and guiding the resident. During an interview on 10/31/25 at 1:06 pm, NA D stated, I was the one who used the Hoyer, when I pulled the Hoyer out [away from the bed], I swung the Hoyer around, both lower straps fell off. NA D stated, [CNA B] was positioning the wheelchair at the foot of the bed and I was pulling the Hoyer away from the bed to put [Resident 1] in her wheelchair. [CNA B] was not next to the resident [Resident 1] and was not assisting (spotting) or guiding hands on while I operated the Hoyer. During an interview on 11/5/25 at 8:50 am, Nurse Assistant Training Program (NATP Instructor) stated, I don't say spotter when I teach, I say two-person transfer, one operated the Hoyer, and the other person is ensuring resident safety by holding and guiding the resident so there is no swinging or swaying and their legs don't hit anything. You're not just standing there, they are looking for feet placement and that the straps are securely in the hooks, all the way, during the transfer. NATP Instructor stated, when the resident was raised up in the Hoyer sling, the resident should be facing the Hoyer operator.During a concurrent interview and observation on 11/5/25 at 12:15 pm, was conducted with CNA B and NA D. NA D confirmed Resident 1 was facing the closet while suspended in the air on the Hoyer lift and stated, [Resident 1's] back was to me and her face and feet were facing [CNA B]. CNA B confirmed she had been standing at the foot of Resident 1's bed during the transfer. CNA B confirmed she had not provided hands on guidance to Resident 1 during the Hoyer transfer and stated, I was not near [Resident 1] during the transfer, I was at the wheelchair. NA D and CNA B were observed by the surveyor and demonstrated their positions during the transfer of Resident 1 and they were approximately five to six feet from each other. CNA B was standing at the foot of Resident 1's bed and NA D was standing on the right side of the bed, near the middle of the mattress. 1c. A review of the undated User Instruction Manual, indicated, a damaged sling should never be used.A review of the facility's 5-day Investigation (the results of the facility's investigation regarding Resident 1's fall), dated 10/31/25, indicated, Upon review, it was noted that the color-coded straps and hooks are quite ridged [unable to bend]; any alterations in tension, whether downward or upward, could shift the entire strap as a unit. The 5-day Investigation indicated it was possible for the sling straps to become dislodged from the Hoyer lift if there was a loss of tension (tightness created in the sling loop when pressure was applied). During an interview on 10/31/25 at 1:30 pm, Admin confirmed, the straps on the sling used on Resident 1, were stiff.During a concurrent observation, interview, and record review, on 11/4/25 at 11:45 am, with Environmental Supervisor (EVS) and Central Supply/CNA (CS/CNA) F, the laundry room was observed. EVS and CS/CNA F showed the surveyor the sling used on Resident 1 when she fell. EVS stated, We held it [kept the sling in the laundry room] to keep it off the floor [from being used]. EVS and CS/CNA F confirmed all four looped straps on the sling were observed to be stiff and when held up, they did not fall, bend, or collapse into itself. The undated, Guideline for Identifying Deteriorated Slings (sling guidelines) was reviewed. CS/CNA F confirmed, the Hoyer sling guidelines indicated that a sling with stiff loops (straps) was considered damaged and should not be used. During an interview on 11/4/25 at 12:25 pm, CNA B confirmed, the loop straps on the sling used on Resident 1 the day she fell were stiff and stated, I didn't know it meant they needed to replaced, they are all [slings] like that.1d. A review of the undated, User Instruction Manual indicated, Hoyer slings and lifts are not designed to be interchangeable with other manufacture's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver.During an interview on 11/4/25 at 3:18 pm, CNA B stated, I've never been provided training on what size Hoyer sling to use for a resident. I eyeball it. The facility provided training on sling size after it happened [after Resident 1 fell out of the Hoyer lift]. During a concurrent interview and record review on 11/4/25 at 10:48 am, with DSD the Total Mechanical/Lift Transfers in-services, dated 10/29/25 and 10/30/25 were reviewed. DSD confirmed staff had not received training on how to select the correct size sling prior to Resident 1's fall with injuries.During an interview on 11/4/25 at 12:15 pm, CNA B and NA D both confirmed eyeballing the sling was how they determined what size to use.During a concurrent observation and interview on 11/4/25 at 11:45 am, with EVS and CS/CNA F, the sling that was used during the Hoyer lift transfer, when Resident 1 fell, was observed. EVS and CS/CNA F confirmed that there was no information label on the sling that indicated the brand name, sling size, or weight limit. CS/CNA F confirmed that without the information that should be on the label attached to the sling, one could not determine what size or brand the sling was.

Based on interview and record review the facility failed to develop a care plan (a written plan that outlined how the facility and staff would meet the resident needs) for four out of five sampled residents (Residents 2, 3, 4, and 5) when there was no care plan present that described the use of a mechanical lift (medical device on wheels that was used to transfer residents who could not bear their own weight).This had the potential for residents not to obtain or maintain their highest practical physical, mental, and psychosocial well-being and lead to potential accidents from not being transferred properly.Findings:A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, indicated a care plan would be developed for each resident that included standards for meeting safety and health care needs.A review of Resident 2's admission Record, dated 7/18/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of quadriplegia (unable to move arms and legs on their own). Resident 2 was their own responsible party (RP, decision maker). A review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/25/25, indicated that Resident 2 was dependent (required maximum assistant could not do on own) upon facility staff for showers, using the bathroom, and to transfer out of bed into a chair. A review of Resident 2's Lift/Transfer Evaluation, dated 11/4/25, indicated Resident 2 could not bear any weight (support weight while standing).A review of Resident 3's admission Record, dated 1/14/16, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of dementia (severe memory loss) and muscle weakness. Resident 3 was not their own RP. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 3's Lift/Transfer Evaluation, dated 8/5/25, indicated Resident 3 could not bear any weight.A review of Resident 4's admission Record, dated 8/12/20, indicated, Resident 4 was admitted to the facility on [DATE] with the diagnoses of dementia and muscle weakness. Resident 4 was not their own RP.A review of Resident 4's MDS, dated [DATE], indicated Resident 4 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 4's Lift/Transfer Evaluation, dated 10/21/25, indicated Resident 4 could not bear any weight.A review of Resident 5's admission Record, dated 9/6/24, indicated, Resident 5 was admitted to the facility on [DATE] with the diagnosis of adult failure to thrive (a gradual decline in health that had no explanation). Resident 5 was not their own RP. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 5's Lift/Transfer Evaluation, dated 10/11/25, indicated Resident 5 could not bear any weight.During a concurrent record review and interview on 11/5/25 at 4:15 pm, with Administrator (Admin), Residents 2, 3, 4, and 5's Care Plans were reviewed. Admin stated, There should be a care plan for [residents that use] a mechanical lift. Admin reviewed each resident's active care plan and the discontinued care plans and confirmed, there was no care plan present that indicated Residents 2, 3, 4, and 5 required the use of a mechanical lift for transfer.

Based on observation, interview, and record review, the facility failed to follow their Resident Safety and Maintenance Service policies and procedures (P&P) when:1. Facility staff knew the mechanical lift (device on wheels used to transfer residents that could not walk) was broken, did not report it, and used it to transfer four out of five sampled residents (Residents 2, 3, 4, and 5); and2. The Maintenance Department failed to ensure the broken mechanical lift was removed from use, reported as broken, and did not consistently perform monthly routine maintenance of all mechanical lifts that were utilized in the facility.This had the potential to cause an accident and injuries from using broken equipment to lift and transfer all residents who required the use of a mechanical lift and negatively impact their physical and emotional well-being.Findings: 1. A review of the facility's P&P titled, Resident Safety, revised 4/15/21, indicated, any facility staff that identified an unsafe situation, should immediately notify their supervisor or the charge nurse. A review of the admission Record, dated 7/18/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of quadriplegia (unable to move arms and legs on their own). Resident 2 was their own responsible party (RP, decision maker). A review of the Minimum Data Set (MDS, a resident assessment tool), dated 10/25/25, indicated a Brief Interview of Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 2 scored 14 out of 15 which indicated good memory. The MDS indicated Resident 2 was dependent upon facility staff for showers, using the bathroom, and to transfer out of bed into a chair. A review of Resident 2's Lift/Transfer Evaluation, dated 11/4/25, indicated Resident 2 could not bear any weight (support weight while standing).A review of the admission Record, dated 1/14/16, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of dementia (severe memory loss) and muscle weakness. Resident 3 was not their own RP. A review of the MDS, dated [DATE], indicated Resident 3 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 3's Lift/Transfer Evaluation, dated 8/5/25, indicated Resident 3 could not bear any weight.A review of the admission Record, dated 8/12/20, indicated, Resident 4 was admitted to the facility on [DATE] with the diagnoses of dementia and muscle weakness. Resident 4 was not their own RP.A review of the MDS, dated [DATE], indicated Resident 4 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 4's Lift/Transfer Evaluation, dated 10/21/25, indicated Resident 4 could not bear any weight.A review of the admission Record, dated 9/6/24, indicated, Resident 5 was admitted to the facility on [DATE] with the diagnosis of adult failure to thrive (a gradual decline in health that had no explanation). Resident 5 was not their own RP. A review of the MDS, dated [DATE], indicated Resident 5 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 5's Lift/Transfer Evaluation, dated 10/11/25, indicated Resident 5 could not bear any weight.During an interview on 11/4/25 at 11:28 am, Maintenance Supervisor (MS) confirmed, when a mechanical lift was broken, it was labeled as broken, and removed from use. During a concurrent observation and interview on 11/5/25, with Certified Nurse Assistant (CNA) B the only mechanical lift that was available for use, located on Station 2 was observed. There were two legs (the base of the mechanical lift that was on wheels) that opened and closed on its own while pushing the mechanical lift forward, and the handle (used to open and close the legs) lifted out and detached from the mechanical lift. CNA B stated, the handle for opening the legs, slides on its own, and comes off. CNA B confirmed that the broken mechanical lift was not reported to anyone today.During an interview on 11/5/25 at 12:35 pm, Central Supply/CNA F confirmed the handle to the mechanical lift came off and stated, They always have to tighten it up. It was just serviced to.During a concurrent observation and interview on 11/5/25 at 12:38 pm, CNA G stated, I have been here since 2021, sometimes when you push or turn the mechanical lift, the legs open. CNA G was in the process of taking the broken mechanical lift into Resident 2's room when MS arrived. MS confirmed having knowledge that the mechanical lift's handle came off and stated, I tighten the bottom, not the handle. CNA G stated, I've been here for four years, it has been reported multiple times. MS stated, If they don't add it to the maintenance log, then it's word of mouth (verbally telling MS something was broken and not writing it down). The handle was removed from the base of the mechanical lift, and the bottom of the handle was covered in black tape. MS walked away and did not remove the broken mechanical lift from service.During a concurrent observation and interview on 11/5/25 at 12:48 pm, CNA B and CNA G were observed taking the broken mechanical lift to Resident 2's room. CNA B asked the surveyor, Can we use the mechanical lift? CNA B was notified, that the surveyor was not allowed to advise. CNA B and CNA G were observed utilizing the broken mechanical lift to move Resident 2 from the wheelchair to the bed. Once Resident 2's body was lowered onto the bed, the entire mechanical lift tilted to the left and both right wheels came approximately two inches off the ground. There was no observed awareness by CNA B or CNA G that the mechanical lift had tilted. Resident 2, CNA B, and CNA G denied feeling or noticing that the mechanical lift had tilted. CNA B and CNA G both looked at the wheels of the mechanical lift and confirmed they were off the floor. During an interview on 11/5/25 at 1:04 pm, CNA H stated, This [broken] mechanical lift was used on Residents [2, 3, 4, and 5] today. I've been here for four years; this mechanical lift has been broken since I started. CNA H confirmed, both legs open and close uncontrollably on their own, with or without residents in the sling (strong fabric that attached to the mechanical lift and suspended residents up in the air). CNA G confirmed, the handle that is supposed to open and close the legs came off the mechanical lift. CNA G stated, I've asked maintenance so many times to fix it, I stopped asking. I don't normally use it, but that's what we had on our hall to use. During the interview, CNAs B, G, H and I were all present during the interview with CNA G. All four CNAs reviewed which residents were transferred utilizing the broken mechanical lift during their shift on 11/5/25. CNAs B, G, H, and I confirmed the following transfers using a broken mechanical lift: CNAs B and G transferred Resident 2 for lunch and back to bed. CNAs H and I transferred Resident 3 after breakfast and CNAs B and I transferred Resident 3 for lunch. CNAs H and I transferred Resident 4 after breakfast and CNAs B and I transferred Resident 4 for lunch. CNAs B and G transferred Resident 5 after breakfast and CNAs G and I transferred Resident 5 for lunch.In total, CNAs B, G, H, and I completed seven transfers for four residents.During an interview on 11/5/25 at 1:18pm, MS stated, I started [working here] in April 2024 and the handle to the mechanical lift had been coming off before I started working here. MS was asked if anyone had reported the earlier observation of the mechanical lift tilting and the wheels coming off the ground and MS stated, They didn't tell me that the wheels came off of the ground.A review of the Battery-Powered Patient Lift (user manual), with the copyright year of 2022, indicated, the mechanical legs must be in the open position, and the shifter handle (the handle) must be locked into place to ensure stability and safety of residents during transfers. The user manual indicated that if the mechanical lift was damaged or broken, the mechanical lift was not to be used. During a concurrent observation and interview on 11/6/25 at 7:43 am, Resident 2 was observed sitting up in bed and smiling. Resident 2 stated, I have concerns about the condition of the Hoyer (brand name of a different mechanical lift and was the term often used for all mechanical lifts), as you've seen, the one used yesterday is not in great shape. When you move that Hoyer forward, the legs open and close and the handle comes out. Resident 2 confirmed, the broken mechanical lift was not utilized often by facility staff and stated, During transfers, while it's moving, and I'm in the air, the legs have closed, or the handle comes off. They have a hard time maneuvering it. Resident 2 stated, I don't feel safe in the Hoyer they used yesterday. It makes me think, oh this one again and it causes extra swinging [movement while suspended in the air].2. A review of the facility's P&P titled, Maintenance Service, revised 1/1/12, indicated, the Director of Maintenance was responsible for maintaining work order requests and maintenance records. The P&P indicated Maintenance Staff would follow safety regulation to ensure residents were safe.During a concurrent observation and interview on 11/5/25 at 12:38 pm, MS was observed holding the handle of the broken mechanical lift in his hand. After MS and CNA G discussed CNA G's concerns about the mechanical lift, MS placed the handle back into the base of the mechanical lift and walked away. MS did not remove the mechanical lift from service.During an interview on 11/5/25 at 1:18 pm, MS stated, I've never reported the handle to anyone, it usually stays on pretty good. A review of the Maintenance Log, dated 7/15/25, indicated, the handle to the mechanical lift needed to be tightened, and the repair was made on 7/16/25.During an interview on 11/5/25 at 1:50 pm, Maintenance Assistant (MA) stated, I didn't know about the mechanical lift legs until today. I inspected the mechanical lift last week, they were loose, and I tightened it. Staff purposely break it because they want new toys. The handle is news to me. MA confirmed, when the mechanical lift was inspected, MA never pulled on the handle to ensure it was securely attached to the mechanical lift and stated, it was fine as of Saturday [11/1/25].During an interview on 11/5/25 at 3:09 pm, Administrator (Admin) stated, No one notified me the mechanical lift was not working.During a concurrent interview and record review on 11/6/25 at 11:05 am, with MS, the instructions for mechanical lift inspections titled, Logbook Documentation, dated 11/3/25 was reviewed. MS confirmed, the instructions indicated, the handle would be inspected to ensure it operated smoothly and was locked into place. MS stated, during inspection the handle should have been pulled. The Work History Report (report) dated 11/30/24 through 11/30/25 was reviewed. MS confirmed, the report indicated, the mechanical lifts had not been provided the monthly inspection by MS or MA from 3/1/25 through 4/30/25. MS confirmed, the report indicated the mechanical lifts were inspected on 11/3/25 and when asked where they documented any issues discovered during inspections, MS stated, there was nowhere to document issues.

Based on observation, interview, and record review, the facility failed to ensure residents remained free from potential accident hazards when: 1. One Fire Door (FD) A (a door that is fire proof and helps contain smoke), which led to the outside of the facility was damaged and could not be completely closed or locked for the past year and a half. The door led to the facility backyard where there was a steep creek. 2. A staff locker room door (LD) B, that residents had access to, was not kept locked and contained rusty unlocked lockers, stainless steel chemical cleaner, personal protective equipment (eye goggles, face shield and face masks), staff belongings, food items, a broken air conditioner, TV monitors [televisions], cardboard boxes, an industrial-sized container of a chemical rust remover. These failures had the potential to negatively impact the health, safety, and welfare of 82 of 82 residents who currently resided in the facility. This put the residents at risk for serious injury, harm or death by allowing for unannounced, potentially dangerous visitors to enter the facility and for residents to wander out of the facility unsupervised, and to ingest harmful cleaning chemicals. On 5/22/24 at 11:25 am, the Administrator (ADM) was notified that an Immediate Jeopardy (IJ) situation (a situation that requires immediate correction on the facility's part to avoid harm to the residents) was identified and Substandard Quality of Care (SQC, care that is below the standard required), due to the facility's inability to close or lock FD A and LD B, which contained harmful chemicals that the residents had access to. On 5/22/24 at 12 pm, an immediate corrective action plan was requested from the ADM. On 5/22/24 at 4:25 pm, the ADM presented an immediate corrective action plan that was accepted which removed the immediate danger to the residents, by securing FD A and LD B so that they closed and locked. On 5/22/24 at 5:10 pm, the survey team was on-site and verified that the facility's immediate corrective action plan had been implemented and the ADM was informed that the IJ was removed. 3. A toilet that was loose and not secured to the floor, that the facility had knowledge of, was not repaired and contributed to the fall of one resident (Resident 38), when he sat down on the toilet and it moved. This resulted in Resident 38 sustaining a large bruise to his hip and caused him unnecessary pain and anxiety. Findings: 1. During review of facility's policy and procedure (P&P) titled, Maintenance Service: Operational Manual - Physical Environment, revised 1/1/12, the P&P indicated its Purpose was to protect the health and safety of residents, visitors, and facility staff. The P&P indicated Maintenance staff will follow established safety regulations to ensure the safety and well-being of all concerned. The P&P indicated the Maintenance Department is responsible for the following: Establishing priorities in providing service repair, Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines, Maintaining the building in good repair and free from hazards, Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order, Maintaining the grounds, sidewalks, parking lots, etc., in good order, Providing routinely scheduled maintenance service to all areas, and Other services that may become necessary or appropriate. During an outside tour of the facility grounds on 5/21/24 at 11:06 am, FD A was observed to be open approximately one-half inch, with a heavy rubber floormat across the threshold under the door. An approximate 1-inch gap was noted between the floor and the bottom of FD A nearest the hinged side. The backyard and area behind the facility contained unmaintained land with weeds and trees leading to a steep embankment which dropped into a (seasonally) dry, rocky creek bed. Observed that LD B was unlocked and there was no locking device on LD B. During concurrent observation of FD A and interview with Maintenance Director (MAINT) on 5/22/24 at 8:55 am, MAINT stated he was aware there was an issue with FD A. MAINT opened FD A and indicated that the door was cracked which caused the heavy door to pull the hinge apart so that FD A was not aligned within the doorframe. MAINT stated it was not possible to fix FD A and that this fire door needed to be replaced. MAINT stated he was waiting for a vendor to give a price quote for a new fire door. MAINT confirmed that LD B was not locked but was equipped with a Wanderguard device (a device worn by residents who tend to wander that triggers the device's alarm). MAINT stated anyone going in or out of LD B wearing a Wanderguard bracelet would set off the alarm; however, an alarm would not sound if a Wanderguard bracelet was not present. Observed that LD B had no lock present. Resident 69 was observed nearing the exit in her wheelchair. Resident 69 stated, I think I'm lost. 2. During observation of LD B and the staff locker room on 5/22/24 at 11:12 am, rusty, unlocked lockers were observed to contain stainless steel cleaner, a protective face shield and eye protection, a box of face masks, and other staff belongings to include clothing and food items. A cupboard across from the lockers contained what appeared to be broken equipment to include an air conditioner device, TV monitors, cardboard boxes, and pieces of wood and metal. An industrial-sized container of Diversey Neutralizer (rust remover) was observed in the corner of the locker room. The Diversey Neutralizer's label indicated the undiluted Diversey product could cause, severe skin burns and serious eye damage and would be harmful if swallowed, causing burns/serious damage to mouth, throat and stomach. The label advised avoiding contact of the product with eyes, skin, and clothing and to avoid inhaling product fumes by using face protection. During an interview on 5/22/24 at 9:40 am, Certified Nursing Assistant (CNA) E indicated that FD A, had not been locked for one and a half years since I have been here. CNA E confirmed residents hang out in the hallway next to FD A and could go outside because they can't be seen by staff. During review of record titled, Proposal dated 10/10/23, regarding the replacement of FD A, indicated that an outside vendor (company or business) proposed a bid (potential cost) to furnish, deliver, and install . One (1) new Hollow Metal Door for your existing opening. The record indicated this would include securing new hinges in place, alignment of the door in the opening for proper clearance, lubrication of all moving parts and our Quality Assurance & Safety Check to insure proper operation of the complete door system. A review of an email dated 10/17/23, sent by the ADM to Governing Body (GB) 1, (the GB is a high level of management that makes policies and oversees all of the affairs of the facility and secures funds), included a capital expenditure (means a high cost item that the GB needs to approve), purchase order form for one hollow metal fire door. The capital expense report indicated the current fire door was unable to close and lock due to issues beyond repair. During an interview on 5/22/24 at 4:50 pm, ADM stated he was aware that FD A needed to be replaced a year and a half ago. ADM stated he received an estimate from one vendor and GB 1 requested two estimates, before approving. ADM stated he explained to GB 1 that there was only one available vendor in the area, but the funds were not approved. During an interview on 5/23/24 at 4 pm, GB 2 stated that he had replaced GB 1 about three weeks ago and was unaware of the oustanding facility building projects needing approval. GB 2 stated the capital expense for the broken FD A, should have been approved back when it was identified as an issue. 49934 3. A review of the facility's Fall Management Program policy, revised 3/13/21, indicated the facility will implement a Fall management Program that supports providing an environment free from fall hazards. The purpose of the policy is to provide residents a safe environment that minimizes complications associated with falls. A review of Resident 38's Admission record indicated he was admitted to the facility on [DATE], with diagnoses that included right sided paralysis (unable to move one side of the body after a stroke) and weakness, and was unsteady on his feet. A review of a Fall Risk Evaluation dated 5/19/24, indicated that Resident 38 was at high risk for falls. A review of Resident 38's Progress Notes dated, 5/20/24, indicated that Resident 38 has had 3 falls. One fall on 3/13/24, 5/11/24, and on 5/19/24. A review of the Minimum Data Sets (MDS- an assessment and care screening tool), dated 5/15/24, indicated that Resident 38 required minimal assistance (only needs a staff member to stand by), with chair to bed transfers, toilet transfers, and walking up to 150 feet. Resident 38 was cognitively intact (ability to make decisions). A review of a Care Plan revised on 5/20/24, indicated Resident 38 was at risk for falls related to balance problems and right sided weakness. Interventions included anticipating needs of resident, call light within reach, and ensure resident was wearing appropriate footwear when ambulating. A review of Progress Notes dated 5/12/24, for a fall that occurred on 5/11/24, indicated Resident 38's fall was due to him losing his footing. There was an evaluation of the environment under contributing factors but had not included the bathroom. A review of a Progress Note written by Licensed Nurse (LN) K dated 5/19/24, indicated that Resident 38 was going to use the restroom and fell to the floor and was found on his right side and there was some bruising to right hip/thigh area. Resident 38 was assisted up to use the bathroom by staff. LN K asked resident if he would like to go the hospital to be evaluated and Resident 38 declined. A review of an Interdisciplinary Team (IDT- healthcare team that ensures residents receive quality care and improve how a facility functions), written on 5/20/24, indicated that medications contributed to Resident 38's fall. There was no record of evaluation of the environment. A review of a Post Fall Evaluation, dated 5/19/24, indicated Resident 38 had a fall due to, Attempting to self-toilet. During an interview and observation with Resident 38 in his room on 5/21/24 at 11:22 am, Resident 38 voluntarily raised his shirt and adjusted the right side of his pants to reveal dark purple discoloration at the right side below the ribs and at the hip. Resident 38 indicated that he fell because his bathroom toilet was very unsteady and not secured to the floor. This was visibly demonstrated when the resident grabbed the front edge of the toilet and spun the toilet from side-to-side. Resident 38 stated, I went to sit down, and the toilet moved. When asked if this was reported to staff, Resident 38 stated that this had been reported, a while ago. Resident 38 stated that he does not use the call light a lot because he wants to get up and do things independently. After the fall, Resident 38 yelled for help, staff came right away, and the nurse did an assessment. A review of a Progress Note by Social Services, dated 05/22/24, indicated that Resident 38 was upset because of the bruising to his right hip and pain and, He feels no one cares. During review of facility records titled, Maintenance Logs, dated 1/1/24 to 5/22/24, the records indicated the following: On 4/28/24, Special Issue/Problem: Resident 38's bathroom toilet was loose and leaking. The record did not indicate Date Addressed, Target Date, Date Completed, or Completed By (staff initials). During an interview on 5/21/24 at 11:30 am, Licensed Vocational Nurse (LVN) F and Infection Preventionist (IP), were interviewed regarding Resident 38's fall. LVN F stated that she heard he fell but did not know it involved the toilet. IP stated was not aware that the bruise was from a fall in his bathroom near the toilet. LVN F and IP both confirmed MAINT just went to get parts to fix the toilet and confirmed that Resident 38's toilet had not been repaired up to now.

Based on observation, interview, and record review, the facility failed to identify, evaluate, and intervene in a timely manner in order to prevent an avoidable pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence, where bones are close to the surface of the skin), for 1 of 3 residents who were sampled for pressure ulcers (Resident 63). This resulted in Resident 63 developing an infected Stage 4 (full thickness skin loss with damage and exposure of muscle, bone, fat and/or tendon), pressure ulcer on his right heel and subsequent right leg amputation (cut off by surgical operation), below the knee which caused the resident anxiety, depression, and uncontrolled pain. Findings: A review of the facility's policy titled, Skin Integrity Management, revised 10/26/23, indicated that the policy of the facility is to identify, evaluate, and intervene to prevent pressure ulcers and any other skin integrity conditions. The purpose of the policy is to develop a plan of care for residents who are at risk for developing skin integrity conditions and to provide guidelines for the treatment of skin integrity conditions to facilitate healing. A review of the facility's policy titled, Pressure Injury [also means pressure ulcer] Prevention, revised 3/30/23, indicated that a plan of care will be developed for residents who have risk factors, or are at risk for development of a pressure injury. The purpose of the policy is to prevent the development of pressure injury in residents identified at risk. A review of the facility's policy titled, Diabetic Care, revised 1/1/2012, indicated that the policy of the facility is to provide the necessary care and services to permit each diabetic resident to attain or maintain optimal well-being while monitoring their care in accordance with their individualized comprehensive assessment and care plan. The purpose of the policy is to ensure residents with diabetes achieve optimal well-being while recognizing the resident's right to refuse treatment and the impacts of the recognized pathology and the normal aging process. Section VII. A Licensed Nurse will assess and document the resident's skin condition at least weekly. Section VIII. A Licensed Nurse will monitor and report any signs of infection. Section XII. Licensed Nurses will provide diabetes education to residents and family, covering the following topics: H. Maintaining clean feet I. Use of white socks J. Removing shoes and socks at night; and K. Keeping heels off bed A review of Resident 63's Admission Record, dated 4/19/22, indicated diagnoses of type 2 diabetes mellitus (adult onset of high blood sugars), idiopathic peripheral autonomic neuropathy (nerve damage causing numbness or weakness), and dementia (confusion and forgetfulness). A review of Resident 63's Minimum Data Set (MDS- an assessment and care screening tool), dated 7/5/23, indicated a risk for pressure ulcers. The MDS assessment indicated no pressure ulcers, other ulcers, open lesions, infections of the foot, wounds, or skin problems present. A review of Resident 63's Care Plans, initiated on 5/3/22, indicated that he had potential for pressure ulcer development related to incontinence [loss of bowel and bladder control], level of assistance needed for transfers and mobility, and cognitive deficits. On 6/7/2023, it is indicated that he had potential impairment to skin integrity related to dementia and diabetes. A review of the Weekly Skin/Wound Assessments, dated 7/27/23, indicated, Resident's skin is warm and dry. No skin issues or open wounds noted. On 8/8/23, another Weekly Skin/Wound Assessment indicated, No skin issues. During a record review of a Progress Note, dated 8/11/23, the Wound Doctor (WD) assessed Resident 63's right foot. WD found an Unstageable (full-thickness pressure ulcer covered by a scab or yellow-white material on the wound), pressure ulcer to the right heel. A review of the Weekly Skin/Wound Assessments, dated 8/15/23, indicated, No skin issues noted. On 08/22/23, the Weekly Skin/Wound Assessment indicated a pressure ulcer Stage 1 (Intact skin with an area of non-blanchable, (an area of redness that does not disappear under pressure), and was in-house acquired (happened while in the facility). A review of the WD's Progress Notes, dated 9/1/23, indicated Pressure Right Heel and staged at unstageable necrosis (the death of most or all the cells in the tissue due to failure of blood supply). The wound bed was 100 percent Eschar (a dry, dark scab), with a length of 2.5 centimeters (cm- unit of measure), width 3 cm, and depth 0 cm. WD recommended to offload (positioning the body so that pressure does not rest on top of the wound) right heel wound, dietician consult, vitamin C and Zinc Sulfate (vitamins), reposition per facility protocol, and Sponge Boot (a soft boot to relieve pressure) with offloading (to take pressure off of the area), heels. A review of the Order Summary Report of Discontinued and Completed Orders, from 2022 to 2024, indicated there was no pressure relieving interventions for Resident 63 such as floating heels, boots, or repositioning, prior to the development of the pressure ulcer to the right heel. A review of the Order Summary Report of Discontinued and Completed Orders, dated 4/19/22, there are orders for Podiatry (foot doctor) service as clinically indicated, but there are no podiatry consultations or assessments found in Resident 63's record. A review of a Progress Note, dated 9/20/23, indicated that Resident 63's pressure ulcer continued to have a foul odor with redness and swelling at the edges and that there were two types of bacteria in the right heel pressure ulcer wound bed. The Progress Note indicated that one of the bacteria was resistant (the antibiobic will not kill that type bacteria), to the antibiotics that were ordered to treat the infection. On 9/23/23, the Progress Note indicated that the wound had become worse with a strong odor, had an excessive amount of dead tissue, was non-blanchable and the resident complained of pain at his right heel. The WD was notified and requested Resident 63 be sent to the hospital for evaluation. A review of an Interdisciplinary Team Note (IDT- healthcare team that ensures residents receive quality care and improve how a facility functions), dated 9/27/23, indicated that prior to admit to local hospital, Resident 63's wound at the right heel was not healing and was deteriorating despite treatment interventions. During an interview on 5/24/24 at 2:14 pm, Certified Nursing Assistant (CNA) D indicated Resident 63 would wear heavy boots in his wheelchair, and frequently self-propelled himself throughout the facility using both heels to maneuver. CNA D explained Resident 63 would dig both heels into his mattress while in bed. CNA D stated Resident 63 was cooperative with care. CNA D described the right heel wound as being deep. During a concurrent interview and record review on 5/24/24 at 2:30 pm, the Director of Nursing (DON) stated Resident 63 was at high risk for pressure ulcers due to being a diabetic. The DON confirmed there were no podiatry visits found in the record and could not find any preventative measures put in place to prevent pressure ulcer development. The DON also confirmed there were no documented nursing skin checks on Resident 63 and stated he should have had foot, skin, and nails checks due to being a diabetic and having behaviors of digging in his heels when in the wheelchair and bed. A review of the Discharge Summary from the local hospital, dated 9/27/23, indicated diagnoses of osteomyelitis (bone infection), diabetic ulcer of right heel with fat layer exposed, diabetic ulcer of right heel associated with diabetes mellitus due to underlying condition, unspecified ulcer stage, diabetes mellitus type 2 with neurological manifestations (symptoms caused by the nervous system). The discharge summary indicated that Resident 63 had an Irrigation and Debridement (I&D- procedure where dead tissue is removed from the wound bed), 8 days prior at the facility and was also given oral antibiotics at the facility, but the wound was not healing properly. The WD was concerned and sent Resident 63 to the local hospital for further evaluation. The discharge summary indicated that Resident 63 had a bedside I&D on 9/24/23 at the local hospital, which resulted in revealing bone and the diagnosis of osteomyelitis. Resident 63 also had an ortho-surgery (branch of medicine that focuses on the care of the skeletal system) consult. The discharge summary stated Resident 63 indicated that the pain is not getting better and does want to get admitted to the hospital and get the wound cleaned up. Resident 63 was admitted to the hospital's Emergency Department on 9/23/23, admitted to the local hospital on 9/24/23, had a below the knee amputation (BKA) to his right leg on 9/25/23, and then was discharged back to the facility on [DATE]. During a review of an IDT Note, dated 9/27/23, the experience of a BKA resulted in a decline in mobility, transfers, ADL (activities of daily living) function, and placed Resident 63 at risk for psychosocial distress (unpleasant emotions). During a review of a Progress Note, dated 9/29/23, Resident 63 stated a desire for a Hospice evaluation and just wanted to die. Resident 63 wasn't going to take anymore medications or eat, and decided this after they took the right foot off.

Based on observation, interview, and record review, the facility failed to protect the safety of one of three sampled residents (Resident 1), who were reviewed for falls and injuries, from a significant avoidable injury when Resident 1 had been evaluated to benefit from bed rails (rails attached to the bed to help with turning over in bed), and Resident 1 had requested bed rails that were never put on her bed. Certified Nursing Assistant (CNA) B told Resident 1 to roll over in bed so that she could change Resident 1 ' s brief (an adult protective underwear for loss of bowel and bladder control). Resident 1 told CNA B that she did not have enough room to turn over and was going to fall off of the bed, and CNA B told her to roll over anyway. This failure to protect Resident 1, resulted in Resident 1 rolling off of her bed onto the floor where she landed on her face and broke her nose in two places and had the potential to put residents who required rolling over in bed to be changed, at risk for falls and serious injuries. Findings: The facility's policy titled, Fall Management Program, revised 3/13/2021, was reviewed and indicated the purpose was to provide residents a safe environment that minimizes complications associated with falls. The facility's policy titled, Bed Rails, revised 12/4/2020, was reviewed and indicated, A bed rail is an assistive device .The licensed nurse will complete the Bed Rail Risk Screen upon admission. The Facility ' s maintenance team is responsible for installing bed rails. The facility's Fact Sheet titled, A Guide to Bed Safety, revised 4/2010, was reviewed and indicated, The benefits and risks of bed rails are aiding in turning and repositioning within the bed, providing a feeling of comfort and security and reducing the risk of patients falling out of bed when being transported. The facility's CNA job specific competencies titled, Repositioning Competency, revised 3/2021, was reviewed and indicated, Aligns resident safely in the center of bed, away from the edge and encourages resident to use bed rails to assist during the repositioning process. Resident 1 s medical record was reviewed. Resident 1 was admitted to the facility on [DATE] with diagnoses that included epilepsy (seizures-uncontrolled body jerking or shaking), depression, weakness and difficulty in walking. Resident 1's Admission Minimum Data Set (MDS, a complete clinical assessment), dated 12/20/23, was reviewed. Resident 1's Brief Interview for Mental Status (BIMS, an evaluation of memory and understanding) score was 15 (ranges from 1-15, with 15 indicating intact cognition). Section GG of the MDS indicated Resident 1 required partial assistance (minimal assistance from staff) for turning in bed, and was dependent (required full assistance from staff) for toileting (the ability to wipe, clean self, adjust clothes before and after going to the bathroom, or changing brief). Section H of the MDS indicated Resident 1 was frequently incontinent (lack of control) of urine and always incontinent of bowel. Resident 1's Interdisciplinary Team (IDT, a group of facility management staff from all departments who work together to determine a residents needs), note dated 3/1/24 at 9:51 am, written by Licensed Nurse (LN) F was reviewed. LN F documented that Resident 1 had rolled out of bed [on 2/29/24] and was found by a CNA lying on the floor by her bed. Interventions documented by LN F were to have the RNA (Restorative Nursing Assistant, a CNA that provides physical assistance to help residents improve strength). LN F documented there were no new physician's orders following the fall. Resident 1's IDT note dated 3/14/24 at 2:43 pm, was reviewed and indicated that Resident 1 had rolled out of bed again on 3/13/24, when CNA B was changing her brief, Resident ' s bed was raised up at this time to allow staff to assist her. Resident fell out of bed on her left side while hitting her face and nose at the same time. EMS [Emergency Medical Services] was called, and [Resident 1] was sent to the hospital for evaluation and treatment. Root cause: poor body position in bed while being assisted with ADL [activities of daily living], B&B [bowel and bladder] needs. New interventions: half rails [short bed rails] placed on bilateral [both] sides of bed for bed mobility, DSD [Director of Staff Development] will give 1:1 education to involved staff related to bedside safety. A review of Resident 1's CT scan report (computerized tomography scan, type of x-ray), that was done at the acute care hospital dated 3/13/24, reflected that Resident 1 had a broken nose on both sides that was comminuted (a bone that is broken in at least two places), and displaced (out of alignment). During an Interview on 3/15/24 at 10:58 am, the DSD stated that on 3/13/24, [CNA B] was in the middle of doing cares [changing Resident 1 ' s brief] when she rolled her [Resident 1] away from her and she fell off the bed. [CNA B] should have had her hand on the resident, and she did not. You should never take your hand off your resident. During a concurrent observation and interview on 3/15/24 at 12:15 pm, in Resident 1 ' s room, Resident 1 was observed lying in bed with bed rails on the upper half of both sides of her bed. Resident 1 had black and blue coloring below her eyes, on her cheeks and on her nose. Her face and nose were swollen. There was a skin tear (scrape), on the right side of her nose with some dried blood around her nose and on the bed sheets. Resident 1 was asked about her most recent fall that occurred on 3/13/24, and she stated, I was being changed by a girl and she said to roll over and I said I ' m too close and she said it ' s all right, I am right here so don ' t worry, the next thing I knew I took a header. She was not there. Resident 1 indicated that the bed rails, were not put on until yesterday. Resident 1 indicated that she had asked for bed rails to help her turn and keep her from falling out of bed after she fell out of bed, two weeks ago on 2/29/24. Resident 1 stated staff told her at that time, they would put them on, but they never did until yesterday. Resident 1 stated, I could have held on to the rail and stopped myself from falling if the rails were on. During an interview on 3/15/24 at 12:20 pm, LN A indicated that Resident 1 was asleep when she rolled out of bed the first time on 2/29/24, and confirmed that bed rails would have prevented Resident 1 from falling out of bed. During a concurrent interview and record review on 3/19/24 at 9:30 am, with MDS LN E, Resident 1 ' s admission document titled, Bed Rail assessment dated [DATE], was reviewed. Section 1 identified that Resident 1 was at risk for falls, displayed poor bed mobility, and had difficulty with balance or poor trunk (middle of the body), control. The Bed Rail Assessment identified that Resident 1 had expressed a desire to have bed rails for safety and/or comfort and bilateral bed rails were recommended for both sides of her bed. The Bed Rail Assessment was signed by Nursing Supervisor (NS). MDS LN E indicated that she was unsure of how the facility implemented their interventions based on the Bed Rail Assessment. MDS LN E confirmed that bed rails had not been put on Resident 1's bed as her Bed Rail Assessment recommended on 12/19/23, and they should have been. During an interview on 3/19/24 at 10 am, CNA C indicated that he had cared for Resident 1 many times. CNA C stated that Resident 1 could assist with turning in bed, But you never knew how hard she would kick her leg over. She would take her leg and swing it right over. She was heavy on the lower end and had extra weight in her legs. She tended to roll with enthusiasm and could easily fall off the bed. I always rolled her toward me when changing her brief. During an interview on 3/19/24 at 10:10 am, CNA D indicated that she had cared for Resident 1. CNA D indicated that she always rolled Resident 1 toward her, and never away from her, when changing her brief because that was how she was trained. During a concurrent interview and record review on 3/19/24 at 10:20 am, with the NS, Resident 1 ' s admission Bed Rail Assessment, dated 12/19/23, was reviewed. NS confirmed that the Bed Rail Assessment indicated Resident 1 expressed a desire to have bed rails for safety and/or comfort and that there was a recommendation for placement of bilateral bed rails. NS confirmed that this was not followed up on, and the bed rails were not put on Resident 1's bed and they should have been. During an interview on 3/19/24 at 10:30 am, the DSD stated that CNA B, should have rolled [Resident 1] towards her and kept a hand on her, but she did not do this. During an interview on 3/19/24 at 10:40 am, CNA B confirmed she had asked Resident 1 to roll away from her while changing Resident 1 ' s brief on 3/13/24. CNA B indicated Resident 1 was in her bed and confirmed that there were no bed rails on her bed. CNA B confirmed that she told Resident 1, I got you. CNA B indicated that Resident 1 swung her top leg over and then she fell off the bed. CNA B stated, I should have rolled her toward me and that would have been safer. CNA B confirmed that bed rails would have helped in this situation because Resident 1 would have been able to hold on to them, but they were not on the bed. CNA B indicated that Resident 1 should have had bed rails placed after her first fall on 2/29/24, and that she had discussed this with, the nurses but nothing was done. A record review of Resident 1's, Falls Care Plan initiated on 12/14/24, identified Resident 1 to be at risk for falls. The intervention for bilateral bed rails had not been added until 3/14/24, three months after Resident 1's Bed Rail Assessment indicated that Resident 1 had requested and could have benefited from bed rails.

Based on observation, interview, and record review the facility failed to protect residents from abuse when: 1. One out of four sampled residents (Resident 1) had been struck in the face by another resident (Resident 2) when Resident 2 heard Resident 1 verbally abuse female staff members. 2. Two out seven sampled residents (Resident 6 and Resident 7) endured ongoing verbal abuse from Resident 1 during resident cigarette (smoke) breaks. This failure placed residents at an increased risk for inability to attain or maintain physical, mental, and psychosocial well-being and caused feelings of anxiety (feelings of worry, nervousness or unease, symptoms could include irritability or aggression) Findings: 1. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention, Screening, and Training Program, revised 7/1/18, indicated, The facility conducted resident pre-admission, admission and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. The P&P indicated The facility establishes a safe environment that reasonably supports residents to the extent possible A review of Resident 1's undated Admission Record indicated admission to the facility on [DATE] with the diagnoses of cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged) and major depressive disorder (a sad mood). Resident 1 was cognitively intact (able to think and remember) and was his own responsible party (RP, made own decisions). A review of Resident 2's undated Admission Record indicated admission to the facility 9/14/19 with the diagnosis of end stage renal disease (kidneys stop working). Resident 2 was cognitively intact and was his own RP. During an attempted interview on 9/26/23 at 9:52 am, Resident 1 declined an interview and stated, I don't want to talk with you. During an interview on 9/26/23 at 9:55 am, Resident 2 stated he was trying to go outside to the resident smoking area and Resident 1 was sitting in the doorway. Resident 2 stated Resident 1 would not move out of the way and Resident 1 began to verbally abuse Resident 2. Resident 2 stated Resident 1 was verbally abusing female staff members who were assisting with the resident smoke break, was tired of it, and Resident 2 struck Resident 1 in the face. During an interview on 9/26/23 at 10:38 am, Certified Nursing Assistant (CNA) D stated, Resident 1 and Resident 2 had a history of behaviors and were moody. CNA D stated Resident 1 will run out of cigarettes and go outside during the resident smoke break and ask other residents for cigarettes. CNA D stated this was against the smoking rules and Resident 1 had been educated many times about the smoking rules. CNA D stated Resident 1's behaviors included yelling at the residents and staff during the smoke break when no one would give Resident 1 a cigarette. CNA D stated Resident 1's behavior was not new and had been on going for a long time. During an interview on 9/26/23 at 11:15 am, with the Director of Nursing (DON), DON confirmed Resident 1 and Resident 2 were involved in a resident-to-resident altercation on 9/21/23 and stated reviewing the facility's video camera footage of the incident. DON stated Resident 2 was attempting to exit the facility for a resident smoke break and Resident 1 was in the doorway. DON stated hearing Resident 2 state Excuse me and then Resident 1 looked like he was about to possibly swing at or potentially hit Resident 2. DON stated Resident 2 stood up out of his wheelchair, Resident 2's hand contacted Resident 1's face, and Resident 1 sustained a bloody nose. A review of the record titled Psychiatric Visit Progress Report, dated 10/13/23, indicated, Resident 1 had a psychiatric history of anxiety and depression. The Psychiatric Visit Progress Report, indicated, Resident 1 had been involved in an alleged altercation with another resident, continued to be extremely irritable, and Lexapro (antidepressant medication) recently increased though patient still with concerning irritability and now conflict with other patients. A review of the record titled Psychiatric Visit Progress Report, dated 2/2/23, indicated, Resident 1 continues to be irritable. A review of the record titled Psychiatric Visit Progress Report, dated 4/7/23, indicated, Resident 1 was irritable and while discussing medication, Resident 1 left the visit. During an interview on 9/26/23 at 11:51 am, Director of Staff Development (DSD) stated Resident 1 and Resident 2 had issues in the past and interventions were in place to keep them both separated. DSD stated interventions had been in place for approximately three months and removed due to Resident 1 and Resident 2 no longer having behaviors. During a concurrent interview and record review on 9/26/23 at 2:33 pm, with DON, Progress Notes dated 6/21/23 was reviewed. DON stated the Progress Note indicated Resident 1 was agitated and yelling profanities at staff because Resident 1 would not be taken outside to smoke a cigarette after the resident smoke break had ended. 2. A review of the undated Admission Record indicated Resident 6 was admitted to the facility on [DATE] with the diagnoses of major depressive disorder and anxiety. Resident 6 was cognitively intact and was her own RP. During a concurrent observation and interview on 9/27/23 at 1:50 pm, Resident 6 stated Resident 1 is always causing issues at the smoke break. Resident 6 stated Resident 1 was verbally abusive to all the smokers. Resident 6 stated the verbal abuse occurred when Resident 1 was out of cigarettes. Resident 6 stated Resident 1 would ask the residents who smoked for cigarettes when Resident 1 was out, and when the smokers did not give Resident 1 cigarettes, he would yell and scream at everyone. Resident 6 was observed fidgeting her hands and feet (repetitive movement), broke eye contact, lowering her eyes to the ground, and stated Resident 1 is verbally abusive to me, yells profanities at me, and blames me when he doesn't have any cigarettes. Resident 6 stated the facility rules for attending the resident smoke break included not attending the smoke break if a resident did not have cigarettes and residents were not allowed to ask other residents for cigarettes. Resident 6 stated an inability to recall how long Resident 1 had been verbally abusive during resident smoke breaks, and stated the verbal abuse had been going for more than one year, staff knew about it, and being near Resident 1 caused Resident 6 feelings of anxiety. A review of the undated Admission Record indicated Resident 7 was admitted to the facility on [DATE] with the diagnosis of heart failure (inability of heart to properly pump blood), was cognitively intact and was his own RP. During a concurrent observation and interview on 9/27/23 at 2:35 pm, Resident 7 was observed to have good eye contact and was calm during the interview. Resident 7 stated when Resident 1 did not have cigarettes, Resident 1 would get obnoxious , verbally abuse everyone who was outside during resident smoke breaks including staff. Resident 7 stated Resident 1 would call them all names. Resident 7 stated when Resident 1 was outside during the resident smoke break, Resident 7 would get an uneasy feeling due to not knowing if Resident 1 was going to blow up or not and did not like how it made him feel. Resident 7 stated when Resident 1's behaviors or mood was elevated, staff would intervene and sometimes Resident 1 would realize how he acted and would leave. Resident 7 stated many times Resident 1 would yell at staff and would tell staff that Resident 1 had the right to be out here and refused to leave the resident smoke area. Resident 7 stated Resident 1 belittled all the smokers and when Resident 1 knocked on the door to come out to the resident smoke area, everyone would tense up. Resident 7 was asked how long Resident 1 had been verbally abusive to him and the other residents who smoked. Resident 7 stated Resident 1 had treated everyone this way ever since Resident 7 had been admitted to the facility. Resident 7 stated even when Resident 1 did not join the resident smoke break, Resident 7 would look over my shoulder with worry that Resident 1 was outside at the resident smoking area. Resident 7 stated smoking was Resident 7's time to relax and enjoy the company of fell ow smokers and Resident 7 can't do that because of Resident 1. During an interview on 9/27/23 at 2:30 pm, CNA D confirmed Resident 1 was verbally abusive to the other residents and staff when out in the smoking area. CNA D stated not knowing what could be done to fix the situation because Resident 1 had rights and CNA D can not force Resident 1 to leave the smoking area. A review of the undated record titled List of Smoking Residents, indicated the facility had 10 residents who smoked cigarettes. During a concurrent interview and record review on 9/27/23 at 2:52 pm, with DON, Progress Note, dated 7/10/23 was reviewed. DON stated the Progress Note indicated Resident 1 had a history of aggressive behaviors, resident-to-resident alterations, verbal aggression, and sexual inappropriateness with other residents. DON confirmed many of Resident 1's behaviors revolved around not having cigarettes, has known of these behaviors for approximately six or seven months (since becoming the facility's DON), and when asked what the facility was doing to protect the other residents from Resident 1's abusive behaviors, DON stated residents have the right to not be verbally abused; but, Resident 1 had the right to be outside in the resident smoking area. During an interview on 9/27/23 at 4:08 pm, with the facility's Administrator (ADMIN), ADMIN stated Resident 1 had been educated many times and redirected to not be outside at the resident smoking area when Resident 1 was out of cigarettes. ADMIN stated Resident 1 had the right to be outside during resident smoke breaks and acknowledged residents who smoke had the right to feel safe and not be verbally abused.

Based on observation, interview, and record review, the facility failed to provide effective pain management for three of 22 sampled residents (Residents, 2, 11, 14) and one out of sample resident (Resident 24) when: 1. Resident 11's severe pain went unrelieved and untreated for [REDACTED]. This resulted in Resident 11 suffering severe leg wound and tailbone pain unnecessarily and emotional distress expressed by crying and feeling crazy when her pain was at its worst. 2. Resident 2 had a new onset of pain related to right toe wounds and lack of assessment and coordination of care, for a four month period. 3. Resident 24 did not receive physician ordered Cryocuff cooling (circulates cold water using ice to assist with reducing swelling and pain at joint sites) therapy consistently for a five day period to assist with pain and swelling to her recent right knee joint replacement. 4. Resident 14, who was on palliative care (all care provided to enhance the residents comfort and not to prolong life), experienced avoidable pain due to a lack of coordination of care between the certified nursing assistants (CNAs) and licensed nurses (LNs). The inadequate pain management resulted in substandard quality of care for Residents 2, 11, 14, and 24 who suffered pain unnecessarily, and had the potential for all residents with pain to not receive the necessary care and services to ensure effective pain management. Findings: The facility's policy titled, Pain Management, dated 1/1/12, indicated the facility staff is responsible for helping the resident attain or maintain their highest level of well-being while working to prevent or manage the resident's pain. The pain assessment flow sheet will be completed every shift for new residents in the first 72 hours following admission. The Licensed Nurse will administer pain medication as ordered and document all medication administered on the Medication Administration Record (MAR). The Licensed Nurse will assess the residents pain and document results on the MAR each shift. If there is a new onset of pain or the pain has not be relieved with current medication the physician will be notified. The Nursing Staff will implement timely interventions to reduce the increase in severity of pain. 1. A review of Resident 11's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 11 was able to make health care decisions for herself. During an interview on 4/30/15 at 10:30 am, Resident 11 was observed in her bed. Resident 11 stated she had multiple bleeding bed sores on both of her legs which cause her pain. Resident 11 explained most of her pain came while at [MEDICAL TREATMENT] (HD, the process of removing wastes from blood when kidneys no longer work) treatments on Mondays, Wednesdays, and Fridays. Resident 11 stated the pain is a result of the transfers between wheelchair via a Hoyer (a mechanical lift used to transfer people) to the HD treatment chair. She stated the transfers caused her wound pain and sitting in the chairs and lying in bed caused her tailbone to hurt. Resident 11 stated she has reported her pain to multiple staff at both facilities many times, with no change in pain medication. She described her pain to be severe, and began to cry. Resident 11 stated she was not premedicated with [MEDICATION NAME] (narcotic pain medication) before wound care twice a day, nor after, as needed. Resident 11 expressed she felt crazy when the pain was at its worst. The Interdisciplinary Team (IDT - nursing, activities, dietary, social services, and/or therapy staff) notes, dated 4/24/15, indicated Resident 11 reported the Hoyer lift used at the HD center bothers her skin and causes her pain, even if pain medication is given before the treatment. The IDT identified an action plan including staff education related to putting a sheet or bath blanket between the Hoyer lift sling and her body, and requesting a pain patch (topical pain medication patch that releases continuous pain medication over a time period) from the physician. During an interview on 4/30/15 at 11:30 am, the Social Services Director (SSD) stated she just called the HD center today to discuss Resident 11's pain and to determine the reason for the increased pain. The SSD stated it was related to the type of Hoyer used. The SSD stated the phone call to the HD center should have occurred one week earlier, after the IDT discussion surrounding the residents pain. The Pain Assessment, dated 4/25/15, completed four days after admission to the facility, indicated Resident 11's pain changed her mood/emotions and she may withdraw from activities. The pain assessment notes indicated the Hoyer lift at the HD center caused her pain and makes the resident cry at treatments. The assessment indicated the resident verbalized pain in the past five days as very bad. The review of the data collection indicated the resident exhibited signs of pain. The medication administration record (MAR) from 4/21-4/29/15 indicated Resident 11's pain was to be monitored every shift, three times a day. There were 12 missing entries out of 27 opportunities from the MAR and [MEDICATION NAME] was given only one time on 4/27/15. The pain assessment flow sheet was not completed every shift for Resident 11 for the first 72 hours following her admission. There was one entry for 4/27/15, six days after admission. A fax was sent to the physician on 4/24/15 at 3:45 pm, the Licensed Nurse (LN) requested a pain patch for Resident 11. The physician sent a response on 4/27/15 with an order for [REDACTED]. There was no signature or date by the physician. The fax was sent to the Pharmacy to fill the medication. The nursing weekly summary from 4/22-4/29/15, under the pain section, had a line through both sections which assessed current and a week look back period for pain; no entry was made in either section. The physician's orders [REDACTED]. During a concurrent interview and record review on 4/30/15 at 7:45 am, LN M stated Resident 11 had pain since admission. LN M stated the [MEDICATION NAME] order should have been followed up on, or called to the physician on 4/24/15, due to the severity and unrelieved pain Resident 11 experienced at HD treatments. LN M stated there was no communication with the HD center about the pain and they were not aware if any medication was being given at the HD center. LN M stated there was an ongoing problem with getting narcotic pain medication from the Pharmacy due to needing a triplicate form (required by law to dispense narcotics) and verification from the physician. During an interview on 4/30/15 at 9:20 am, LN M stated the [MEDICATION NAME] was not applied until last evening on 4/29/15, 5 days after the original request, and Resident 11 reported the pain patch helped her pain. LN M stated the HD center was only giving Tylenol (mild pain medication) for pain. During an interview with Resident 11 on 4/30/15 at 10:30 am, she began crying and stated that her pain was much better today, once the physician ordered pain patch was applied. The policy titled, [MEDICAL TREATMENT] Care indicated the facility maintains a contract with the [MEDICAL TREATMENT] service provider which includes communication between the two providers. The communication and collaboration will occur on a regular basis between the nursing staff, the [MEDICAL TREATMENT] center staff and the medical doctor. The [MEDICAL TREATMENT] Communication Form (used to communicate between facility and [MEDICAL TREATMENT] center important resident specific assessment information) sent by the facility will indicate any changes in the resident and the [MEDICAL TREATMENT] provider will communicate any problems while the resident was at treatment. The [MEDICAL TREATMENT] Communication forms were reviewed. There was only one form, dated 4/22/15, since admission. The [MEDICAL TREATMENT] communication form had no documentation of changes in condition related to pain upon departure from the facility and upon return from the HD center. There were missing [MEDICAL TREATMENT] communication forms from 4/24-4/29/15, three [MEDICAL TREATMENT] center treatment days. During a concurrent record review and interview on 4/29/15 at 1:10 pm, LN M confirmed there should have been change of condition information communicated between the two facilities related to Resident 11's pain and there were missing [MEDICAL TREATMENT] communication forms from 4/24-4/29/15. During an interview with the Director of Nursing (DON) on 4/29/15 at 3 pm, the DON stated if Resident 11 was reporting severe pain the nursing staff should do whatever necessary to get a pain medication order implemented as soon as possible, a phone call versus a fax. The DON stated the HD center should be involved to coordinate pain management care and the facility policies were not followed. 2. Resident 2's record review indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 was unable to make health care decisions for himself. During an observation and interview on 4/27/15 at 2 pm, Resident 2 was holding his right foot in his hand. Resident 2 grimaced and when asked if in pain, he replied, my toes hurt. Resident 2's physician's orders [REDACTED]. Review of the podiatry (foot care) evaluation and treatment form, dated 1/16/15, indicated the podiatrist (foot doctor) documented Resident 2 had a painful ischemic (limited blood movement) right fifth toe with painful toe nail fungus (nail infection). A fax sent to the physician, dated 1/17/15, indicated Resident 2 has discoloration to his 4th and 5th toe with swelling, complaints of severe pain to right foot, family requests treatment. No new pain medication orders. Resident 2's psychotherapy progress notes, dated 2/26/15, under the findings summary, indicated, depression along with pain, anxiety, [MEDICAL CONDITION] are complex, planning treatment using frequent measures and tools will be implemented. Pain assessment positive, follow up due. A progress note, dated 3/5/15, indicated, Patient was complaining about foot pain. The IDT conference records were reviewed from 12/8/2014 through 4/21/15. The IDT met at total of 10 times to discuss Resident 2. Pain management was reviewed only one of the ten meetings on 3/31/15. The IDT identified that Resident 2 takes [MEDICATION NAME] twice a day for chronic pain and uses the as needed [MEDICATION NAME] occasionally. The MAR's were reviewed and indicated Resident 2 was medicated with the as needed [MEDICATION NAME] 12-14 times for each month from January-April 2015. The nursing weekly summaries were reviewed from January 2014-April 2015, for a week look-back period for pain, and indicated the following: 1/6/15 - history of pain, moderate pain level; 1/13/15 - no pain; 1/20/15 - [MEDICAL CONDITION], intermittent moderate pain level with grimacing and restlessness; 1/27/15 - foot pain, constant moderate pain level, restlessness; 2/3/15 - foot pain, constant moderate pain, restlessness; 2/10/15 - no pain assessment; 2/17/15 - feet, inconsistent severe pain, grimace, restlessness, guarding; 2/24/15 - inconsistent severe pain, restlessness and guarding; 3/3/15 - back and leg pain, inconsistent severe pain, grimaces, moaning, restlessness and guarding; 3/17/15 - back and leg pain, inconsistent severe pain, grimaces and moaning; 4/1/15 - leg and feet, constant severe, grimaces and guarding; 4/7/15 - foot pain, inconsistent severe pain; 4/14/15 - right toes to touch, inconsistent moderate to severe, grimaces, moaning, restlessness and guarding; and 4/28/15 - foot pain, inconsistent severe pain, grimaces, restlessness, and refusal of care. Resident 2 had only one pain assessment flow sheet in the record for the month of March 2015 which had three pain assessment entries. The pain assessment flow sheet for April 2015 had six pain assessment entries. A nurses note, dated 4/7/15 and timed 11:30 am, indicated the DON was notified of all Resident 2's ongoing refusals of care. During an interview on 4/30/15 at 9:15 am, Certified Nursing Assistant (CNA) L stated Resident 2 started reporting painful toes in December of 2014. During an interview on 4/28/15 at 10 am, the Minimum Data Set (MDS) assessment nurse stated pain can trigger behaviors and Resident 2 had been monitored. A communication fax to the physician, dated 4/26/15 and timed 2:30 pm, indicated Resident 2 had dementia and does not always indicate need for as needed pain medication verbally. Resident 2 does have care resistance and agitation episodes, may be possibly related to un-managed pain. Request was made for increase in routine pain medication. The physician response was to increase the [MEDICATION NAME] to three times a day. During an interview on 4/28/15 at 3:30 pm, the Director of Staff Development (DSD) stated Resident 2 needed more pain medications which had not been tried since new toe wounds happened around February 2015. DSD explained she wanted to see if the pain was related to his behaviors. 3. Resident 24's record indicated she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 24 was her own responsible party. During the initial tour of the facility on 4/27/15 at 8:30 am, Resident 24 was observed sitting in her wheelchair waiting for physical therapy and for staff to apply her Cryocuff cooler (circulates cold water using ice to assist with reducing swelling and pain at joint sites). Resident 24 stated the staff was not trained to use the Cryocuff and, for the last four days, it was not applied, as ordered by physician. She stated it was applied once on 4/24-4/25/15, and four times 4/26/15. Resident 24 stated the cold works the best for her pain and she does not like to take pain medication. She further explained the cold water keeps the swelling down and it will help her heal faster so she can get home. The pain assessment, dated 4/23/15, indicated Resident 24 had constant chronic pain at her right knee, and at its worst it was severe and at its best, after medication, it was mild. The pain assessment flow sheets from 4/27-4/29/15 indicated Resident 24's pain was severe. Review of a physician's orders [REDACTED]. During an interview on 4/29/15 at 4 pm, Resident 24 reported the Cryocuff was applied only two times on 4/27-4/28/15 and three times today. During an interview with the DON on 4/29/15 at 12:45 pm, she stated nursing staff were not trained on the Cryocuff until 4/26/15, three days after admission, though staff could have been applying ice packs. The treatment record for the month of April 2015 indicated missing entries for ice packs on 4/24/15 at 3 pm and 10 pm and 4/27-4/28/15 at 8 am and 12 pm; six missing Cryocuff applications. During an interview on 4/29/15 at 3:30 pm, LN O confirmed the missing entries and explained she thought it was only for two times a day. During an interview on 4/30/15 at 7:45 am, LN M stated they had no training on how to apply the Cryocuff equipment. 4. Resident 14's record indicated she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 14 was not able to make her own healthcare decisions. Resident 14 was totally dependent on staff for all activities of daily living and care needs. On 4/28/15 at 3:45 pm, during an interview, a confidential resident explained her roommate (Resident 14) had been crying out in pain for the past two weeks. On 4/30/15 at 7:55 am, during an interview with CNA W and concurrent observation, Resident 14 was non-responsive but appeared comfortable while resting in bed. When asked if Resident 14 was in pain and how it was exhibited, CNA W explained Resident 14 had been like this for the past couple weeks. When asked when or if Resident 14 had pain, CNA W stated Resident 14 had pain whenever she was turned or when care was provided. On 4/30/15 at 8:15 am, during an interview, LN N explained all of Resident 14's medications had been discontinued except pain and antianxiety medications on 4/15/15. LN N explained Resident 14 was on palliative care to honor her end of life wishes. When asked about Resident 14's pain management, LN N explained Resident 14 had orders for as needed medications every two hours that included [MEDICATION NAME] (a potent narcotic pain medication to treat severe pain) and as needed anti-anxiety medications every four hours that included the medication [MEDICATION NAME]. LN N explained the CNA's were very good about letting her know if Resident 14 appeared to be in pain. When asked if there had been any coordination between the CNAs and LNs to pre-medicate Resident 14, prior to the provision of resident care, LN N stated, no. When asked if hospice care (organization that coordinates end of life care to promote resident dignity and comfort in dying) had been considered for Resident 14, LN N stated she was not sure. LN N explained the social service department would obtain hospice care if/when needed. On 4/30/15 at 9 am, during an observation of the provision of resident care (included a mini-bath, providing incontinence care, turning and repositioning) and an interview with CNA W, Resident 14 appeared to be in pain as she moaned whenever her body was moved. CNA W confirmed Resident 14 appeared to be in pain and stated Resident 14 had called out or moaned with pain during resident care for the past couple weeks. CNA W confirmed she was not aware of any coordination between the LN's and CNA's to pre-medicate Resident 14, prior to resident care. When asked how often Resident 14 was supposed to be turned and repositioned, CNA W stated, every two hours. Resident 14's Pain Assessment Flow Sheet,dated 4/15/15 through 4/30/15, indicated she experienced daily episodes of severe pain. On 4/30/15 at 10:20 am, during an interview and review of the end of life care policy and procedure and palliative care-plan for Resident 14, SSD explained that hospice services had not been offered to Resident 14's healthcare decision maker. On 5/4/15 at 2:15 pm, during an interview and concurrent review of the palliative care-plan for Resident 14, the DSD confirmed the goal of the palliative care-plan is to ensure resident dignity and comfort during end of life care. DSD confirmed coordination between CNAs and LNs to premedicate Resident 14, prior to resident care, would be important to ensure Resident 14's comfort in the circumstances described above. DSD confirmed this could result in avoidable pain for Resident 14.