Every finding on record at Oroville Hospital Post-Acute Center

Based on observation, interview and record review, the facility failed to ensure an effective pest control program was implemented when a pattern of:Multiple sightings of cockroaches were not reported to the Maintenance Department.The Maintenance Department did not adhere to the facility's pest control policy and procedures.The lack of action had the potential for all residents, employees and visitors to be exposed to cockroaches and other insects that carry disease and placed the facility at increased risk for infestation.FindingsA review of the facility's Pest Control Policy (PCP), undated, stated under Purpose, to maintain a safe and healthy environment for all resident's, staff and visitors by preventing, identifying, and addressing pest infestation within the skilled nursing facility.1.A review of the PCP Section 2, titled, Reporting and Escalation stated, Any staff member who observes pests (e.g., insects) or evidence of pest activity must immediately notify the Maintenance Department.On 8/4/2026 at 12:00 pm, The California Department of Public Health Licensing and Certification Branch received an anonymous complaint alleging the facility had a cockroach infestation.During an observation on 8/4/2026 at 2:15 pm in the kitchen, a dead, black, oval shaped bug with multiple legs and antennas was lying on its back at the far-left hand corner of the dry food storage room. Observed a couple pieces of dried cereal that were round with a hole in the center located on the floor underneath the food storage racks on the left side of the dry food storage room.During a concurrent observation and interview on 8/4/2026 at 2:30 pm with the Cook, the [NAME] indicated last month there were cockroaches in the kitchen. The [NAME] confirmed there was a dead cockroach in the far-left hand corner of the dry food storage room. The [NAME] confirmed there was dried cereal on the floor and indicated the cereal could attract cockroaches.During an interview on 8/5/2026 at 6:25 am with CNA (Certified Nursing Assistant) A, CNA A indicated they did not report sightings of large outdoor cockroaches inside the facility near the back doors, hall doors and courtyard doors on the [NAME] Hall.During an interview on 8/5/2026 at 7:00 am with CNA B, CNA B indicated the facility had a huge cockroach problem especially during the nighttime between the hours of 11:00 pm to 3:00 am. CNA B indicated when they go to the break room during the night shift (7:00 pm to 7:00 am), they heard crunch, crunch when walking and this also occurred in residents' rooms and hallways. CNA B indicated rooms [ROOM NUMBERS] near the resident's oxygen concentrators (a medical device that delivers purified oxygen to residents with low blood oxygen levels) and small bedside dresser were hot spots for cockroaches. CNA B indicated they found cockroaches on a resident's body and in their bed when they went to change them. CNA B indicated they reported sightings to the Maintenance Department however they had not observed a decrease in cockroaches.During an interview on 8/5/2026 at 7:20 am with Hospitality Aide (HA) A, HA A indicated they did not report sightings of cockroaches they saw every night all over the place.During an interview on 8/5/2026 at 7:25 am with HA B, HA B indicated they reported to other CNAs and Nurse's that they saw cockroaches every night in the halls and resident rooms. HA B indicated it was their understanding that the Nurse's follow up with Maintenance.During an interview and record review on 8/5/2026 at 7:35 am with the Maintenance Director (MD), MD acknowledged cockroaches were in the facility and it was difficult to keep them out. The MD indicated they rely on nursing staff to report sightings in the Maintenance Request Log binder located at each nurse's station. MD identified the dead bug in the photo from the dried food storage room taken on 8/4/2026 at 2:15 pm may have been a beetle and stated, I rely on the pest control company to identify the bugs, I am not a bug expert.A record review of the facility Maintenance Request logs for East, North and [NAME] Halls during the months of 1/2026 to 6/2026, indicated one of eight reports received were for specifically for roaches.During a concurrent interview and record review on 8/5/2026 at10:25 am with the MD, MD indicated they were not informed by the night shift or aware of the nightly observations of cockroaches in the facility.During a concurrent interview and record review on 8/5/2026 at 11:00 am with the Executive Director of Nursing (EDN), EDN acknowledged nursing staff have not been reporting roach concerns to Maintenance as often as they claimed to have seen them and would need to be re-educated on their responsibilities to report roach sightings to Maintenance.2.A review of the PCP Section 1 titled, Routine Inspections stated, The Maintenance Department will conduct weekly inspections of high-risk areas, including kitchens, dining rooms, laundry rooms, and storage areas, to identify signs of pest activity (e.g., droppings, nests, or damage). Documentation of inspections will be recorded in a pest control log and reviewed by the Maintenance Supervisor monthly. Section 4 titled, Preventative Measures stated, The Maintenance Department will: Seal Entry Points: Inspect and seal cracks, holes, and gaps in walls, windows, doors, and foundations. Under Roles and Responsibilities, Maintenance staff. implement preventative measures as outlined in this policy.During an interview on 8/4/2026 at 7:35 am with the MD, MD acknowledged cockroaches have been sighted within the facility and come in through produce deliveries for the kitchen, air conditioner ducts in the windows of residents' rooms, and through residents and visitors coming into the facility. MD indicated they did not have documentation of the weekly inspections they had performed and there was no pest control log. MD acknowledged they were not following the pest control policy.A review of the Scope of Work for the facility's contracted pest control agency stated, Interior Stations: 24-30 interior monitoring devices (bait devices) will be placed throughout the facility and will be checked with each service.A record review of the facility's Pest Control Inspection Reports (PCIR) indicated:On 1/20/2026 a total of 7 Field Roaches and 13 German Roaches were found during the inspection of bait devices 2,3,8,9,14, and 29. PCIR indicated three bait devices were missing, and one device was inaccessible at the time of the inspection.On 2/17/2026 a total of 7 Field roaches and 13 German roaches were found during the inspection of bait devices 3,5, 6,16, and 28. PCIR indicated 4 bait devices were 4 were skipped.On 3/17/2026 a total of 9 German roaches was found during the inspection of bait device 9. PCIR indicated one bait device was inaccessible and three were missing.On 4/21/2026 a total of 4 field roaches and 24 German Roaches were found during the inspection of bait devices 3, 4, 5,6, 9, and 14.On 5/19/2026 a total of 14 Field Roaches and 10 German Roaches were found during the inspection of devices 3, 8, 9, 10,11,14,16, 22, 27, and 28. PCIR indicated three bait devices were missing.On 6/16/2026 a total of 31 Field Roaches was found, during the inspection of bait devices 2, 5,11,13, 14,15, 27, 28, and 29.On 7/21/2025 a total of 20 Field Roaches and 31 German roaches was found during the inspection of bait devices 3, 5, 7, 8, 9,10,11,14,15,16,19, 27, 28, and 30.During an observations on 8/5/2026 at 10:12 am gaps in door casings and at the base of doors were found on the [NAME] Hall door near the medical records room, [NAME] Hall dining room door, back [NAME] Hall in the alcove three rooms down from the activity directors room, North Hall courtyard door, and East Hall courtyard doors.During a concurrent interview, and record review on 8/5/2026 at 10:25 am with the MD, MD indicated the contracted pest control company provided the PCIRs monthly. MD indicated the inaccessible bait devices on the PCIRs were not inspected due to the devices being in areas where resident care was taking place at the time of inspection. MD denied following up on these bait devices. MD indicated they were aware of the missing bait devices but had not requested replacements because the pest control company handles the devices. MD indicated they do not know how many bait devices there were or where all of them were located. MD indicated they do not review PCIRs monthly to determine areas of concern and further pest control strategies. MD acknowledged the inspections were not complete and it was their responsibility to review these reports.During a concurrent observation and interview on 8/5/2026 at 11:00 am with the MD, MD acknowledged there was a gap and light was showing through at the base of the [NAME] Hall door near the medical records room. MD declined to view other doors that had gaps. MD acknowledged further prevention measures such as door guards would prevent insects from entering the facility.

Based on observation, interview and record review, the facility failed to ensure discontinued and completed medications for three of three Residents (Residents 1,2, and 3) were stored securely until destroyed.This failure resulted in various resident medications being removed from the facility and being in the possession of an unauthorized person (UAP). This had the increased potential to harm any person taking the unprescribed medications.Findings: On [DATE] at 8:00 am, the California Department of Public Health received a facility reported incident (FRI) report alleging unauthorized removal and possession of facility medications belonging to Resident's 1, 2, and 3 found at UAP's residence.The FRI summary indicated that standard facility protocol dictated that when medications are discontinued or completed, they were removed from the medication cart and stored in a secured container within the locked medication room. The FRI indicated these medications were held approximately one month until they were destroyed or donated to a third party.During a concurrent observation and interview on [DATE] at 8:53 am, with the Clinical Case Manager (CCM), observed in the [NAME] Nurse's Station Medication Room, multiple medications in a clear three-drawer plastic container with the top draw labeled Bed Hold Meds (medications stored for residents that are temporarily hospitalized ). These medications were not double locked and could be accessed by pulling open drawers. Observed an unlabeled black container with a black lid containing multiple prescription medication cards on the left side of the medication room. Black container was not double locked and could be accessed by opening the lid of the container. CCM indicated the black container held discontinued, expired, and discharged residents unused medications. CCM stated that all licensed nursing staff including Licensed Vocational Nurses (LVN), Registered Nurses (RN), CCMs, House Supervisors, the Assistant Director of Nursing (ADON) and the Executive Director of Nursing (EDN) had keys to the medication room and medication carts.During an interview on [DATE] at 9:45 am, with RN A, confirmed non-narcotic medications were not tracked once they were removed from the medication carts and placed into the assigned containers in the medication room prior to this incident.During a concurrent interview and record review on [DATE] at 2:00 pm with the EDN, stated on [DATE] at 11:30 am, they received a call from the House Supervisor of the facility's affiliated hospital stating a person reported they were dog sitting and found prescription medication cards from the facility in the residence of an UAP's house that were not prescribed to them. EDN stated the UAP was a former Registry (temporary, on call) Certified Nurse's Assistant (person who is certified by the State to provide basic care to residents such as bathing and feeding) whose last day of services was [DATE]. EDN presented a photograph from [DATE] that was sent to the House Supervisor by the person who reported the incident. The photograph showed three prescription medication cards with labels that read as follows:Medication Card 1's resident name blacked out, prescription label read, Cyclobenzaprine (muscle relaxer) issued on [DATE] and discontinued on [DATE]. There were no pills in the compartments of the card.Card 2 read, Resident 2, Gabapentin (nerve pain medication) 300 mg capsules, for diagnosis of neuropathy (nerve pain), issued [DATE] and discontinued [DATE]. There were eight capsules in the compartments of the card.Card 3 read, Resident 3, Hydroxyzine (allergy medication used to treat short-term anxiety) 25 mg tablets, issued [DATE] and discontinued on [DATE]. There were no pills in the compartments of the card.EDN indicated Card 1 was determine to be Resident 1's medication card and Card 3 was Resident 3's. EDN stated their investigation of the incident was inconclusive because they could not determine the quantity medications and the timeline of removal because the facility protocol's prior to this incident did not require tracking of non-narcotic discontinued and completed medications once they left the medication cart and were placed inside the destruction containers within the medication rooms. EDN indicated the discontinued and completed non-narcotic medications stay in the destruction containers within the locked medication rooms at each Nurse's station until they are destroyed and/or donated. EDN stated destruction and/or donation happened approximately once a month.EDN confirmed the black containers with black lids storing the expired and discontinued non-narcotic medications in the medication rooms were not double locked and all licensed nurses entering the medication room could access and remove these medications by opening the lid and reaching into the container. EDN indicated the Pharmacy Consultant (PC) recommended a one-way medication drop box for storing medications for donation or destruction.During an interview on [DATE] at 2:35 pm with the Pharmacy Consultant (PC), PC acknowledged the facilities plan of correction did not limit access for licensed nurse's because any nurse entering the locked medication room can open the container lids and reach in to remove medications therefore, licensed nursing staff continue to have access to all stored medications that are not double locked.During a concurrent observation and interview on [DATE] at 6:40 am, with LVN A, indicated it is their practice to keep the medication room door open when they are inside the North Nurse's Station. LVN A indicated there are spare keys for the medication carts and medication rooms with the EDN and in a lock box. Observed in the Biohazard room a medication destruction white container with an unsecured blue lid containing expired, discontinued, and discharged resident's pills, medication liquids, and syringes with medication. There were no chemical destructive agents within the container. LVN A confirmed there were no chemical destructive agents in the container and that all licensed nurses could access these medications by reaching into the container and removing medications. LVN A indicated had to be filled before the blue lid was secured and sent for destruction. LVN A confirmed all nurses have access to keys for the Biohazard room. During an interview on [DATE] at 9:20 am, with the [NAME] President of Nursing (VPN), VPN acknowledged access issues still exist because the medication storage containers inside the medication rooms are not locked and can be accessed easily by all licensed nurses. VPN acknowledged further security measures could be implemented to further limit access.

Based on interview and record review the facility failed to ensure staff assigned to perform food and nutrition services possessed the competencies and skill sets necessary to carry out those functions. When the facility utilized Certified Nursing Assistants (CNA) to prepare and alter food without documented training or competency validation. These failures had the potential to place residents, a highly susceptible population, at risk of receiving improperly prepared or altered meals that did not meet prescribed therapeutic diets, texture modification, nutritional requirements.Findings:A review of the undated facility's Certified Nursing Assistant (CNA) job description identified the CNA's primary duties included providing direct resident care, assisting with activities of daily living, feeding residents, obtaining vital signs, and completing resident documentation. The CNA job description did not include food preparation or food and nutrition service functions as assigned duties.A review of the undated facility's Dietary Aide (DA) job description indicated that the DA's essential functions included preparing food, assembling meal trays, checking trays for accuracy, preparing snacks between meals, keeping food at safe temperatures, and completing kitchen cleaning tasks.During an interview on 6/24/26 at 11:45 am, with [NAME] J who was responsible for breakfast and lunch meals, [NAME] J stated that when the dietary department required additional assistance, CNAs were reassigned from the nursing units to assist in the kitchen with food preparation tasks. [NAME] J stated the dietary department was currently short staffed due to one employee being absent because of a death in the family.During an interview on 6/24/26 at 11:50 am, with [NAME] K who prepared the dinner meal, stated the dinner shift normally required three staff, or sometimes four if an evening snack worker was scheduled or a morning staff member stayed to assist. [NAME] K reported that the dietary department had been short staffed throughout June, and as a result, CNAs were sometimes pulled from the nursing units to help with kitchen duties.During an interview on 6/25/26 at 11:55 am, with Registered Dietician (RD), RD was asked to provide a list of dietary staff, a list of CNAs who helped in the kitchen, and the training and competency records for each staff member. The RD provided a blank packet of training and competency materials that were reportedly given to kitchen staff at hire, at the 90 day review, and then annually, along with a copy of the Dietary Aide job description. The RD stated the facility did not have any formal written training records or competency documentation for CNAs who were assigned to assist with dietary tasks in the kitchen.During an interview on 6/25/26 at 1:48 pm, with RD, RD stated facility has been required to pull staff for help intermittently for the past three weeks due to a dietary employee being out on a leave of absence. The RD stated that when CNAs assist with kitchen tasks, they are paired with a DA.During a phone interview on 6/25/26 at 2:07 pm, with CNA F, CNA F was asked about assigned kitchen duties. CNA F explained they were pulled from the nursing unit to help in the kitchen. Their tasks included preparing pudding, cottage cheese, and fruit cups. CNA F stated that some items were pre prepared, while others required measuring ingredients and portioning them into containers. They also blended cottage cheese with milk in a blender to make the correct consistency for a pureed diet. CNA F reported that dietary staff did not provide continuous supervision but checked in periodically to ensure the tasks were done correctly and to offer help if needed.During a phone interview on 6/26/26 at 11:53 am, with CNA G, CNA G stated they had worked in the kitchen three to four times, with the first assignment occurring about two weeks earlier, around 6/12/26. When asked about assigned duties, CNA G reported assisting with preparation of snacks such as pudding and sandwiches. CNA G stated they assisted in the preparation of tuna salad, serving food on the tray line. CNA G further stated they assisted in making a cake using a recipe from the facility recipe book with support from a dietary aide. When asked about supervision and direction, CNA G stated they were provided with both assigned tasks and general instruction. CNA G stated if questions arose, they would locate dietary staff for clarification and assistance.During an interview on 6/25/26 at 3:23 pm, with RD, RD was asked to clarify expectations for CNA involvement in kitchen and dietary preparation tasks. The RD stated CNAs may complete simple tasks independently after receiving instruction, if a DA is present in the kitchen. When informed that CNAs reported mixing and preparing pudding and blending cottage cheese for pureed diets, the RD stated they were not aware of these activities and confirmed CNAs should not be blending cottage cheese or modifying food textures. The RD added that CNAs are expected to perform only simple tasks and should not alter, prepare or modify food for consistency, including pureed textures. The RD further acknowledged that no formal written training, competency validation, or supporting documentation was present in CNA personnel files to demonstrate that CNAs had been trained or deemed competent to perform assigned dietary-related tasks.

Based on observation and interview the facility failed to maintain food safety requirements in the kitchen for all residents receiving their nutritional intake from the kitchen when a gallon of milk and a jar of dill pickle relish were not labeled with the open date following the opening and use of the products.This failure had the potential to result in improper prolonged, out of date use leading to disease transmission, increasing environmental health complications, and overall wellbeing issues to those residents' receiving their nutritional intake from the facility kitchen.Findings:During a review of facility's policy and procedure titled, Labeling and Dating of Foods, dated 2023, indicated, Newly opened food items will need to be closed and labeled with an open date and use by the date that follows the various storage guidelines.During an observation and interview on 5/5/26 at 11:00 am, with Dietary Service Manager (DSM) in the kitchen the three-door refrigerator was observed for adequate food storage. The DSM confirmed that the gallon of milk and jar of pickle relish were not labeled with opening dates as per the regulation guidelines.

Based on observation, interview, and record review the facility failed to maintain essential equipment in operable condition affecting all residents that partake in nutrition provided by the kitchen facility and residents using bathroom units when:1. The oven in the kitchen had broken doors rendering the unit inoperable to perform the function of cooking.2.The wall by the dishwasher unit had incomplete repairs performed leaving the drywall open to moisture, and potential mold and bacterial growth which could result in infection control issues and food borne illness propagation.3.The bathroom facilities, sink and toilet, in room [ROOM NUMBER] were not working. These failures had the potential to create an inhospitable environment for residents to reach their highest practicable level of health and well-being when not offered the basic essentials for adequate nutrition and available facilities at their procurable disposal.Findings: During a review of the document titled, Job Description for the Maintenance Director, dated 4/1/2022, the Maintenance Director Job Description indicated that the maintenance director was to ensure the operations of the maintenance department in making repairs and conducting preventative maintenance. Essential Functions (included) Perform carpentry work.Assist carpenters on maintenance (including) Repair plaster and drywall.Maintain plumbing systems and fixtures.Maintain and repair kitchen equipment (fryers, steamers, stoves, ovens.) .Repair and replace faucets, drains. During a review of the document titled, Job Description for the Maintenance Technician, dated 4/1/2022, the Maintenance Technician Job Description indicated, the technician was to perform repairs and maintenance on facility structures. Essential Functions (included) Perform carpentry work.Assist carpenters on maintenance (including) Repair plaster and drywall.Maintain plumbing systems and fixtures.Maintain and repair kitchen equipment (fryers, steamers, stoves, ovens.).Repair and replace faucets, drains. 1.During an observation and interview on 5/5/26 at 09:45 am, with AM [NAME] (AMC) in the kitchen, the oven was observed to have broken doors. AMC stated that the oven had been broken for quite some time, they (kitchen staff) could not use it to cook food, but just to warm plates. During an observation and interview on 5/5/26 at 11:00 am, with Dietary Service Manager (DSM) in the kitchen, the oven was observed to have broken doors. DSM stated that the oven doors have been broken for greater than seven months, it doesn't appear to be fixable because of the age of the unit. Maintenance has tried to fix the oven, but it keeps breaking. The oven cannot be used to cook anything; roasts have to be purchased precooked and just warmed up in the small standing convection oven or small standing steamer. The broken oven makes it very difficult to prepare the best meals for the residents, especially in a timely manner. During a confidential interview on 5/5/26 at 2:00 pm, five of five residents indicated the food quality could be improved upon and oftentimes food service seemed to be late. During an interview on 5/6/26 at 10:30 am, with the Registered Dietician (RD) in the kitchen, the RD stated that the oven has been broken for a while. The oven is necessary to make the best food for the residents and to do an efficient and effective job in the kitchen. During a concurrent interview and record review on 5/7/26 at 3:30 pm, with Maintenance Service Director (MS) and Maintenance Service Assistance (MSA) outside the Maintenance office, MS and MSA confirmed there was no policy on the maintenance of equipment for the entirety of the facility. The document titled, Preventative Maintenance Task Sheet dated January 2026 through May 2026, was reviewed for the Wolf Range Vulcan (stove/oven brand). The sheet indicated what services were performed each month and what was unable to be completed for specific reasons. The sheet indicated that the oven doors were not properly working from January 2026 to May 2026 and the explanation was provided under Comments: 1/15/26 Need's repairs done on oven door's will be done ASAP (As soon as possible). MS confirmed the oven needed to be fixed. 2.During an observation and interview on 5/5/26 at 11:00 am, with Dietary Service Manager (DSM) in the kitchen, the wall by the dishwasher was observed to be under construction with open areas revealing unfinished drywall (porous flat panel used in construction for wall structuring). DSM stated, The wall by the dishwasher was being renovated but the work has never been completed. The dishwashing area is very wet and is damaging the open drywall, it needs to be completed. During a concurrent interview and record review on 5/7/26 at 3:30 pm, with Maintenance Service Director (MS) and Maintenance Service Assistance (MSA) outside the Maintenance office, MS and MSA confirmed there was no policy on the maintenance of equipment for the entirety of the facility. MS confirmed the wall by the dishwasher needed to be fixed. During an interview on 5/7/26 at 4:40 pm, with Director of Nursing (DON) in DON's office, DON stated there is no policy on equipment maintenance and equipment being operable for and within the facility. DON confirmed that the oven needs to work, and wall must be completed. 3.During an observation on 05/07/2026 at 2:35 PM, room [ROOM NUMBER]'s bathroom was observed to have a sign that indicated out of order. The caregiver of a resident stated he was informed that there was a root growing out of the toilet. A review of an invoice from a local plumbing company dated 4/6/2026, indicated they ran a cable 10 feet into the toilet and there was mud on the end of the cable. During a concurrent interview and record review on 5/07/26 at 2:30 pm, MSA confirmed the sink and toilet do not have running water in room [ROOM NUMBER]. MSA provided the facility repair log, and it indicated the problem was reported on 4/7/26. A local plumbing company came out and put a camera down the water pipe. MSA stated the pipe had disintegrated and can no longer be used. During a interview on 05/08/26 7:50 am, MS confirmed room [ROOM NUMBER] toilet and sink were not working. MS stated there was no capital expense plan to repair the bathroom water pipe in room [ROOM NUMBER].

Based on interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS).This failure has the potential for nursing homes to have inadequate staffing to care for residents and can lead to adverse clinical outcomes. Findings:During a concurrent interview and record review on 5/5/26 at 8:00 am., with the Director of Nursing (DON), the PBJ reporting data was reviewed, the PBJ indicated the CASPER report 1705D fiscal year quarter 1 2026 (October1 - December 31), the facility failed to submit data for the quarter. DON stated they tried to submit the PBJ, but their password didn't work and they did not contact CMS in a timely manner.The facility was unable to provide evidence, by the conclusion of the survey on 5/8/26, demonstrating compliance with the regulatory requirement to submit Payroll-Based Journal (PBJ) data and reports to CMS.

Based on interview and a review of facility records, the facility failed to maintain adequate nursing staff to meet residents' care needs, when:1.Resident council meetings and resident grievances from January to May 2026 documented delays in staff response to call lights.2.Seven of twenty-four residents reported insufficient direct care staff, resulting in delayed responses to call lights and inadequate assistance with activities of daily living, including toileting, oral care, and pain management. 3.The facility did not take resident acuity (complexity and intensity of care needs) into account when scheduling Certified Nursing Assistant (CNA) staff for the [NAME] and North Nursing Stations.As a result of these staffing deficiencies, resident care needs were not consistently met. Residents expressed feelings of neglect and frustration due to delayed responses and unmet care preferences.Findings:1.A review of Resident Council meeting minutes and grievance forms revealed repeated concerns:On 01/21/2026, a resident commented, call light response times are too long, while another asked for help with preparing her toothbrush.On 01/23/2026, a resident reported waiting two hours and twenty-five minutes to be changed, leaving her feeling I do not matter.On 01/27/2026, a resident stated she was not changed for six hours, which occurred three times that week.On 02/21/2026, a resident noted she was not changed between 10:00 pm and 5:22 am.On 02/25/2026, a resident commented, we do not have enough CNAs.On 03/08/2026, a resident stated her incontinent brief was not changed for seven hours.On 04/29/2026, a resident indicated the facility needs more CNAs.During confidential interviews on 03/05/2026 at 02:15 pm, three out of five residents confirmed that staffing was insufficient and that this concern had been repeatedly raised in Resident Council meetings. All three agreed that the staffing issue remained unresolved.2. During interviews with residents:On 05/05/2026 at 08:55 am, Resident 7 described wounds causing constant pain and reported frequent waits of 30 minutes to two hours for pain medication, making pain management difficult and discouraging participation in daily activities.On 05/07/2026 at 02:58 pm, Resident 88 stated that staff did not honor her care preferences, such as timely delivery of coffee, which affected her sleep and increased her anxiety. She also felt rushed during showers.On 05/08/2026 at 08:55 am, Resident 2 expressed concern about inadequate staffing during both day and night shifts, specifically mentioning only two CNAs working on her hall and frequent delays for assistance, particularly at night.On 05/05/2026 at 10:25 am, Resident 93 reported wait times of up to two hours for brief changes and personal care, with delays occurring regardless of staff shift or gender.On 05/05/2026 at 11:05 am, Resident 59 described waiting up to thirty minutes after activating the call light, including while in the bathroom, causing her anxiety.On 05/06/2026 at 07:45 am, Resident 42 stated, sometimes it takes an hour to get my call light answered, noted many call lights ringing in the hall, and said staff complained about heavy workloads and high patient-to-staff ratios.On 05/06/2026 at 04:00 pm, Resident 95 reported inconsistent call light response times, sometimes waiting up to ninety minutes. He noted that delays led to accidents, especially after bladder surgery, and emphasized the need for more staff.3. During a concurrent interview and record review on 05/06/2026 at 3:10 pm, the facility Scheduler (SCH) explained the staffing patterns on the West, East, and North Nursing Stations from January to March 2026 schedules:Day shift: CNAs allocated based on census 4 CNAs West, 5 East, 2 North if census above 110-115; If census lower CNAs 3 West, 4 CNAs EAST, 2 CNAs North.Evening shift: 4 CNAs each on East and West, and 2 on North. When census low 3 CNAs on West, 4 CNAs on East and 2 on North.Night shift: CNAs 4 [NAME] and East and 2 CNAs North. When census low 3 CNAs East and [NAME] on both evening and night shift.SCH stated their scheduling process was mostly resident census driven not resident acuity, and the long-term care (East Nursing Station) gets more staff than short term side (West and North Station.) SCH stated they rely on CNAs to inform them if residents on a Nursing Station become dependent and they need more CNAs to assist.A review of a Resident Alert Tally report dated 05/7/2026, had 20 dependent residents who required one-on-one staff feeding assistance for all meals. The report indicated:Seven residents on East Nursing StationEight residents on [NAME] Nursing StationFive residents on North Nursing Station A review of a facility weight entry report dated 03/12/2026, indicated a list of residents who required the use of a Hoyer lift for transfers. There was a total of 44 residents in the facility, 18 on the East Nursing Station, 13 on both the North/West Nursing Stations.During an interview on 05/05/2026 at 9:29 am, Licensed Nurse (LN G) stated staffing on days and evenings, were running short for Rooms in the 100's (West) and 300's (East). LN G stated residents have informed them they have been waiting for 30 minutes for staff assistance.During an interview on 05/06/2026 at 03:10 pm, with Director of Rehab Services (DRS) stated Restorative Nursing Assistants (RNAs, works with the physical therapy department) are pulled from their RNA duties when the facility needs to ensure resident are receiving necessary observation and direct resident care. During an interview with RNA C on 05/07/2026 at 10:58 am, RNA C stated at least one of the three days they worked this week, additional responsibilities were assigned beyond his RNA tasks. RNA C stated this affects their ability to complete his RNA tasks with residents. RNA C stated they were frequently pulled from RNA duties to provide one-on-one observation and direct resident care.During an interview on 05/08/2026 at 9 am, RNA D and RNA E confirmed they do get pulled from their RNA duties to assist with CNAs often. RNA D and E stated sometimes it happens days in a row then they have to speak up to remind administration that they have RNA work to complete. RNA D and RNA E stated East Nursing more dependent with Hoyer lift (a mechanical lifting device requiring 2 staff to transfer residents with limited mobility safely between from bed to wheelchair), residents with behaviors (requires increased supervision.) During an interview on 05/08/2026 at 09:10 am, CNA F stated the workload on [NAME] Nursing Station was heavier due to residents coming from the hospital.During an interview on 05/07/2026 at 09:30 am, SCH confirmed he does not consider resident acuity when scheduling, such as residents who require Hoyer lifts, who are dependent for dining assistance and residents who have behaviors. SCH stated he relies on information from the CNAs about the level of resident acuity. SCH stated CNA scheduling was mostly resident census driven and that they scheduled more CNAs on the long-term care nursing station (East) and scheduled more staff on the short term side (West).During an interview on 05/07/2026 at 10 am, the Director of Nursing (DON) confirmed there was no hospital-like system for determining resident acuity to guide sufficient staffing. DON acknowledged the absence of call light audits and a system to track resident call light complaints. DON confirmed administrative have not collected resident concerns through executive rounds (staff interview residents about concerns). DON confirmed staffing levels was not being addressed in the facilities Quality Assurance Performance Improvement program, although they had in the past.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and home-like environment for four of 24 sampled residents (Residents 34, 42, 45, and 59) when the facility failed to maintain resident's personal clothing and belongings, resulting in lost clothing items.This failure had the potential to compromise residents' dignity, comfort, and quality of life.Findings:During a review of the facilities policy titled, Theft and Loss Control, undated, indicated the facility would make efforts to safeguard residents' personal property and valuables and that suspected loss or theft of resident property would be timely and thoroughly investigated. The policy further indicated residents clothing was to be permanently labeled with a laundry marking pen or identifying tag. During a review of the facility policy titled, Notice of Theft and Loss Control Policy, undated, indicated staff would be oriented to theft and loss investigation procedures upon hire and during regular in-service training, that staff were to complete a grievance form when notified of a missing item, and that social services would initiate an investigation upon receipt of the grievance form. During a review of the facilities policy titled, Personal Care Items and Clothing, undated, the policy indicated that residents are to have personal care items and clothing available, and that social services are to distribute or arrange for donated items for residents with little or no resources.During a review of Resident 34's admission Record, the record indicated that Resident 34 was admitted on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) ,Seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), Cerebrovascular Accident (CVA-stroke, loss of blood flow to a part of the brain), and high blood pressure. During a concurrent observation and interview on 5/5/26 at 8:17 am, with Resident 34, in Resident 34's room, Resident 34 stated, that 20 labeled pairs of socks sent to the laundry were never returned. Resident 34 also stated that a pink dress sent to laundry in a bag labeled with their name for identification was not returned. Residents 34 stated they had not received the missing items and that no one had followed up with them regarding the loss. Observation of the residence closet revealed no socks or pink dress present. During a review of Resident 42's admission Record, the record indicated that Resident 42 was admitted on [DATE] with diagnoses of end stage renal disease (the kidneys [an organ that filtered waste from the blood] no longer functioned well enough to support life) and dependence on renal dialysis. During a review of a resident council facility grievance form, dated 11/26/25, indicated, that clothing was removed from Resident 42's clothing hamper by an unknown individual. During a review of a Social Service note, dated 1/5/26, indicated, Resident 42 continued to have missing personal items, including two phone charging cords, a pedal bike charging cord, and a silver necklace with a black stone. During a review of a resident council facility grievance form, dated 1/2/26, indicated, that a resident reported that clothing was not being consistently returned from laundry. The grievance form indicated the clothing was not returned to the resident until 2/1/26, 11 days after the grievance was initiated. During a review of Resident 45's admission Record, the record indicated that Resident 45 was admitted on [DATE] with diagnoses that included, Lung Cancer, COPD, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and high blood pressure. During an interview on 5/6/26 at 2:00 pm, with Family Member (FM) 1, in Resident 45's room, FM 1 stated, they had purchased several pajama sets for Resident 45 and multiple pajama tops were missing. FM 1 stated Resident 45 also had a blanket go missing and had received items that did not belong to them. FM 1 further stated Resident 45 lost her phone during a fire evacuation standby and it was never replaced. FM 1 stated they were told there was no facility lost and found by staff. During a review of Resident 59's admission Record, the record indicated that Resident 59 was admitted on [DATE] with diagnoses that included, Kidney Disease, COPD, DM, Heart Failure (HF, heart pumps blood inadequately), and high blood pressure. During a concurrent observation and interview on 5/7/26 at 4 pm, with Resident 59, in the resident's room, Resident 59 stated that a dark navy pair of pants sent to the laundry had not been returned despite notifying laundry and nursing staff. Resident 59 stated that approximately 2 weeks ago a staff member brought her a red pair of pants removed from her roommate and told her that the clothing needed to be better labeled. Resident 59 stated that clothing items belonging to her roommate had been found in her closet and that her own clothing had been found in her roommate's closet. Resident 59 stated she does not have many clothes that fit her and that losing clothes is frustrating. An observation of the residence closet revealed no dark navy pants were present. During an interview on 5/7/26 at 4:18 pm, with Licensed Nurse (LN) A, LN A stated, that Resident 59's clothing had previously been found in the roommate's closet. LN A stated that the clothing was unlabeled and was sent to laundry to be labeled. During an interview on 5/7/26 at 4:50 pm, with the facility Environmentalist (ENVIR), ENVIR stated, the facility maintained one lost and found clothing rack and that unclaimed items were moved to a donation rack after 30 days. Clothing may be lost during room changes, when items are not properly labeled upon admission or by families, or when personal laundry is mistakenly sent to that facility laundry, and unlabeled clothing made items difficult to return to residents, particularly for residents who are unable to identify their belongings. ENVIR confirmed the facility had a large amount of lost and found clothing and could benefit from a better system for returning clothing to residents. During an interview on 5/7/26 at 11:14 am, with Social Services (SS), SS stated, that residents had reported missing belongings, including clothing. SS department worked with laundry staff to locate and return missing items, but unlabeled belongings made ownership difficult to determine once items reached the laundry, and there was hesitation in returning items from the lost and found area without confirming ownership. SS confirmed the facility had a large amount of lost and found clothing and that the process of returning belongings could be improved.During a concurrent observation and interview on 5/7/26 at 3 pm with the Director of Nursing (DON) in the laundry room, a large quantity of lost clothing items was observed. The DON confirmed that a new process was needed to address the lost and found clothing issues and improve management of resident clothing.

Based on interview and record review, the facility failed to complete:The admission Minimum Data Set (MDS) assessment in a timely manner for one of five sampled residents (Resident 123).The Annual MDS assessments for two of five sampled residents (Residents 14 and 126).These failures had the potential to delay the development of comprehensive care plans necessary to provide appropriate, individualized care and services for Residents 14, 123, and 126 to attain and maintain their highest practicable physical, mental, and psychosocial well-being.Findings:A review of the he Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, dated 10/1/25. The RAI Manual requires admission MDS assessments to be completed within 14 calendar days of admission and Annual MDS assessments within 14 days of the Assessment Reference Date (ARD-the specific endpoint of a look-back period for an MDS assessment in long-term care).A review of Resident 123's clinical records indicated Resident 123 was admitted on [DATE], with the admission MDS due by 5/1/26. As of 5/2/26, the admission MDS remained in progress with no care areas documented, exceeding the required completion timeframe.A review of Resident 126's clinical record indicated Residet 126 was admitted on [DATE] with diagnoses that included dementia, seizures, and irregular heart rate. A review of Resident 126's most recent MDS assessment, with an ARD of 4/21/26, due by 5/5/26. The assessment was three days overdue. A review of Resident 14's clinical record indicated Resident 14 was admitted on [DATE] with diagnoses that included history of falling, diabetes (high blood sugar), and chronic pain. A review of Resident 14's most recent MDS assessment, with an ARD of 4/17/26, due by 5/1/26. The assessment was seven days overdue. During a concurrent interview and record review on 5/7/26 at 10:35 am, with MDS Nurse (MDSN) A, the MDSN A stated admission MDS assessments are Supposed to be done in seven days however it is not always done in this time frame. MDSN A stated, this facility is A beast and it is difficult to complete these assessments on time due to the patient population, acuity (severity and urgency of the resident's medical conditions), and frequent turnover (resident admissions and discharges). During a concurrent interview and record review on 5/7/26 at 12:01 pm, with MDSN A, the MDSN A stated the facility uses the Centers for Medicare and Medicaid approved RAI manual regulations to determine the type and timing of MDS assessments. MDSN A could not produce a hard copy of the admission MDS assessment for Resident 123 and the Annual MDS assessments for Residents 14 and 126. MDSN A stated the MDS assessments for Residents 14, 123, and 126 were not completed and were overdue.

Based on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) assessment within 92 calendar days of the previous assessment for two of five sampled residents (Residents 11 and 12). This failure had the potential to delay the development of comprehensive care plans necessary to provide appropriate, individualized care and services for Residents 11 and 12.Findings:A review of Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, effective 10/1/25, indicates that Quarterly Review assessment must be completed no less frequently than every 92 days. The ARD for a quarterly assessment must be set no later than 92 days after the ARD of the previous assessment (Admission, Annual, or Quarterly).A review of Resident 11's clinical record indicated Resident 11 was admitted on [DATE] with diagnoses including diabetes type 2 (high blood sugar), restless legs, and hypertension (high blood pressure). Resident 11's most recent MDS assessment, dated 9/19/26, indicated the quarterly assessment was due by 5/3/26 and was five days overdue.A review of Resident 12's clinical record indicated Resident 12 was admitted on [DATE] with diagnoses including stroke, restless leg, and anxiety. Resident 12's most recent MDS assessment, dated 4/19/26, indicated the quarterly assessment was due by 5/3/26 and was five days overdue.During a concurrent interview and record review on 5/7/26 at 10:35 am, with MDS Nurses (MDSN) A and B, the MDSN B stated that Quarterly MDS assessments are required every three months or every 92 days. MDSN A stated that MDS assessments are Not always done in this time frame due to the facility's resident population, acuity, and frequent turnover.During a concurrent interview and record review on 5/7/26 at 12:01 pm, with MDSN A, the MDSN A stated the facility uses the RAI manual to determine the type and timing of MDS assessments. MDSN A could not produce a hard copy of the Quarterly Comprehensive MDS assessments for Residents 11 and 12 and confirmed that the Quarterly MDS assessments for Residents 11 and 12 were not completed and were overdue.

Based on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 12) was free from unnecessary medications when the required psychotropic (a medication that altered the brain) medication informed consent form was not renewed every six months as required.This failure had the potential to compromise Resident 12's ability to maintain their highest practicable mental, physical, and psychosocial well-being.Findings: A review of the facility's undated policy and procedure titled, Informed Consent for Psychotropic Drugs, indicated the facility would follow Federal and State regulations regarding informed consent when the Physician prescribed a psychotropic medication. A review of the All Facilities Letter (an official document that notified facilities of changes to regulations), dated 10/7/25, indicated psychotropic informed consent forms were required to be renewed every six months. A review of Resident 12's admission Record, dated 11/3/20, indicated admission the facility on 11/3/20 with the diagnoses of chronic (long lasting) pain and major depressive disorder recurrent (feelings of deep sadness and hopelessness that comes and goes). A review of Resident 12's Order Listing Report, dated 11/20/22, indicated that on 11/20/22 the Physician prescribed Cymbalta (an anti-depressant medication that was also a psychotropic medication and was also used for pain management) 60 milligrams (mg, unit of measure), to be given by mouth one time a day for chronic pain. During a concurrent interview and record review on 5/7/26 at 9:31 am, with Assistant Director of Nursing (ADON), Resident 12's Psychotropic Drugs Disclosure and Consent form dated 11/27/22 was reviewed. The ADON confirmed the informed-consent form for Resident 12, who received Cymbalta 60 mg daily, was outdated and had not been renewed every six months as required.

Based on observation, interview, and record review, the facility failed to ensure that adequate dialysis (a life-saving medical treatment performed to filter toxins out of the blood) care and services were provided for one of one sampled resident (Resident 42), when: Required dialysis communication forms were missing and incomplete.Licensed Nurses did not perform and document daily assessments of the resident's dialysis fistula (the surgically created access used for dialysis).Resident 42's care plan (a document that described resident goals and the care that would be provided) did not include instructions describing the assessments required for monitoring the fistula. This failure had the potential to result in undetected, life-threatening complication. Findings: 1.A review of the facility's undated policy and procedure (P&P) titled, Dialysis, indicated, the facility and dialysis center would communicate with each other by utilizing the Dialysis Transfer Form. A review of Resident 42's admission Record, dated 1/4/25, indicated admission to the facility on 1/4/25 with the diagnoses of end stage renal disease (the kidneys [an organ that filtered waste from the blood] no longer functioned well enough to support life) and dependence on renal dialysis. Resident 42 was their own responsible party (decision maker).During a concurrent observation and interview on 5/6/25 at 7:45 am, located in Resident 42's room, Resident 42's right upper arm was observed and Resident 42 indicated, receiving dialysis three times a week, every Tuesday, Thursday, and Saturday. On 5/7/26 at 4:20 pm, a request was made to Medical Records for the last four months (2/1/26 through 5/7/26) of Resident 42's Dialysis Transfer Form. At 4:58 pm the same day, the forms provided were reviewed and found to be incomplete. Dialysis Transfer Forms for the periods 2/1/26 through 2/28/26 and 5/1/26 through 5/7/26 were missing. During a concurrent interview and record review on 5/8/26 at 8:41 am, with the Assistant Director of Nursing (ADON), the previously provided Dialysis Transfer Forms for the last four months were reviewed. The ADON confirmed that the forms dated 4/7/26 and 4/23/26 lacked a complete LN assessment of the resident's dialysis fistula. A second request for February and May's Dialysis Transfer Forms had been made. During a concurrent interview and record review on 5/8/26 at 11:22 am, with the ADON and the Director of Nursing (DON), additional Dialysis Transfer Forms were provided for review. The ADON confirmed that the additional forms did not include the required forms for February or May. The DON stated that the wrong months had been requested from the Medical Records department. The ADON further confirmed that, among the forms that were provided, the forms dated 3/14/26, 4/11/26, and 4/19/26 were missing. 2. A review of the facility's undated P&P titled, Dialysis, indicated, the facility Provides ongoing monitoring of the dialysis access site, observing for signs and symptoms of infection, edema [swelling], ischemia [lack of blood flow], bleeding and dislodgement. The P&P indicated, the LN would document the fistula assessment in the Medication Administration Record (MAR).During an interview on 5/6/25 at 7:45 am, located in Resident 42's room, Resident 42 stated, They don't listen to my fistula. The only people who listen are the student nurses. (part of the assessment of a fistula included placing a stethoscope on top of the fistula site to listen to the swishing sound called the bruit). During a concurrent interview and record review on 5/7/26 at 4:18 pm, with LN B, Resident 42's MAR dated 4/1/26 through 5/7/26 was reviewed. LN B confirmed that no assessments of Resident 42's dialysis fistula were documented during this period. LN B stated that the fistula should be assessed daily, including visual inspection, auscultation for a bruit, and palpation for a thrill, to ensure the access site was free from infection and functioning properly. During a concurrent interview and record review, on 5/8/26 at 11:22 am, with ADON, Resident 42's April and May MARs were reviewed. ADON indicated that Resident 42 received a fistula to the upper right arm on 3/31/26 and confirmed, since the fistula's placement, there were no LN assessments. 3. A review of the facility's undated policy and procedure (P&P) titled, Dialysis, indicated, the facility would develop a comprehensive plan of care for residents that received dialysis. During a concurrent interview and record review, on 5/8/26 at 11:22 am, with ADON, Resident 42's care plan, titled Dialysis, dated 10/27/25 was reviewed. ADON indicated, Resident 42 received the fistula on 3/31/26 and confirmed, the care plan was not updated to include assessing the fistula site daily.

Based on interview and record review the facility failed to ensure that one out of 24 sampled residents (Resident 46) was free from abuse when Resident 128 punched Resident 46 in the face.The incident resulted in a laceration to Resident 46's upper lip requiring stitches and caused temporary feelings of insecurity regarding personal safety. Findings: A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition, revised 7/15/21, indicated, residents had the right to be free from physical abuse.A review of Resident 46's admission Record, dated 9/1/24, indicated, admission to the facility on 9/1/24 with the diagnoses of anxiety (feelings of fear and worry) and personal history of traumatic brain injury (a head injury that caused impaired thinking). Resident 46 was not their own responsible party (RP, decision maker). A review of Resident 128's admission Record, dated 3/25/26, indicated, admission to the facility on 3/25/26 with the diagnosis of an unspecified mental disorder (the resident had a mental health condition but there was not enough information to determine a diagnosis). Resident 128 was their own RP. During an interview on 5/5/26 at 1:59 pm, with Resident 46, Resident 46 confirmed, on 3/28/26, Resident 128 punched Resident 46 on the face while exiting the [NAME] Wing dining room. Resident 46 stated, I was scared half to death. A review of the Interdisciplinary [group of facility staff] Note, dated 3/29/26, indicated, Resident 46 and Resident 128 were in an altercation, which resulted in Resident 46 sustaining a three-centimeter-long laceration to the left upper lip, requiring sutures (stiches) and an emergency room visit. The Interdisciplinary Note indicated, Resident 46 was provided with a one-on-one sitter (someone always stayed nearby) for safety concerns. During an interview on 5/8/26 at 9:09 am, with Assistant Director of Nursing (ADON), the ADON indicated, reviewing video surveillance of the resident-to-resident altercation that occurred on 3/28/26 and confirmed Resident 128 punched Resident 46 in the face. During an interview on 5/8/26 at 10:23 am, Resident 42 indicated, facility staff had provided extra monitoring and stated, I had fear he would come back and get me. Resident 42 indicated the fear had lasted for three or four days.

Based on interview, and record review, the facility failed to protect one of ten sampled residents (Resident 2) when: 1. Registered Nurse (RN) B willfully took the bed remote from Resident 2 and hid it out of reach.2. RN B willfully shut the door while Resident 2 was yelling for help. 3. RN B willfully left Resident 2 in isolation and neglected to provide services needed. This failure caused involuntary seclusion (isolation) to Resident 2, and the potential for emotional distress, and a fall.Findings: During a review of the facility's policy revised 7/15/21 titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property Prohibition, indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. The definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, or pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means that the individual must have acted deliberately, not that the individual must have unintended to inflict injury or harm. The definition of Involuntary Seclusion is the separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident's legal representative. The definition of neglect is failure of the Center, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. During a review of Resident 2's medical record the, admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (common known as a stroke), hemiplegia (inability to move one side of the body) affecting the left side, frontal lobe and executive function deficit (the parts of your brain that control self-motivation, planning, and inhibition do not work, affecting the ability to follow a sleep pattern, and navigating social situations), dysphagia (difficulty swallowing), depression (persistent feelings of sadness and a loss of interests in daily tasks), diabetes (too much sugar in the blood), hypokalemia (low potassium in the blood), high blood pressure, heart disease, atrial fibrillation (fast and irregular heart beat), and toxic encephalopathy (a change in how the brain works due to an underlying health condition). A review of the most recent Minimum Data Set, (MDS, a resident assessment tool), indicated that Resident 2 had a Brief Interview for Mental Status, (BIMS) score of 2 out of 15 and had a severe cognitive (able to think and reason) and communication (ability to verbalize needs) deficits. A review of a facility document dated 7/27/25 titled, Suspected Abuse, indicated Licensed Nurse (LN) C walked by Resident 2's room and found RN B exiting the room and closing the door. RN B explained to LN C she had been in the room to lower the bed from a high position to a low position and left the bed remote on the bed. LN C reported RN B stated, We are not supposed to do this, but I am not going to put up with bad behavior. RN told LN C to leave the door closed and then walked away. During an observation and attempted interview on 8/7/25 at 12:58 pm, Resident 2 was lying in bed with eyes closed. The surveyor attempted to speak with and interview Resident 2, but she did not speak. Resident 2 opened her eyes and then shut them again, but did not verbally respond. During a follow up observation and attempted interview on 8/7/25 at 2:50 pm, Resident 2 was lying in bed, on her left side, no signs or symptoms of pain or discomfort, but did not try to communicate. Resident 2 had no restlessness noted or any signs of anxiety, opened her eyes, then quickly shut them without speaking. During an interview on 8/7/25 at 3:12 pm, LN C confirmed she had reported RN B for closing the door to Resident 2's room, while resident 2 was yelling for help and was asked by RN B to not open the door. LN C confirmed RN B stated to her at the time of closing the door we are not going to put up with these bad behaviors and RN B then walked away. During an interview on 8/7/25 at 3:45 pm, the Executive Nurse Director (END) confirmed RN B had abused Resident 2 by withholding services and confinement. END stated, I will send you the termination report, RN B will no longer work at this facility. We will not tolerate abuse. During a review of a facility document dated 8/8/25 titled, Employee Termination Report, indicated RN B to be in violation of the Code of Conduct and the Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, Prohibition Policy and has brought us to the conclusion of termination of employment. During a follow up interview with LN C on 8/14/25 at 8:04 am, LN C stated, I did wound care on another resident and immediately came back to check on [Resident 2], the Certified Nurse Assistant (CNA) J saw the door was shut, but did not know who had shut it. CNA J caught [Resident 2] trying to climb out of bed. [Resident 2] had no apparent injury, and the door remained opened the rest of the shift.

Based on interview and record review, the facility failed to follow the care plan for one of three residents (Resident 1) when Resident 1 was left unattended in his room when a hospitality aide (HA - someone hired by the facility to provide non-medical assistance to residents, focused on their comfort, safety, and well-being) took a break and left Resident 1's room. This failure had the potential to result in physical and/or psychosocial harm to other residents when Resident 1 eloped (unsupervised wandering) from his room and entered Resident 2's room. Findings: A record review of facility job description titled Job Description for Hospitality Aide dated 4/1/22 indicated HAs must demonstrate the ability to .understand, plan and carryout resident care plans. A record review of facility policy titled Care Plans (undated) did not indicate any policy related to developing, implementing or following resident care plans. A record review of Resident 1's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses that included Wernicke's encephalopathy (a serious neurological condition caused by a deficiency of vitamin B1 often due to chronic alcohol abuse), Alzheimer's Disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), and dementia with agitation (involves behavioral and psychological symptoms like anxiety, depression, and aggression, in addition to cognitive decline). A record review of Resident 1's Care Plan dated 2/17/24 indicated Resident 1 had a history of elopement with impaired safety awareness. Intervention listed was 1:1 supervision. Care plan also indicated Resident 1 had multiple behaviors (agitation, restlessness, aggression, yelling, and irritability) related to dementia. Intervention listed was 1:1 supervision. Care plan indicated Resident 1 had potential to wander into others rooms related to dementia. Intervention listed was 1:1 for redirection. Care plan further indicated Resident 1 had a communication problem related to expressive aphasia (difficulty expressing their thoughts and ideas through spoken or written language,), weak or absent voice, and word salad (confused or unintelligible mixture of seemingly random words and phrases). Intervention listed was 1:1 sitter to assist with care and communication. A record review of Social Service Progress Note dated 11/18/24 10:04 am indicated Resident 1 was considered a wandering and elopement risk and had a 1:1 sitter for all shifts. A record review of Social Service Progress Note dated 2/13/25 10:01 am indicated Resident 1 was considered a wandering and elopement risk and had a 1:1 sitter for all shifts and is in the wandering risk binder. During an interview with Director of Nursing (DON) on 4/22/25 at 10:20 am, DON confirmed facility did not have a care plan policy. DON confirmed facility document titled Policy: Care Plans (undated) was not an appropriate care plan policy. DON stated she did not consider the document to be a care plan policy. DON stated Resident 1 was expected to have a 1:1 sitter every shift, every 24 hours, every day. DON confirmed at time of incident, Resident 1 should have had a sitter even if it was for a short duration of time. DON stated facility expectation was for HAs to have another staff member go into Resident 1's room when they took a break. DON further confirmed HA did not follow their job description when Resident 1 wandered from his room. DON stated although HA told Registered Nurse (RN) A they needed a break, DON confirmed RN A should have physically been in Resident 1's room. DON confirmed staff did not follow Resident 1's care plan.

Based on observation, interview, and record review, the facility failed to implement downtime policies and procedures (P&P) when there was an internet outage on 12/13/24. This failure caused an inability for facility staff to access the residents electronic medical record (EMR) and could cause a delay in resident care needs. Findings: A review of the undated P&P titled, Downtime Access to Patient Records, indicated, Each day HER Support will run and save a copy of the 24 Hr. Summary. The P&P indicated, Staff members will have access to the downtime folder and will be able to pull up the 24 Hr. Summary for review or print out hard copy. The P&P indicated, In the event of a network outage or scheduled network maintenance, staff will be able to access the EMR system (Point Click Care) by using a jetpack device to connect to wireless network. We will then activate emergency access protocol to allow staff to access the EMR remotely. During a concurrent observation, located at the East Wing nurses' station, and interview on 12/13/24 at 7:11 am, unidentified staff members were observed talking to each other about the facility's internet. An unidentified staff member stated, the internet had been down since midnight. Licensed Nurse (LN) A confirmed the internet had been down since midnight and stated unawareness of the downtime plan. LN A stated, the facility provided a cell phone that could be utilized for accessing the Medication Administration Record (MAR, document that indicated what medications were due, at what time, and LN utilized to sign that the medication was provided), however, there was no way to document the medication was provided until the internet came back on. LN A stated, LN A was not able to log into the computer system utilizing the cell phone and had no access to resident records. During an observation, located at the East Wing nurses' station, on 12/13/24 at 7:20 am, LN A and LN B were observed stating they could not log into the facility's computer system using the cell phones that had been provided. LN A was observed looking at a desktop computer with an unidentified staff member. The unidentified staff member stated, there was one desktop computer at every nurse's station that worked and could be utilized to access the EMR. The CCM was observed at the nurse's station on the phone with the facility's Information Technology (I.T.) department discussing the current situation. During a concurrent observation, located at the East Wing nurses' station, and interview on 12/13/24 at 7:25 am, LN B stated, LN B was required to call the facility's I.T. department to unblock LN B's access so that LN B could utilize the cell phone and access the resident's MAR. The facility's Assistant Director of Nursing (ADON) was observed talking to the LN's and informing them that the paper MARS were currently being printed. During a concurrent observation and interview on 7/13/24 at 7:50 am, LN A and LN B were observed at the East Wing nurses' station, attempting to log into the computer system utilizing the computers and cell phones. LN A and LN B both stated, the desk top computer could be utilized to access the EMR, but they could not print from it. During an observation, located at the East Wing nurses' station, on 12/13/24 at 8:22 am, LN A and LN B were both observed stating they still had no access to the facility EMR. During an observation, located at the East Wing nurses' station, on 12/13/24 at 8:26 am, Nurse Practitioner (NP) was observed stating there was a jetpack device that could be used to access the internet and was observed assisting LN A with the jetpack device. NP was observed stating, I don't know why we have a jet pack at all these nurses' stations, if they aren't working. During a concurrent observation, located at the East Wing nurses' station, and interview on 12/13/24 at 8:29 am, LN A was observed on the phone with the I.T. department attempting to gain access to the EMR utilizing the facility's cell phone. LN A stated, the I.T. department stated, the internet was down and the I.T. department was not able to assist LN A. During an observation, located at the East Wing nurses' station, on 12/13/24 at 8:32 am, NP was overheard on the phone stating, the I.T. department was not being helpful, was unable to access resident records, and stated the jet pack devices were not working. During an observation on 12/13/24 at 8:42 am, an unidentified male arrived at the East Wing nurses' station with paper MARS. During an observation, located at the East Wing nurses' station, on 12/13/24 at 8:54 am, the ADON was observed stating that the facility's internet was back on. During an observation, located at the East Wing nurses' station, on 12/13/24 at 9:04 am, LN A was observed logged into the facility's computer system and preparing to administer morning medications to the residents. During an interview on 12/16/24 at 8:34 am, the ADON confirmed, the facility's internet had been down since midnight on 12/13/24 and the jet pack devices did not work.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two out of 29 sampled residents (Residents 44 and 5) when: 1. Coccyx (the skin over the tailbone) treatments were not provided for Resident 44 who had Moisture Associated Skin Damage (MASD, skin breakdown caused by prolonged expsure to moisture). This failure had the potential for Resident 44's health and wellbeing to decline and her skin redness to worsen. 2. The facility failed to ensure consistent assessments of a skin condition for Resident 5. This failure had the potential for a change in condition to go unattended, with possible negative health outcomes for Resident 5. Findings: During a review of the facility's policy and procedure (P&P) titled Skin Integrity (undated), the P&P indicated, In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin . wounds, the Center has a systematic approach and monitoring process for evaluating and documenting skin integrity. In the even that a resident is admitted with or develops a skin . wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. During a review of the facilities policy titled Medication Administration, reviewed 9/18, the policy indicated The resident's MAR/TAR (Medication Administration Record/ Treatment Administration Record) is initialed by the person administering the medication, in space provided under the date, and on the line for that specific medication dose administration and time. A review of Resident 44's Admission Record (undated) indicated Resident 44 was admitted to the facility on [DATE] with diagnoses that included Sepsis (serious infection) due to Escherichia Coli (a bacteria [germ] found in fecal matter), urinary tract infection, chest pain, Parkinson's (a progressive disorder that affects the nervous system and causes tremors, stiffness and slowing of movement), diabetes (high sugar in the blood) , lung disease, anxiety disorder, heart failure, and chronic kidney disease. She made her own decisions about her health care. A review of Resident 44' Annual Minimum Data Set (MDS, a standardized resident assessment) dated 11/8/24 indicated her cognition was intact. Resident 44 was dependent fully on staff for toileting, perineal hygiene (cleaning her bottom after going to the bathroom), showering, and bathing. Resident 44 was incontinent of bowel and bladder and used disposable briefs. During an interview on 12/11/24 at 2:34 pm, Resident 44 indicated she had sores to her bottom and the inside of her thighs because she sat in her urine and poop. Resident 44 stated I just get them cleared up and then I sit in my urine again and they open up. During an interview on 12/16/24 at 2:29 pm, Certified Nursing Assistant AA (CNA) indicated that Resident 44 had redness on her bottom and in-between her thighs. CNA AA indicated Resident 44 was incontinent of urine and bowel and had a lot of moisture to her skin. CNA AA indicated she assisted Resident 44 with brief changes every one-and-a-half to two hours during her shift. During an interview and record review on 12/16/24 at 2:39 pm, Treatment Nurse (TN) indicated that Resident 44 had recurring redness on her buttocks. TN stated, It tends to get better than breakdown again. A review of Resident 44's December TAR showed an order dated 12/5/24 for coccyx MASD (moisture associated skin damage): cleanse with NS (normal saline) pat dry, apply Medi-honey (a treatment cream) and foam sacral (coccyx) dressing every day and evening shift . Out of 22 opportunities for treatments 13 opportunities were not documented as being done. TN indicated that according to Resident 44's TAR the treatments had not been done as ordered and they should have been. During an interview with the Assistant Director of Nursing (ADON) and record review on 12/18/24 10:31 am, Resident 44's December TAR was reviewed. The ADON confirmed there was missing documentation for the coccyx treatments, so she could not confirm that the treatments were done. The ADON indicated she expected her staff to render the treatments and sign the TAR when done. 41567 2. Resident 5 was admitted to the facility with anoxic brain damage (in which the brain was deprived of oxygen for sufficient time to cause permanent damage,) dementia (a general term for a progressive decline in thinking, behavioral and social skills that affects a person's ability to function,) and lymphedema (a chronic condition in which lymph fluid does not drain properly and builds up in the tissues, causing them to swell), among other diagnoses. Resident 5 did not have capacity to make her own healthcare decisions. A review of Resident 5's orders was made. On 12/2/24, an order was created, to take effect on 12/3/24: LLE (left lower extremity, or leg) venous ulcers (sores that develop on the skin due to problems with blood flow through the veins) scabs - monitor for s/s (signs/symptoms) of worsening/infection every shift. A review was made on 12/18/24 of a treatment administration record for the month of December 2024. From 12/3/24 through 12/17/24 there were 30 shifts when Resident 5's LLE should have been monitored for worsening of her skin condition. There were 7 shifts in which it appeared the order was not followed. A concurrent interview and record review was conducted on12/18/24 2:10 pm, with the Assistant Director of Nurses (ADON). Resident 5's medical record was reviewed to determine if nursing staff had documented monitoring the ulcerations elsewhere; four records were found that confirmed nurses had followed the order and charted in nursing notes or health notes. ADON confirmed that there were three shifts (12/3/24 day shift; 12/10/24 day shift, 12/11/24 day shift) in which the assessments were not performed.

Based on observation, interview, and record review, the facility failed to ensure seven of twenty-nine sampled residents (Resident 5, 334, 23, 29, 73, 291, and 46) received the necessary treatment and services to maintain ADL's (activities of daily living). when: 1. Resident 5's lunch tray was not set up by staff and therefore she was unable to eat. 2. Resident 334's fingernails were long with black matter underneath them. 3. Resident 23 stated, staff did not assist with oral care or hair brushing unless Resident 23 asked for help. 4. Resident 29's hair was tangled. 5. Resident 73's mucus membranes (the moist, inner lining if the mouth) were dried and contained a thick, white, debris that was attached to the roof of the mouth and the tongue. 6. Resident 291 didn't receive consistent oral care. 7, Resident 46 didn't receive consistent oral care. This deficient practice had the potential for the residents to decline in their abilities to achieve the resident's highest practicable well-being and quality of life. Findings: 1. A review of Resident 5's Admission Record (undated), indicated she was admitted to the facility on [DATE] with the diagnoses that included anoxic brain damage (when the brain is deprived of oxygen, which can lead to brain cell death and serious or permanent brain damage), dementia, and anxiety disorder. A review of Resident 5's quarterly Minimum Data Set (MDS, a standardized resident assessment) dated 12/2/24, indicated her Brief Interview of Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to 15) was 8 indicating Resident 5's cognition was severely impaired. Section GG indicated Resident 5 required supervision or touching assistance for eating. A review of Resident 5's Activity of Daily Living (ADL) Care Plan revised on 4/28/24 indicated Resident 5 had an ADL self-care performance deficit related to anoxic brain damage and advanced dementia. Resident 5's ADL care plan goal was that all her needs would continue to be anticipated and met daily. Interventions included The resident requires (Set up assistance) by (1) staff to eat. During an observation on 12/10/24 at 1:42 pm, Resident 5 was observed lying in bed. Resident 5's lunch tray was sitting on her over bed table next to her bed and out of Resident 5's reach. The food on the plate was uncovered and had not been touched. The milk, boost (a high protein drink), dessert, salad, dressing, and juice were covered and unopened. Resident 5 was looking around and asking for help. Resident 5 indicated that she could not reach her food and wanted to be pulled up. Resident 5 also indicated she was unable to open her milk and boost by herself and needed help. During an observation on 12/10/24 at 1:43 pm, Certified Nursing Assistant U (CNA U) was observed sitting at the bed of Resident 5's roommate and assisting with lunch. CNA U stated, whoever left the (Resident 5's) tray must not have known she needed help. CNA U indicated that Resident 5 needed help because she can only use her right arm. CNA U indicate they should have helped Resident 5 with her lunch tray, and they did not. During an interview on 12/18/24 at 2:24 pm, the Assistant Director of Nursing (ADON) indicated that when staff brought the food tray into Resident 5' room they should have reposition her and set up her tray so she could have eaten. 2. A review of Resident 334's Admission Record (undated) indicated Resident 334 was admitted to the facility on [DATE] with diagnoses that included stroke, respiratory failure, left sided paralysis, and seizures. He was unable to make his own decisions. A review of Resident 334's Admission MDS dated [DATE], indicated his BIMS score was 12 indicating Resident 334's cognition was moderately impaired. Section GG indicated Resident 334 had upper and lower impairment on one side of his body and was dependent on staff for bed mobility (moving self in bed), personal hygiene, dressing, toileting, and transfers. During an observation on 12/10/24 at 12:58 pm, Resident 334 was observed being assisted with his lunch. Resident 334's fingernails were long, chipped and had black matter underneath the nails on all fingers. During a concurrent observation and interview on 12/10/24 at 2:26 pm, with Nursing Assistant Student V (NA V), Resident 334's fingernails were observed. NA V stated, yes they are dirty and needed cutting. NA V indicated she had not noticed Resident 334's nails earlier. NA V indicated that resident fingernails should be cleaned and trimmed, if needed, when they are given a shower but if the resident is a diabetic, then we tell the nurse, and they will trim the nails. Resident 334 was not diabetic. During an interview and document review on 12/13/24 at 3:50 pm, with Licensed Nurse B (LN B), the shower sheets were reviewed. LN B indicated that nowhere on the shower sheets was there a place to document the state of resident's nails or if they were trimmed or needed trimming. LN B stated, I could see them (the nails) getting missed. LN B indicated that there was no place to document that nails needed cleaning or trimmed and there should be. During an interview on 12/18/24 at 2:17 pm, Assistant Director of Nursing indicated that it was her expectations that the nails should be cleaned and cut during showers if needed. 45315 3. A review of the undated Admission Record, indicated Resident 23 was admitted to the facility on [DATE] with the diagnoses of muscle weakness, limitation of activity due to disability, and chronic pain. A review of the MDS, dated [DATE], indicated, Resident 23's BIMS score was 15 and had good cognition. Section GG of the MDS, dated [DATE], indicated Resident 23's upper extremities (shoulders, arms, hands) were impaired (did not have full use), required substantial to maximum assistance from staff to brush her teeth, bathing, and putting on clothing. A review of the ADL Care Plan, revised 9/29/24, indicated Resident 23 required the assistance of staff for routine oral care (brushing teeth, cleaning mouth) every morning, after meals, and at bedtime. The ADL Care Plan indicated, Resident 23 required extensive assistance by one staff member for all personal hygiene (brushing hair, brushing teeth, and bathing). During an interview on 12/10/24 at 12:17 pm, Resident 23 stated, the facility staff did not offer to assist Resident 23 with oral care or hair brushing daily. Resident 23 had tears in her eyes and stated, it bothered Resident 23 to ask facility staff for assistance when Resident 23 knew they were busy. During a concurrent observation and interview on 12/11/24 at 9:11 am, Resident 23 was observed sitting up in bed. Resident 23 stated, facility staff had not offered her oral care today, and there was food observed in-between Resident 23's teeth. 4. review of the undated Admission Record, indicated, Resident 29 was admitted to the facility on [DATE] with the diagnoses of wedge compression fracture of T9-T10 vertebra and chronic pain (the mid-section of the spine [middle of back] collapsed causing mid-back pain and stiffness) and chronic pain. A review of the MDS, dated [DATE] indicated, Resident 29 had a BIMS score of 14 and had good cognition. Section GG of the MDS indicated, dated 10/22/24, indicated, Resident 29 had impairment to both upper extremities, required substantial to maximum assistance from staff for oral care, bathing, and putting on clothing. A review of the ADL Care Plan, revised 9/19/24, indicated Resident 29 required the assistance of staff for routine oral care every morning, after meals, and at bedtime. The ADL Care Plan indicated, Resident 29 required extensive assistance by one staff member for all personal hygiene (brushing hair, brushing teeth, and bathing). During a concurrent observation and interview on 12/10/24 at 12:30 pm, Resident 29 stated, no one helps me brush my teeth or even offers. While Resident 29 was speaking, the teeth were observed to have a buildup of debris over the teeth and Resident 29's hair was observed to have large knots on the back of the head. Resident 29 confirmed the knots in her hair and stated, no one brushes my hair. Certified Nurse Assistant (CNA) C came into Resident 29's room and confirmed the knots in Resident 29's hair. CNA C stated, Resident 29 often refused hair brushing due to neck pain and Resident 29 stated, loudly, that's not true. 5. A review of the undated Admission Record indicated, Resident 73 was admitted on [DATE] with the diagnoses of acute respiratory failure (a condition where there is not enough oxygen in the blood, making it hard to breathe) and gastrostomy status (a tube was surgically inserted through the abdomen into the stomach and delivered liquid hydration and nutrition). A review of the MDS, dated [DATE], indicated, Resident 73 did not have a BIMS score and had severely impaired cognition. Section GG of the MDS, dated [DATE], indicated Resident 73 was dependent upon staff for care needs. A review of the ADL Care Plan, revised 11/24/24, indicated Resident 73 required extensive assistance by one staff member for all personal hygiene (brushing hair, brushing teeth, and bathing). During an observation on 12/10/24 at 12:33 pm, Resident 73 was observed lying on her left side in bed with her mouth open wide. There was a thick, dried film covering the teeth, dried, thick, yellowish debris all over the tongue, and a thick, white, stringy like debris that could be seen in the mouth. The mucus membranes and tongue were dry. During an observation on 12/11/24 at 8:46 am, Resident 73 was observed to have white, crusty debris around the lips and on the right side of the face. It appeared as if liquid drained out of the mouth and trailed down to the right side of the chin. The mucus membranes were dry, and a thick, white substance was attached to the roof of the mouth and connected to the top of the tongue. During an interview on 12/11/24 at 10:11 am, CNA D stated, Resident 73 received oral care every two hours, and CNA D had not provided oral care to Resident 73 this morning. During a concurrent observation and interview on 12/16/24 at 9:54 am with the Director of Nursing (DON), Resident 73's mouth was observed. DON confirmed, there was a thick, yellowish debris that covered Resident 73's teeth and the mucus membranes and tongue were dry. CNA D entered the room to perform oral care and stated, the last oral care had been performed around 7:00 am. CNA D utilized a small, pink sponge on a stick that was soaked in mouth wash to wipe the teeth and inside of Resident 73's mouth. During the observation of oral care, DON confirmed, CNA D removed two medium sized, thick, yellowish pieces of debris from Resident 73's mouth. DON stated, it took longer than two hours for the mucous membranes to become dry and for the thick yellowish debris to form in the mouth. DON stated facility staff was expected to offer residents oral care four times a day (before every meal and at bedtime) and for their hair to be brushed. DON stated, residents were not required to ask for care, the facility staff was expected to provide it, unless the resident refused or could perform the care independently. 43739 During a review of the facility's job description titled, Job Description for Certified Nurse Assistant (CNA), revised 3/2012, at the section of Job Summary, indicated, The CNA is expected to perform duties in compliance with state and federal regulations. The CNA's job duties include, Provides assistance with bathing, dressing, toiletry, and oral hygiene activities of daily living (ADLs); Completes documentation (e.g. meal monitor, Intake & output records, ADL, and Aide flow sheets ) 6. Resident 291 During a review of Resident 291's clinical record, indicated she was originally admitted to the facility on [DATE] with diagnoses which included right hip fracture, urinary tract infection (UTI- an infection in the bladder/urinary tract). Resident 291 was her own responsible party, and she was capable of making her own healthcare decision. During a review of Resident 291's Minimum Data Set (MDS - an assessment and care screening tool), dated 12/5/24, the MDS indicated that Resident 291 had a brief interview for mental status (BIMS) score of 9, at section C Cognitive Patterns indicating that her cognition was mildly impaired. During a review of Resident 291's MDS at section GG - Functional Abilities and Goals, the MDS indicated it was incomplete, and was in progress. (see F 636). During a review of Resident 291's Admission Summary progress note, dated 12/1/24 at 3:17 pm, indicated Resident 291 was admitted to the facility for Physical Therapy, Occupational Therapy, and ADL assistance. During a review of Resident 291's Interdisciplinary team note (IDT-a group of people from different disciplines who work together to achieve common goals, such as providing care for a patient), dated 12/6/24, at 11:21 am, indicated, Resident 291 was here for Physical Therapy, Occupational Therapy with goals working towards safe transfers and ADL assistance. During a concurrent observation and interview on 12/11/24 at 8:24 am, in Resident 291's room, when asked about staff offering oral hygiene care, Resident 291 stated, They don't do that, I wish they did, it felt awful On Resident 291's bedside table, and in the bathroom, oral hygiene items, such as a toothbrush, and toothpaste, were not located. During a concurrent observation and interview on 12/12/24 at 11:59 am, in Resident 291's room. CNA U stated that she did Resident 291's ADLs in the shower room when Resident 291 had shower day, if not her shower day, CNA U would provide the care at the bedside. CNA U stated that Resident 291's toothbrush, comb, and toothpaste should be kept inside the drawer of Resident 291's bedside table. Observed CNA U checking Resident 291's bedside table, and the bathroom, CNA U confirmed that she could not locate those items. CNA U stated that CNAs documented what ADLs care were provided for the residents in the residents' record. CNA U said, Everything is there. During a concurrent observation and interview on 12/12/14 at 1:52 pm, with LN W, the LN W stated CNAs provided oral care in the morning for the residents. LN W stated, Every resident had their nightstand, we kept their brushes inside a bag, and the bag was kept inside the nightstand drawer. Observed LN W went to Resident 281' room, opened the nightstand drawer, and located a bag with toothbrush, toothpaste, and comb. Resident 281 stated the staff provided oral care for him in the morning. During a concurrent interview and record review on 12/16/24 at 9:30 am, with LN X, Resident 291's record titled, ADL-Personal Hygiene, dated 12/1/24 to 12/12/24 was reviewed. The record indicated Personal hygiene including coming hair, brushing teeth, shaving, applying makeup, washing/drying face and hands, and Resident 219 was provided with such care on: - 12/1/24, at 1:48 pm. - 12/2/24, at 12:18 am, 1:58 pm, and 10:17 pm. - 12/3/24, at 12:25 pm. - 12/4/24, at 11:18 am, and 10:57 pm. - 12/5/24, at 10:24 pm. - 12/6/24, at 3:26 pm, and 9:35 pm. - 12/7/24, at 8:53 am. - 12/8/24, 1:34 am, and 1:38 pm. - 12/9/24, at 1:30 am, and 9:33 am. - 12/10/24, at 12:26 am, and 6:03 pm. - 12/11/24, at 10:03 pm. - 12/12/24, at 6:48 am, and 9:59 am. The ADL record indicated nine out of twelve days, Resident 291 did not receive personal hygiene care in the morning, before/ and or after breakfast. LN X stated breakfast time was around 8 am, and the record was correct, LN X said, That's the correct record to look at the resident's ADL service, we look at that too. 7. Resident 46 During a review of Resident 46's clinical record, indicated he was originally admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which included protein-calorie malnutrition, pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) of right hip and left hip, stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). Resident 46 was not his own responsible party, but he had the capacity to understand & make health care decision and/or participate in treatment plan. During a review of Resident 46's MDS, dated [DATE], the MDS indicated that Resident 46 had a BIMS score of 14, at section C Cognitive Patterns indicating that his cognition was intact. During a review of Resident 46's MDS at section GG - Functional Abilities and Goals, dated 11/12/24, indicated Resident 46 need partial/moderate assistance (helper lifts, held, or supports trunk of limbs) for Oral hygiene. During an interview on 12/11/24 at 8:34 am, with Resident 46, in Resident 46' room, when asked about staff offering oral hygiene care, Resident 46 stated that the staff had never offered him oral care or washing his face. Resident 46 said, I would like to have On Resident 46's bedside table, and in the bathroom, oral hygiene items, such as a toothbrush, and toothpaste, were not located. During a concurrent observation and interview on 12/13/24 at 9:54 am, with CNA Z, in Resident 46's room, the CNA Z stated, Night shift provided oral care in the morning, I didn't do oral care before breakfast. We did oral care after each meal, and before bedtime. At 10:37 am, observed CNA Z checking Resident 46's the drawer of the bedside table, and the bathroom, CNA Z confirmed that she could not locate Resident 46's oral hygiene items. CNA Z stated, It should be there. For me, after I was done with the oral care, I would leave the toothbrush inside the drawer. During a review Resident 46's record titled, ADL-Personal Hygiene, dated 12/1/24 to 12/12/24, The record indicated Resident 46 was provided with inconsistent care on: - 12/1/24, at 10:34 am. - 12/2/24, at 6:45 am, and 10:29 am. - 12/3/24, at 12:14 am, and 9:41 am. - 12/4/24, at 2:54 am, 11:05 am, and 10:49 pm. - 12/5/24, at 3:39 pm, and 10:05 pm. - 12/6/24, at 2:44 pm, and 9:52 pm. - 12/7/24, at 9:16 am, and 10:13 pm. - 12/8/24, at 9:04 am. - 12/9/24, at 1:03 am, 2:02 pm, and 9:03 pm. - 12/10/24, at 6:22 pm. - 12/11/24, at 4:59 am, 5:38 pm, and 10:52 pm. - 12/12/24, at 6:59 am, 6:59 pm, and 9:42 pm. During an interview on 12/13/24 at 10:27 am, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) in the Administrator's office, the ADON stated, Oral hygiene care is indicated in each resident's care plan. It's provided before and after each mean, and before bedtime. The DON stated, It depends. Some residents wanted to have it done before they ate, some preferred after. So, it's personal preference. The ADON stated the personal preference would also indicate in the residents' care plan.

Based on interview and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, a standardized resident assessment) for 12 of 29 sampled residents (Residents 41, 44, 7, 87, 73, 27, 55, 96, 100, 291, 293, and 294) when MDS assessments were not completed within 14 days. These failures had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for Resident 44 and 41 related to the care areas identified on the Comprehensive MDS. Findings: The Resident Assessment Instrument (RAI) Manual gives clear guidance about how to complete the MDS. According to the RAI, Chapter 2 page 9, Assessment completion refers to the date that all information has been collected and recorded for the particular assessment type and staff have signed and dated that the assessment is complete. Page 10 indicated that Comprehensive MDS assessments include Annual Assessments. Page 17 indicated that the Annual assessment completion date (Item Z0500B) must be no later than 366 days from the previous Comprehensive Assessment (Previous comprehensive assessment date +366 calendar days). A review of Resident 44's Admission Record (undated) indicated that Resident 44 was admitted to the facility on [DATE] with diagnoses that included sepsis, urinary tract infection, Parkinson's disease, and diabetes. The most recent completed Annual Assessment was dated 11/24/23. On 12/16/24 at 10:48 am, a review of Resident 44's MDS's showed there was a completed annual assessment MDS with assessment date of 11/24/23. There was another annual MDS labeled in progress with assessment date of 11/8/24 with sections A (Identification Information, B (Hearing, Speech, and Vision), E (Behavior), GG (Functional Abilities), H (Bladder and Bowel), I (Active Diagnosis), J (Health Conditions), K (Swallowing/Nutritional Status), L (Oral, Dental Status), M (Skin Conditions), N (Medications), O (Special Treatment, Procedures, and Programs), P (Restraints and Alarms), S (California State Specific) and V (Care Area) assessments labeled as In Progress. The in progress MDS with assessment date of 11/8/24 was to be completed by 11/24/24 and was identified as 8 days overdue. During a concurrent interview and record review, with Minimum Data Set Licensed Nurse (MDS LN) on 12/16/24 at 10:54 am, Resident 44's MDS was reviewed. MDS LN indicated that Resident 44's annual MDS with assessment date of 11/8/24 was not completed and it should have been. MDS LN indicated that the facility was a very busy building, and that they were behind with completing resident's MDS's. A review of Resident 41's Admission Record (undated) indicated that Resident 41 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, seizures, diabetes, and depression. On 12/16/24 at 10:45 am, a review of Resident 41's MDS's showed there was an annual MDS labeled in progress with assessment date of 11/3/24. Sections A, B, E, GG, H, I, J, K, L, M, N, O, P, S, and V were labeled as in progress. The annual MDS with assessment date of 11/3/24 was due on 11/10/24 and was identified as being 24 days overdue. 41567 Resident 7 was admitted to the facility with sepsis (systemic reaction to what started as a localized infection,) chronic obstructive pulmonary disease (COPD, a group of inflammatory lung conditions that obstruct airflow and make it hard to breathe,) diabetes mellitus (a chronic disorder that affects how the body converts food into energy,) heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for nutrients and oxygen,) and renal disease (decreased functionality of the kidneys, the organs that clean the blood of toxins and waste,) among other diagnoses. During a record review conducted on 12/13/24 it was noted that Resident 7 was discharged from the facility on 9/20/24, as documented in a discharge summary note dated 9/20/24 at 10:27 am by Licensed Nurse H. A review of Resident 7's resident assessments found the discharge MDS was incomplete. An interview was conducted on 12/13/24 1:39 pm, with MDS RN who stated, We're behind on our discharges, going back to the end of August 2024. 45315 A review of MDS section (the area of the electronic medical record that contained resident information and the dates that the MDS was completed, due, or late), dated, 6/12/24 through 12/11/24, indicated, Resident 14 was admitted to the facility on [DATE] with the diagnosis of cellulitis of left lower limb (infection of left lower left). The MDS section indicated, the Discharge MDS, dated [DATE], was three days overdue, and labeled In Progress. The MDS section, indicated, the next Medicare ARD, dated 12/12/24, was five days overdue, and labeled in Progress. A review of the MDS section, dated 10/25/23 through 11/20/24, indicated, Resident 73 was admitted to the facility on [DATE] with the diagnosis of cerebral infarction, unspecified (stroke). The MDS section indicated, the Discharge ARD, dated 11/17/24, was 12 days overdue, and labeled In Progress. The MDS section indicated, the ARD, dated 10/31/24, was 29 days overdue, and labeled In Progress. A review of the MDS section, dated, 8/5/23 through 11/11/24, indicated Resident 87 was admitted to the facility on [DATE] with the diagnosis of unspecified sequelae of cerebral infarction (long term issues related to a stroke). The MDS section indicated, the ARD, dated 11/11/24, was 22 days overdue, and labeled In Progress. 43739 During a review of Resident 27's clinical record, indicated that Resident 27 was admitted to the facility on [DATE] with diagnoses which included right arm fracture, heart failure, and diabetes (high blood sugar). Resident 27 was his own healthcare decision maker. Resident 27 was discharged on [DATE]. During a review of Resident 27's discharge MDS (a MDS assessment that is completed when a resident is leaving a nursing facility), the status indicated that it's In Progress, and the record indicated that Resident 27's Discharge Assessment Reference Date (ARD) was 10/8/24 and it's 52 days overdue. During a review of Resident 55's clinical record, indicated that Resident 55 was admitted to the facility on [DATE] with diagnoses which included sepsis (a life-threatening blood infection), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and muscle weakness. Resident 55 was not his healthcare decision maker. Resident 55 was discharged on [DATE]. During a review of Resident 55's discharge MDS, the status indicated that it's In Progress, and the record indicated that Resident 55's ARD was 9/5/24 and it's 85 days overdue. During a review of Resident 96's clinical record, indicated that Resident 96 was admitted to the facility on [DATE] with diagnoses which included infection of the intervertebral disc in the cervical region (a bacterial infection within the disc space of the neck vertebrae), sepsis, and muscle weakness. Resident 96 was his own healthcare decision maker. Resident 96 was discharged on [DATE]. During a review of Resident 96's discharge MDS, the status indicated that it's In Progress, and the record indicated that Resident 96's ARD was 11/20/24 and it's 9 days overdue. During a review of Resident 100's clinical record, indicated that Resident 100 was admitted to the facility on [DATE] with diagnoses which included sepsis, shigellosis (a bacterial infection of the intestines that causes diarrhea, stomach pain, fever, and a strong urge to have a bowel movement), and severe protein-calorie malnutrition. Resident 100 was her own healthcare decision maker. Resident 100 was discharged on [DATE]. During a review of Resident 100's discharge MDS, the status indicated that it's In Progress, and the record indicated that Resident 100's ARD was 11/22/24 and it's 7 days overdue. During a review of Resident 291's clinical record, indicated that Resident 291 was admitted to the facility on [DATE] with diagnoses which included right hip fracture, urinary tract infection (UTI- an infection in the bladder/urinary tract). Resident 291 was her own healthcare decision maker. During a review of Resident 291's entry MDS (the initial MDS assessment completed when a resident is admitted to a Medicare or Medicaid certified nursing home), the status indicated that it's In Progress, and the record indicated that Resident 291's Entry- ARD was 12/1/24, and it's 5 days overdue. Resident 291's Admission/Medicare MDS (the initial comprehensive assessment, that is completed on every resident admitted to a Medicare-certified nursing home, providing a standardized evaluation of their health needs and functional capabilities upon entering the facility) ARD was dated 12/8/24, and it's 5 days overdue. During a review of Resident 293's clinical record, indicated that Resident 293 was admitted to the facility on [DATE] with diagnoses which included sepsis, cellulitis (a skin infection that causes swelling and redness) of face, and pneumonia (an infection/inflammation in the lungs). Resident 293 was her own healthcare decision maker. Resident 293 was discharged on [DATE]. During a review of Resident 293's entry MDS, the status indicated that it's In Progress, and the record indicated that Resident 293's Entry- ARD was 12/4/24, and it's 2 days overdue. During a review of Resident 294's clinical record, indicated that Resident 294 was admitted to the facility on [DATE] with diagnoses which included acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right ankle and foot, sepsis, diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 294 was her own healthcare decision maker. Resident 294 was discharged on [DATE]. During a review of Resident 294's entry MDS, the status indicated that it's In Progress, and the record indicated that Resident 294's Entry-ARD was 11/14/24, and it's 22 days overdue. During an interview on 12/16/24 at 11:23 am, Minimum Data Set Registered Nurse (MDS RN) stated unfortunately we are that far behind. It's just me and two other nurses. MDS RN indicated that there was a lot of MDS's not completed and that she had discussed the issue with her Administrator a few weeks ago and asked for more nursing hours in this department. MDS RN indicated that her main concern with the MDS's not being complete was that the residents care plans may not reflect the up-to-date interventions for their care. MDS RN stated It is a terrible feeling because I want to be sure things are good for our residents. During an interview on 12/17/24 at 2:43 pm with the Administrator, the Administrator stated, I knew we were behind, but not that much. I would expect the MDS RN reported to me, so I could do root cause analysis to find out what happened, and from there, we could go find the cause and fix it.

Based on interview, and record review, the facility failed to provide five residents (Residents 2, 14, 73, 130, 292) out of a sample of 32 with the bed hold agreement in writing when residents were transferred out of the facility to a hospital or for therapeutic leave. This failure had the potential for residents to be unaware that, for a period of up to seven days after the transfer, the facility must readmit them when the resident is ready to return, and that the resident has only a 24-hour window in which to inform the facility that they intend to return. Findings: A facility document titled, California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, undated, was reviewed. The document is a collection of information provided to residents when they are admitted to the facility. Contained in the document is the facility's bed hold policy which outlines that they will hold a resident's bed for seven days upon transfer to a hospital, and that the resident has 24 hours after receiving the notice to inform the facility whether or not the resident wants the bed held for them. Resident 2 was admitted to the facility with dementia (a general term for a progressive decline in thinking, behavioral and social skills that affects a person's ability to function,) Parkinson's disease (a progressively worsening disorder caused by degeneration of nerve cells in the part of the brain,) severe intellectual disability (a developmental disability that starts in infancy or childhood and which limits a person's ability to learn, function, and adapt to their environment,) and schizophrenia (a serious mental illness that affects how a person thinks, perceives reality, expresses emotion, acts, and relates to others) among other diagnoses. Resident 2 does not have capacity to make his own healthcare decisions. A review was made of a nursing progress note dated 12/13/24 at 2:32 pm, by Registered Nurse (RN) G who documented that Resident 2 was transferred to an acute care emergency department after an incident where he became unconscious while sitting in his wheelchair. An interview was conducted on 12/15/24 at 4:30 pm, with RN G who confirmed the events outlined in her nursing progress note of 12/13/24. A review of Resident 2's medical record failed to find evidence that the resident or his representative had been given notification of the bed hold requirement. An interview was conducted on 12/17/23 at 3:15 pm, with the Assistant Director of Nurses (ADON) who confirmed that notice of bed hold was not given to patients or representatives upon transfer to a hospital, and that they were working on a plan of correction. A review of the facility's undated policy and procedure (P&P) titled, Bed Hold, indicated, at the time of transfer, the resident or their responsible party (RP, decision maker) would receive a copy of the bed hold policy. The P&P indicated, depending upon the medical insurance or if the resident was private pay, they would be required to use their own income, and pay the facility for the bed hold. A review of the facility's policy titled Attachment F: Resident [NAME] of Rights (undated) indicated on page 28; (2) Bed-hold notice upon transfer. At the time of transfer of a resident or hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration for the bed-hold policy . A review of Resident 292's Admission Record (undated) indicated Resident 292 was admitted to the facility on [DATE] with diagnoses that included anemia (low red blood cells), depression, anxiety, chronic (ongoing) pain, heart disease, and lung disease and post-operative right leg mass removal. Resident 292 was her own RP (she made her own decisions). During an interview with the Assistant Director of Nursing (ADON) and record review on 12/12/24 at 1:46 am, the ADON indicated that Resident 292 was only in the facility for a less than a day, and she did not return to the facility after discharging to the hospital. Resident 292's records were reviewed and were as follows: (a) A nurse's progress note dated 10/21/24 indicated Resident 292 arrived to the facility on [DATE] at 12:30 pm. (b) A discharge summary, by Family Nurse Practitioner (FNP), dated 10/21/24 at 16:58 pm indicated Resident 292 was in the facility for less than 24 hours. FNP indicated Resident 292 became quite agitated, and she is [was] reporting chest pain 10/10. She was sent to the acute hospital for further evaluation. During an interview on 12/16/24 at 3:53 pm, ADON indicated she was unable to provide the surveyor with bed hold document provided to Resident 292 at discharge. During an interview on 12/18/24 at 2:15 pm, the ADON indicated there was no bed hold policy given to Resident 292 for her transfer/ discharge and there should have been. 45315 A review of Resident 14's undated Admission Record, indicated, Resident 14 was admitted to the facility on [DATE] with the diagnosis of chronic kidney disease (a long-term disease where the kidneys did not work well). Resident 14 was her own RP. A review of the Transfer/Discharge letter, dated 6/5/24, indicated, the facility notified the Long-Term Care Ombudsman (a representative that assisted residents with protecting their rights) that Resident 14 was transferred to the hospital for treatment on 6/5/24. A review of Resident 73's undated Admission Record, indicated, Resident 73 was admitted to the facility on [DATE] with the diagnosis of cerebral infarction (a stroke). Resident 73 was not her own RP. A review of the Transfer/Discharge letter, dated 11/18/24, indicated, the facility notified the Long-Term Care Ombudsman that Resident 73 was transferred to the hospital for treatment on 11/17/24. A review of Resident 130's undated Admission Record, indicated, Resident 130 was admitted to the facility on [DATE] with the diagnosis of presence of right artificial knee joint (knee replacement surgery). Resident 130 was her own RP. A review of the Transfer/Discharge letter, dated 9/16/24, indicated, the facility notified the Long-Term Care Ombudsman that Resident 130 was transferred to the hospital for treatment on 9/15/24. During an interview on 12/16/24 at 3:27 pm, the Assistant Director of Nursing (ADON) stated, the bed hold agreement was reviewed with residents upon admission to the facility. ADON stated, when a resident was transferred out of the facility to the hospital, the Ombudsman was provided with a written notice of transfer and stated the resident or the resident's RP was not provided with a written bed hold policy.

Based on interview and record review the facility failed to ensure one of 12 sampled residents (Resident 1) was free from mistreatment, misappropriation of property, and mental abuse when he was abducted (removed by force) from the facility by a restricted visitor (not authorized to visit or call). This resulted in Resident 1 to be taken out of the facility for 90 minutes with a restricted visitor who would attempt to financially abuse him. An Immediate Jeopardy (IJ) situation was identified on 7/19/24 at 3:45 pm, in the presence of the Executive Director (ED) and Director of Staff Development (DSD), due to not implementing a restricted visitor screening system that ensured residents were protected from any type of abuse from unauthorized visitors. An immediate jeopardy removal plan was requested from the ED and DSD. An IJ removal plan was provided by the ED and accepted on 7/19/24 at 4 pm. The IJ removal plan included all facility staff training on the new policy titled Visitation which included checking identification for all visitors coming to visit a resident on the Visitor and Phone Call Precaution list (restricted visitors). The Visitor ' s log will now include reason for visit and pictures of restricted visitors. The nursing staff should be aware of all visitors and any concerns regarding visitors should be reported to immediately supervisor or security/maintenance. The IJ removal plan was verified that it was fully implemented by an onsite visit. The IJ was removed on 7/23/24 at 4:10 pm. Findings: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property Prohibition revised on 7/15/2021, indicated that each resident has the right to be free from mistreatment, neglect, misappropriation of property. The 'Center' implements policies and processes so the residents are not subjected to abuse by individuals who may have unsupervised access to residents. Abuse is defined as Misappropriation of Residential Property, which is a deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident ' s belongings or money without the resident ' s consent. This document also indicated that Mental Abuse through either verbal or nonverbal conduct which has caused or has potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. A review of the facility's Visitation Policy, undated, that was in existence prior to incident, there were no procedures to address any visitors' precautions or restrictions. A review of a facility reported incident dated 7/17/2024 at 7:00 am, the facility notified California Department of Public Health (CDPH) that a Restricted Visitor (RSV 1) entered the facility at 9:44 am on 7/16/2024 and abducted (take someone away by force) Resident 1. RSV 1 took Resident 1 to a local check cashing business with a check belonging to Resident 1 in the amount of $7,836.03. Local Police Department returned Resident 1 to facility at 12:20 pm. A review of Resident 1's admission record indicated he was admitted into the facility on [DATE], with diagnoses which included dementia, anxiety disorder, and generalized muscle weakness. Resident 1 was unable to make his own healthcare decisions and the facility Interdisciplinary Team (ID, a group of multiple disciplines who develop plan of care for residents) was his decision maker until he was conserved (judge appoints another person to act or make decisions for a resident) by the county. A review of the Minimum Data Set (MDS, a resident health assessment) dated 6/18/2024, indicated the Brief Interview for Mental Status (BIMS) was a score of 3 (severe cognitive impairment). Resident 1 can walk 10 to 50 feet with supervision and/or touching assistance. Resident 1 was unable to walk 150 feet due to his medical condition or safety concerns and had a walker (an assistive device to walk), no wheelchair. A review of the Social Services Progress Note dated 11/16/2023 at 9:46 am, the Social Services Director (SSD) documented upon admission that she spoke with Ombudsman (resident advocate) about Resident 1. The Ombudsman stated there was suspected elder financial abuse with the previous caregiver (RSV 1 and RSV 2). SSD also spoke with Adult Protective Services (APS, agency to help elder adults who are victims of abuse, neglect, or exploitation). APS asked SSD to put in place a do not contact order put in for the safety of the Resident 1 while the investigation is still on going. SSD notified front desk and email was sent to all facility managers. A review of the Social Service Progress note dated 12/12/2023 at 4:16 pm, indicated Social Services Assistant (SSA) received a call from RSV 1 wanting to talk to Resident 1 and requested information regarding his care. A review of the Social Service Progress note dated 5/24/24 at 11:50 am, SSD documented that RSV 2 came to the facility in person attempting to visit Resident 1. RSV 1 and RSV 2 was NOT to have any contact per APS. A record review of an Order Summary Report, a Physician Order dated 6/12/2024 indicated, Resident 1 may leave the facility with responsible party with medications. A review of the Visitor Log dated 7/16/2024 at 9:44 am, RSV 1 came to the facility and signed in with a fictitious (false) name and wrote room [ROOM NUMBER]B (Resident 1 ' s room). A review of the Visitor and Phone Call Precautions list dated 7/16/2024, indicated that the fictitious name given by RSV 1 was not on the precaution visitor list. The list indicated RSV 1 and RSV 2 were not allowed to visit or call Resident 1. During a concurrent interview and record review on 7/19/2024 at 11:10 am, Receptionist (REC A) stated her process for when a visitor enters the facility lobby. REC A greets the visitor and asks the visitor their name and the room they are visiting. The visitor fills out the Visitor Log. On the day of the abduction on 7/16/24, REC A explained RSV 1, and two gentlemen came in, she asked them to sign the Visitors Log, only RSV 1 signed the log with a false name, and she did not offer a reason for visiting Resident 1. REC A explained she was not completely trained on the expectations of handling facility visitors. REC A stated, I trained myself the rest. She does check the Visitor and Phone Call Precautions list posted at the desk which lists the resident's names and the names of visitors that are not allowed. REC A confirmed Visitors Log included date, time in, visitors name, resident room number and time out, and did not include a space for the reason for the visit. REC A does not ask for precautionary visitor identification and REC A there were not any pictures of restricted visitors. REC A stated the receptionists get busy sometimes and people can get by them. REC A stated it would have been better if we had descriptions of restricted visitors and better to include on log reason for visiting resident. A record review of the Facility's In-Service Education Summary dated 7/17/2024, indicated that only the six facility receptionists received this training and it lasted 30 minutes. The Reception Meeting Agenda included the changes implemented by the facility after the incident: -Visitors wear name badges -Visitors sign in and sign out on log -Check visitor identification if they are on the restrictive list -Add picture of restrictive visitor to elopement binder at front desk in lobby -Page for help During an interview on 7/19/2024 at 11:25 am, Executive Director (ED) reviewed her investigation of the event on 7/16/24. ED confirmed no other facility staff had been trained after the abduction event just the six receptionists. Asked ED that if the facility was asking for identification for only the names on the Visitor and Phone Call Precautions list, would that have stopped the recent abduction? ED confirmed just checking for the names of the visitors on the list would not stop a restricted visitor who gave a false name. ED agreed that it would be better to ask for all visitor's identification for the residents listed on the Visitor and Phone Call Precautions list. ED confirmed all facility staff are responsible for identifying visitors, not just the receptionists. ED confirmed they made no changes to facility policies, and the visitor badges was an older practice in place and ED brought it back. No face-to-face in-services were conducted with facility staff except receptionists. ED explained she had a Security alert in the Electronic Medical Record (EMR) system in the Facility Bulletin section leaving instructions for staff on how to handle visitors in the facility. During an interview on 7/19/2024 at 1 pm, Family Visitor (Visitor A) was interviewed when seen pushing his wife in a wheelchair in the hallway. Visitor A stated the visitor badge/sticker just started again this week. Visitor A stated it is not consistent at the front desk whether he was greeted or asked to wear a badge/sticker. During a concurrent observation and interview on 7/19/2024 at 1:10 pm, Resident 1 was laying in his bed watching television upon entering room. Resident 1 did not remember anything about the abduction event. When asked how far he can walk, Resident 1 explained from his bed to the door. Resident 1 stated he needs a walker and assistance to walk. During an interview on 7/19/2024 at 1:20 pm, Activity Assistant (Activity A) explained the visitor pass sticker was just started this week due to what happened, otherwise Activity A would not know who a visitor was. Activity A had no visitor training this week and did not see the security message. During an interview on 7/19/2024 at 1:25 pm, Registered Nurse (RN) A at north nurse's station was able to show that they had a paper titled Visitor and Phone Call Precaution list to reference. RN A stated the visitor sticker badges started two days ago. RN A was unaware that the special instructions on the resident profile in EMR had information about restricted visitors. RN A had no recent training and was not sure if they care plan restricted visitors in the EMR. During a concurrent interview and record review on 7/19/2024 at 1:30 pm, Certified Nurse's Assistant (CNA) A had not heard about any resident leaving the facility with a restricted visitor recently. CNA A stated she did not know about the restricted list, about the resident dashboard special instructions in EMR, nor was she aware of the security message on the facility bulletin page that notified all staff of the abduction on 7/16/24. During a review of Resident 1 ' s records, CNA A confirmed there was no visitor abuse care plan found in Resident 1 ' s record. CNA A explained she had no training in orientation about visitors and how to deal with them. During an interview on 7/19/2024 at 2 pm spoke with Director of Staff Development (DSD). DSD was asked if any training for new direct staff included how to deal with visitors and restricted visitors. DSD stated he just reviews residents rights and talks to direct care staff in orientation during their first week. DSD stated he has not given any in-services to direct care staff about the changes made after the abduction event. DSD stated he has been working on some training. DSD stated the restricted visitors are identified initially upon admission with IDT team. DSD stated all employees are responsible for ensuring residents are safe with visitors, not just the front desk receptionists. During a concurrent interview and record review on 7/23/2024 at 1 pm, REC B stated she received new training about dealing with visitors. REC B stated now all visitors receive a sticker/badge with their name and room number of the resident. REC B stated the badge was now enforced and was not prior to the abduction event. The receptionists have a new binder called elopement/visitor precautions that has a lot more information in it on each resident and visitor including pictures. REC B showed the binder page for Resident 1, and it had a picture of two individuals who were not allowed (RSV 1 and 2). REC B stated the binder was more readily available. REC B stated they will be asking for identification for all visitors who visit a resident listed on the Visitor and Phone Call Precaution list. A review of a new policy title Visitation, undated, indicated the restricted visitor list has to be posted, reception desk, all nursing stations, and provided to all managers. Facility staff will request of all patient's visitors that are on the restricted visitor list. Facility staff are to contact the supervisor or ED immediately if a restricted visitor attempts to enter the facility. The Visitor Log now includes the request that the visitor writes, Reason for Visit. Staff are to page Security overhead when a restricted visitor attempts to come into the facility. During an interview on 7/23/2024 at 1:35 pm, LVN C stated on 7/16/2024, the day of the abduction, a woman came up to the East nursing station and asked if she could have a wheelchair for her Dad. LVN C stated she went to check with Physical Therapy (PT) to see about a wheelchair. PT referred her to maintenance department since they did not have any wheelchairs available. LVN C stated it was time for lunch, so she clocked out at 10:18 am and clocked back in at 10:48 am. LVN C stated I remembered after returning from lunch that Resident 1 does not have family or visitors just an APS worker. She explained Resident 1 used a walker and could walk short distances with Restorative Nursing Assistance. Resident 1 did not have a wheelchair, only a walker. LVN C stated there was really no reason for a need for a wheelchair. LVN C stated she came back from lunch and asked CNA B to ask the visitor her name, since LVN C remembered he did not have family. LVN C stated she could have asked more questions of the visitor, like her name. LVN C stated communication will be better now that all visitors will have a badge to identify them and who they are visiting. LVN C was asked if nursing staff were made aware of residents discharging daily? LVN C stated, Yes, it is on their EMR main page dashboard, and the social worker puts the information in the dashboard as to who is discharging that day. LVN C stated she did not check the restricted visitor list and did not check on the PCC dashboard under special instructions on the day of the abduction of Resident 1. During an interview on 7/23/2024 at 2 pm, LVN D confirmed she was assigned to Resident 1 that day he was abducted. LVN D explained RSV 1 wanted to take her Dad home. LVN D informed RSV 1 that she would need to talk to Social Services about that. LVN D stated that RSV 1 requested a wheelchair and nursing asked PT/Maintenance for a chair. At around 10:55 am, Resident 1 was in a wheelchair, then LVN D pointed RSV 1 in the direction of the Social Services office; but did not follow them or check to see if they went to the Social Services Office. LVN D stated she trusted that they went there. Twenty minutes later, CNA B came to her and explained that Resident 1 never had visitors and was not in his room. LVN D realized Resident 1 had restricted visitors. LVN D stated the facility staff checked the entire facility, notified Social Services, and paged for missing Resident 1 overhead throughout the facility. Resident 1 was nowhere to be found. LVN D stated the wheelchair was located outside and the SSD initiated 911. LVN D explained Resident 1 could only walk short distances and would get short of breath. LVN D explained it is okay to ask questions of visitors, just do not assume who they are, and if you do not know, ask. LVN D agreed care planning would have been another good place to indicate restricted visitors in addition to special instructions. LVN D confirmed the physician order that Resident 1 can go out with RP was confusing since he did not have one. LVN D stated she did not check to see if Resident 1 was discharging that day. During an interview on 7/23/2024 at 2:15 pm, CNA B who was not assigned to Resident 1 that day but keeps on eye on the entire hallway and stated, All residents are my patients and I keep an eye on everyone. CNA B stated she observed RSV 1 on 7/16/24, and she was acting suspicious. CNA B stated RSV 1 was moving her head back and forth in the hallway in front of Resident 1 ' s room. CNA B thought to herself, Is this his daughter? And went to check with the charge nurse, and they were not sure. CNA B was instructed to go back and ask her name and RSV 1 was gone. CNA B stated she should have stopped everything when RSV 1 was acting suspicious and not left Resident 1 alone with her. During an interview on 7/23/2024 at 2:30 pm, SSD gave the account of the day of the abduction. SSD stated LVN C came down looking for Resident 1 and his Daughter. LVN C stated RSV 1 wanted to talk about discharge planning, SSD was puzzled because Resident 1 does not have a daughter. SSD thought of RSV 1, a restricted visitor and remembered she was reported by APS upon admission last year. SSD stated RSV 1 was his In-Home Support Services (IHSS, county program for people who need help to stay in their home) worker and charged with neglect and financial abuse. SSD stated RSV 1 was restricted, then began to search for Resident 1, went to front desk and reviewed the visitor log. SSD noticed RSV 1 used fictitious name. SSD stated out of all the residents on the restricted visitor list, Resident 1 was the most vulnerable due to his BIMS of 3 and easy-going nature. SSD called 911 after searching the building. SSD stated they now have a binder which will include detailed information about the residents and their visitors. SSD stated she will keep it updated for all staff. SSD explained the binder identified restricted visitors upon admission, at resident care conferences and speaking with the residents. SSD stated every facility staff member was responsible for questioning and identifying visitors in the facility. SSD stated Resident 1 thought he was in trouble because the local police returned him after 90 minutes of being gone. SSD stated she had to reassure Resident 1. During an interview on 7/23/2024 at 2:45 pm, Maintenance Director (MaintD) stated he was not security before the incident, and now after the abduction, he has been asked to step in like security until the hospital ' s actual security team can arrive from across the parking lot. MaintD stated the maintenance team has been trained on deescalating visitors. MaintD stated now all facility visitors will wear stickers to identify them.

Based on interview and record review, the facility failed to develop and implement a policy and procedure (P&P) to ensure that all facility staff who provide any care, treatment, or other services for the facility and/or its residents are fully vaccinated for COVID-19 (an illness that can cause severe symptoms and in some cases death, especially in the elderly) when: 1.a. The facility did not develop a P&P that included COVID-19 vaccination of facility staff. 1.b. Contingency plans (alternate plan) that include additional precautions for COVID-19 unvaccinated staff. 1.c. Medical exemption (reason for not getting the vaccination) and medical delay (reason to get vaccinated at a later date) forms did not include required documentation stating which COVID-19 vaccine was clinically contraindicated (reason to not receive the vaccination) and was missing a supporting statement from the provider. 1.d. Did not have a processes to accurately track staff COVID-19 vaccination status, medical or spiritual exemptions (exemptions), and medical delays. Staff included but not limited to individuals who provide direct resident care from outside sources. 2. Facility staff were not informed about the new facility policy or contingency plan for COVID-19 unvaccinated staff. This failure resulted in an Immediate Jeopardy (IJ, situation in which the provider's noncompliance with one or more. requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident.) when 30 residents (Resident 2-31) tested positive for COVID-19 in a four week period from 1/28-2/24/2022. This had potential for serious harm or death to all residents, and ongoing COVID-19 outbreaks in the facility. An IJ was declared on 3/8/2022 at 2:00 pm, in the presence of the facility Executive Director (ED) and Corporate Executive Officer (CEO) when the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19, and did not have contingency plans to mitigate (applying preventative measures) for the use of COVID-19 unvaccinated staff. The facility ED provided an acceptable plan of action on 3/8/2022 at 4:45 pm. The actions to remove the IJ situation included a facility P&P for staff COVID-19 vaccinations with contingency plans, auditing the staff line listing (tracks staff COVID-19 vaccination status) daily for accuracy of staff COVID-19 vaccination rates, conduct infection control meetings weekly, develop a Quality Assurance and Performance Improvement (QAPI, identifies quality issues and plans to correct) if threshold was not met, educate employees on COVID-19 vaccination policy, and update employee medical exemption form to include all criteria. The IJ was abated onsite by surveyors (reduced in amount, degree or intensity and immediacy) on 3/10/2022 at 3:45 pm, when the facility was able to demonstrate the staff COVID-19 vaccination policy was implemented when administrative staff were trained on the new policy and procedure (P&P), contingency plans were developed to assign non COVID-19 vaccinated staff to low risk residents, auditing the accuracy of the facility staff line listing to be done daily, and exemptions/medical delays included medical contraindication. Findings: 1.a. A review of Attachment A of the Quality Safety & Oversight memoranda 22-07-ALL (QSO, The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring the health and safety of nursing home residents by enforcing the standards required to help each resident attain or maintain their highest level of well-being) dated 12/29/2021. CMS is committed to ensuring America's healthcare facilities respond effectively in an evidence-based way to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE). This new regulation establishes requirements regarding COVID-19 vaccine immunization of staff among Medicare and Medicaid certified providers and suppliers, dated 12/28/2021, indicated the facility must develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19. The QSO indicated the deadline was 3/1/2022 for all facilities to become 100 percent (%) compliant with the regulation. A record review of the Staff Vaccination line listing for 2/25/2022 indicated the facility percentage rate for staff COVID-19 vaccination was 85 %. A review of the P&P, titled Infection Prevention and Control Program, dated 2019, indicated that no update had been made to reflect the new requirements for staff COVID-19 vaccination as outlined in Attachment A of QSO. During a concurrent interview and record review on 2/25/2022, at 10:44 am, the Infection Preventionist (IP, person responsible for facility activities aimed at preventing healthcare associated infections), confirmed the P&P dated 2019, had not been updated to meet the requirements of the QSO due to the increase of a new COVID-19 strain. IP stated that developing this policy was a part of the IP's responsibility. During an interview on 3/1/2022, at 12:53 pm, the Executive Director (ED) confirmed the P&P did not reflect the new staff COVID-19 vaccination requirements and stated the Director of Nurses (DON) and ED are discussing the development of staff COVID-19 vaccination P&P and this process just had been started. During an interview and record review on 3/8/2022, at 1:30 pm, ED stated infection control had been discussed during informal and irregular scheduled department meetings. Meeting minutes (written record of everything that happens in a meeting) were not provided. ED confirmed that meeting minutes had not been taken during any of the meetings. During interview with ED, the CEO arrived at the facility and joined the interview. CEO confirmed being a member the governing body (a group of people who make decisions and develop/implement policies); stating it was CEO's responsibility to provide data and resources to ED that were needed to develop and implement the new COVID-19 staff vaccination policy. The CEO stated that he did not provided the data or resources to ED. ED provided a new P&P titled: COVID Vaccination for Employees, dated 2/28/2022. Two out of six administrative team members had signed the policy as of 3/8/2022. During an interview on 3/8/2022, at 3:36 pm, with ED, Assistant Director of Nursing (ADON) , and IP, the ED stated the P&P for staff COVID-19 vaccinations was not available on 2/28/2022 and had not been completed until the evening of 3/1/2022. ED stated the new P&P had not been implemented and staff had not been educated on the new P&P. A review of the COVID Vaccine Policy Approval, dated 3/9/2022, the administrative team signed the P&P on 3/9/2022. During an interview on 3/11/2022, at 12:11 pm, MD stated that he was unsure about the QSO; but, followed the staff immunizations at the facility and spoke with the Chair of Infection Control (ICS) from the acute care hospital. MD stated he was not involved with development of the COVID-19 staff vaccination policy. MD stated that the ICS was in charge of developing the infection control P&P. MD stated having no knowledge of the QSO and was not aware there was a deadline. MD confirmed not seeing the new P&P for staff COVID-19 vaccination requirements until 3/8/2022. 1.b. A review of the QSO, dated 12/28/2021, indicated the policies and procedures must include, at a minimum, the following components . contingency plans for staff who are not fully vaccinated for COVID-19, that included a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. The QSO indicated that there are a variety of job modifications that can be done for unvaccinated staff including assigning staff to residents who are not immunocompromised (having a weakened immune system placing a person at a higher risk for severe symptoms or death from COVID-19). During an interview on 2/25/2022, at 9:52 am, Certified Nurse Assistant (CNA F) confirmed that no instructions had been provided in regards to resident care assignments based on COVID-19 staff vaccination status. A review of the undated record, titled Admission Record, indicated five out of 116 residents (Residents 10, 22, 32, 33, and 34) are immunocompromised (having a weakened immune system). During an interview on 2/25/2022, at 10:39 am, with IP, explained that COVID-19 unvaccinated staff can care for any residents, including immunocompromised residents because all staff are required to wear full personal protective equipment (PPE, N-95 face mask, gloves, gown, goggles) and confirmed there was not an alternate work plan for COVID-19 unvaccinated staff in the current P&P. During a concurrent interview and record review on 2/25/2022 at 12:12 pm, with IP, an updated staff list was provided. IP confirmed there had been a total of 17 staff members who had not received the COVID-19 vaccination and had not been removed from the schedule or reassigned to other areas. During an interview on 3/1/2022, at 12:53 pm, with ED, stated that no disciplinary action had been taken against staff that did not follow the COVID-19 staff vaccination mandate despite staff being aware of the COVID-19 vaccination regulation. ED confirmed that the COVID-19 vaccination is a requirement for employment. ED stated that the QSO had been looked at in December 2021 and during that time 100% of staff had been COVID-19 vaccinated and assumed the facility was still at 100%. During an interview on 3/8/2022, at 2:00 pm, with CEO confirmed that a contingency plan had not been implemented, staff had not been educated on the contingency plan, and COVID-19 unvaccinated staff had not been removed from the schedule until 3/7/2022. During an interview on 3/10/2022 at 1 pm, the Staff Scheduler (SCH) explained before the staff COVID-19 P&P was implemented on 3/9/2022, there was no formal written plan to ensure COVID-19 unvaccinated staff did not directly work with immunocompromised residents, it was verbal conversation. SCH stated the new process was that a daily email comes from the DON or ADON who ensure COVID-19 unvaccinated staff are not assigned immunocompromised residents. SCH further explained it was good information to be aware of for scheduling purposes. 1.c. A review of the QSO, dated 12/28/2021, indicated the policies and procedures must include, at a minimum, the following components .a process by which staff may request and exemption from the staff COVID-19 vaccination requirements, a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated, the reason why, and a statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the clinical contraindications. During a concurrent interview and record review on 2/25/2022 at 12:12 pm, with IP, 43 spiritual exemptions were provided for review. IP also provided medical exemptions for ED dated 8/24/2022, Resident Assistant dated 1/20/2022, LN N dated 8/30/2021 and a Rehabilitation staff member, dated 1/13/2022. Medical Records (MR 3) had a medical delay dated 9/10/2021. IP confirmed the medical exemption and medical delay forms did not include which COVID-19 vaccination was clinically contraindicated, a statement from the provider recommending COVID-19 vaccination exemption, or the clinically approved reason why. A review of the QSO, dated 12/28/2021, indicated that there needed to be a process for staff to request an exemption or delay for the COVID-19 vaccination. During an interview on 2/25/2022 at 1:52 pm, CNA G confirmed they were COVID-19 booster eligible. CNA G stated they were not able to receive the COVID-19 booster due to an issue with the COVID-19 vaccination card. CNA G confirmed the need for a medical delay, but had not been provided the paperwork. During an interview on 3/1/2022 at 10:12 am, LN G stated they had just recovered from COVID-19 and requested a medical delay and had not been provided the paperwork. During a concurrent record review and interview on 3/1/2022, at 11:28 am with IP, the CNA student list was reviewed and six out of 15 CNA students (NAS A-F) were not fully vaccinated for COVID-19 and no exemptions or medical delays had been provided. IP confirmed that CNA classes started the week of 2/28/2022 and CNA students would be providing resident care. 1.d. A review of the QSO, dated 12/28/2021, indicated the policies and procedures must include, at a minimum, the following components .a process for tracking and securely documenting the COVID-19 vaccination status of all staff and a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended. During a review of the record titled Staff Assignment Sheet, dated 2/25/2022, the record indicated that CNA F had been fully vaccinated. During an interview on 2/25/2022, at 9:52 am, CNA F stated they were eligible for the COVID-19 booster and did not plan to get the COVID-19 booster for another week or two. CNA F stated no reason for delay in obtaining the COVID-19 booster did not meet exemption or delay requirements. During a concurrent interview and record review on 2/25/2022, at 12:12 pm, IP stated the total number of staff working at the facility was 224. Using the equation provided in the QSO, the total staff vaccinate rate was 90.25%. The QSO was reviewed with IP to re-evaluate total number of staff to include: CNA students, medical providers, beauticians, pharmacists, and registry (staff that performs direct resident care who are not employed by the facility). IP provided a new staff total of 240. Using the same equation from the QSO, with the correct total of staff, the staff vaccination rate dropped to 85%. IP stated the CNA class would be starting class in the facility the week of 2/28/2022, and did not have the COVID-19 vaccination status of the CNA students. A review of the record titled COVID-19 Vaccination Record Card, with multiple dates (dates reflect date of COVID-19 Vaccination), indicated CNA F received the COVID-19 booster vaccine on 3/2/2022. During an interview on 2/25/2022 at 1:52 pm, CNA G was eligible for the COVID-19 booster and was not able to receive the booster due to an issue with the COVID-19 vaccination card. CNA G stated had a clinical reason for a medical exemption but had not been provided the paperwork. A concurrent record review and interview on 3/8/2022, at 2:00 pm, the CEO explained, when tracking the staff vaccination status for COVID-19, they were mainly depending on the data from their COVID-19 vaccination clinics that were done at the hospital. CEO stated staff did not always bring in their proof of COVID-19 vaccination from outside agencies (pharmacies and physician offices). The CEO confirmed that this contributed to the inaccurate COVID-19 vaccination tracking. 2. During a review of the record titled In-Service Education Summary, dated 1/10/2022 through 01/16/2022, the record indicated education provided to staff about the original staff COVID-19 vaccination deadline of 2/1/2022. During a review of the record titled Nurse's Meeting Agenda, dated 2/25/2022, the record indicated the COVID-19 booster vaccine was discussed and that Proof of COVID-19 vaccination needed to be turned in to IP. No meeting minutes or information/education had been provided. A review of the record titled Facility Bulletin Board, dated 2/25/2022, indicated all staff that did not meet the 3/1/2022 deadline for being fully COVID-19 vaccinated or having qualifying exemption would be removed from the schedule. During an interview on 2/25/2022, at 9:52 am, with CNA F stated, there had been no education provided about a plan to mitigate the spread of COVID-19 for unvaccinated staff or if there was a plan in place that involved which residents COVID-19 unvaccinated staff could care for. During an interview on 2/25/2022 at 1:52 pm, with CNA G stated nothing officially had been said by management about staff COVID-19 vaccinations and the understanding was get it or you aren't working. During an interview on 2/25/2022, at 10:44 am, IP stated that communication about mandated COVID-19 vaccine deadline was posted on the dashboard (electronic communication area available to all staff) for staff to read. During an interview on 2/25/2022 at 1:40 pm, with LN D stated that there had been no restrictions or education provided for COVID-19 unvaccinated staff caring for residents and the facility had two immunocompromised residents on the hall LN D worked. During an interview on 2/25/2022 at 1:50 pm, with LN E, stated, there was no education provided or knowledge of a plan in place for COVID-19 unvaccinated staff. During an interview on 3/1/2022 at 10:10 am, with LN F, stated not knowing the difference required in the use of PPE for COVID-19 unvaccinated staff. LN F stated not knowing if there was a difference for resident care based on COVID-19 vaccination status. During an interview on 3/10/2022 at 1:30 pm, SCH explained, staff education and inservices around the deadline for required COVID-19 vaccinations was 3/1/2022, and it started about three weeks ago. During an interview on 3/8/2022 at 2 pm, the DON stated, the new policy and procedure for staff COVID-19 vaccination gave administrative staff a process to follow for addressing COVID-19 unvaccinated staff. DON explained the DON 2 (hospital chief nursing officer) was responsible for creating the new policy for COVID-19 staff vaccination. During a interview on 3/8/2022 at 2:30 pm, IP explained having a completed P&P that addressed COVID-19 staff vaccinations and alternate plans to implement was helpful. IP stated it was unclear who in the facility was responsible for ensuring the policy was created and implemented. IP stated DON 2 at the hospital had been working on writing the new policy. IP stated I thought we had more time to get the policy created and implemented. A review of the record titled Vaccination Status indicated 30 residents (Resident 2-31) tested positive for COVID-19, in a four week period, from 1/28/2022 through 2/25/2022. A review of an untitled and undated record indicated that 26 staff members (ED, IP, LN H - M, CNA F, CNA H - O, OTA, MR 1-2 , Maint, EVS, Rec, PT, DT, and BOM ) tested positive for COVID-19, in just a little over a four week period, from 1/27/2022 through 2/28/2022.

Based on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 8) did not develop a pressure ulcer/sore (bedsore, injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure). Resident 8 was admitted with a red left heel. No further assessments and no interventions were done until 11 days later when the area had progressed to an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer. The plan of care was not consistently implemented following the discovery of the unstageable pressure ulcer. These failures resulted in an avoidable pressure ulcer, pain, had an adverse effect on Resident 8's well-being, and had the potential to prolong and complicate her rehabilitation process. (Refer to F 278 and F 279) Findings: The facility's policy and procedure, titled "Skin Integrity," last updated 6/2013, indicated that the nurse would "complete the Skin Integrity Evaluation Form at admission and weekly for the next three weeks following admission. . . . Upon discovery of newly identified skin impairment (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc.) the licensed nurse completes the following: Documents skin impairment that includes measurements of size, color, presence of odor and exudates (drainage); documents presence of pain associated with the skin impairment; . . . implements interventions and document on the resident's Care Plan (CP) and Care directive (CD); documents resident's response to the interventions in the nurses notes." The facility's form title, "Skin Integrity Definitions," last updated 6/2013, included: "Avoidable pressure ulcer means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate." A review of Resident 8's record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The record indicated that Resident 8 was alert and oriented, and capable of making her own healthcare decisions. The MDS (minimum data set, an assessment tool), dated 5/6/14, indicated that, with the exception of requiring set-up assistance for meals, Resident 8 required extensive assistance from staff for other activities of daily living. Nurses' notes, dated 4/30/14, indicated that Resident 8's "left heel is red." No further description was found. A review of Resident 8's care plan to address skin integrity, dated 4/30/14 and updated on 5/15, included an intervention to float her heels. A care plan intervention, dated 5/19/14, indicated a zero gravity boot (a soft boot used to aid in healing by reducing pressure from the heels) was to be worn by Resident 8 when not in therapy. Resident 8's undated Care Directive (a form used to communicate resident care needs to the CNAs (Certified Nursing Assistants), was reviewed. There was nothing to indicate that the heels were to be floated. The section of the form titled, "Skin At Risk," indicated that Resident 8 had a zero gravity boot to be worn as tolerated, and that she was to be turned as desired. There was no indication of a pressure ulcer on Resident 8's left heel. Resident 8's nurse's notes were reviewed from 4/30/14 through 5/22/14 as follows: The notes, dated 4/30/14 at 12:45 pm, indicated that Resident 8's "left heel is red." No further description was found. From 4/30 through 5/10/14, no further notation was found regarding the redness on Resident 8's heel, nor any notation that the heels had been floated. The notes, dated 5/11/14 (11 days after admission), indicated "passed in report, patient has purplish color area to left heel 5/10/14, no increase in size noted, treatment nurse notified, day nurse for evaluation, heel is floated." There was no notation in the notes from 5/15 through 5/18/14, that her heels were floated. The notes, dated 5/19/14 at 2:30 pm, indicated that a new order had been received for Resident 8 to have a zero gravity boot. The notes, dated 5/19/14 at 5:10 pm and dated 5/21/14 at 4 am, indicated that the heels were floated. There was no notation that the boot was applied as ordered by the physician The Certified Nursing Assistant (CNA) documentation titled, ADL (activities of daily living) Flowsheet, dated 5/1 through 5/22/14, was reviewed. No indication was found regarding interventions related to Resident 8's left heel. During an interview on 5/22/14 at 12 pm,the Director of Nurses (DON) stated that the care plan initiated on 4/30/14 showed that Resident 8's heals should be floated. When asked where this should be documented, DON stated that it would be documented by the licensed nurses in the nurses notes and/or the treatment nurse's notation and/or in the Nutrition/Hydration/Skin notation. The DON confirmed there were no other skin assessment from 4/30 until 5/11/14. The treatment nurses documentation titled, "Wound/Skin Evaluation and Documentation Form," was reviewed and indicated that the first assessment of Resident 8's left heel, by the treatment nurse, took place on 5/11/14. This assessment indicated the presence of a deep tissue injury which was classified as an unstageable pressure ulcer. The assessment indicated the ulcer was purple/red in color, the length and width were two centimeters (cm) by two cm in size, with a depth that was unable to be determined (UTD). During an interview on 5/20/14 at 8 am, the wound Treatment Licensed Nurse (TXLN) described the wound on Resident 8's left heel as a deep tissue injury that was classified as an unstageable pressure ulcer. TXLN confirmed that the wound was initially dark purple when she first evaluated it on 5/11/14, and was now black/brown in color. TXLN confirmed that the wound had been acquired after admission to the facility. On 5/22/14 at 10:45 am, an observation of Resident 8 revealed that there was a pillow under her legs, but her heels were resting on the bed. The zero gravity boot was observed on a chair next to the bed. During a concurrent interview CNA E was asked about what type of interventions were used to help in healing of Resident 8's left heel wound. CNA E explained that she had placed a pillow under Resident 8's legs so that her heels would be "floating" and not touching the bed. CNA E stated that Resident 8's heels were floating when she put the pillow under her legs, but the resident had slid down in the bed so they were no longer floating. A review of Resident 8's Care Directive with CNA E, indicated "zero gravity boot as tolerated". CNA E stated this meant that it was up to the resident how much she wore the boot and she was unsure how much Resident 8 was supposed to wear the boot. CNA E stated that Resident 8 had not been wearing the boot that morning. CNA E asked Resident 8 if it would be ok to put the boot on her left foot and Resident 8 replied yes. CNA E proceeded to put the boot on Resident 8's left foot. During an interview on 5/22/14 at 11:45 am, Resident 8 stated that her left heel had "really been hurting" her, especially whenever she walks on it. During an interview on 5/22/14 at 12 pm, the DON confirmed that the facility's skin integrity/pressure ulcer policy was not followed. She confirmed the Care Directive was incomplete when it did not show that Resident 8's heels should be floated and direct care staff were not aware of the importance and/or recommended duration for the zero gravity boot. She confirmed that Resident 8 was admitted with a "red heel", and although a care planned intervention was in place to float the heel, no evidence was found that Resident 8's heel had been floated until the left heel redness had progressed to be an unstageable pressure ulcer.

Based on interview and record review, the facility failed to assure laboratory (lab) results for a positive [MEDICAL CONDITION] (C- diff., a bacteria that causes diarrhea, and life threatening inflammation of the colon) for Resident 1 were addressed, when the lab results were misread as negative and Resident 1 did not receive treatment. This resulted in Resident 1 not being treated for [REDACTED]. [MEDICAL CONDITION] (inflammation of the bowel) being a contributing diagnosis. Findings: Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility's Minimum Data Set (MDS, an assessment tool), dated [DATE], indicated that Resident 1 needed extensive assistance with all daily activities of living, and was able to make her own decisions. On [DATE], Resident 1's medical records were reviewed. Resident 1 had a nurse's note, dated [DATE], that read Resident 1 had loose foul smelling stools two times that morning and that the physician had been called and an order obtained. Resident 1's medical record contained a physician order, dated [DATE], for stool to be tested for [MEDICAL CONDITION]. related to foul smelling mucus stools. Resident 1's medical record contained a laboratory result, dated [DATE], that read, positive for [MEDICAL CONDITION]. toxins. Resident 1's medical record contained a nurses note, dated [DATE], that read, lab results returned, negative for [MEDICAL CONDITION]. Resident 1's record contained a nurses note, dated [DATE], that read, Family Member came in and requested that Resident 1 be discharged to him, he was taking her back to the assisted living facility she had been in before. On [DATE], Resident 1's acute care medical records were reviewed. Resident 1's medical records indicated that she was admitted to the acute care hospital on [DATE] with [DIAGNOSES REDACTED]. Resident 1's acute care medical record indicated she was moved from the acute care section of the hospital to the skilled nursing section of the hospital on [DATE] and died on [DATE]. On [DATE] at 9 am, during an interview and concurrent medical record review, Administrative Nurse B stated that she had been contacted by a discharge planner from the local acute care hospital a few days after Resident 1 was discharged . The discharge planner explained Resident 1 was in their facility, and was asked about the lab results for [MEDICAL CONDITION]. Administrative Nurse B confirmed that she reviewed the record and discovered that Resident 1's results were positive. Administrative Nurse B stated that the results had been misread and documented in the nurse's notes incorrectly as negative.

Based on interview and record review, the facility failed to ensure Resident 1 received daily injections of an antibiotic, [MEDICATION NAME], to treat a urinary tract infection [MEDICAL CONDITION] as ordered by her physician on [DATE] at 12:20 am. The first dose of [MEDICATION NAME] was administered on [DATE] at 3:20 pm, two and a half days after it was ordered. This failure resulted in Resident 1 developing urosepsis; a life-threatening bacterial infection of the blood from the urinary tract infection. Urosepsis requires treatment with antibiotics and if untreated, urosepsis can progress to septic shock. Resident 1 developed septic shock and died on [DATE]. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool), dated [DATE], described Resident 1 as having disorganized thinking, short and long term memory problems, and severely impaired decision-making ability. She was totally dependent on staff assistance in transfers, dressing, eating, toileting and bathing. She required the use of a wheelchair to move about the facility. Resident 1's nursing notes revealed that Resident 1 was not eating well in early ,[DATE]. On [DATE] the physician ordered a urine analysis (a test to determine if there is bacteria/infection in urine) with culture and sensitivity (a test that identifies the type of bacteria and the antibiotic medications that would kill the bacteria). The tests, completed on [DATE], showed that Resident 1 had a urinary tract infection. On [DATE] at 1:15 pm, Resident 1's physician ordered an antibiotic; [MEDICATION NAME] 100 mg twice a day for seven days. Resident 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE], Resident 1 again began refusing meals and medications. A urinalysis performed on [DATE], confirmed that Resident 1 had urinary tract infection. A nurse's note dated [DATE] at 10 pm, read, "Urine analysis report in, notified M.D. Requests that results be faxed to him. Done." On [DATE] at 12:32 am, the physician faxed the report back to the facility. On the report the physician wrote,"Please give [MEDICATION NAME] 1 gm (gram) every 24 hours for 7 days," followed by the date of [DATE], time 12:20 am, and the physician's initials. Review of Resident 1's ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse's notes written two and a half days later, on [DATE] contained the following documentation. At 1:30 pm, Resident 1's tempeture was 100.1, she was alert and oriented to person only and unable to swallow. Resident 1's physician and her responsible party were notified of the resident's change of condition. The nursing entry written three hours later, at 4:30 pm, described the events of the previous hour. Resident 1's temperature had risen to 101.8. At 3:20 pm, Resident 1's physician started an intravenous (IV) line in Resident 1's right hand to administer [MEDICATION NAME]. At 4 pm, the IV was discontinued because it had infiltrated causing fluid and medication to enter the surrounding tissue rather than the vein. The nurse's note, dated [DATE] at 10:30 pm, read, "The CNA (certified nursing assistant) informed me that the resident had stopped breathing." On [DATE] at 3:10 pm, Licensed Nurse (LN) A stated she talked with the physician on the evening of [DATE] and faxed him a copy of Resident 1's lab results confirming that the resident had a UTI. LN A stated that she did not remember any mention of an order for [REDACTED]. On [DATE] at 9:30 am, LN B stated he worked with two other nurses the night of [DATE] and barely remembered Resident 1. He stated he checked the fax machine "Two to three" times that night and did not remember seeing an order for [REDACTED]. On [DATE] at 4:15 pm, LN C who worked with LN B on the night of [DATE], stated that he had no knowledge of an order for [REDACTED]. A review of the facility's emergency drug supply showed that it contained [MEDICATION NAME], however the supply was not accessed and the medication was not administered to Resident 1 as ordered on [DATE]. On [DATE] at 5:15 pm,the Director of Nurses stated that she had reviewed all of the documents regarding unusual occurrences and medication errors and was unable to locate any reference to the failure to administer [MEDICATION NAME] to Resident 1 on [DATE]. Resident 1's physician's progress note, dated [DATE], read, "Called to see resident because of fever, change in condition, when I saw her patient was obtunded, doesn't respond to painful stimuli, hand cold but dry. Temperature 102, blood pressure 100. Chest is clear respirations (breathing) labored. Heart rate 108 regular rhythm. E-coli (type of bacteria) UTI. [MEDICATION NAME] ordered on [DATE], but order was not carried out. Impression: Urosepsis, probable pending septic shock." During an interview on [DATE] at 4:25 pm, Resident 1's physician verified that he had faxed the order for [MEDICATION NAME] to the facility late on [DATE] and "someone picked it up." The physician stated, "We might have been able to prevent it (urosepsis) if she (Resident 1) had gotten the first shot." A certified copy of Resident 1's Death Certificate, dated [DATE], listed the cause of death on [DATE] as "Urosepsis."

Based on interview and document review, the facility failed to ensure Resident 2 was treated with consideration, respect and full recognition of dignity and individuality when Licensed Nurse (LN) E knelt down, positioning himself at Resident 2's seated level, then yelled in the resident's face. Resident 2 stated that she felt scared and humiliated. This had the potential to increased Resident 2's anxiety, and negatively impact her psychosocial well-being. Findings: Resident 2, an [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a resident assessment tool, dated 3/10/12, described Resident 2 as alert, able to understand and make herself understood, with no hearing deficit. Resident 2 has short term memory problems and was unable to recall the incident that had occurred three days earlier on 4/22/12. During an interview on 4/25/12 at 11:30 am, Nurses Assistant (NA) D stated that on 4/22/12 at 7:30 pm, she was walking down the hall toward the north nurses station when she heard yelling. When she reached the nurses station she saw LN E on his knees, in front of and nose to nose with Resident 2. LN E was yelling at Resident 2, telling her she needed to listen and wait for help. NA D stated that LN E looked mad and his tone seemed angry. NA D explained that she then offered to help and took Resident 2 to her room. During an interview on 4/25/12 at 1:15 pm, LN E stated that on 4/22/12 at 7:30 pm, he was working at the nurses station and Resident 2 was sitting in her wheelchair at the nurses station waiting for a CNA to help her to bed. LN E stated that he was glancing up from his work to check on Resident 2, and when he looked up again she was gone. LN E stated that he went to Resident 2's room, and found her out of her chair with the fall alarm going off. LN E said that he assisted Resident 2 into her wheelchair and took her back to the nurses station. LN E stated that he knelt down in front of Resident 2's wheelchair, and was talking loudly in her face, explaining that she needed to wait for assistance before attempting to go to bed. LN E stated that Resident 2 was a fall risk and was trying to get her to understand that if she did not wait for assistance she might fall. LN E acknowledged that Resident 2 was a small woman, and that his large stature and behavior may have scared her. During an interview on 4/25/12 at 1:40 pm, with Social Service Assistant B and Resident 2, Resident 2 stated, "The man behind the counter yelled in my face." Resident 2 was unable to recall why she was behind the counter or exactly what was said. Resident 2 repeated, in a very tearful voice, "he yelled at me." Resident 2 said that she "felt sad, scared and humiliated."

Based on interview and record review, the facility failed to provide necessary care and services in accordance with physician orders [REDACTED]. This failure contributed to Resident 1's death on [DATE]. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1 was diagnosed with [REDACTED]. The facility's Minimum Data Set (MDS, an assessment tool), dated [DATE], described Resident 1 as able to understand others and be understood when communicating. Resident 1 had a court appointed responsible party (RP) because he was not capable of making sound decisions for himself. Resident 1 passed away on [DATE]. On [DATE], Resident 1's record was read. Resident 1 had a document dated [DATE] titled, "Physician orders [REDACTED]." The document also stated to provide "comfort measures only." The document stated to "Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of [REDACTED]. Antibiotics only to promote comfort. Transfer if comfort needs cannot be met in current location." The facility's nurses notes read that on [DATE] at 6 pm, Resident 1 developed a cough. Resident 1's physician was contacted by phone and orders were received to start Resident 1 on antibiotic pills and to obtain a chest x-ray to check for pneumonia. On [DATE], Resident 1's chest x- ray results came back positive for pneumonia. On [DATE] at 9 pm, the facility's nursing note read that Resident 1 had a temperature of 101.4 degrees (normal is 98.6 degrees), was breathing 42 breaths per minute (normal is 12 to 18 breaths per minute) with wheezing (a [MEDICATION NAME] or rattling sound in the lungs that happens when there is obstruction in the air passages) in all four areas of his lungs, was short of breath and had vomiting and diarrhea. The nursing note read that Resident 1's physician was notified, new physicians orders were obtained and Resident 1 was put on "Alert charting." The nurses note stated that Tylenol was given for Resident 1's temperature, that there were no signs or symptoms of side effects from antibiotics and that she would continue to monitor Resident 1. On [DATE] at 8:50 pm, Resident 1's physician order [REDACTED]. A normal O2 sat is 95 to 100%). The physician ordered that if the O2 sat was less than 90%, to administer oxygen as necessary and to give [MEDICATION NAME] and Atrovent (medication that is inhaled from the mouth to help difficulty breathing) every four hours as needed for shortness of breath. On [DATE] at 2:20 am, a nurses note read that an order to start giving an IM antibiotic (intramuscular/injectable antibiotic) was received and that Resident 1's RP was notified. There was no documentation in the [DATE] 2:20 am note or any further nursing note that described Resident 1's condition, why he needed and was prescribed an injectable antibiotic instead of the pills he had been receiving, what his present vital signs were or what information had been discussed with Resident 1's responsible party. There were no additional notes after the [DATE], 9 pm entry, that described whether Resident 1's condition was improving or worsening, what Resident 1's vital signs were, what Resident 1's O2 sats were, if he was receiving any oxygen, if any breathing treatments had been administered or what comfort measures had been provided. Resident 1 died on [DATE] at 8:50 am (11 hours and 50 minutes later). On [DATE] at 2:10 pm, Licensed Nurse A (LN A) was interviewed. LN A confirmed that she remembered Resident 1 and the evening of [DATE] very well. LN A stated that she reviewed Resident 1's POLST before she contacted his physician. LN A stated that she did not contact Resident 1's RP because she thought Resident 1 was comfort care only (do not seek to cure or treat illness aggressively). LN A stated that Resident 1 looked like he was close to death and that he "wouldn't last very much longer." On [DATE] at 10 am, a concurrent interview and review of Resident 1's record was conducted with LN B. LN B stated that he remembered Resident 1 and that he had heard that Resident 1 had died . LN B confirmed that he received information that Resident 1 had been placed on "Alert charting" when he received report from the previous shift. LN B stated that he remembered obtaining an order for [REDACTED]. LN B stated that on the night he cared for Resident 1, he did not recall what he told Resident 1's RP when he phoned her to tell her that Resident 1 was prescribed an IM antibiotic. LN B confirmed that did not take any vital signs, obtain an O2 sat, listen to how Resident 1's lungs sounded or give him any breathing treatments on the night shift between ,[DATE] and [DATE]. On [DATE] at 1:50 pm, LN C was interviewed. LN C confirmed that he remembered Resident 1 and the morning of [DATE] very well. LN C stated that he was aware that Resident 1 was on "Alert charting" and the report that he received from the nurse on the previous shift was that he had some lung congestion. LN C stated that vital signs were due by 10 am so they had not been taken yet and that he did not perform an O2 sat or assessment because he had all shift to obtain that information. LN C stated that Resident 1 passed away at 8:50 am on [DATE]. On [DATE] at 8:25 am, an interview occurred with Resident 1's RP. RP stated that she received a telephone call at 2:30 am on [DATE] to inform her that Resident 1 had a cough and that his doctor ordered some antibiotics. RP stated that no one told her that Resident 1 had pneumonia or that he was so sick that he might not survive this infection. RP stated that she was, "shocked," when she received a call on [DATE] at 8:50 am informing her that Resident 1 had been found dead during the morning medication administration. RP stated that irregardless of Resident 1's DNR status, her expectations were that she would have been informed about Resident 1's pneumonia and be given the opportunity to make a decision whether or not to send Resident 1 to the hospital so he could receive more aggressive treatment. RP stated that Resident 1 had not been sick recently and that she would have directed the facility to send Resident 1 to the emergency room for further evaluation. On [DATE], two of the facility's policy and procedures were reviewed. 1. The facility's policy titled, "Alert Charting Policy," dated ,[DATE], stated that the nurses responsibility was to: * Evaluate the Resident when a change from baseline (normal condition) was observed or reported. Examples given were abnormal vital signs (blood pressure, pulse and temperature), shortness of breath, congestion and signs and symptoms of infection. * Place the Resident on alert charting and enter the Resident's name on the 24-Hour Report. * Document the observed/reported change and plan of action in the Resident's medical record. * Notify the Resident's authorized representative. Document the notification in the Resident's medical record and check on the Alert Charting Form. * Document until resolution or stabilization. 2. The facility's policy titled, "24-hour follow up system policy," dated ,[DATE], stated that it was a system to monitor and communicate changes in Resident condition: * Examples of occurrences that should be placed on the 24-hour report were changes in condition, changes in level of care and abnormal vital signs. * The nursing staff should observe, evaluate, document change in the medical record and care plan, place the resident on alert charting and place the Resident's name in the appropriate section of the 24 hour report. * The reports were to be archived for 12 months. On [DATE] at 3:15 pm, Staff D (SD) was asked to retrieve the 24-hour report for Resident 1. SD stated that the record was not available because she was instructed to shred the report because it was not a permanent part of the record. On [DATE] at 12:10 pm, an interview occurred with the Nursing Administrator (NA). NA was asked whether her staff adequately monitored Resident 1's change of condition when he developed pneumonia, implemented the facility's "Alert charting" and "24 hour follow up system" policy and procedures, initiated all available treatments and gave Resident 1's conservator an accurate description of his illness before Resident 1 died . NA shook her head side to side indicating no.

Based on interview and record review, the facility failed to implement their abuse prohibition policy. On three separate occasions, Resident 1 sexually abused two female residents (Residents 2 and 3). Resident 3 reported the sexual abuse to the Dietary Department Supervisor (DDS), however, DDS did not report the incident to facility administration or the California Department of Public Health as required by law and facility policy. As a result of this failure, Resident 3's allegation of sexual abuse was not investigated, Resident 1's behavior was not addressed, other facility residents were not protected, and Resident 2 was also sexually abused by Resident 1. Findings: The facility's Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy, dated 10/2010, consisted of seven components to ensure residents were not subject to abuse. The first addressed the screening for persons with abusive behaviors. The second component training, noted that employees receive training on the facility's abuse prohibition policies and related policies and procedures during their "orientation, annually, and more often as determined by the facility." The third component, prevention included, "Facility supervisors immediately intervene and correct reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring." The fourth addressed identification of causes or triggers for potential or actual abuse situations. The fifth component, investigation, described the facility's investigation and reporting requirements and read, "The facility conducts a thorough investigation of allegations of ...abuse," and "reports investigation findings to the state agency within five working days." The sixth component was to ensure the resident was protected from harm during the investigation. The last component described the facility's responsibility to report allegations of abuse to administration and state agencies as required by law. On 5/21/12 at 4:15 pm, Resident 3 stated that approximately two months ago she was in the front hallway, returning to her room, when Resident 1 wheeled up to her and grabbed her breast. Resident 3 stated that she told Resident 1"No" and Resident 1 released his and immediately attempted to grab her breast again. Resident 3 also reported that approximately two weeks after the above mentioned incident, while in the same area of the facility, Resident 1 grabbed her crotch. Resident 3 again told Resident 1 "No" and he released momentarily and immediately attempted to grab Resident 3 again. Resident 3 stated that there was a group of staff in the hall at that time and she reported it one of them. During an interview on 5/22/12 at 10:25 am, Dietary Department Supervisor (DSS) B confirmed that while assisting Resident 3 back to her room on either 4/24 or 4/25/12, Resident 3 told her that she felt a little uncomfortable because Resident 1 had grabbed her crotch and that there had been a prior incident where he had grabbed her breast. DSS confirmed that she did not inform the facility's Abuse Coordinator or report Resident 3 allegation to the state survey and certification agency. In-service documentation provided by the facility showed that on 4/10 and 4/25/12, DDS received training on the facility's abuse prevention policy and mandated reporter requirements.

Based on observation, interview and record review, the facility failed to treat Resident 1 with dignity and respect when Licensed Vocational Nurse (LVN) E directed and assisted Certified Nursing Assistants (CNA) to shower the resident against his will. This resulted in Resident 1 experiencing anxiety, agitation and emotional harm. Findings: During an interview on 2/23/12 at 5:30 pm, Complainant A (C A) stated that Resident 1 told her he was forcefully given a shower against his will. She stated that Resident 1 said to her, "The bastard held me down!" C A said that the incident had occurred on a Thursday, Resident 1's usual shower day, between 1/26/12 and 2/9/12, and that Certified Nurse Assistant (CNA) B, "May have some knowledge of the incident." Resident 1 clinical record was reviewed on 2/24/12. Resident 1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's Minimum Data Set (MDS - an assessment tool) dated 11/14/11, described Resident 1 as having severe cognitive (the process in knowing) impairment, and that he was usually able to understand and be understood by others. The MDS further described Resident 1 as needing one person to physically help him with bathing. A care plan for Resident 1 titled Behavioral Disturbance, dated 7/2/11, indicated that a behavior of Resident 1 was his rejection of care. One of the goals of the care plan was for Resident 1 to have all his needs met. As an approach to meet this goal, the care plan read, " If appropriate, stop giving care when Resident is hostile, protect Resident's dignity, and ensure safety, try later." During an observation on 2/24/12 at 3:55 pm, CNA D approached Resident 1 and asked him if he wanted a hot shower. Resident 1 responded, "Absolutely not! Last time they dragged me in there!" During an interview on 2/24/12 at 4 pm, CNA D stated, "This is the first time that he (Resident 1) mentioned being forced to take a shower to me." CNA D was asked how she responded when Resident 1 refused to accept a shower. She replied, "I would make other attempts in other ways to see if Resident 1 would accept care." Resident 1's Shower/Bath sheets data for the months of 1/2012 and 2/2012 showed that Resident 1's last shower was given on 1/21/12. A nurse's note dated 2/23/12 9( no time) indicated that Resident 1 had become upset when he was asked to take his shower. It further indicated that the last time Resident 1 was given a shower, staff made him take the shower. During an interview with CNA B on 3/9/12 at 10:15 am, she stated that on 1/21/12 at 11 am, she reported to Licensed Nurse (LN) E that Resident 1 refused to take a shower. CNA B stated that LN E told her and CNA C to put Resident 1 in a shower chair and him a shower. CNA B replied to LN E, "We do not want to do this!" and suggested other forms of care such as a bed bath. CNA B stated that LN E wheeled Resident 1 to the shower room and Resident 1 was yelling that he did not want to take a shower all the way down the hallway. CNA B stated that she and CNA C then proceed to give Resident 1 a showered as directed by LN E while LN E held Resident 1's shower chair from behind. CNA B stated, Resident 1 was very upset from the time he was offered a shower until he was back in his room. During an interview with CNA C on 3/9/12 at 10:40 am, she stated that on 1/21/12 at 11 am, she entered Resident 1's room and the room smelled of urine. She said that Resident 1 was sitting in his wheelchair with urine "Pouring" out of the back of his adult incontinence briefs (absorbent underwear worn for the unintentional leakage of urine) into the seat of his wheelchair. CNA C stated that she notified LN E. LN E then went to Resident 1's room with CNA C and told her to give Resident 1 a shower. When Resident 1 heard the word shower, "He looked like he was about to cry." CNA C stated that she offered Resident 1 a bed bath, but before he could answer her LN E told her, "Get him (Resident 1) in the shower!" LN E then pulled Resident 1 down the hall in a shower chair. CNA C stated, "Resident 1 was combative while in the shower; he continually refused to have a shower the entire time of the incident." During an interview with LN E on 3/9/12 at 11:15 am, he stated that Resident 1 was sitting in his wheelchair in "Overly saturated adult incontinence briefs." LN E stated that CNA B and CNA C asked him to help them with Resident 1 because, "The resident was upset about taking a shower." LN E said that he redirected Resident 1 by explaining the importance of a shower after which Resident 1 agreed to a shower. LN E said that he provided stand by assistance to prevent injury to the staff or resident.

The facility failed to protect Residents 1, 2, and 3's right to be free of coercion and reprisal, when they were threatened with discharge from the facility, if they would not agree to sign a new form about stricter smoking rules. Resident 1, 2, and 3 had been found in possession of tobacco and or lighters and the facility threatened them with discharge, if they did not agree to sign the new smoking form. 1. Resident 1, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's minimum data set (MDS, an assessment tool), dated 12/14/11, described her as being understood and able to reason, think, and understand clearly. The MDS indicated the facility had determined it was not feasible to discharge Resident 1 to the community and had no plan to discharge the resident. Resident 1's record contained a nurses note, dated 1/1/12, that read, "...Follows all rules and regs (regulations) reg (regarding) smoking rules..." Resident 1's record contained a physicians progress note, dated 1/28/12, that showed the physician did not plan to discharge her and had planned to continue supportive care. On 2/8/12 at 8 am, Resident 1 stated that on 2/3/12, Administrative (Adm) Staff A asked her to sign the new form about following the facility's smoking policy and told her she would be issued a 30 day notice to leave the facility if she did not agree to sign it. Resident 1 stated she refused to sign the new form because she had already signed a smoking policy upon admission. Resident 1 stated she felt she was being singled out. Resident 1's record contained a social progress note, dated 2/6/12, that showed she refused to sign the new smoking policy and was issued a 30 day notice (discharge). On 2/8/12 at 8:40 am, Resident 1 stated that when she called her physician on 2/3/11, he was unaware she was being discharged from the facility. Resident 1 stated she did not understand why she would be sent to a homeless shelter, as told to her by Adm Staff A, when she had family living in town. Resident 1 stated she was worried that she would have a [MEDICAL CONDITION] at the homeless shelter and die. On 2/8/12 at 11:20 am, Adm Staff C explained that earlier in the week, Residents 1 and 2 had cigarettes (no matches) in their possession during a smoke break she supervised. Adm Staff C confirmed the new smoking form was developed because she brought this to the attention of Adm Staff A and the facility's administration on 2/3/12. On 2/8/12 at 11:30 am, Adm Staff A confirmed the new smoking form was developed on 2/3/12 after Resident 1 and 2 were found with cigarettes. When Adm Staff A was asked how she determined that Resident 1 no longer needed long term care and that transfer to a homeless shelter with no medical supervision was appropriate, she confirmed she was not qualified to determine that and had not received medical guidance. Adm Staff A recalled that she told Resident 1 that she would revoke the discharge notice if the resident would sign the form. Adm Staff A confirmed that the facility was "not actually trying to discharge" Resident 1 but gave her the notice to get her to sign the form and to impress upon her the seriousness of the situation. On 2/8/11 at 3 pm, Adm Staff B was asked if the facility intended to discharge Resident 1, she stated that they were trying to "scare her into compliance" to sign the smoking form. Adm Staff B confirmed they would not have discharged Resident 1. 2. Resident 2, a [AGE] year old female, was admitted to the facility on [DATE]. The facility's MDS, dated [DATE], described her as able to think, reason, and understand clearly. On 2/8/12 at 8:15 am, Resident 2 (Resident 1's roommate) confirmed that on 2/3/12, when Adm Staff A asked her to sign the new smoking form, Adm Staff A was not frustrated with her, because she signed without objection. Resident 2 stated that when Adm Staff A approached Resident 1 to sign, she had acted totally different towards Resident 1, was not nice, and was on a "power trip." Resident 2 stated that Adm Staff A told Resident 1, "You have 30 days to get out; vacate the premises," if she did not sign the form. Resident 2 stated that Adm Staff A did not explain the discharge to Resident 1 but said, "You'll be transported to the (a local homeless shelter)." Resident 2 stated that she feared Resident 1's [MEDICAL CONDITION] made it unsafe for her to be sent to a homeless shelter. 3. Resident 3, a [AGE] year old male, was admitted to the facility on [DATE]. The facility's MDS, 1/18/12, described him as able to think, reason, and understand clearly. On 2/8/12 at 1:55 pm, Resident 3 stated he was asked to sign the form by Adm Staff A and she told him that if he did not sign or got caught with any smoking items, he would get "kicked out or get a discharge notice." Resident 3 stated that he felt he had no choice, so signed the form and it made him feel angry towards the facility staff. Therefore, the facility failed to ensure Residents 1, 2, and 3's right to be free of coercion and reprisal was protected, when they were verbally threatened with a written Notice of Proposed Transfer/Discharge to leave the facility, if they would not agree to a new form about smoking rules. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients.

Based on observation, interview, and record review, the facility failed to ensure Resident 1 was free from unnecessary drugs when multiple psychotherapeutic (related to the treatment of [REDACTED]. Additionally, the facility failed to recognize and report adverse side effects; repeated falls, recurrent UTIs, increased agitation and aggression, confusion, wandering and increased sedation, that Resident 1 demonstrated from the use of multiple psychotherapeutic medications. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE], [DATE], and [DATE], a review of Resident 1's clinical record indicated the following: The [DATE] Physician order [REDACTED]. [MEDICATION NAME], an antidepressant medication; [MEDICATION NAME], an antianxiety medication; [MEDICATION NAME], an antipsychotic medication; [MEDICATION NAME] Sodium Extended Release (ER), a mood stabilizer; and [MEDICATION NAME], an opiate (narcotic) containing pain medication. The physician ordered injections of [MEDICATION NAME], an antipsychotic medication, on four occasions between [DATE] and [DATE] for acute agitation (striking out at staff and residents). Resident 1 also received [MEDICATION NAME], an antipsychotic medication, for combativeness. A physician discontinued the [MEDICATION NAME] on [DATE] as it, "was ineffective." According to Lexi-Comp ONLINE, a nationally recognized medication reference resource, [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME], all had [MEDICATION NAME] (a drug classification) adverse side effects including [MEDICAL CONDITION]/hesitancy (the bladder abnormally retains urine), urinary tract infection [MEDICAL CONDITION], sedation/drowsiness, increased falls/dizziness, confusion, anxiety/agitation, and akathasia (a pattern that included uncontrolled movements, restless overactivity, and pacing). [MEDICATION NAME] also had adverse side effects that included [MEDICAL CONDITION], and dysuria (difficult or painful urination). Additionally, [MEDICATION NAME] and [MEDICATION NAME] are central nervous system depressants, lending to sedation/drowsiness, increased falls/dizziness, and anxiety/agitation. A Incontinence (inability to control urine flow) Care Plan (CP) for Resident 1, started [DATE], and most recently reviewed [DATE], included his problems of "urine incontinence: daily with some control," and "bowel incontinence ,[DATE] times a week." To carry out the plan of care, staff was to, "assist with toileting, bedpan, urinal every two hours and as needed." An Elimination Care Plan, started [DATE], listed "chronic UTIs" as a problem, and instructed staff to monitor Resident 1's bowel (feces) and bladder (urine) every two hours. IDT (Interdisciplinary Team) Notes, dated [DATE], documented, "...Resident also has a long standing history of chronic UTI's. He has a tendency to have aggressive behaviors, especially when he has a UTI...Resident was last treated for [REDACTED]." An IDT CP for Antidepressant Therapy for Resident 1 was first dated [DATE]. An IDT CP for Antipsychotic Therapy was first dated [DATE]. An IDT CP for Resident 1's Antianxiety therapy was first dated [DATE]. Each of these care plans specified that the side effects of the related medications were to be monitored. During an interview on [DATE] at 2:10 pm, Staff H stated that Resident 1 had had at least one resident-to-resident altercation each shift; and that almost every shift, he strikes out at staff. She stated that when he had a roommate, he would crawl out of bed to get to the roommate and claw at him; and that, three weeks ago, when she was assigned "1 on 1" with Resident 1, he, "punched me in the mouth and busted my lip." From ,[DATE] to ,[DATE], the following was documented in Resident 1's health record: confusion, disorientation, persistent anger, verbal and physical abuse/aggression, repetitive anxious complaints, intruding on others, tearfulness, sleeping more, agitation, combativeness, striking out at staff, and pacing (via wheelchair). A physician added or changed Resident 1's psychotherapeutic medications and/or [DIAGNOSES REDACTED]. Behavior data for the month of [DATE] showed that Resident 1 received 35 doses of [MEDICATION NAME] in response to aggressive or agitated behavior. The behavior data indicated that there had been no side effects from his psychoactive medications. A Behavior Evaluation Review form, dated [DATE], documented the following for the month of ,[DATE]: 10 episodes of Resident 1 striking out at staff; 35 doses of "as needed" [MEDICATION NAME] administered (a minimum of one dose per day) to Resident 1... Notify MD of potential non-verbal signs and symptoms of pain, resident unable to communicate need. Possible routine pain medication would be beneficial to resident." Twenty-four nursing note entries and IDT notes from [DATE] to [DATE], described Resident 1's behaviors as confusion, refusing vital sign checks (assessment of blood pressure, heart rate, respiration rate and temperature), indications of pain, agitated, spitting, yelling out, verbally aggressive to other resident, whining, crying, pounding on glass at nurses' station, verbally combative, argumentative, restless, anxious, crying for his daddy, kicking and striking out at staff, physical aggression with minor injuries to other residents, and that a visitor reported Resident 1 wandering outside the facility in his wheelchair. The facility did not correlate any of Resident 1's behaviors to the side effects of his medications. On [DATE], Resident 1 was involved in an altercation where he caused skin tear injuries to another resident. Facility team notes on [DATE] stated that his aggression had increased and that he had, "a history of becoming increasingly angry/abusive when he has a UTI." A physician progress notes [REDACTED]. Resident to resident altercations. Combative. Frequent UTIs?...plan: increase [MEDICATION NAME]. Increase [MEDICATION NAME]" An IDT note, dated [DATE], documented that Resident 1 became agitated, attempted to hit staff, and grabbed staff...resident has significant history of multiple UTIs...episodes have historically been related to UTI prevalence...IDT recognizes that aggressive/abnormal behaviors noted almost daily since [DATE]...recommend...a broad spectrum antibiotic for pending UA results, as well as, consider [MEDICATION NAME] (preventative) antibiotic for chronic UTI's." Resident 1 suffered from at least ten UTIs ([DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]). The facility's policy, Urinary Tract Infections, dated [DATE], stated that the, "Residents will receive appropriate treatment and services to prevent UTIs," and "The licensed nurse assesses for contributing factors, identifies risk factors for reoccurrence and establishes interventions to reduce risk of reoccurrence." There was no evidence of assessment or interventions by facility staff for the contributing factors. In Resident 1's health record, there was no documentation by staff, clinicians, administration, or a pharmacist, that recognized that Resident 1 was potentially suffering from any or all of the adverse side effects of the medications that he was given. Between [DATE] and [DATE], Resident 1 had increasingly abnormal laboratory results that indicated his prostate was becoming progressively larger. Per Taber's Cyclopedic Medical Dictionary, edition 15, and MayoClinic.com, the prostate (a gland that secretes fluid for semen) surrounds the neck of the urinary bladder and the urethra (urine outlet tube) in the male; and when the prostate enlarges, either with or [MEDICAL CONDITION], it results in urethral obstruction and urine retention. The urine retention often contributes to urinary tract infections. On [DATE], a clinician ordered Resident 1 to be referred to a urologist (a doctor who specializes in issues related to the urinary system and the prostate gland). On [DATE], three days after this surveyor brought the issue of Resident 1's prostate to the facility's attention, a physician ordered [MEDICATION NAME] (a medication to treat the symptoms of of an enlarged prostate by relaxing muscle tissue in the neck of urinary bladder and in the prostate, thereby improving the flow of urine). On [DATE], a physician's progress note stated, "...This gentleman has (progressively increasing) aggression (with) current Rx (treatment). Last night, he tried to strike the care taker, but additional [MEDICATION NAME] to help. It was in my plan to increase [MEDICATION NAME] tomorrow if any aggression. This behavior problem is probably a complication of chronic UTI and his Alzheimer dementia. Most likely cause of UTI (probable) bladder outlet obstruct, incomplete emptying of urinary bladder ([MEDICAL CONDITION])." The physician discussed difficulty in catheterization (inserting thin plastic tubing) of the bladder to obtain residual urine from Resident 1 and stated, "Meantime, we are increasing [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]), (and as needed injections of) [MEDICATION NAME]. Rx (treat) UTI." During an interview on [DATE] at 11:42 am, Staff B stated that she had found no record of Resident 1 having a urology consult, and that she had called the urologist's office and was told Resident 1 had not been seen. Adverse effects of medications, a failure to investigate the cause of the UTIs, and the progressive enlargement of his prostate, potentially contributed to the recurrence of Resident 1's UTIs, and continuation of his agitated and aggressive behaviors. As stated on MayoClinic.com: [MEDICAL CONDITION] is a progressive disorder of the nervous system that impairs movement. Those with [MEDICAL CONDITION] may fall more easily; may be thrown off balance by just a small push or bump, or by reaching or leaning. As stated in Mosby's Drug Guide for Nurses (eighth edition) and/or Lexi-Comp's Handbook, [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] each had the adverse effects of causing the same symptoms that are common to [MEDICAL CONDITION], including impaired memory, confusion, and impaired urination. Resident 1's [MEDICAL CONDITION], multiple [MEDICATION NAME] and sedating medications, potentially inhibited Resident 1's cognition, memory, and control of his movement and balance. Interdisciplinary team notes, post fall evaluation forms, and nurses notes indicated that Resident 1 had had at least ten falls (some with minor injuries such as swollen hand, bruises, and skin tears), additional unexplained injuries, an incident of wandering outside the facility, and repeated episodes of confusion, from [DATE] to [DATE]. A CP for Fall Risk was noted as not being started until [DATE], despite falls dating back to ,[DATE]. Resident 1's MARs indicated that in [DATE] he received 12 doses of [MEDICATION NAME] and 37 doses of [MEDICATION NAME]. In [DATE] he received two injections of [MEDICATION NAME] 0.5 mg, 27 doses of [MEDICATION NAME] and 48 doses of [MEDICATION NAME]. In August (through [DATE]) he received 66 doses of [MEDICATION NAME] (routinely and as needed) and 35 doses of [MEDICATION NAME]. On [DATE] at 10:55 am, Resident 1 was observed sleeping in his bed with Staff I in attendance. Staff I stated that she had awakened him, showered him, and taken him to breakfast in the dining room. She stated that he had been given "all his medicines right before breakfast," and that when he had become "fussy and loud and was tired," she assisted him back to his room and to bed, "and he has been sound asleep ever since." On [DATE] at 1:05 pm, Resident 1 was observed asleep in bed, in the same position as was observed at 10:55 am. On [DATE] at 2:25 pm, Resident 1 was observed in bed asleep. During a concurrent interview, Staff I stated that she had gotten him up for lunch, he had become tired, and she put him back to bed. During an interview on [DATE] at 9:40 am, the facility's pharmacist (Pharm G) concurred that complete chart reviews by the facility's pharmacist should have included a review of the repeated UTIs with pain, and of the comments that Resident 1's UTIs were correlated with an increase in Resident 1's negative behaviors. She further stated that the pharmacist should have reviewed all of Resident 1's prostate workups. She agreed that Resident 1's negative behaviors may not have been due to [MEDICAL CONDITION] or mood disorders, and yet the behaviors were treated with multiple psychotherapeutic medications. She stated that the notes regarding falls should have been considered. She did not respond to questions regarding the possible correlations between Resident 1's falls, confusion, and sedation; and the amounts of sedative and central nervous system depressant medications he had received. On [DATE], Resident 1 was transferred to an acute care hospital. He died on [DATE]. The admitting and "discharge" (time of death) [DIAGNOSES REDACTED].