Every finding on record at Overland Terrace Healthcare & Wellness Centre, LP

Based on interview and record review, the facility failed to ensure the policy for pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care assessment and treatment was followed, for one of three sampled residents (Resident 1) by failing to:Identify and document the pressure ulcer upon re-admission to the facility.Document a change of condition once the pressure ulcer was identified.Contact the resident's responsible party upon identification of a new pressure ulcer.Implement a low air-loss mattress (pressure ulcer intervention) in a timely manner after pressure ulcer was identified.These deficient practices resulted in Resident 1 having a delay in assessment, treatment and interventions for the sacrococcyx (area including the sacrum, large, triangular bone at the base of the spine and the coccyx the tailbone) pressure ulcer identified six days after re-admission from hospitalization on 5/8/26.1. During a review of Resident 1's admission Record, dated 6/30/28 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), hypertension, (HTN - high blood pressure), muscle weakness, hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream), vascular dementia (decline in thinking, reasoning, and memory caused by decreased blood flow to the brain), chronic kidney disease (CKD - progressive damage to kidneys reducing their ability to function), metabolic encephalopathy (dysfunction caused by chemical imbalances in the brain), dysphagia (difficulty swallowing), and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 5/15/26 indicated, Resident 1 had severe cognitive (function of the mind, related to thinking memory, problem-solving, decision making, judgement) impairment and was totally dependent on staff for bed mobility, transfers and activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), and the resident was at risk for pressure ulcers. During a review of Resident 1's hospital physician transfer notes and orders dated 5/8/26 indicated the resident had wounds on the right 4th toe with order of betadine daily and one on the left leg which had an ordered treatment of collagenase (an enzyme that specifically breaks down collagen, a structural protein found in connective tissues like skin, bone, and tendons) (Santyl) ointment topical daily to left leg, first dose 5/2/26. During a review of Resident 1's Clinical Admission note dated 5/8/26, no documentation of a sacrococcyx pressure ulcer noted.During a review of Resident 1's Skin Check note dated 5/10/26, no documentation of a sacrococcyx pressure ulcer noted.During a review of Resident 1's Long Term Care Evaluation note dated 5/10/26, no documentation of a sacrococcyx pressure ulcer noted.During a review of Resident 1's Skin Issues note dated 5/14/26, no documentation of a sacrococcyx pressure ulcer noted.During a review of Resident 1's IDT (interdisciplinary team) Progress notes - Skin dated 5/15/26 indicated IDT done for left shin diabetic ulcer resolved and 4th toe with stable gangrene - again no documentation of a sacrococcyx pressure ulcer.During a review of Resident 1's Long Term Care Evaluation note dated 5/17/26, no documentation of a sacrococcyx pressure ulcer noted.During a review of Resident 1's Skin Issues note dated 5/20/26 indicated the first time the sacrococcyx pressure ulcer was documented, as unstageable (wound covered by dead tissue that which one cannot see the depth and underlying tissues). During a concurrent telephone interview on 6/30/26 at 3:45 pm with Treatment Nurse (TXN) 2 Resident 1's nursing progress notes above were reviewed. TXN verified she had not documented the pressure ulcer on admission because she does not stage the wounds and stated when the wound care specialist saw the resident on 5/13/26 he said it was an unstageable pressure ulcer. TXN 2 further stated the Registered Nurse does the admission assessment, and does not know why the pressure ulcer was not captured on her assessment. During a concurrent interview and record review with Registered Nurse (RN), 1 on 6/30/26 at 2:26 pm, Resident 1's admission summary note dated 5/8/26 was reviewed, the summary indicated resident re-admitted from hospital Has right foot fourth toe dry with skin gangrene, left lower leg shin diabetic skin ulcers with dressing dry and intact noted. RN 1 verified this and stated she noted the resident came from the hospital without a documented or endorsed (verbal report) of any pressure ulcer, in contradiction to the TXN 2's account the resident arrived with the pressure ulcer. During a telephone interview with the Director of Nursing (DON), on 7/7/26 at 3:49 pm, the above documentation omissions were discussed and the DON acknowledged there was no documentation of a sacrococcyx pressure ulcer done upon admission, so it is not possible to know when it was identified. DON agreed the treatment nurse should have documented something in the resident's chart upon the admission before the day the wound care specialist Physician's Assistant documented their consult note on 5/13/26, and it was within her scope to document and describe the pressure ulcer. 2. During a review of Resident 1's Wound Assessment documented by Physician's Assistant (PA) 1 indicated Consult on hospital acquired unstageable PU to sacrococcyx.During a review of Resident 1's Skin Issues note dated 5/20/26 indicated the first time the sacrococcyx pressure ulcer was documented by a nurse.During a concurrent interview and record review with Registered Nurse (RN) 1 on 6/30/26 at 2:26 pm, the above notes were reviewed. RN 1 verified and stated a change of condition should be done for any new changes on the resident. 3. During a review of Resident 1's care plan titled: The resident has potential for pressure ulcer development r/t decreased mobility, use of anticoagulants (medication that prevents or slows down blood clotting)/antiplatelet (blood thinner, prevents clotting factors in the blood from clumping together and clot) to medication revised 6/8/26 indicated 5/27/26 Resident has an unstageable wound to sacrococcyx. Educate the resident/family/caregivers as to causes of skin breakdown. 5/27/26 low air loss mattress for skin management. inform the resident/family/caregivers of any new area of skin breakdown. During an interview with RN 1 on 6/30/26 at 2:26 pm the RN 1 stated there were various times she and the other staff spoke with the Responsible Party (RP) to inform them of the resident's care but they did not document it but should have to record it. During a review of the facility's policy and procedures (P&P) titled Pressure Injury Prevention, reviewed January 2026, the P&P indicated a skin evaluation upon admission/re-admission, weekly for four consecutive weeks after admission, quarterly and when there is a significant change in condition. A weekly skin check will be completed and documented in the medical record. During a review of the facility's P&P titled Skin Integrity Management, reviewed January 2026, the P&P indicated Assessments. A Licensed Nurse will complete a skin evaluation when there is a change in skin integrity. The physician and responsible party will be notified when there is a change of condition of the pressure injury or skin integrity condition. Review the resident's care plan and update as necessary. 4. During a review of Resident 1's Wound Assessment documented by Physician's Assistant (PA) 1 indicated Consult on hospital acquired unstageable PU to sacrococcyx.During a review of Resident 1's Order Summary Report dated from 4/1/26 - 6/30/26 indicated an order entered on 5/19/25 for Low air loss mattress for skin management. every shift for skin and wound management.During a review of Resident 1's care plan titled: The resident has potential for pressure ulcer development r/t decreased mobility, use of anticoagulants (medication that prevents or slows down blood clotting)/antiplatelet (blood thinner, prevents clotting factors in the blood from clumping together and clot) to medication revised 6/8/26 indicated 5/27/26 Resident has an unstageable wound to sacrococcyx. Educate the resident/family/caregivers as to causes of skin breakdown. 5/27/26 low air loss mattress for skin management. inform the resident/family/caregivers of any new area of skin breakdown. During a telephone interview on 6/30/26 at 3:45 pm with TXN 2. TXN verified the resident records above and stated there was not a delay in implementing the intervention of the low air loss mattress for skin management on the resident even though the resident was assessed with pressure ulcer on 5/13/26 and the mattress was not ordered until 5/19/26, contradicting herself she further stated however that interventions on the care plan should be followed. During a review of the facility's P&P titled Pressure Injury Prevention reviewed January 2026, the P&P indicated, implement interventions identified in the plan of care for the resident's risk factors. Implement interventions identified in the plan of care which may include, but are not limited to the following. Pressure redistributing devices for bed and chair.

Based on observation, interview and record review, the facility failed ensure staff followed infection prevention policies and procedures for Enhanced Barrier Precautions (use of personal protective equipment, PPE [gloves, gown, mask and goggles or face shield] when providing wound care to a resident where EBP was indicated for one of three sampled residents (Resident 2).This deficient practice had the potential to result in exposure or transmission of infections to other residents and/or staff.During a review of Resident 2's admission Record, dated 6/30/26, the admission record indicated, the resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), hypertension, (HTN - high blood pressure), muscle weakness, hyperlipidemia (HLD - a condition characterized by elevated levels of lipids (fats) in the bloodstream), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 2's History and Physical (H&P), dated 1/1/26 indicated, the resident had capacity for medical decision making. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/6/26 indicated, resident 2 was independent to requiring supervision from staff for most activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 2's Order Summary Report, dated 6/30/26 indicated an order for wound care of Santyl external ointment 250 unit/gram (Collagenase - an enzyme that specifically breaks down collagen, a structural protein found in connective tissues like skin, bone, and tendons), apply to right anterior ankle every day shift. Cleanse with normal saline (NS - a sterile mixture of salt and water containing exactly 0.9% sodium chloride) pat dry apply Santyl ointment cover with dressing ad wrap with ACE wrap daily and as needed (PRN). During an observation on 6/30/26, at 10:45 am outside Resident 2's room there was signage posted indicating Resident 2 to be on EBP and an isolation cart stocked with gloves, gowns and surgical masks. Further observation at Resident 2's bedside Treatment Nurse (TXN) 1 was observed providing wound care to Resident 2 without donning (putting on) a gown. During a concurrent observation and interview on 6/30/26 at 2:20 pm, outside Resident 2's room with TXN 1, the Enhanced Barrier Precautions sign (undated), was reviewed. The sign indicated, Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Wound care: any skin opening requiring a dressing., TXN 1 acknowledged the sign and stated she was nervous earlier and forgot to don the gown before doing the wound care, TXN 1 further stated a risk would be cross contamination. During a review of facility's policy and procedure (P&P), titled, Enhanced Barrier Precautions (EBP), reviewed January 2026, the P&P indicated, When Transmission-based precautions (advanced infection-control measures used in healthcare settings, i.e., isolation and PPE) are not appropriate and in addition to Standard Precautions (the minimum infection prevention practices used at all times for all patients in healthcare settings, i.e., hand washing, environmental cleaning), Enhanced Barrier Precautions will be used. Purpose. To reduce the risk of transmission of epidemiologically important microorganisms (infectious agents with a high potential to cause severe public health outbreaks, transmit rapidly through populations, or resist standard treatments) by direct or indirect contact. For residents for whom EBP are indicated, EBP is employed when performing the following. Wound care: any skin opening requiring a dressing.

Based on observation and interview, the facility failed to:1. Ensure kitchen staff labeled all foods stored in the freezer with the correct food name, date of food delivery, date the food container was opened, and best by date. 2. Ensure staff did not pick up a meal ticket off the floor then placed the contaminated (something has been made impure, unclean, or dangerous by contact with or the addition of a harmful, foreign, or undesirable substance) meal ticket on one of six residents' (Resident 12) food trays then walked towards the dining room to serve the food tray to Resident 12 with the contaminated meal ticket still on the food tray. These deficient practices had the potential for Resident 12 and the residents who consume food from the kitchen to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages) and food to contamination (the introduction of pathogens or infectious material into or on normally clean or sterile objects, spaces, or surface) resulting in hospitalization. Findings: a. During an initial kitchen tour 6/01/2026 at 8:18 AM, several food items in the freezer were not properly labeled: Diced ham - food label did not indicate what the dates 4/15/26 and 4/13/2027 were for.Chicken patties - food label did not indicate what food the label was for; the food label indicated the date 5/11/26 was for shell life and 5/15/26 was the used by date.Beef steak - food label indicated date opened was on 5/25/2026 but did not indicate when the food was delivered and when was the expiration date.Barbeque (BBQ) pork - food label indicated date opened was on 5/26/2026 but did not indicate when the food was delivered and when was the expiration date. During a concurrent observation and interview on 6/01/2026 at 8:27 AM with the Dietary Services Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations), DSS stated the frozen chicken patties are good for five days after opening. DSS added the BBQ pork & beef steak are good for 1 month from the date it was opened. During an interview on 6/03/2026 at 2:06 PM with dietary aide (DA - assists in preparing, serving, and delivering meals in healthcare settings) 2, DA 2 stated as soon as the food is delivered to the facility, the delivered food is labelled and the label must include food name, date of delivery, date the food was opened, and when the food will expire. DA 2 also stated that when a food label has incomplete information, the food must be thrown away. b. During an interview on 6/03/2026 at 2:17 PM with DA 1, DA 1 stated all foods received must be labeled when it's delivered to the facility. DA 1 also stated all foods must be labeled so we know when the food will expire or when we opened the bag and we don't want to use expired food to serve the residents and food may be bad and it may make them (residents) sick they might go to the hospital for that. During an interview on 6/03/2026 at 2:26 PM with the dietary cook (DC), DC stated, the reason why food labeling is important is to tell us when food is good to use for residents to eat; we need to know when the food was received, when it's good for and when it will expire. During a follow interview on 6/03/2026 at 2:39 PM with DSS, when asked why several food items in the freezer were not labeled, DSS stated, I in-serviced the staff about it but some of them may be forgot and food labeling is important because, you don't know how long the meat has been there. Some items are good for example two years but once the package is opened, the date of expiration is now changed. For frozen foods once opened, it's only good for 5 days. If the food was in the refrigerator, you will still have it good for up to 5 days. According to DSS stated that, the food might cause them (residents) illness like nausea, vomiting, diarrhea and stomach pains. A review of the facility's in-service education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) dated 2/21/2026 indicated dietary staff were educated on which products need labeling, how to label products, and which items need dating which includes date items were received, used by date, and date all items when opened. A review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Food Storage and Handling with a revision date of 1/2026 indicated, raw meat.should be labeled, dated, and stored in refrigerators/freezers. and frozen meat.should be labeled, dated. A review of the facility's P&P titled Receiving Food and Supplies with a revision date of 1/2026 indicated, items received should be dated. CROSS REFERENCE F880c. During a dining observation on 6/01/2026 at 12:33 PM, Activities Director (AD - designs and leads recreational, social, and therapeutic programs to improve residents' quality of life) was observed picking up a meal ticket that fell on the floor with her bare right hand. AD proceeded to place the contaminated meal ticket on Resident 12's food tray then proceeded to walk towards the dining room. AD was stopped by the surveyor prior to entering the dining room. AD stated, I was going to give [Resident 12] the food tray. AD also stated [Resident 12] might get sick if [Resident 12] ate the food because I contaminated the food tray. AD stated that had Resident 12 consumed the food that was on the contaminated food tray, Resident 12 will have stomach pains.might vomit.will have a lot of pain because of the stomach pains, and the resident will go to the bathroom a lot. I am so sorry. During an interview on 6/01/2026 at 12:42 PM with Activities Assistant (AA - assistant to the Activities Director), AA stated that a meal ticket that fell on the floor is a dirty meal ticket because all floors are dirty. AA also stated that the dirty meal ticket should not be put on the food tray because food is clean. AA stated Resident 12 will get sick from eating the food.will have diarrhea, vomiting.might go to the hospital if [Resident 12] is too sick. During an interview on 6/03/2026 at 2:17 PM with DA 1, DA 1 stated that when staff break infection control (measures taken to prevent or stops the spread of infections in the healthcare settings), residents might get diarrhea, infection, vomit. They [residents] might end up in the emergency room. During an interview on 6/03/2026 at 2:39 PN with DSS, DSS stated the residents are vulnerable and we don't know what the [residents'] immune system can or cannot tolerate. We always have to make sure we follow proper rules and instructions. DSS added that residents get so sick like bad diarrhea and vomiting or bad food poisoning that they end up in the hospital. A review of the facility's in-service education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) indicated education on infection control was not provided to the staff prior to the 6/03/2026 break in infection control incident. A review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees with a revision date of 3/25/2026 indicated, during food preparation, as often as necessary to remove soil and contamination, and to prevent cross-contamination when changing tasks.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 77) who received dialysis (process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, by failing to:1. Complete Post Dialysis Assessment following Resident 77 returning from dialysis treatment.2. Implement the physician's order for fluid restriction of 1200 cubic centimeters (cc-unit of measurement) a day. These deficient practices had the potential to result in harm to the resident which could include edema or unchecked bleeding. Findings: A review of Resident 77's admission record indicated the facility originally admitted the resident on 1/2/20213 and readmitted the resident on 8/1/2025 with diagnoses that included end stage renal disease (ESRD - loss of kidney function in which the kidneys no long work to meet the body's needs) and dependence on renal dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) and heart failure (heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). A review of Resident 77's care plan (CP) on ESRD and Dialysis Dependence, initiated 3/5/2022, indicated Resident 77 receives dialysis treatment every Tuesday, Thursday and Saturday. The CP goal was for the resident to have no signs or symptoms of fluid overload (occurs when the body retains too much fluid, particularly in the bloodstream or tissues). The CP interventions included approaches included fluid restriction of 1200 cc per day. The CP interventions also included if bleeding occurs at arteriovenous (AV-a surgically created connection between an artery and a vein used for hemodialysis) shunt (a passage or medical device used to divert the flow of bodily fluids from one part of the body to another site) anytime after dialysis, to apply pressure with clean gauze (a loosely woven, breathable cotton material used in healthcare for wound management, fluid absorption, and surgery) for 5 minutes-10 minutes Repeat until bleeding stops. If this intervention does not control bleeding, notify the physician. A review of Resident 77's Quarterly Minimum Data Set (MDS - a resident assessment tool), dated 3/18/2026, indicated Resident 77's cognition (the mental ability to make decisions of daily living) was intact. The MDS indicated Resident 77 was independent with eating, required supervision with oral hygiene and required substantial assistance with showering and dressing. The MDS also indicated Resident 77 was receiving dialysis treatment. A review of the Physician's History and Physical dated, 5/23/2026, indicated Resident 77 has the capacity to understand and make decisions. The MDs also indicated that Resident 77 was diagnosed with ESRD and was on hemodialysis (HD- a life-sustaining medical procedure that acts as an artificial kidney. HD filters waste, removes excess fluid, and balances electrolytes in the blood for patients experiencing acute or chronic kidney failure). A review of Resident 77's Physician Orders, dated 5/22/2026, indicated Resident 77 was to receive:- Dialysis treatment every Tuesday, Thursday and Saturday at a dialysis center from 8:30 AM to 12 PM and- Resident 77 had a fluid restriction of 1200 cc every 24 hours. A review of Resident 77's Physician Orders, dated 5/23/2026, indicated staff are to observe Resident 77's left upper arm catheter for dialysis for redness, tenderness, bleeding and drainage every shift A review of Resident 77's Certified Nursing Assistant (CNA) Documentation log for the month of May 2026 indicated Resident 77 received 1200 cc of fluid on the evening shift (3pm-11pm) on 5/4/2026, 5/5/2026, 5/6/2026, 5/10/2026, 5/13/2026, 5/14/2026, 5/18/2026, 5/19/2026, 5/24/2026, 5/28/2026 and 5/31/2026. A review of Resident 77's Pre Dialysis Evaluation, dated 6/2/2026 indicated the evaluation was completed prior to Resident 77 receiving dialysis. The review of the facility's Pre-dialysis Evaluation Form indicated is a two section form. The first section is the pre dialysis assessment to be completed by the facility. The second section is for the dialysis unit/center to fill out. The form indicated the resident had a left AV shunt and the resident's condition had not changed since the last dialysis treatment. During a concurrent interview and record review on 6/3/2026 at 11:12 AM, Resident 77's Electronic Medical Chart (EMC) and the facility's Dialysis binder was reviewed. Licensed Vocational Nurse (LVN) 6 stated Resident 77 receives dialysis on Tuesday, Thursday and Saturday and has a left arm AV shunt. LVN 6 stated nursing staff complete pre (before) and post (after dialysis form when the resident goes to dialysis. LVN 6 further stated a pre dialysis form was filled out for the resident yesterday on 6/2/2026). LVN 6 also stated a post dialysis form was not completed. LVN 6 stated the nurse must complete a post dialysis form to evaluate the resident's vital signs (body temperature, blood pressure, pulse [heart rate], and breathing rate to help assess the general physical health of a person), access site for bleeding. LVN 6 also stated, it's important to assess the resident post dialysis because the resident could have low blood sugar or unchecked bleeding. During an interview on 6/3/2026 at 11:52 AM, Certified Nursing Assistant (CNA) 1 stated Resident 77 goes to dialysis. CNA 1 stated Resident 77 is on a fluid restriction and that a water pitcher is not provided to the resident. CNA 1 stated several times she has had to remove the water pitcher from Resident 77's bedside when CNA 1 comes to work in the morning. CNA 1 further stated staff can document the amount the resident drinks on the CNA documentation. During a concurrent interview and record review on 6/3/2026 at 12:39 PM with Registered Nurse Supervisor (RNS) 1, Resident 77's CNA documentation for the months of May and June 2026 was reviewed. RNS 1 stated Resident 77 receives dialysis Tuesday Thursday Saturday and that the resident was on a fluid restriction. During a concurrent review of Resident 77's physician orders. RNS 1 stated Resident 77 had a fluid restriction of 1200 cc per day. Dietary could provide Resident 77 700cc per day and CNAs could provide 240cc on the day and evening shift and the night shift could give 100cc. Upon review of Resident 77's CNA documentation, RNS 1 stated Resident 77 received 1200 cc during the evening shift on 6/2/2026. RNS 1 further stated in May 2026, it was documented that Resident 77 received 1200 cc during the evening shift on 5/24/2026, 5/28/2026 and 5/31/2026. RNS 1 stated Resident 77 could become overloaded (swollen due to too much fluid trapped in the body's tissues). During an interview on 6/5/2026 at 11:23 AM, the Director of Nursing (DON) stated a post dialysis assessment is completed within 30 minutes of the resident returning from dialysis. The DON stated bleeding could happen from not assessing the resident when they have returned from dialysis. The DON further stated CNAs report the resident's fluid intake to the charge nurses and the charge nurses complete the documentation. A review of the facility's policy and procedures titled, Dialysis Management, reviewed 2/2026, indicated, .3. A pre and post dialysis evaluation will be completed by the licensed nurse. a. Diet and fluid restrictions will be followed as ordered6. Emergency Care and Precautions:a. AV fistulai. If a patient's access site is oozing, apply moderate pressure for 5min-10 min until bleeding subsides. Repeat until bleeding stopsii. If bleeding continues, this needs to be evaluated by physician for further intervention.7. Documentationa. All documentation concerning dialysis services and care of the dialysis resident will bemaintained in the resident's medical record.b. Dialysis Communication Recordi. The Nursing Staff will send a dialysis communication form to the dialysis center every time a resident is scheduled for off-site dialysis.ii. The dialysis provider's nurse will be responsible for documentation of dialysis treatment and providing the resident's post dialysis weight. A review of the facility's P&P, Fluid Restriction, dated 5/26/2026, indicated: I. Residents on fluid restriction must have a Provider order and a plan of care for the restriction which indicates the amount of fluid allowed within a 24-hour timeframe.II. The Licensed Nurse will :A. Educate the Resident and/or responsible party regarding the fluid restriction. B. Complete Intake and Output documentationC. Notify the Provider and Resident and/or Responsible Party regarding any changes in the Resident's condition.

Based on observation, interview, and record review, the facility failed to ensure one of one staff (Licensed Vocational Nurse (LVN) 7) completed Elder Abuse Mandated Reporter training according to the facility's policy and procedures (P&P) titled, Training Requirements dated reviewed, January 2026. had proof in the personnel file of the necessary training to care for residents in a safe and secure manner. This deficient practice had the potential for LVN 7 not to be able to identify and report suspected/allegation of abuse and placed the residents in the facility at increased risk for abuse. Findings: During a concurrent interview and record review on 6/5/26 at 12:04 PM of LVN 7's personnel file. The personnel file indicated LVN 7 did not have Elder Abuse Mandated Reporter training upon hire. The Director of Staff Development (DSD)/LVN 2, stated, there is no Elder Abuse Mandated Reporter training in this staff members' file. DSD/LVN 2 checked and reviewed the facility electronic system but was not able to provide any additional information regarding abuse training for LVN 7. DSD/LVN 2 stated she was not aware that the LVN 7's personnel file did not have the Elder Abuse Mandated Reporter training as evidence that LVN 7 was trained on Elder Abuse Mandated Reporting. During an interview on 6/5/26 at 11:08 AM, the Director of Nursing (DON) stated that if the abuse training is not in the file, then there is no way to verify the Elder Abuse Training was done. The abuse training provided to new employees should remain in the file to prove they have received the training they are supposed to have to safely perform their duties for the residents in the facility. If it is not in the file, then they (staff) may not have received the training, and they (staff ) will not know what to do when they start working with residents in the facility. The DON stated that lack of Elder Abuse Training may put the residents in the facility at risk for abuse. A review of the facility's policy and procedures titled Training Requirements dated reviewed: January 2026, indicated:PolicyThe facility must develop, implement, and maintain an effective training program for new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The facility must determine the amount and types of training necessary based on a facility assessment and special needs of the residents.PurposeTo provide required education and training in accordance with federal and state regulations.ProcessTraining topics must include but are not limited to:Communication: effective communication as mandatory training for direct care staff.Resident's rights and facility responsibilities: educate on the rights of the resident and the responsibilities of the facility to properly care for its residents.Abuse, neglect, and exploitation: In addition to the freedom from abuse, neglect, and exploitation requirements, education should also include:The types of actions that constitute abuse, neglect, exploitation, and misappropriation of resident propertyProcedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property.Dementia Management and resident abuse prevention.

Based on interview and record review, the facility failed to ensure that enteral feed tubing (a flexible tube for delivering nutrient-rich liquid formula directly into the stomach or small intestine) was labeled with the date and time when hung up for one of one sampled resident (Resident 43). This deficient practice had potential for Resident 43 to suffer abdominal discomfort and infection.Findings: During a review of Resident 43's admission Record, the admission record indicated the facility admitted the resident on 4/6/2026 with diagnoses that included but not limited to Dysphagia (inability to swallow) and unspecified Protein-Calorie malnutrition (potentially life-threatening condition due to inadequate intake of protein, calories or both). During a review of Resident 43's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 43 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 43 was dependent on staff and required maximum staff assist for activities of daily living (ADL- fully dependent on staff for eating, toilet hygiene, shower/bathe, personal hygiene, laying/sitting and chair/bed transfer, and need maximum staff assist for oral hygiene, lower body dressing, roll left/right and upper body dressing). During the review of Resident 43's Order Summary, dated 5/20/2026 at 7:26 pm, order stated, Enteral feeding: Jevity 1.2 @ rate of 75 ml/hr x 20 hours provides 1500 ml in 12 hours - 1800 calories in 20 hours via Kangaroo Pump. Flush G-tube with 50 l of water before and after administration of medications.During an observation on 6/2/2026 at 9:15 am, Resident 43 was observed in bed. Resident 43 was connected to Jevity 1.2 calories enteral feeding (a method of delivering nutrients, fluids and medications in liquid form into the stomach or small intestine through a soft flexible tube to someone who is not able to eat or drink safely) via a GT/JT. The Jevity 1.2 calories bottle was attached to a feeding pump (device that delivers nutrients/fluids/medications in liquid form at a set rate and frequency per physician's order). The Resident 43 was receiving Jevity 1.2 calories 75 milliliters ( ml: unit of measurement in liquid) at 75 ml/hour. The enteral feeding tubing (soft flexible tube that is used to deliver nutrients, fluids and medications in liquid form into the stomach or small intestine) was not labeled with a date and/or time when hung up. During an observation on 6/2/2026 at 2:20 pm, Resident 43's same enteral feeding tube was not labeled with a date and/or time when hung up. During an interview on 06/03/2026 at 2:05 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated that, not labeling the enteral feed tubing is not the right practice. It's impossible to tell whether the enteral feed tube was opened on the same day or if it has been in use for several days. If tubing from a previous day or even earlier, was used, bacteria could develop and cause an infection. During an interview on 06/04/2026 at 12:58 PM with Director of Nursing (DON), DON stated, It's important to label tubing for enteral feeding to make sure that tubing is changed so that the residents do not get an infection from the old feeding tube The DON stated, We wouldn't know by looking at an unlabeled tubing if it was changed the same day or previous days. During a review of the facility's policy and procedures (P&P) titled, Nursing Manual - Dietary & Dining - DD16 Enteral Feedings reviewed on 1/2026, the P&P indicated, Label bag and tubing with date and time hung, Hung time is for no more than 24 hours.

Based on interview and record review, the facility failed to document the assessment, observation and communication entries on the nursing progress notes for two of the five residents (Residents 1 and 9). Resident 1 had a behavior of throwing feces on the floor. This deficient practice had the potential to negatively affect the plan of care and delivery/provision of necessary care and services for Resident 1 and Resident 9. 1.During a record review of Resident 1's admission Record (face sheet - a document containing demographic and diagnostic information) indicated the facility admitted Resident 1 on 5/20/2020 and was re-admitted on [DATE] with the following medical diagnoses: muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), cognitive communication deficit (trouble participating in conversations), epilepsy (a long term brain disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), atherosclerotic heart disease of native coronary artery (damage or disease in the heart's major blood vessels), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), contracture (curl or pull in towards the palm), quadriplegia (paralysis [complete or partial loss of muscle strength] that affects all four limbs and body from the neck down), anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death within minutes), transient ischemic attack (TIA - a temporary blockage of blood flow to the brain, schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) with a date initiated on 11/24/2024, revision date of 5/05/2026 and a target date of 8/05/2026, the CP indicated that Resident 1 had new behavioral problem of throwing feces on the floor. The CP goal indicated that Resident 1 will decrease frequency of throwing feces on the floor by the next review date (review date was not indicated). The CP interventions included encourage Resident 1 not to touch feces; monitor behavior and episodes and attempt to determine underlying cause; monitor more frequently and provide bedside care; and provide good hand hygiene and skin care to Resident 1. During a record review of Resident 1's History and Physical (H&P - a thorough assessment of a patient's health, combining a detailed conversation about their medical history and a physical examination) dated 4/15/2026, indicated the patient is at significant risk of worsening medical status and readmission to the hospital and the patient has waxing and waning (a patient's symptoms, condition, or disease intensity alternate between getting better [waning] and getting worse [waxing] over time) capacity for medical decision making due to dementia. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026 indicated, Resident 1 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 used a manual wheelchair for mobility (the ability to move or be oved freely, easily, and without restriction). As indicated by the MDS, Resident 1 has functional limitations in range of motion in both upper and lower extremities (upper extremities are the arms from the shoulder to the hands and the lower extremities are the legs from the hip to the toes). The MDS also indicated Resident 1 was completely dependent on staff with activities of daily living (ADLs - tasks of everyday life) and was incontinent (lack of voluntary control over urination or bowel movement) of urinary and bowel. During a review of Resident 1's care plan with a date initiated on 11/24/2024, revision date of 5/05/2026 and a target date of 8/05/2026, the CP indicated that Resident 1 had a behavioral problem related to constant tearing apart [Resident 1]s] diaper and making mess on the floor while sitting on a chair at dining hall and while in bed. The CP goal indicated that Resident 1 will have no evidence of behavior problems by review date (review date was not indicated). The CP interventions included intervene as necessary to protect the rights and safety of others; minimize potential for Resident 1's disruptive behaviors by offering tasks which divert attention; monitor behavior episodes and attempt to determine underlying cause. During an interview on 6/01/2026 at 2:26 PM with Resident 1, Resident 1 could not answer simple questions such as name, date of birth , time of day (day or night time) or location. During a concurrent interview and record review on 6/04/2026 at 3:30 PM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated nursing observation, progress notes or documentation regarding Resident 1's behaviors of throwing feces on the floor and tearing Resident 1's own incontinent brief (material used to contain urine/feces) during the months of May and June 2026 were not found in the electronic health record called Point Click Care (PCC - technology platform that specializes in providing software solutions for the senior care industry, particularly skilled nursing facilities and assisted living facilities) I cannot find anything. LVN 4 stated that nursing observation, progress notes or documentation are all important so we know what we are doing for the resident and if that is helping the resident or not. LVN 4 added something may be missed when nursing documentation was not done. During a concurrent interview and record review on 6/04/2026 at 4:11 PM with the Director of Nursing (DON), the DON stated there is nothing here (referring to PCC) when asked to locate in the PCC any nursing observation, progress notes or documentation regarding Resident 1's behaviors of throwing feces on the floor and tearing Resident 1's own diaper during the months of May and June 2026. DON stated that documenting nursing care and interventions meant the care will be continuous if it's done; once it's written, it's done; if not written, it was not done. DON also stated that when nurses do not document the care and interventions they provided to Resident 1, care will be inconsistent because we don't have any idea what interventions were provided to [Resident 1]. 2. During a record review of Resident 9's admission Record, the record indicated the facility admitted Resident 9 on 1/23/2023 and re-admitted on [DATE] with the following diagnoses: multiple sclerosis (a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), acute cystitis without hematuria (a sudden infection of the bladder without blood in the urine), paraplegia (paralysis of the legs and lower body), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), chronic pain syndrome (a condition where persistent pain lasts beyond the expected healing time [typically 3 to 6 months] and is accompanied by emotional, physical, and behavioral symptoms like depression, anxiety, and severe sleep disruption that severely interfere with daily life), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition of excessive worry about daily issues and situations), muscular dystrophy (cause progressive muscle weakness and loss of muscle mass over time), generalized muscle weakness (lack of physical or muscle strength), cognitive communication deficit (trouble participating in conversations), contracture of the right and left hips and knees (conditions where the soft tissues [muscles, tendons, and ligaments] around the joints tighten and shorten, permanently restricting movement), essential (primary) hypertension (high blood pressure without a single identifiable cause), presence of urogenital implants (the existence of artificial devices or materials within the urogenital system, which includes the urinary and reproductive organs), neuromuscular dysfunction of the bladder (a condition where the nerves and muscles controlling bladder function don't work properly due to damage to the brain, spinal cord, or nerves), and muscle spasm (sudden, involuntary contractions of a muscle that cannot relax). During a review of Resident 9's Care Plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on dependency on staff with an initiated date of 12/10/2024, revision dates of 2/23/2025 and 5/03/2026, and a target date of 8/16/2026, indicated Resident 9 dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The CP's goal indicated Resident 9 will attend/participate in activities of choice by next review date (date was not indicated). The CP interventions included modifying daily schedule and treatment plan as necessary to accommodate activity participation requested by the [Resident 9]. During a record review of Resident 9's Nursing Progress Notes for February 2026, Notes from a licensed staff as to why Resident 9 required to be transferred to a general acute care hospital (GACH - a health facility having a professional responsibility and an organized medical staff that provides 24-hour inpatient care) on 2/21/2026 were not found. No notes found that indicated the reason why Resident 9 required to be transferred to GACH, date and time the transfer happened, vital signs (clinical measurements, specifically heart rate, temperature, respiration rate, blood pressure and pain, that indicate the state of a patient's essential body functions) prior to hospital transfer, and the date and time the physician and family/responsible party were notified. During a record review of Resident 9's MDS dated [DATE] indicated, Resident 9 has intact cognition (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). The MDS indicated that Resident 9 used a wheelchair for mobility. As indicated by the MDS, Resident 9 has functional limitations in range of motion in lower extremities (the legs from the hip to the toes) and substantially required assistance from the staff with his ADLs and toileting (incontinent of urinary and bowel). During a record review of Resident 9's H&P dated 5/30/2026 indicated, Resident 9 is at significant risk of worsening medical status and re-admission to the hospital. H&P also indicated that Resident 9 has the capacity for medical decision making. During an interview on 6/03/2026 at 3:16 PM with Resident 9, Resident 9 stated that on the morning of 6/03/2026, Resident 9 reminded Social Service Director (SSD) that on 6/02/2026 and again on 5/28/2026 or 5/29/2026 (Resident 9 unsure which date in May), Resident 9 expressed to SSD about not wanting Licensed Vocational Nurse (LVN) 7 assigned to Resident 9's care anymore. Resident 9 explained to SSD that LVN 7 was being unprofessional, not a nice nurse and disrespectful to [Resident 9]. According to Resident 9, SSD stated sorry about that; okay so for tonight [6/03] for the 11 PM to 7 AM shift, [LVN 7] will not go your room, if anything, another nurse will give you your medications. Resident 9 stated that on 6/03/2026 SSD was reminded I don't want [LVN 7] to care for me. I reminded [SSD] that we talked about it already like 4-5 days (5/28/2026 or 5/29/2026) ago. During a record review of the facility's Medication Administration Audit Report (a report that shows what and when a medication is scheduled to be given, what is the actual date & time the licensed nurse administered the medication, date and time the licensed nurse documentation the medication administration, and the name of the license nurse who gave the medication to the patient), LVN 7 gave the following medications to Resident 9: Sunday, 5/31/2026, 11 PM to 7AM shift:5/31/2026 at 11:14 PM: oxycodone 10 milligram (mg - a unit of measure of mass [amount of material it contains] in the metric system) by mouth every 8 hours as needed for severe pain 9-10 pain levelXanax 1.5 mg by mouth every 8 hours for anxiety as manifested by the inability to relax leading to panic 6/01/2026 at 6:11 AM: oxycodone 10 mg by mouth Monday, 6/01/2026, 11 PM to 7 AM shift: 6/01/2026 at 11:30 PM: Xanax 1.5 mg by mouth Tuesday, 6/02/2026, 11 PM to 7 AM shift: 6/03/2026 00:19 AM: Xanax 1.5 mg by mouth. During a record review of Resident 9's Nursing Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time), LVN 7 continued to care for Resident 9 for a total of 14 times after Resident 9 requested a change in nursing assignments to SSD on 5/29/2026. The Notes indicated LVN 7 provided nursing assessments, administered medications, and nursing care to Resident 9 on the following dates and times: 5/31/2026 at 6:39 AM 5/31/2026 at 11:14 PM6/01/2026 at 6:11 AM 6/01/2026 at 11:30 PM6/01/2026 at 11:58 PM 6/02/2026 at 5:39 AM6/03/2026 at 00:19 AM 6/03/2026 at 1:30 AM 6/03/2026 at 2:30 AM6/03/2026 at 2:45 AM 6/03/2026 at 3 AM 6/03/2026 at 4:56 AM 6/03/2026 at 6 AM6/03/2026 at 6:50 AM During a record review of Resident 9's Nursing Progress Notes for May and June 2026, Notes from SSD or any licensed staff about Resident 9's request to not have LVN 7 assigned to Resident 9's care anymore were not found. During a review of the facility's nursing assignment sheets (a structured document used to clearly assign specific residents to nurses and Certified Nursing Assistants [CNAs]), the assignment sheets for 11 PM to 7 AM shift indicated that on 6/01/2026, and 6/02/2026, LVN 9 was assigned to care for Resident 9. During a concurrent interview and record review on 6/03/2026 at 4:09 PM with RN Supervisor (RNS) 1, RNS 1 stated that staff are aware about Resident 9's desire not to have LVN 7 care for Resident 9, we are all aware, he tells everyone about it. RNS 1 stated RNS 1 have known about this probably a couple of months. RNS 1 asked why LVN 7 continued to be assigned to care for Resident 9 even after Resident 9 expressed his right to assign a different nurse during the 11 PM to 7 AM shift, RNS 1 stated we only had two LVNs that shift. When asked why not just switch the two LVNs assignments, RNS 1 stated because LVN 7 has always been assigned to that side, nursing station B (where Resident 9's room was located). RNS 1 was also asked why there were no documentation from any licensed nurses, including RNS 1, about Resident 9's request to change nursing assignments, RNS 1 stated I don't know, there should have been. When asked how Resident 9 felt about not having Resident 9's right to request for a different nurse not honored, RNS 1 stated upset, may become verbally abusive, aggressive. During a concurrent interview and record review on 6/04/2026 at 2:51 PM with LVN 4, LVN 4 stated I can't find anything in the PCC when asked to find any written progress notes, observations or documentations in the PCC related to Resident 9's hospital transfer on 2/21/2026 and Resident 9's request not to have LVN 7 to care for Resident 9 anymore. LVN 4 stated it was important that nurses document why Resident 9 required to be hospitalized on [DATE] because we have to know what is going on with [Resident 9].reason for the transfer. If it's not done then no one knows what happened to [Resident 9], what interventions were done or not done for [Resident 9]. LVN 4 stated residents always have the right to choose another nurse to care for them. During a concurrent interview and record review on 6/04/2026 at 4:41 PM with the Director of Nursing (DON), the DON stated yes, it's known to most of us when asked about Resident 9's request to change nursing assignments. DON stated that the DON was notified about Resident 9's request to change nursing assignments on 6/01/2026. When asked about why LVN 7 continued to be assigned to Resident 9's care even after 6/01/2026, DON responded RNS 1 did the scheduling.I don't know. DON was asked to show any nursing documentation that indicated Resident 9's hospital transfer on 2/21/2026 were documented and Resident 9's request to [NAME] nursing assignment was documented, DON stated there is nothing here (referring to the PCC). DON added that when documentation was not done nothing was done; it should have been documented, the result, the follow up. DON stated that the nursing documentation should have been done on the same hour it happened and they lax in their documentation. DON stated that Resident 9 has the right to choose a nurse always.it's their right. During a review of the facility's policy and procedure (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Completion & Correction with an effective date of 3/25/2026 indicated, the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation and documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner. The P&P also indicated the purpose of this policy is to ensure that medical records are complete and accurate.

Based on interview and record review, the facility failed to develop a baseline care plan for one of four sampled residents (Resident 1) in accordance with the facility policy and procedures (P&P) titled Person-Centered Care Planning with a revision date of 1/2026, by failing to initiate a baseline care plan within 48 hours after the resident was readmitted to the facility on [DATE]. This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 1 immediately upon admission.Findings: During a record review of Resident 1's admission Record (face sheet - a document containing demographic and diagnostic information) indicated the facility admitted Resident 1 on 5/20/2020 and was re-admitted on [DATE] with the following medical diagnoses: muscle weakness (when muscles are weak causing difficulty performing normal activities that require strength), cognitive communication deficit (trouble participating in conversations), epilepsy (a long term brain disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), atherosclerotic heart disease of native coronary artery (damage or disease in the heart's major blood vessels), unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), contracture (curl or pull in towards the palm), quadriplegia (paralysis [complete or partial loss of muscle strength] that affects all four limbs and body from the neck down), anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to brain cell death within minutes), transient ischemic attack (TIA - a temporary blockage of blood flow to the brain, schizophrenia (a mental illness that is characterized by disturbances in thought), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a record review of Resident 1's history and physical (H&P - a thorough assessment of a patient's health, combining a detailed conversation about their medical history and a physical examination) dated 4/15/2026, indicated the patient is at significant risk of worsening medical status and readmission to the hospital and the patient has waxing and waning (a patient's symptoms, condition, or disease intensity alternate between getting better [waning] and getting worse [waxing] over time) capacity for medical decision making due to dementia. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026, indicated Resident 1 is cognitively impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 used a manual wheelchair for mobility (the ability to move or be oved freely, easily, and without restriction). Resident 1 has functional limitations in range of motion in both upper and lower extremities (upper extremities are the arms from the shoulder to the hands and the lower extremities are the legs from the hip to the toes) as indicated by the MDS. The MDS also indicated Resident 1 was completely dependent on staff with activities of daily living (ADL - tasks of everyday life) and was incontinent (lack of voluntary control over urination or bowel movement) of urinary and bowel. During a concurrent interview and record review on 6/04/2026 at 3:30 PM with Licensed Vocational Nurse (LVN) 4, Resident 1 care plans were reviewed. LVN 4 stated the baseline care plan (an initial, temporary healthcare roadmap created immediately upon admission to a facility; it is designed to bridge the gap before a comprehensive plan is established, it must be developed and implemented within 48 hours of admission) will tell us what [Resident 1's] needs are and what interventions we need to do for [Resident 1]. Baseline care plan is created just for Resident 1. LVN 4 stated the baseline care plan for Resident 1's re-admission date of 4/13/2026 should be completed within 48 hours from the time Resident 1 was admitted to the facility. When LVN 4 was asked to show the baseline care plan, LVN 4 stated I cannot find anything here (referring to the electronic health record called Point Click Care (PCC - technology platform that specializes in providing software solutions for the senior care industry, particularly skilled nursing facilities and assisted living facilities). LVN 4 stated when there is no baseline care plan for Resident 1, then we don't know what is the resident's needs, how we can help the resident, we might miss something important. During a concurrent interview and record review on 6/04/2026 at 4:11 PM with the Director of Nursing (DON), the DON stated baseline care plan for resident's readmission to the facility on 4/13/2026 I cannot find anything here (referring to the PCC). DON also stated the baseline care plan tells us what resident will need help with, what interventions we need to do to help the resident get better while in our facility. When asked what potential harm may happen to Resident 1 when the baseline care plan was not completed at all, DON stated immediate interventions for the resident will be missed; delay in care. DON stated the baseline care plan should be completed within 48 hours from Resident 1's re-admission. During a record review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Person-Centered Care Planning with a revision date of 1/2026 indicated that the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. In addition, the P&P indicated, it should address resident-specific health and safety concerns to prevent decline or injury. The P&P also indicated that the baseline care plan will be developed within 48 hours of admission.

Based on observation, interview, and record review, the facility failed to ensure the toilet bowl was clean and sanitary for one of three sampled residents (Resident 79). This deficient practice placed Resident 79 at risk for infections, lowered self esteem, and embarrassment. Findings: During a review of Resident 79's admission Record, the admission record indicated the facility admitted the resident on 1/16/2026 with diagnoses that included but not limited to Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle spasm (sudden, involuntary tightening of muscle which is difficult to relax). During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool) dated 4/25/2026, the MDS indicated Resident 79 had no cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 79 needed set up or clean up assistance with activities of daily living (ADL- including upper/lower body dressing, personal hygiene, eating, oral hygiene, shower and toileting hygiene and independent for rolling left/right, sit/laying, chair/bed transfer. Tub/shower transfer, car transfer toilet transfer and walking 150 feet). During an observation on 06/02/2026 at 10:31 am, the toilet commode in resident's bathroom had brown dried uneven stains around the inside rim (top portion of inside portion of the toilet bowl) of the commode. During a concurrent observation and interview on 06/02/2026 at 11:32 am with Maintenance, Housekeeping & Central Supply Supervisor (MHSS) in Resident 79's room, the toilet commode in resident's bathroom had brown dried uneven stains around the inside rim (top portion of inside portion of the toilet bowl) of the commode. MHSS stated, It's not clean. Resident wouldn't be comfortable using this restroom. They wouldn't feel like it's their home. During an interview on 6/4/2026 at 12:55 pm with Director of Nursing (DON), DON stated, Resident will feel dirty. Resident wouldn't want to use the restroom. They wouldn't feel like its home when they would have to use dirty toilet. During a review of the facility's policy and procedures (P&P) titled Residents Room and Environment revised on 3/2026, the P&P indicated, Facility Staff aim to create a personalized, home like atmosphere, paying close attention to cleanliness and order.

Based on observation, interviews and record review, the facility failed to protect the residents' rights to privacy and confidentiality of records when Licensed Vocational Nurses (LVN) 1 and LVN 5 left two of two residents' (Resident 8 and Resident 11) personal and medical information displayed on the computer screen unattended. This deficient practice of violating the residents' rights to privacy and confidentiality of records had the potential to cause psychological and financial harm to Resident 8 and Resident 11. Findings: 1.A review of Resident 8's admission record (face sheet - a document containing demographic and diagnostic information) indicated the facility admitted Resident 8 on 12/31/2025 with the following diagnoses: type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), acute kidney failure (when kidneys suddenly cannot remove waste from the blood), myocardial infarction type 2 (caused by a severe imbalance between the heart's oxygen supply and demand, rather than a blocked artery), tachycardia (heart rate that exceeds 100 beats per minute), calculus of gallbladder (gallstone - hardened deposits of digestive fluid that form in the gallbladder), depression (a common but serious mood disorder that causes a persistent feeling of sadness and loss of interest), essential (primary) hypertension (high blood pressure without a single identifiable cause), dysphagia (difficulty swallowing), cognitive communication deficit (trouble participating in conversations), generalized muscle weakness (lack of physical or muscle strength), long term (current) use of insulin (an effective treatment for advanced Type 2 diabetes when oral medications are no longer sufficient), and osteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage). During a review of Resident 8's history and physical (H&P - a physician's complete patient examination) dated 1/05/2026 indicated, Resident 8 was at significant risk of worsening medical status and re-admission to the hospital. H&P also indicated Resident 8 had the capacity for medical decision making. During a review of Resident 8's Minimum Data Set (MDS - a mandated resident assessment tool) dated 4/08/2026 indicated, Resident 8 has moderately impaired cognition (make poor decisions, cues and supervisions required). MDS also indicated Resident 8 used a walker and wheelchair for mobility (ability to move freely, purposefully, and independently). The MDS indicated that Resident 8 required supervision or touching assistance with activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). 2. A review of Resident 11's admission record indicated the facility admitted Resident 11 on 5/10/2026 with the following diagnoses: atherosclerotic heart disease (damage or disease in the heart's major blood vessels), presence of coronary angioplasty implant and graft (long-term medical recording of a patient who has received heart stents or bypass grafts to restore and maintain blood flow), hypertensive chronic kidney disease (elevated blood pressure caused by kidney disease), generalized muscle weakness), dysphagia (difficulty swallowing), cognitive communication deficit (trouble participating in conversations), anxiety disorder (a condition of excessive worry about daily issues and situations), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and essential hypertension (primary high blood pressure without a single identifiable cause). During a review of Resident 11's H&P dated 5/11/2026 indicated, Resident 11 was at significant risk of worsening medical status and re-admission to the hospital. H&P also indicated that Resident 11 had the capacity for medical decision making. During a review of Resident 11's MDS report dated 5/17/2026, MDS indicated Resident 11 has intact cognition (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired). During a facility tour on 6/01/2026 at 11:58 AM, a laptop computer sitting on top of Medication Cart A (Med Cart - a mobile workstation used by nurses to securely store, organize, and administer daily medications to residents) was observed unattended. Med Cart A was parked in the hallway against a wall. The writer touched the computer mouse and Resident 8's personal and medical information was displayed on the laptop computer screen. During the same facility tour and concurrent interview at 12 noon, LVN 1 arrived at Med Cart A. LVN 1 confirmed and stated that LVN 1's name written on the top right corner of Med Cart A laptop computer screen. LVN 1 stated Resident 8's personal and medical information including the resident's name, date of birth , physician's name, code status, allergies, vital signs (blood pressure reading, respiratory rate, temperature, blood glucose [measure the amount of glucose in your bloodstream], heart rate, oxygen level, weight, and pain) and medical record number were displayed on the computer screen. LVN 1 stated Honestly, I thought I closed the computer screen. LVN 1 stated that LVN 1 violated Health Insurance Portability and Accountability Act (HIPAA - a privacy rule which establishes national standards to protect individuals' medical records and other individually identifiable health information) law when LVN 1 left Resident 8's personal and medical information displayed on the laptop computer screen unattended. LVN 1 stated Resident 8's information may be used for identity theft, impersonation, and stolen financial information. LVN 1 added that Resident 8 may experience that the trust is gone, may feel hurt and anger. During a facility tour on 6/01/2026 at 12:58 PM, a laptop computer sitting on top of Med Cart B was observed unattended. Med Cart B was parked in the hallway parked against the wall between rooms [ROOM NUMBERS]. When surveyor touched the mouse pad on the computer screen, Resident 11's personal and medical information were displayed on the screen within one second. During the same facility tour and concurrent interview at 12:59 PM, LVN 5 arrived at Med Cart B was parked. LVN 5 confirmed and stated that LVN 5's name was on the top right corner of the Med Cart B laptop computer screen. LVN 5 stated Resident 11's personal and medical information such as name, date of birth , vital signs (heart rate, weight, oxygen level, pain level and blood pressure reading), doctor's name and the medication acetaminophen (a common over-the-counter [OTC] medication used to relieve mild to moderate pain [e.g., headaches, toothaches, muscle aches] and reduce fever) were displayed on the computer screen. When asked why Resident 11's personal and medical information were displayed on the computer screen unattended, LVN 5 stated I was called by another resident. I thought I closed the screen. LVN 5 stated LVN 5 violated HIPAA law when LVN 5 left Resident 11's personal and medical information on Med Cart B laptop computer screen for anyone to see. LVN 5 stated that Resident 11's information may be used for financial and insurance fraud and identity theft. LVN 5 stated Resident 11 may feel very upset, distraught, anger, and disappointed when Resident 11's privacy and confidentiality was violated. During an interview on 6/04/2026 at 2:15 PM with LVN 4, LVN 4 stated, HIPAA law is important to follow because it's the law and you don't want residents' information out there for all to see, it should remain private. LVN 4 stated that when Residents 8 and 11 personal and medical information were displayed on the computer screen unattended, both residents may become depressed, may have psychological impact, and have their identities fraudulently used. During an interview on 6/04/2026 at 3:49 PM with the Director of Nursing (DON), DON stated HIPAA is a federal law that protects patient's privacy and confidentiality. DON also stated that when Residents' 8 and 11 personal and medical information were displayed on the computer screen unattended, both residents may feel violated causing Residents 8 and 11 mental anguish, feel depressed, and experience loss of esteem. DON added Residents 8 and 11 may have their health and well-being negatively affected. A review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Electronic Protected Health Information Security with a revision date of 1/2026 indicated, when not in use, laptops or other mobile electronic devices should be stored in a physically secure location and after a certain period of inactivity, the user will be logged off of the electronic record keeping system.

Based on observation, interview, and record review, the facility failed to provide television (TV) remote control for two of two sampled residents (Resident 7 and 62). This deficient practice resulted in Resident 7 feeling frustrated and complained of inability to watch TV and and feeling bored., and Resident 62 complaining of not having a TV remote for a long time and did not keep getting up to change the TV channel. Findings: During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 4/26/2026 with diagnosis that included but not limited to muscle weakness, Type 2 Diabetes Mellitus without complications (DM type 2- (high blood sugar) and dependance on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During the review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 4/23/2026, the MDS indicated Resident 7 had a moderate cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 7 was dependent on staff for activities of daily living (ADL- set up/clean-up assistance for eating, supervision for oral hygiene, maximum assistance for shower/bathe and lower body dressing, moderate assistance for upper body dressing, laying/sitting/standing, chair/bed transfer, personal hygiene and walking 10 feet). During the review of Resident 62's AR, the AR indicated the facility admitted the resident on 6/23/2025 with diagnoses that included but not limited to DM type 2 without complications, hypertension (HTN-high blood pressure) and insomnia (difficulty sleeping at night). During the review of Resident 62's MDS) dated [DATE], the MDS indicated Resident 62 had a severe cognitive (the mental ability to make decision of daily living) impairment. The MDS indicated Resident 62 was dependent on staff for ADL -(set up/clean-up assistance for eating) and wheel with wheelchair 50 feet with two turns, moderate assistance for oral hygiene, upper body dressing, laying/sit/stand, chair/bed transfer, toilet transfer and partial assist for toilet hygiene, lower body dressing and wheel 150 feet). During a concurrent observation and interview on 6/3/2026 at 9:48 am with Resident 7 in resident's room, Resident 7 stated that Resident 7 did not have a TV remote control. There was no TV remote control was found in the resident's room. Resident 7 stated that she has to get up from the bed or ask someone to turn the TV on or change the channel/volume manually from wall mount TV set. Resident 7 stated that she does not feel comfortable getting up frequently or repeatedly to ask the staff to help with TV. Resident 7 stated that, it has been several days that she did not have TV remote control. During an interview on 6/3/2026 at 10:17 am with Resident 7 in resident's room, Resident 7 stated, I can't watch TV. It's frustrating, I miss home. I am bored, I don't know what to do when I am bored coz I can't watch TV. During a concurrent observation and interview on 6/03/2026 10:15 am with Resident 62, in Resident 62's room, Resident 62 stated that Resident 62 did not have a television (TV) remote control. There was no TV remote control was found in the resident's room. Resident 62 stated, I don't have TV remote for a long time. I can't remember for how long I didn't have TV remote. I like to watch TV but its only at one channel. I would like to change the channel but there is no TV remote control to change it. I can't keep getting up to change the channel. During an interview on 6/3/2026 at 10:25 am, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated not having access to TV remote control can affect the resident's mood. LVN 1 stated that the residents will not feel like home in the facility if they don't have TV remote. LVN 1 stated that the resident will not t be able to be entertained when they are bored. During an interview on 6/04/2026 1:02 pm with Director of Nursing (DON), DON stated, If the residents does not have a TV remote control, they will feel lonely, they will feel isolated. There is no stimulation for residents, they won't know what's going on in outside world. It could make them sad. During a review of the facility's policy and procedures (P&P) titled Residents Room and Environment revised on 3/2026, the P&P indicated, The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences.

Based on interview and record review, the facility failed to ensure that three of five residents (Resident 1, Resident 43, and Resident 61) who had severe cognitive (the mental ability to make decisions of daily living), did not sign the consent forms for Influenza (flu - illness caused by a virus that infect nose, throat and lungs), Pneumonia Immunization (immunization that protects against bacteria that causes pneumonia [infection of lungs)] and Corona Virus disease 2019 (COVID 19- is a highly contagious illness that affect lungs and then entire body) according to the facility's policies and procedures titled Resident Rights - Quality of Life reviewed on 1/2026, and P-NP67 Informed Consent effective date 1/30/2026. This deficient practice violated the rights of Resident 1, Resident 43 and Resident 61 and the residents' representatives to make informed decisions whether or not to receive and refuse the Flu, Pneumonia, and COVID 19 vaccines. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 4/13/2026 with diagnoses that included but not limited to quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), muscle weakness and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/28/2026, the MDS indicated Resident 1 had severe cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 1 needed staff assistance with activities of daily living (ADL- dependent on staff for using shower/bathe/toileting, dressing and tub/shower transfer, oral hygiene, personal hygiene, sitting/laying/standing and, supervision with eating). During a review of Resident 1's History and Physical (H&P - medical document which include resident's background, physical exam and assessment) by resident's physician and signed by the same physician, dated 4/15/2026, H&P indicated, The patient (Resident 1) has waxing and waning (increases or decreases)capacity for medical decision making due to dementia (a progressive state of decline in mental abilities). During a review of Resident 43's AR, the AR indicated the facility admitted the resident on 4/6/2026 with diagnoses that included but not limited to Dysphagia and unspecified Protein-Calorie malnutrition (potentially life-threatening condition due to inadequate intake of protein, calories or both). During a review of Resident 43's MDS dated [DATE], the MDS indicated Resident 43 had severe cognitive impairment. The MDS indicated Resident 43 was dependent on staff and required maximum staff assist for ADL- (fully dependent on staff for eating, toilet hygiene, shower/bathe, personal hygiene, laying/sitting and chair/bed transfer, and need maximum staff assist for oral hygiene, lower body dressing, roll left/right and upper body dressing). During a review of Resident 43's H&P dated 5/21/2026, H&P indicated, The patient (Resident 43) does not have the capacity for medical decision making due to: CVA, encephalopathy (brain disease characterized by mental confusion, memory loss, loss of coordination or muscle twitching). During a review of Resident 61's AR, the AR indicated the facility admitted Resident 61 on 2/14/2026 with diagnoses that included but not limited to dysphagia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (neurologic symptom characterized by weakness or partial paralysis on one side of the body). During a review of Resident 61s MDS dated [DATE], the MDS indicated Resident 61 had moderate cognitive impairment. The MDS indicated Resident 61 needed staff assistance with ADL- dependent on staff for using wheelchair and tub/shower transfer, maximum assistance with toileting hygiene, shower/bathe, lower body dressing, and sitting/laying, and moderate staff assistance with personal hygiene, upper body dressing, chair/bed transfer and laying/sitting, supervision with rolling and setup/cleaning assistance with eating and oral hygiene. During a concurrent interview and record review of immunization record on 6/4/2026 at 9:21 am, with Infection Prevention Nurse/licensed vocational nurse (LVN) 3, LVN 3 stated that Influenza vaccine is offered to all residents annually starting in August every year, pneumococcal vaccine and COVID 19 offered once upon admission. LVN 3 stated that LVN 3 obtains the consent for influenza, COVID 19, and pneumococcal vaccines from residents or the residents' representatives. LVN 3 confirmed and stated the following:a)Resident 1 signed to refuse to receive influenza vaccine (dated 8/5/2025), pneumococcal vaccine (dated 12/29/2023), and COVID - 19 (dated 8/5/2025). b)Resident 43 signed the consent forms to receive influenza vaccine (dated 8/5/2025), and COVID-19 vaccine (dated 4/8/2028).c)Resident 61 signed the consent forms to receive influenza vaccine (dated 8/5/2025), pneumococcal vaccine on(dated 3/29/2024), and COVID-19 vaccine (dated 2/4/2026). During an interview on 6/4/2026 at 11:40 am, with LVN 3, LVN 3 stated that informed consent is that the resident understands (has the knowledge) the vaccine, the side effects of the vaccine, and the resident making decisions about the vaccines. LVN 3 sated that the resident should be fully coherent (capable of thinking clear and logical) so that the resident understands the vaccine/s, and the effectiveness and side effects of the vaccine/s. LVN 3 stated that if a resident cannot make decisions, their representative should decide and sign the consent form on their behalf, as the representative understands the resident's wishes about receiving vaccines. During an interview on 06/04/2026 at 1:09 pm, with Director of Nursing (DON), DON stated that Resident 1, Resident 43 and Resident 61 did not have the capacity to make decision and sign the consent forms for receive or refuse any vaccine. DON stated that when a resident is not able to make decisions, facility needs to call the residents representative to give consent to receive or refuse vaccines. DON stated that if there is no family present for a resident, then the facility ethic committee (group of individuals that helps patient, families and medical staff navigate moral and legal dilemmas in care and treatment) makes the decision for the resident. DON stated that the facility is not respecting resident's wishes if resident with severe cognitive impairment signs any consent form/s. During a review of the facility's policy and procedures (P&P) titled, Resident Rights - Quality of Life reviewed on 1/2026, the P&P indicated that, Residents have freedom of choice., as much as possible, about how they wish to live their everyday lives and receive care, subject to facilities rule and regulations and applicable state and federal laws governing the protection of resident health and safety. During a review of the facility's P&P titled, P-NP67 Informed Consent, effective date 1/30/2026, P&P indicated that, If the resident lacks capacity to provide informed consent, the surrogate decision maker will provide informed consent. If the resident lacks capacity to provide informed consent and does not have a surrogate decision maker, the facility will convene a surrogate interdisciplinary team, IDT.

Based on observation, interview, and record review the facility failed to ensure that staff treated residents with respect and dignity and did not calling the residents feeders for seven of seven sampled residents (Residents 2, 3, 20, 56, 57, 58 and 84) who needed assistance with feeding. This deficient practice had the potential for Residents 2, 3, 20, 56, 57, 58 and 84 not attain and maintain the highest practicable physical, mental and psychosocial well-being and also suffer lowered self esteem.Findings: A review of Resident 2's admission record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included, muscle weakness (a lack of physical or muscle strength, throughout the body), diabetes Type 2 (high blood sugar). A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 5/6/2026, indicated Resident 2's cognition (the mental ability to make decisions of daily living) was severely impaired. Resident 2 required substantial/maximal assistance with all activities of daily living (ADL- bed mobility, transfer, eating, toilet use and personal hygiene). During a concurrent lunch observation and interview on 6/01/2026 at 12:58 PM, in the presence of Resident 2, Certified Nursing Assistant (CNA) 3 stated she was currently helping Resident 2 with lunch because the resident, is a Feeder. A review of Resident 3's admission record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included, pressure ulcer (also known as bedsore or pressure sore, is damage to the skin and underlying tissue caused by prolonged pressure, due to lying or sitting in one position for too long), of sacral region (the area between the lower back and the tailbone), and muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 3's MDS, dated [DATE], indicated Resident 3's cognition was severely impaired. The MDS indicated Resident 3 required substantial/maximal assistance with all ADL (bed mobility, transfer, eating, toilet use and personal hygiene). A review of Resident 20's admission record, indicated Resident 20 was admitted to the facility on [DATE], with diagnoses that included, heart failure (a condition where the heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs), and muscle weakness (a lack of muscle strength). A review of Resident 20's MDS dated [DATE], indicated Resident 20's cognition was intact. The MDS indicated Resident 20 required substantial/maximal assistance with all ADL (bed mobility, transfer, eating, toilet use and personal hygiene). A review of Resident 56's admission record, indicated Resident 56 was admitted to the facility on [DATE], with diagnoses that included, hypertension (HTN-high or raised blood pressure), and muscle weakness. A review of Resident 56's MDS, dated [DATE], indicated Resident 56's cognition was severely impaired. The MDS indicated Resident 56 required substantial/maximal assistance with all ADL (bed mobility, transfer, eating, toilet use and personal hygiene). A review of Resident 57's admission record, indicated Resident 57 was admitted to the facility (skilled nursing facility [SNF]) on 10/17/2025, with diagnoses that included, HTN, and muscle weakness. A review of Resident 57's MDS dated [DATE], indicated Resident 57's cognition was moderately impaired. The MDS indicated Resident 57 required substantial/maximal assistance with all ADL (bed mobility, transfer, eating, toilet use and personal hygiene). A review of Resident 58's admission record, indicated Resident 58 was admitted to the facility on [DATE], with diagnoses that included, depression (a serious mood and brain disorder characterized by a persistent feeling of sadness, emptiness, and a significant loss of interest in activities), and muscle weakness. A review of Resident 58's MDS dated [DATE], indicated Resident 58's cognition (the mental ability to make decisions of daily living) was severely impaired. The MDS indicated Resident 58 required substantial/maximal assistance with all ADL (bed mobility, transfer, eating, toilet use and personal hygiene). A review of Resident 84's admission record, indicated Resident 95 was admitted to the facility on [DATE], with diagnoses that included, HTN, and muscle weakness. A review of Resident 84's MDS dated [DATE], indicated Resident 95's cognition was severely impaired. The MDS indicated Resident 84 required substantial/maximal assistance with all ADL (bed mobility, transfer, eating, toilet use and personal hygiene). During an interview on 6/3/2026 at 3:05 PM Director of Staff Development (DSD)/Licensed Vocational Nurse (LVN) 2 stated that she has a list of feeders (Residents who need assistance with feeding) and that she makes the assignment for the two Restorative Nursing Assistants (RNAs) to care for the feeders. During a concurrent interview and record review with Registered Nurse Supervisor (RNS) 1 on 6/4/2026 at 2:23 PM, the facility's document titled Feeders was reviewed. RNS 1 stated, we have a list of all the feeders in the facility and not only the RNAs feed them the CNAs also feed them so that they do not loose weight. RNS 1 stated that the residents on the current feeders list are Residents 2, 3, 20, 56, 57, 58, and 84. RNS 1 stated the list that is titled feeders contain all the feeders in the facility. During an interview on 6/4/2026 at 2:58 PM, the Director of Nursing (DON) stated, we have only a few feeders, the ones on the list entitled FEEDERS is correct they are (Residents 2, 3, 20, 56, 57, 58, and 84) are all currently feeders. When asked if the word feeder is appropriate for a resident who needs assistance with feeding, the DON stated, Yes, although I do not use the word feeders out loud. It is just between the staff, so they know who the feeders are. The DON state, It is not appropriate to use the word feeders around the residents; it is a matter of respect and providing the residents with dignity while they are being cared for in the facility. During an interview on 6/05/2026 at 9:01 AM, CNA 3 stated all the residents on the list entitled FEEDERS is correct. CNA 3 stated Residents 2, 3, 20, 56, 57, 58, and 84 are all feeders and has the feeders listed on her assignment. CNA 3 stated the charge nurse writes in the word FEEDERS so that the CNAs assigned to assist the residents with feeding assistance, will know how many feeders the CNA has. During an interview on 06/05/2026 9:18 AM LVN 6 stated, I write in the assignment the residents that are feeders so the CNAs will know how many feeders they have. I have the RNA help with at least one of the feeders. During record review on 6/3/2026 at 3:27 PM, the facility's of a document entitled FEEDERS, was reviewed. The document revealed a list of residents that needed assistance with feeding and the residents corresponding room and bed numbers. During record review on 6/5/2026 at 1:18 PM of the facility's policies and procedures (P&P) titled Residents Rights - Quality of Life, the P&P indicated the following:PurposeTo ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.PolicyEach resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.ProcedureVII. Facility staff speaks respectfully to residents at all times, including addressing the resident by his or her name of choice.

Based on observation, interview, and record review the facility failed to maintain proper weight settings for the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) for three of five sampled residents (Resident 3, Resident 19 and Resident 57).This deficient practice had the potential for Resident 3, Resident 19 and Resident 57's pressure injuries to worsen or to develop new pressure injuries.Findings: 1. A review of Resident 3's admission record indicated the facility originally admitted the resident on 9/20/2024 and readmitted the resident on 5/8/2026 with diagnosis that included unstageable pressure ulcer of sacral region (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar), type 2 diabetes mellitus (high blood sugar) with foot ulcer, and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). A review of Resident 3's potential for pressure ulcer care plan, initiated 2/4/2025, indicated the resident was at risk for pressure ulcer development due to decreased mobility and the use of anticoagulants (medication that prevents blood clot formation). The care plan goal was for the resident to have intact skin, with no redness, blisters or discoloration. The care plan interventions included a low air loss mattress for skin management to be calibrated by resident's weight and to monitor for accurate settings every shift. A review of Resident 3's Physician Orders, dated 5/8/2026, indicated staff were to cleanse the unstageable pressure injury with normal saline (NS - a saltwater solution), pat dry, apply Santyl (a prescription ointment used to remove dead tissue from pressure injuries). A review of Resident 3's Braden Scale (pressure ulcer risk predictor tool) dated 5/8/2026, indicated Resident 3 had a Braden score of 10 which placed the resident in the high-risk category to develop a pressure ulcer. A review of Resident 3's History and Physical (H&P), dated 5/10/20206, indicated the resident weighed 152 pounds (lbs). The H&P also indicated Resident 3 did not have the capacity to make medical decisions. A review of Resident 3's Minimum Data Set (MDS – a resident assessment tool), dated 5/15/2026, indicated Resident 3's cognition (ability to think, reason and learn) was severely impaired. The MDS also indicated Resident 3 had one unhealed unstageable pressure ulcer and the resident was at risk for developing pressure injuries. A review of Resident 3's Order Summary Report, 6/5/2026 indicated on 5/19/26 the physician ordered the resident to have a LALM for skin management to be calibrated by resident's weight and to monitor for accurate settings every shift. A review of Resident 3's Monthly Weight Report, dated 6/5/2026, indicated Resident 3 weighed 153 lbs in May 2026 and 152 lbs in April 2026. During an observation on 6/2/2026 at 9:37 AM Resident 3 was observed laying on a LALM, with the settings for the LALM observed on the weight setting of 200 to 250 lbs. During an observation on 6/3/2026 at 10:13 AM Resident 3 was observed laying on a LALM, with the settings for the LALM observed on the weight setting of 200 to 250 lbs. During a concurrent interview and observation on 6/4/2026 at 2:26 PM inside Resident 3's room, the resident's wound care was observed. Licensed Vocational Nurse (LVN) 8 cleansed Resident 3's removed the resident's sacral pressure ulcer dressing LVN 8 described the wound bed as having 70 % slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) and 30% granulation tissue (tissue that grows from the wound bed to fill the gap while the wound heals). LVN 9 cleansed the site with normal saline pat dry applied Santyl covered with gauze then an adhesive bordered dressing. LVN 8 stated Resident 3's LALM setting was on 250 pounds earlier today, LVN 8 stated they changed the setting after calling the mattress company and being told to reduce the setting to the resident's weight of 152 lbs. LVN 8 also stated the LALM is to prevent the resident's wound from worsening. During an interview on 6/5/2026 at 11:22 AM, the Director of Nursing stated the LALM prevents the breakdown of the resident's skin and to aid in a wound's healing. The DON further stated the mattress' setting is set according to the residents weight and the wound may not improve if the mattress is on the wrong weight setting. During a review of the facility's policy and procedures (P&P) titled, Mattresses reviewed on 1/2026, the P&P indicated, Purpose To provide mattress appropriate for the resident's need. An air mattress is used under the direction of an attending physician's order or when the resident's clinical condition warrants pressure reducing devices. I. The Facility will provide mattresses capable of meeting the following needs of residents: To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. To provide stimulation and pressure relief to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. To promote comfort to the bedridden resident and help prevent decubiti and other complications of immobility. To reduce pressure and evenly distribute body weight over a larger area of body surface. 2. During a review of Resident 19's admission Record (AR), the AR indicated the facility admitted Resident 19 on 10/7/2025 with diagnoses that included but not limited to cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) and Right and left knee contracture (a stiffening/shortening at knee, that reduces the knee's range of motion). During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 had severe cognitive impairment. The MDS indicated Resident 19 needed staff assistance with activities of daily living (ADL- dependent on staff for using wheelchair, maximum assistance with shower/bathe/toileting, moderate assistance with upper body dressing and personal hygiene, and set up/cleaning assistance for eating and oral hygiene, supervising in sitting/laying). During the review of Resident 19's Order Summary, dated 3/24/2026 at 7:24 pm, Low air loss mattress for skin support/management every shift, verify functioning of low [NAME] loss mattress. Low air loss mattress for skin/wound management to be calibrated by resident's weight. Monitor for accurate settings QSHIFT using (+/-) (+ = Accurate) (- = Inaccurate) every shift. During the review of Resident 19's Weights and Vitals Summary, dated 5/6/2026, resident's weight was 156 pounds (lbs- unit to use for weight measurement). During an observation on 6/3/2026 at 10:40 am, Resident 19 was observed in bed. Resident was on LAM, which was set at 200 lbs. During a concurrent observation and interview on 6/3/2026 at 1:46 pm, with LVN 8 in Resident 19's room, Resident 19 lying in bed. LVN 8 confirmed and stated that Resident 19's LAM was set at 200 lbs. LVN 8 stated Resident 19's recent weight was 156 lb. LVN 8 stated that the LAM was supposed to set at 150 lbs to ensure that LAM was set closest to Resident 19's actual weight. 2. During a review of Resident 57's AR, the AR indicated the facility admitted Resident 57 on 10/17/2025 with diagnoses that included but not limited to CVA, muscle weakness, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (neurologic symptom characterized by weakness or partial paralysis on one side of the body). During a review of Resident 57's MDS dated [DATE], the MDS indicated Resident 57 had moderate cognitive impairment. The MDS indicated Resident 57 needed staff assistance with ADL- dependent on staff for using wheelchair, toileting hygiene, upper/lower body dressing, shower/bathe, personal hygiene, tub/shower transfer, maximum assistance with roll in bed left/right and moderate assistance with eating and oral hygiene. During the review of Resident 57's Order Summary, dated 11/07/2025 at 8:08 am, Low air loss mattress for skin management, to be calibrated by resident's weight. Monitor for accurate settings QSHIFT using (+/-) (+ = Accurate) (- = Inaccurate). Every shift verify the functioning of Low air loss mattress. During the review of Resident 57's Weights and Vitals Summary, dated 5/6/2026, resident's weight was 160 lbs. During an observation on 6/3/2026 at 10:01 am, Resident 57 was observed in bed. Resident was on LAM, which was set at 200 lbs. During a concurrent observation and interview on 6/3/2026 at 1:48 pm with LVN 8 in Resident 57's room, Resident 19 lying in bed. LVN 8 confirmed and stated that the Resident 57's LAM was set at 200 lbs. LVN 8 stated that Resident 57's recent weight was 160 lbs. LVN 8 stated that the LAM was supposed to set at 150 lbs to ensure that LAM was set closest to Resident 57's actual weight . During an interview on 06/04/2026 at 12:48 pm, with Director of nursing (DON), DON stated, Low air loss mattress should be set at the correct weight and at resident's closest weight for all residents who are on low air loss mattress. DON stated that if LAM is set at higher settings than resident's actual weight, it can affect their (residents) mobility in bed and the residents can have skin impairment with that extra pressure from the mattress, and the residents can develop pressure ulcers. There will be a negative outcome and will impair resident's quality of life. During an interview on 6/4/2026 at 2:50 pm, LVN 8 stated that the LAM settings were incorrect for Resident 19 and Resident 57 in relation to the resident weights. LVN 8 stated that if a resident's LAM is set at higher weight than resident's actual weight, it can create more pressure on the resident's skin and that more pressure can create redness on resident's effected skin and resident can potentially develop pressure injury. During a review of the facility's policy and procedures (P&P) titled, Mattresses reviewed on 1/2026, the P&P indicated, Purpose To provide mattress appropriate for the resident's need. An air mattress is used under the direction of an attending physician's order or when the resident's clinical condition warrants pressure reducing devices. I. The Facility will provide mattresses capable of meeting the following needs of residents: To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. To provide stimulation and pressure relief to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. To promote comfort to the bedridden resident and help prevent decubiti and other complications of immobility. To reduce pressure and evenly distribute body weight over a larger area of body surface.

Based on observation, interview and record review, the facility failed to observe infection control measures for three of four sampled residents (Resident 3, Resident 12, and Resident 79) by failing to ensure: 1. Resident 3's urinals (a container used to collect urine closed parentheses were labeled with the residents names and room numbers. 2. Ensure staff did not pick up a meal ticket off the floor then placed the contaminated (something has been made impure, unclean, or dangerous by contact with or the addition of a harmful, foreign, or undesirable substance) meal ticket on one of six residents' (Resident 12) food trays then walked towards the dining room to serve the food tray to Resident 12 with the contaminated meal ticket still on the food tray. 3. Ensure the toilet bowl in one of one resident (Resident 79) was clean and sanitary (clean and free from germs). These deficient practices had the potential for the residents to suffer from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages) and food to contamination (the introduction of pathogens or infectious material into or on normally clean or sterile objects, spaces, or surface) resulting in hospitalization. Findings: 1. A review of Resident 3's admission record indicated the facility originally admitted the resident on 9/20/2024 and readmitted the resident on 5/8/2026 with diagnoses that included unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) of sacral region (tail bone), Type 2 diabetes mellitus (high blood sugar) with foot ulcer, and chronic kidney disease (kidneys are damaged and cannot filter blood as well as they should). A review of Resident 3's Minimum Data Set (MDS – a resident assessment tool), dated 5/15/2026, indicated Resident 3's cognition (ability to think, reason and learn) was severely impaired. The MDS indicated the resident had an indwelling urinary catheter. The MDS also indicated Resident 3 had one unhealed pressure ulcer injury and the resident was at risk for developing pressure injuries. During a concurrent interview and observation on 6/4/2026 at 2:40 PM with Certified Nursing Assistant (CNA) 2, a urinal was observed hanging from the grab bar near the toilet in the restroom located in Resident 3's room. A small amount of urine was also observed in the urinal. CNA 2 stated the urinal belonged to Resident 3. CNA 2 stated the urinal should be marked with the resident's name, room number and date for infection control and to prevent cross contamination. During an interview on 6/5/2026 at 11:27 AM, the Director of Nursing (DON) stated, urinal must have the resident's name, room number and a date so we know when to replace it. The DON also stated, this is an infection control issue as we would not know who used the urinal. A review of the facility's policy and procedures (P&P), Urinal and Bedpan - Offering and Removing, reviewed 1/2026, indicated staff are to: I. Empty the bedpan/urinal into the commode. Flush the commode. J. Sanitize the bedpan/urinal. Wipe dry with a clean paper towel. Discard paper towel into designated container. Store the bedpan or urinal; do not leave it in the bathroom or on the floor. A review of facility's P&P, Infection Control - Policies & Procedures, reviewed 1/2026, indicated, the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 2. During a dining observation on 6/01/2026 at 12:33 PM, Activities Director (AD – designs and leads recreational, social, and therapeutic programs to improve residents' quality of life) was observed picking up a meal ticket that fell on the floor with her bare right hand. AD proceeded to place the contaminated meal ticket on Resident 12's food tray then proceeded to walk towards the dining room. AD was stopped by the surveyor prior to entering the dining room. AD stated, I was going to give [Resident 12] the food tray. AD also stated [Resident 12] might get sick if [Resident 12] ate the food because I contaminated the food tray. AD stated that had Resident 12 consumed the food that was on the contaminated food tray, Resident 12 will have stomach pains.might vomit.will have a lot of pain because of the stomach pains, and the resident will go to the bathroom a lot. I am so sorry. During an interview on 6/01/2026 at 12:42 PM with Activities Assistant (AA – assistant to the Activities Director), AA stated that a meal ticket that fell on the floor is a dirty meal ticket because all floors are dirty. AA also stated that the dirty meal ticket should not be put on the food tray because food is clean. AA stated Resident 12 will get sick from eating the food.will have diarrhea, vomiting.might go to the hospital if [Resident 12] is too sick. During an interview on 6/03/2026 at 2:17 PM with DA 1, DA 1 stated that when staff break infection control (measures taken to prevent or stops the spread of infections in the healthcare settings), residents might get diarrhea, infection, vomit. They [residents] might end up in the emergency room. During an interview on 6/03/2026 at 2:39 PN with DSS, DSS stated the residents are vulnerable and we don't know what the [residents'] immune system can or cannot tolerate. We always have to make sure we follow proper rules and instructions. DSS added that residents get so sick like bad diarrhea and vomiting or bad food poisoning that they end up in the hospital. A review of the facility's in-service education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) indicated education on infection control was not provided to the staff prior to the 6/03/2026 break in infection control incident. A review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees with a revision date of 3/25/2026 indicated, during food preparation, as often as necessary to remove soil and contamination, and to prevent cross-contamination when changing tasks. 3. During a review of Resident 79's admission Record, the admission record indicated the facility admitted Resident 7 9 on 1/16/2026 with diagnoses that included but not limited to Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle spasm (sudden, involuntary tightening of muscle which is difficult to relax). During a review of Resident 79's MDS dated [DATE], the MDS indicated Resident 79 had no cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 79 needed set up or clean up assistance with ADL (including upper/lower body dressing, personal hygiene, eating, oral hygiene, shower and toileting hygiene and independent for rolling left/right, sit/laying, chair/bed transfer. Tub/shower transfer, car transfer toilet transfer and walking 150 feet). During an observation in Resident 79's bathroom on 06/02/2026 at 10:31 am, the toilet commode had solid brown dried uneven stains and feces like substance around the inside rim (top potion of inside portion of the toilet bowl) of the toilet commode. During an interview on 6/4/2026 at 12:55 pm with DON, DON stated, Resident would not want to use the restroom. It is a sanitation issue. It is infection issue. (Resident 79) can get an infection from dirty commode. During an interview on 06/05/2026 at 11:24 am with Infection Prevention Nurse (IPN)/licensed vocational nurse LVN) 3, LVN 3 stated that Resident 79 can get infection from using the dirty toilet bowl. LVN 3 stated that the resident's condition can potentially get worse, the resident might have to receive treatment for infection or get hospitalized . LVN 3 stated that it is important for Resident 79 to have sanitary toilet. During a review of the facility's policy and procedures (P&P) titled ,Infection Control – Policies & Procedures, P&P indicated, a) Intent: The facility's Infection Control policies and procedures are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.b) Objective: Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation, interview and record review, the facility failed to implement their policy regarding reporting resident to resident's allegation of physical abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of six sampled residents (Resident 1 and Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further physical abuse for Resident 1.Findings: A. During a review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left dominant side, dysphagia (difficulty swallowing) following cerebral infarction and heart failure (a condition in which the heart does not pump blood as well as it should). During a review of Resident 1's Minimum Data Set (MDS - resident assessment tool) dated 3/24/2026, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired for daily decision-making and required maximal assistance to dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 4/10/2026, the SBAR indicated, Other resident (Resident 2) accidentally bumped into his right face hitting his right upper cheek, the other resident (Resident 2) apologetic for what had happened.During a concurrent observation and interview with Resident 1 on 4/16/2026 at 12:55 p.m., Resident 1 stated, Resident 2 was yelling and arguing with him and hit (Resident 2) hit him on his face. Resident 1 did a hand gesture of how Resident 2's both fist hit him on his face. Resident 1 stated, Resident 2 ended up on top of his bed after he had tried to push the bedside table to push Resident 2 away from him. Resident 1 stated, there was no staff around when it happened and he explained what happened to the staff.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 4/16/2026 at 1:23 p.m., LVN 1 stated, on 4/10/2026, Resident 2 came back from out on pass and was yelling and walking wobbly. LVN 1 stated, I could smell alcohol from Resident 2. LVN 1 stated, he assumed it was alcohol as Resident 2 came back holding a brown paper bag with a can inside. LVN 1 stated, he had asked Resident 2 to go back inside his room, where Resident 1 was in the same room as his (Resident 2). LVN 1 stated, he then heard a loud crashing sound inside Resident 2's room and when he went inside, he found Resident 2 on top of Resident 1. LVN 1 stated, he then saw Resident 1 with a black eye after that incident. LVN 1 stated, he asked Resident 1 what happened, where Resident 1 stated, he (Resident 2) fell on top me and Resident 1 asked him not to let him go back to his room. LVN 1 stated, he did not witness what happened and Resident 2 was unable to explain exactly what happened because he was intoxicated. LVN 1 stated, he reported the incident to Registered Nurse 1 (RN 1). B. During a review of Resident 2's Face Sheet, the Face Sheet indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired for daily decision-making and required setup assistance to dependent from staff for ADLs.During a review of Resident 2's Progress Notes (PN), dated 4/10/2026, the PN indicated, Resident (2) from out on pass, resident walked in started screaming, yelling in the dining room by himself. he (Resident 2) started cursing at the staff nurses. Resident (2) was walking towards his bed that resident accidentally able to grabbed the bedside table for support but then resident (2) elbow touched other neighbor resident's (1) right cheek. staff able to support resident to prevent fall. During a concurrent interview and record review with RN 1 on 4/16/2026 at 1:57 p.m., RN 1 stated, on 4/102026, LVN 1 reported to her that Resident 2 was intoxicated and found Resident 2 on top of Resident 1. RN 1 stated, Resident 1's face was red when she assessed her. RN 1 stated, she documented that when Resident 2 went inside the room, Resident 2 was able to grab the bedside table for support but resident (2)'s elbow accidentally touched other neighbor (Resident 1)'s right cheek. RN 1 stated, she did not witness that Resident 2's elbow accidentally touched Resident 1's right cheek. RN 1 stated, she should not have documented it that way and she should have investigated that incident further. During an interview with Administrator (ADM) on 4/16/2026 at 2:51 p.m., ADM stated, he was not in the facility when the incident happened. ADM stated, he had just seen Resident 1 and he had a black eye on his right eye. ADM stated, he have to further investigate the incident and will interview staff and residents. A review of the facility's policy and procedures (P&P) titled, Abuse Prevention and Management, reviewed on 1/2026, the P&P indicated, When the Administrator or designated representative receives a report of an allegation of resident abuse, mistreatment, neglect. the Administrator or designated representative, will initiate an investigation immediately. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime. the Administrator or designated representative will notify law enforcement by telephone immediately, or as soon as practicably possible, but no longer than (2) hours of an initial report and send a written SOC341 report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within two hours.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with Order Summary Report for psychological/psychiatrist consult follow-up treatment dated 9/23/2025 and the facility's policy and procedures titled Behavior Management reviewed on 1/2025, when:1. Resident 1's exhibited episodes of aggressive behavior towards Resident 4 (roommate) and became extremely agitated, disruptive, thrashing arms, uncontrolled screaming, and yelling on 9/23/2026 at 9:30 am., and used curse words, derogatory names, and racial slurs directed at Resident 4 and Resident 4's family members.2. Resident 1 became verbally abusive, extremely agitated, and physically aggressive towards Resident 4's family members. These deficient practices risked the safety of Resident 4, Resident 4's family members, other residents and staff negatively impacting the psychosocial wellbeing of Resident 4, Resident 4's family members, other residents and staff in the facilityA review of Resident 1's (Resident 4's roommate) admission record indicated the facility admitted the resident on 8/29/2025 , with diagnoses that included diabetes mellitus, hypertension, and cerebra infarction (stroke), post-traumatic stress disorder (PTSD-is a mental health condition that can develop after experiencing or witnessing a traumatic event, like combat, assault, accidents, or disasters, causing severe anxiety, intrusive memories [flashbacks/nightmares], avoidance of reminders, emotional numbness, and hyperarousal, significantly impairing daily life), and major depressive disorder (MDD-is a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities, significantly affecting daily life, work, and relationships). A review of Resident 1's care plan on The Resident has a behavior problem extreme agitation m/b (manifested by) verbally and physically aggressive towards staff and other residents initiated on 9/23/2025. A review of Resident 1's Order Summary Report, indicated, Resident 1 for psychological/psychiatrist consult follow-up treatment as indicated dated 9/23/2025. A review of Resident 1's Order Summary Report, indicated, Please add diagnosis: PTSD MDD and Cluster B Personality Disorder (a group of conditions characterized by dramatic, emotional, or erratic behaviors, intense emotions, and significant challenges with impulse control and stable relationships, including antisocial, borderline, histrionic, and narcissistic personality disorders [a personality disorder characterized by an exaggerated sense of self-importance, a need for admiration, and a lack of empathy for other people], often leading to interpersonal chaos and difficulty managing feelings) on 9/23/2025. A review of Resident 1's Progress Note dated 9/23/2025, indicated that Resident 1 was yelling, screaming, and hitting others including other residents. The progress note indicated that Resident 1 was coughing and spitting in the rehabilitation (rehab) sink; The patient (Resident 1) was asked to leave the rehab area to protect others/residents. The patient (Resident 1) became violent and putting others in danger. A review of Resident 1's care plan (CP) on The Resident has a behavior problem extreme agitation m/b (manifested by) verbally and physically aggressive towards staff and other residents initiated on 9/23/2025, indicated that on 9/30/2025, Resident 1 with episode of verbally abusive towards family member of Resident 4. Resident 1 has a behavior problem of extreme agitation m/b verbally and physically aggressive towards staff and other residents. The CP goal indicated that Resident 1 will have no evidence of agitation, will have fewer episodes of agitation daily. The CP interventions initiated on 9/24/2025, indicated, If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Remove from situation and take to alternate location as needed. Psychiatry and psychology consult as indicated. A review of Resident 1's Behavior Note dated 9/23/2026 at 9:30 am, indicated that Resident 1 became, extremely agitated, disruptive in behavior thrashing arms, uncontrolled screaming, yelling towards others after being told by physical therapy staff that he cannot be coming to the rehab sink to spit out secretions, gagging, coughing out in the sink. and not to empty urinal (a device to collect urine) into the sink multiple times. Resident 1 continued to be agitated and began scratching, biting, hitting, spitting and yelling. Resident 1 continued with disruptive behavior . and roommate (Resident 4) feeling unsafe towards Resident 1. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 9/28/2025, indicated the resident had moderate cognitive impairment (poor decision-making requiring cues and supervision). The same MDS indicated Resident 1 required between supervision or touching assistance to set up or clean-up-assistance for Activities of Daily Living (ADLs) such as eating, oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and putting on/taking off footwear. A review of Resident 1's Behavior Note dated 10/1/2025 at 9:04 pm, indicated that IDT met with Resident 1 regarding the resident's Moody, temperamental sudden outburst anger behavior . Resident 1 would not listen or adhere to staff instructions. A review of Resident 1's care plan on The Resident has a behavior problem extreme agitation m/b (manifested by) verbally and physically aggressive towards staff and other residents indicated that on 11/20/2025, Resident 1 had an episode of yelling curse words and racial slurs towards Resident 4's family member. the goal indicated that Resident 1 will have no evidence of agitation. The CP interventions indicated that staff to intervene as necessary to protect the rights and safety of others.Psychiatry consult and psychology consult as indicated. A review of Resident 1's Behavior Note dated 11/20/2025 at 1:45 pm, indicated that Resident 1 was heard yelling curse words and racial slurs towards roommate (Resident 4) family member. The behavior note indicated Resident 1 expresses that no one crosses his boundaries. (Resident 1) Is unable to calm down or able to reason. A review of Resident 1's Behavior Note dated 12/5/2025 at 10:55 pm indicated that Resident 1 was made aware that Resident 4's family was visiting to collect Resident 4's dirty clothes and Resident 1 became frustrated and stated he did not want anybody in the room. A review of Resident 1's Psychological (refers to anything related to the mind, emotions, thoughts, and behavior, influencing health and illness) Consultations dated 12/5/2025, indicated, .Initial evaluation. Treatment goals. 3. Stabilization of irritability/anger and increase appropriate expression of angry feelings. The psychological consultations indicated that Pt (patient/Resident 1) discussed frustration with being physically impaired and having to be in this facility . endorsed . ongoing sadness and difficulty adjusting to current living situation and loss of independence. A review of Resident 1's CP on The resident (Resident 1) has depression r/t Dx (diagnosis) MDD, PTSD, Cluster B personality disorder. initiated on 12/5/2025, indicated interventions included to arrange for psych (psychiatry) consult, follow up as indicated. A review of Resident 4's admission record indicated the facility initially admitted the resident on 10/24/2024 and readmitted on [DATE], with diagnoses that included major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in enjoyable activities, lasting at least two weeks and significantly interfering with daily life, work, or relationships, differing from temporary sadness by its severity and long-lasting impact on feelings, thinking, and behavior), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), metabolic encephalopathy (a disorder that affects brain function), cognitive communication deficit (trouble with communication because of underlying thinking problems, like issues with attention, memory, problem-solving, organizing thoughts, or social skills), and Parkinson's disease (a brain disorder that makes it hard to control movements, causing shaking [tremors], stiffness, slow movement, and balance problems because brain cells that make dopamine [ chemical for movement] die off). A review of family member (FM) 1's letter to the facility dated 12/3/2025 , indicated that FM 1 complained that since the beginning of 10/2025 to present and on several negative encounters, Resident 1 called FM 2 a derogatory term N*** when FM 2 was assisting Resident 4 and FM 1 was on facetime with FM 2. The letter indicated that the encounter when FM 2 bumped into Resident 1's table which was unseen due to drawn curtain. Resident 1 made the derogatory comment that FM 2 was careless and . FM 2 was taken aback and stated it could be dangerous not just for Resident 4. FM 2 left but feared for Resident 4 as Resident 4 is unable to defend himself. A review of Resident 4's MDS dated [DATE], indicated the resident had severe cognitive impairment (when thinking, memory, concentration, and decision-making are so impacted that a person can't live independently or fully understand their world, often losing the ability to talk, write, or perform basic self-care like eating, requiring constant support). The MDS indicated Resident 4 required between supervision or touching assistance to being dependent on staff for ADLs such as eating, oral hygiene, toileting hygiene, shower/bathe, upper and lower body dressing, and putting on/taking off footwear. During an interview with Resident 1 on 12/18/25 at 1:26 pm, Resident 1 stated that Resident 4's bedside table is placed right at the privacy curtain between Resident 1 and Resident 4. Resident 1 stated that when Resident 4's family come in the room, they push the side table towards his side knocking down his water and urinal (a device for collecting urine). Resident 1 stated this has happened three times and told the Administrator and the ombudsman (is a neutral, independent advocate who investigates and resolves complaints for patients, residents, or consumers regarding their care, billing, or rights, acting as a liaison between individuals and healthcare systems) but he felt like the Administrator and ombudsman didn't care. Resident 1 stated Resident 4's come in after 9 pm, 11 pm and 2 am in morning. Resident 1 stated that that the ombudsman found that the roommate (Resident 4) had the right for visitation which made Resident 1 very upset. Resident 1 stated that he was frustrated with the table issue and called Resident 4, a n****r, and Resident 4's family members the N word because of free speech. Resident 1 stated and confirmed that Resident 4 never called Resident 1 any names or racial slurs. However, Resident 1 was quiet for a moment and then stated that, it would appear to be abusive to be called a racial slur. During an interview with Registered Nurse Supervisor (RNS) on 12/18/25 at 2:14 pm, RNS stated that there were some issues between Resident 1 and roommate (Resident 4). RNS stated that Resident 1 was admitted to the facility on [DATE]. RNS stated that when she wheeled Resident 4 to share a room with Resident 1. RNS stated that when Resident 1 saw Resident 4 in the room, Resident 1 stated that he did not like *b.* people and did not want Resident 4 in the same room with him (Resident 1). RNS stated she left Resident 4 in the same room with Resident 1 and did not think there were going to be issues because Resident 1 had a window view. RNS stated that Resident 1 was later offered a different room (room change) on several occasions occasion, however, Resident 1 declined because Resident 1 wanted Resident 4 to be moved instead to another room. RNS stated that Resident 1 has constant mood changes where one minute Resident 1 is upset and the next minute Resident 1 is interactive. When asked why the facility allowed Resident 1 and Resident 4 to remain in the same room, RNS stated, can you imagine moving him (Resident 1) to another resident's room and the issues? During an interview with the facility administrator (FA) on 12/18/2025 at 3:47 pm, FA stated, that there is a history between Resident 1 and roommate's (Resident 4) family. Resident 1 had a tendency of calling them (Resident 4's) derogatory names. He (Resident 1) was upset that they (facility) did not restrict the visitors which is their right. The FA stated that the facility does not restrict and place time limits on the visitation. The FA stated that whenever the roommate's (Resident 4) family come to visit, they (family members) are not even in the room, but Resident 1 still gets upset maybe because Resident 1 felt left out that he (Resident 1) did not have visitors. During a telephone interview with the Resident 4's FM 1 on 12/18/2025 at 5:40 pm, FM 1 stated that Resident 4 has been in the facility for about four to five years. FM 1 stated that when Resident 1 first moved into the room, Resident 4's family and FM 1 had no issues until a few days later when Resident 1 had placed his bedside table so close to the privacy curtain and FM 1 accidentally bumped it. FM 1 stated Resident 1 yelled at FM 1 and started to curse even though FM 1 quickly apologized and told Resident 1 that it was an accident. FNM 1 stated that another time when FM 1 was on FaceTime with FM 2 who was at bedside visiting Resident 4, FM 2 accidentally bumped into the Resident 1's table that's always constantly at the privacy curtain and cutting into Resident 4's space. FM 1 stated she couldn't hear that resident one became so I read and agitated called her the N word. FM 1 stated that Resident 1 was very upset and said so many words forcing FM 2 to leave. FM 1 stated FM 2 verbalized to FM 1 concerns about Resident 4's safety given that Resident 4 was remaining in the room with Resident 1 who seemed agitated given that Resident 1 is bedridden and could not physically protect himself. FM 1 stated that she did not want Resident 4 moved out of the because Resident 4 has dementia and Parkinson's which may cause Resident 4 to get even more confused. FM 1 stated that one time she was visiting Resident 4 when Resident 1 started yelling and cursing so badly that the staff ran into the room to find out what was going on. FM 1 stated the facility asked her to report or file a grievance but refused because she wanted the incident documented. FM 1 stated that FM 1 wrote a very detailed letter to the facility outlining everything of how FM 1 and Resident 4's family members felt about Resident 1's behavior. During an interview with Social Services Director (SSD) on 12/19/2025 at 1:06 pm, SSD stated that Resident 1 does not get along with Resident 4's family members. SSD stated that Resident 1 has been offered a room change but refuses and that SSD feels like Resident 1 wants a private room. SSD stated FM 1 and FM 2 was offered a room change for Resident 4 but FM 1 and FM 2 (decision makers) declined. SSD stated that on 9/25/2025, Resident 1 was agitated in the lobby and that other residents were also present. SSD stated that on 10/1/2025, IDT was conducted with Resident 1 because Resident 1 risked the safety of other residents by kicking, screaming, yelling and scratching. SSD stated that Resident 1 used racial slurs against Resident 4. During an interview with Physical Therapist Assistant (PTA) on 12/19/2025 at 2:50 pm, PTA stated Resident 1 uses the rehab therapy room sink to washes his face, spit phlegm, and to brush his teeth and that other residents come to do therapy in the rehab therapy room. PTA stated that Resident 1 gets agitated when things don't go Resident 1's way. A review of the facility's P&P titled Behavior Management reviewed on 1/2025, indicated that, The facility will ensure that when a resident displays a mental disorder, psychosocial adjustment difficulties (e.g. crying, yelling, hitting, etc) or has a history of trauma and /or post-traumatic stress disorder, they will receive appropriate treatment to address the problem . Efforts will be made by the interdisciplinary Team (IDT) to implement non-pharmacological interventions to alleviate behavior symptoms before initiating any psychoactive medications.

Based on interview and record review, the facility failed to report to the Department of Health Services (CDPH), Licensing and Certification and the local health officer an unusual occurrence for two of six sample residents (Residents 17 and 71) an unwitnessed fall with injury within twenty-four (24) hours of confirmed occurrence per facility policy. On 12/23/2024 at around 11:35 AM, Resident 17 had an unwitnessed fall and sustained a skin tear to the right upper eyebrow. On 12/23/2024 Resident 17 was transfered to a General Acute Care Hospital (GACH) for a higher level of care and evaluation. On 2/28/2025 at 6:42 PM, Resident 71 had an unwitnessed fall and sustained a cut to the left eyebrow. On 2/28/2025, Resident 71 was transferred to GACH for higher level care and evaluation. This deficient practice resulted in a delay of an onsite inspection by CDPH to ensure Residents 17 and 71 allegation of an unwitnessed fall with a significant injury was investigated in a timely manner placing the residents at risk for undetected elder neglect and/or abuse. Findings: a. During a record review, Resident 17's admission record indicated Resident 17 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included history of falling, osteoporosis (a decrease in bone mass and density, leading to increased bone fragility and fracture risk.), cognitive communication deficit (disorder that affect a person's ability to communicate), history of traumatic fracture (a bone break that results from an external force or trauma), Alzheimer's (a progressive, neurodegenerative disorder characterized by the gradual decline of memory, thinking, and other cognitive functions) and dementia (a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, that significantly interferes with daily life and activities.), During a record review, Resident 17's History and Physical report dated 1/2/2025, indicated Resident 17 does not have the capacity to understand and make decisions. During a record review, Resident 17s Minimum Data Set (MDS - a resident assessment tool) dated 1/6/2025, indicated Resident 17s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 17 partial/moderate assistance with eating, substantial/maximal assistance and oral hygiene and upper body dressing, and was dependent for toileting hygiene, shower/bathing, lower body dressing and putting on/ taking off footwear and was non-ambulatory. During a record review, Resident 17's SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for communication between members of the health care team) form and progress notes dated 12/23/2024, indicated that on 12/23/2025 at around 11:35 AM, Resident 17 had an unwitnessed fall that occurred in the hallway and sustained a skin tear to the right upper eyebrow. Resident 17 was reaching for item(s) at time of the fall. Resident 17 was assessed, provided first aid care, vital signs were within normal limits and neuro checks were initiated. Resident 17's doctor was notified of the fall who ordered to transfer Resident 17 to a General Acute Care Hospital (GACH) for a higher level of care and evaluation. During a record review, Resident 17s GACH (which records ED/HP?) records dated 12/24/2024, indicated, the reason/chief complaint for admitting Resident 17 was an unwitnessed fall, elevated troponin and left shoulder pain. During a record review, Resident 17's GACH head computerized tomography scan (CT scan - a non-invasive imaging procedure that uses X-rays and computer technology to produce detailed images of the body's internal) impressions dated 12/24/2024, indicated Resident 17 did not sustain any fractures. During an interview on 03/06/2025 at 2:45PM, the Director of Nursing (DON) stated, acute injury due to a fall, should be reported to the appropriate federal and state agencies within 24 hours. During a record review, the facility policy and procedures (P&P) titled Unusual Occurrence Reporting, reviewed on 01/2025 indicated, the facility reports the following events by phone and in writing to the appropriate state or federal agencies other occurrences that interfere with And affect the welfare, safety or health of residents . The P&P further indicates that, unusual occurrences are reported to the appropriate agency within 24 hours by telephone and the confirmed in writing. 45037 Cross Reference F689 b. During a record review, Resident 71's admission record indicated was readmitted on [DATE], with a diagnoses of history of falling and unspecified Dementia (cause of dementia cannot be determined, often used when a person's cognitive decline is present). During a record review, Resident 71's MDS- a resident assessment tool dated 2/8/2025, indicated Resident 71's cognition was moderately impaired. The MDS further indicated Resident 71 needed moderate/maximum assistance with ADL (activities of daily living). During a record review, Resident 71's History and Physical report dated 2/27/2025, indicated Resident 71 has a diagnosis of dementia and does not have the capacity to make medical decisions. During a record review, Resident 71's SBAR form and progress notes dated 2/28/2025, indicated Resident 71 was found on the floor unwitnessed, breathing unlabored, verbally responsive, vital (blood pressure, temperature, pulse, respirations) stable. Resident 71 noted with skin open cut in left eyebrow, applied dressing, and cailed 911 to GACH, not on blood thinner, and family notified and MD (medical doctor). During a record review, Resident 71's Physician Orders dated 02/28/2025, indicated to transfer Resident 71 to GACH via 911 due to fall causing a cut in skin. During a record review, Resident 71's GACH After Visit Summary Emergency Department dated 02/28/2025, indicated Resident 71 unwitnessed fall and sustained left eyebrow laceration, and for Resident 71 to return to the emergency room in 5 days for suture removal. During an observation and interview on 3/4/2025 at 9:43 am., Resident 71 was noted with dark discoloration under the left eye, and sutures to his left eyebrow. During an interview with Resident 1 he stated he fell in the library and hit his left eye. During an interview on 03/04/25 at 2:21 pm, Registered Nurse Supervisor (RNS) stated that on 2/28/2025, Resident 71 climbed out of bed, had an unwitnessed fall and sustained an injury the required Resident 71 to be sent to GACH via 911 (Emergency response telephone number) by the paramedics. RNS stated she had to apply pressure to stop the bleeding to Resident 71's left eye and applied steri-strips (thin, adhesive bandages that help close wounds) to Resident 71's left eye prior the paramedics arriving to the facility to transfer Resident 71 to the hospital. RNS stated she did not report the unwitnessed fall with a significant injury to CDPH. RNS stated she notified the Director of nursing and reported the fall with significant injury to the DON. During an interview on 03/04/25 at 2:27 pm, the Director of Nursing (DON) stated the RNS reported to DON that Resident 71 fell and was sent to GACH via 911. The DON stated DON did not report the unwitnessed fall with significant injury (left eyebrow laceration) to CDPH because the RNS reported that the injury to Resident 71's left eye was an abrasion. The DON stated DON was aware that RNS steri-strips to Resident 71's left eye and that Resident 71 was transported to GACH via 911. The DON stated DON should have reported the unwitnessed fall with significant injury to CDPH within 24 hours. During an interview on 03/06/25 at 11:34 am, Administrator stated the DON notified Administrator on the day of the incident (02/28/2025) that Resident 71 fell and was transferred to GACH via 911. Administrator stated he did not report the unwitnessed fall to CDPH because Resident 71 did not sustain a significant injury. Administrator stated he was aware that the RNS applied steri-strips and transferred Resident 71 to GACH via 911. Administrator stated Administrator does not have any medical training/background and could not define a laceration, and did not consider the bleeding to a Resident 71's left eye and eyebrow and RNS calling 911 for Resident 71 as significant. During a record review, the facility policy and procedures titled Unusual Occurrence Reporting reviewed and dated 1/25, indicated, 2. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, and homelike environment for residents in the facility by failing to: 1. Maintain residents' room temperature between 71 and 81 degree Fahrenheit ( F) as required by the Federal regulation for one of three sampled residents (Resident 70) and five of five rooms checked during a facility tour. This deficient practice resulted in Resident 70 stating of being cold and feeling uncomfortable making it hard for the resident to sleep. 2. Provide a clean, sanitary and in good repair environment in one jack and [NAME] bathroom (a shared bathroom situated between two bedrooms, featuring at least two entrances (one from each bedroom),) for residents in rooms [ROOM NUMBERS]. This deficient practice had the potential to expose Residents and disease-causing pathogens/ micro-organisms that can cause infection, spread diseases. Findings: a. During an observation on 3/3/2025 at 8:55 AM, Resident 70 sleeping in bed covered with multiple blankets. During a record review, Resident 70's admission record indicated the facility originally admitted the resident on 6/27/2024 and readmitted the resident on 12/27/2024 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), anemia (a condition where the body does not have enough healthy red blood cells) and high blood pressure. During a record review, Resident 70's Minimum Data Set (MDS - a resident assessment tool) dated 1/3/2025, indicated Resident 70's cognition (mental ability to make decisions of daily living) was moderately impaired. The MDS also indicated the resident could make themselves understood and could understand others. It also indicated the resident required partial to substantial assistance with eating, toileting hygiene, showering, dressing and personal hygiene. During a general observation of residents rooms with Maintenance (MNT) on 3/3/2025 at 9:34 AM, MNT checked Residents rooms 202, 203, 212, 216 and 220 temperature using the facility laser temperature thermometer. The residents rooms temperature was ranging from 62 degrees farenheit ( F- unit of measurement) to 68 F. MNT stated residents' rooms temperatures should be between 71 F and 81 F. The room temperature of Resident 70's room was 68 F. During a concurrent interview and observation on 3/4/2025 at 10:36 AM at Resident 70's bedside, Resident 70 was observed laying in bed covered with two blankets. Resident 70 stated the room was cold the day before (3/3/2025) and that nursing staff provided the resident extra blankets when they notice that the resident is cold. Resident 70 stated being cold makes the resident uncomfortable and makes it hard to sleep. During an interview on 3/6/2025 at 1:00 PM, Director of Nursing (DON) stated they didn't know the exact temperature resident room should be maintained at. The DON further stated the resident room temperatures should be comfortable and homelike. During a record review, the facility policy and procedures titled, Resident Rooms and Environment, reviewed 1/2025, indicated, the purpose of the policy was to provide residents with a safe, clean, comfortable and homelike environment. The P&P further indicated facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: E. Comfortable levels of ventilation; F. Comfortable temperatures; and G. Comfortable noise levels. 45455 Cross Reference F880 b. During initial tour on 3/6/25 at 1:40 PM, rooms [ROOM NUMBERS] shared bathroom walls were observed to have chipped paint, holes, dry hard brown smear was observed on the walls by the light switch and on the bedside BSC that was inside the residents bathroom. During a concurrent observation and interview on 3/6/2025 at 1:43PM, Resident 17 was observed ambulating inside room [ROOM NUMBER]. Resident 17 stated the bathroom has chipped walls, and holes, there is poop (fecal matter) on the walls, and that housekeeping cleans the toilet and floor only every day. During an interview on 3/6/25 at 1:49 PM, Director of Staff Development (DSD) stated housekeeping staff is responsible for cleaning the residents bathrooms. DSD stated the dried hard smear by the light switch, and the BSC was fecal matter. DSD stated the fecal matter on the walls and BSC placed Residents at risk of contamination with disease causing pathogens micro-organisms that can cause infection and does not reflect good hygiene of a safe, clean, sanitary homelike environment. During a record review, the facility policy and procedures (P&P) titled Resident rooms and Environment dated 1/2025 indicated, the facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: Cleanliness and order . During a record review, facility (P&P) titled infection control- Policies & Procedures dated 1/2025 indicated, the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseased and infections.

Based on interview and record review, the facility failed to treat two out of 20 residents (Residents 11 and 45) with respect, dignity and, care by failing to provide person-centered care in a manner that promotes and supports the Residents quality of life. This deficient practice had the potential to negatively affect the Residents' 11 and 45 physical, mental and psychosocial well-being. Findings: During a record review, Resident 11's medical record indicated Resident 11 was originally admitted to the facility on [DATE] with diagnoses that muscle weakness, falling, depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities.), cognitive communication deficit (disorder that affect a person's ability to communicate.), and anxiety (excessive and persistent worry, fear, and unease). During a record review, Resident 11's history and physical (H&P) dated 12/6/2024 indicated Resident 11 has the capacity to understand and make medical decisions. During a record review, Resident 11's Minimum Data Set (MDS-a resident assessment tool), dated 12/10/2024 indicated Resident 11's cognition (the mental ability to understand and make decisions of daily living) was intact. The MDS indicated Resident 11 requires set-up or clean up assistance with eating, requires supervision for oral hygiene, require partial moderate assistance with personal hygiene, requires substantial/maximum assistance with shower/bathing self, is dependent for toileting hygiene, lower body dressing and putting on/taking off footwear and is non-ambulatory. During a record review, Resident 45's medical record indicated Resident 45 was originally admitted to the facility on [DATE] spinal stenosis (narrowing of the spinal column that causes pressure on the spinal cord,), muscle weakness, chronic obstructive pulmonary disease (COPD-lung diseases that cause airflow obstruction and breathing difficulties), cognitive impairment (decline in one or more cognitive functions, such as memory, attention, reasoning, judgment, and problem-solving), and anxiety disorder (excessive and persistent worry, fear, and unease.) During a record review, Resident 45's history and physical (H&P) dated 1/31/2025 indicated Resident 45 has the capacity to understand and make medical decisions. During a record review, Resident 45's MDS, dated [DATE] indicated Resident 45's cognition was intact. The MDS indicated Resident 45 requires substantial maximal assistance with eating, oral hygiene, toileting hygiene, shower/bathing, upper body dressing and personal hygiene. Resident 45 is dependent with lower body dressing and putting on /taking off footwear and in non-ambulatory. During an initial facility tour on 3/3/2025 at 9 AM Resident 11 stated 2 nights ago (3/1/2025) the 11AM-7AM certified nurse assistant (CNA) 1 (assigned to Resident 11) told Resident 11, that CNA 1 did not want to provide incontinent care to Resident 11, Resident 11 stated Resident 11 asked CNA1 if Resident 11 had done something wrong to CNA1, however, CNA1 did not respond. Resident 11 stated she asked CNA1 for the name of the CNA assigned to Resident 11 and CNA 1 stated she (CNA1) was the one assigned to Resident 11. Resident 11 further stated that the 11AM -7AM staff seem very angry, do not introduce themselves or even say hello when called to assist with ADL care for Resident 11. Resident 11 stated she felt scared and thought she was going to be abandoned. During an initial tour on 3/3/2025 at 10:23AM Resident 45 stated, the day before yesterday (3/1/2025) during the 11AM-7AM shift he waited for 2 hours for call light response. Resident 45 stated a female nurse staff (no name provided) came to Resident 45's room, did not introduce self to Resident 45, and rudely asked Resident 45 what do you want? Resident 45 stated he asked the female nurse to provide Resident 45 with incontinence care, however, the staff rudely stated, I have other residents ahead of you and stormed out of Resident 45's room. Resident 45 stated he was unable to state the female nurse's name because the female nurse and the nurses wear their badges in a manner that does not show their names. During a record review, the facility staff assignment dated 3/1/2025 11PM-7AM shift indicated, CNA1 was assigned to provide care to Resident 11 while, CNA2 was assigned to Resident 45. During a telephone interview on 3/6/2025 at 9:42AM, CNA1 stated CNA1 had no issues with any of the residents assigned to her care on 3/1/2025. CNA1 stated there was a miscommunication between CNA1 and CNA2 on room assignments, CNA1 denied telling Resident 11 which CNA did not want to provide Resident 11 with incontinence care. During a telephone interview on 3/6/2025 at 8:41 AM, CNA 2 denied addressing Resident 45 rudely, CNA2 stated when Resident's call for assistance, CNA2 will ask the residents what they want and get them what they need, CNA2 stated, some residents in the facility are difficult. During an interview on 3/6/2025 at 2:50 PM, Director of Nursing (DON) stated, all staff are supposed to be polite when addressing the residents. DON further stated, staff are required to knock on the resident rooms, introduce themselves and treat all residents with dignity and Respect. During a record review, the facility policy and procedures (P&P) titled Resident Rights dated 01/2025 indicated, Employees are to treat all residents with kindness, respect and dignity and honor the exercise of Resident rights. During a record review, the facility P&P titled Resident Right-Quality of life dated 01/2025 indicated, each Resident shall be cared for in a manner that promotes and enhances the quality of life, dignity and respect, individuality and receive services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.

Based on interview, and record review, the facility failed to protect the residents' right to be free from physical abuse and sexual abuse for two of five sampled residents (Residents 2 and 3) by failing to: 1. Protect Resident 3 who was threatened by his roommate (Resident 1) on 3/2/2023 with a butter knife. 2. Ensure Resident 1 was not found in Resident 2's bedroom on 3/7/2023 on top of Resident 2, who was developmentally delayed (someone who have not gained the developmental skills expected of him or her, compared to others of the same age) and whose incontinence briefs and pants were observed at her ankle. Resident 1's private part (the genital organs of the male) was observed exposed. 3. Provide the required staffing personnel including providing a Certified Nursing Assistant (CNA) to Resident 2 and a one-to-one sitter (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) to Resident 2 as indicated in Resident 2's care plan. 4. Assess and revise Resident 1's care plan to identify the potential risks to other residents related to the behaviors of Resident 1 who had a known history of sexually inappropriate behaviors. These deficient practices resulted in Resident 2 experienced sexual abuse and severe psychosocial harm as a result of the sexual abuse. Resident 2 was found grimacing, crying, and change in behavior of not leaving her bed and not moving out of her bed. And Resident 3 experienced mental anguish, and who stated that he was fearful every time he saw Resident 1 in the hallway after the incident. On 4/13/2023 at 1:50 pm., the State Agency (SA) called an Immediate Jeopardy (- a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Director of Nursing (DON) and the Registered Nurse Supervisor 1 (RN 1) for failing to protect Residents 2 and 3s' right to be free from physical and sexual abuse. On 4/14/2023 at 1:29 p.m., the IJ was removed in the presence of the Administrator, RN 1, and Registered Nurse Consultant (RNC) after an on-site verification of the implementation of the acceptable IJ Removal Plan (a plan with interventions to correct the deficient practices) through observations, interviews, and record reviews. The acceptable IJ removal plan that included the following summarized actions/items: 1. The Administrator and DON investigated the incident between Resident 3 and 1, and reported to the California Department of Public Health, Ombudsman and Local Law Enforcement on 3/2/23 at 8:30AM. 2. On 3/2/2023, Resident 1 was assessed by a Licensed Nurse, and the butter knife was taken from resident's possession. Resident 1 was provided a quiet environment. On 3/2/23, the Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) evaluated Resident 1 and ordered to increase the Risperidone (A drug used to treat certain mental disorders) due to self-endangerment and harm to others. Local police came to the facility and conducted their investigations and interviewed Resident 1. On 3/2/23, the RN Supervisor informed the dietary department to avoid sharp utensils to be given to resident during mealtimes for Resident 1. 3. On 3/2/2023, Resident 3 was moved to a different room away from Resident 1. Resident 3 was assessed by the Licensed Nurse and the attending physician was notified. Resident 3 was seen and evaluated by the Psychiatrist. Resident 3's care plan was updated with interventions. On 4/7/2023, Resident 3 was seen and evaluated by the Psychiatrist again. On 4/13/2023, Resident 3 was reassessed by the Licensed Nurse. On 4/13/2023, the Attending Physician was notified of the status of Resident 3. 4. The Administrator and DON immediately investigated the incident between Resident 1 and 2 and reported to CDPH, Ombudsman and Local Law Enforcement on 3/7 /23 at 9:00AM. 5. On 3/7/23, Resident 2 was assessed by a Licensed Nurse and the attending physician was notified regarding the incident that occurred between Residents 1 and 2. Resident 2 was transferred to the acute hospital on 3/7/23 and returned to the facility on the same day. Resident 2 was provided a 1:1 (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act) sitter upon return from the acute hospital. On 3/8/23, the Social Services Designee visited Resident 2 for psychosocial support. Resident 2 exhibited a positive and stable mood. Resident 2 no longer resides at the facility as of 3/9/23. 6. Resident 1 no longer resides at the facility as of 3/8/23 and was transferred to Acute Care Hospital. The resident has not returned to the facility and was placed in another facility that is a locked unit. 7. The Administrator/DON/designee provided education to the staff on Abuse Prohibition with emphases on ensuring residents rights are protected and be free from any physical and sexual abuse or any forms of abuse and the importance of timely notification and reporting of abuse as per the policies and procedures and regulations. 3/2/2023 at 9 am 3/7/2023 at 8:00 am to 5 pm 3/13/2023 at 2:45 pm 3/15/2023 at 2:30 pm. 8. On 4/13/23, the DON/designee conducted an audit of current residents with a total census on 79 to identify residents with behaviors such as aggressive or inappropriate/ sexual behaviors. No other residents were identified to be affected by the same deficient practice. 9. On 4/13/23, the Administrator/designee conducted an audit of current staffing in April 2023 to ensure that adequate staffing is provided to our residents. 10. On 4/13/23, the DON/designee conducted an audit of current residents with an order for 1:1 supervision. The are no other residents with an order for 1:1 supervision; therefore, no other residents were affected. 11. On 4/13/23, the DON/designee conducted an audit of current residents' care plans who have a known history of sexually inappropriate behaviors. There were no other residents identified to have inappropriate sexual behaviors at this time; therefore, no other residents were affected. 12. The DON/designee provided education to the Nursing staff on the Policies and Procedures for Abuse Prohibition, Behavior Management and Person-Centered Care Plan Development. 4/13/2023 at 2:45 pm 4/13/2023 at 3 pm. 13. On 4/14/23, the Social Service Consultant is scheduled to visit the facility to provide further education to the staff regarding Abuse Prohibition, Behavior Management, and Care Planning. 14. On 4/15/23, the [NAME] President of Behavioral Health and Social Services is scheduled to visit the facility to provide further education to the staff regarding Abuse Prohibition, Behavior Management, and Care Planning. 15. The Licensed Nurses will conduct a thorough assessment of Newly admitted residents and those with changes of condition and will develop, update, or revise the care plan with risk factors, goals of care and person- centered interventions. During the morning clinical meeting with the IDT, new admissions and changes of conditions will be reviewed to ensure that resident assessments and care plans are completed, developed, updated/revised, and implemented. 16. The Administrator and DON together with the Department Managers during the morning stand-up meeting will review the current nursing staffing of the facility to ensure adequate staffing is provided to meet the needs of the residents. When a staff member calls off, the Administrator and DON will be notified to attempt replacement of staff by calling other staff who are off or by asking current staff at the facility to extend hours and ensure that residents especially with order for one-to-one sitters are provided with adequate supervision according to the care plan. If unable to find staff that could come in or extend hours for those who are currently at the facility at the time a staff calls off, the Administrator and/or DON will assign a licensed nurse available to provide 1:1 monitoring and supervision to ensure safety of the resident. 17. During Morning Clinical Meeting, Monday to Friday, the IDT (The Interdisciplinary Team [IDT] is a group of dedicated healthcare professionals who work together to provide you with the care you need, when you need it) will review New Admissions and Changes of condition such as new behaviors and incidents/accidents to ensure that Residents with identified known history of behaviors such aggressiveness or sexually inappropriate behaviors are assessed by the IDT and a person-centered care plan to address potential risk related to the behaviors including interventions are developed to prevent or minimize adverse outcomes to the residents in the facility. Identified concerns will be immediately addressed and reported to the DON. 18. During Morning Clinical Meeting, Monday to Friday, the DON, and Director of Staff Development (DSD) will review the current nursing staffing of the facility to ensure adequate staffing is provided to meet the needs of the residents. Any concerns identified will be reported to the Administrator and will be addressed immediately. Findings: a. A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right tibia (the shinbone, the larger of the two bones in the lower leg), multiple fractures of the ribs, hypertension (high blood pressure) and history of cerebral infarction (stroke, brain tissue damage due to a blood clot or bleed in the brain). A review of Resident 1's Clinical Admission Evaluation, dated 12/23/2022, indicated Resident 1 was alert and oriented (being aware of person, place, time and/or situation), communicated verbally, speech was clear and was able to understand and be understood when speaking. A review of Resident 1's Change in Condition (CIC / COC) Evaluation, dated 3/2/2023, indicated Resident 1 had a change in behavior of threatening his roommate (Resident 3). The COC indicated that Resident 3 (Resident 1's roommate) came to the nursing station alleging that Resident 1 wanted to hurt him with a butter knife. Licensed Vocational Nurse 3 (LVN 3) checked on Resident 1 in his room and found Resident 1 holding a butter knife. The note indicated Resident 1 admitted to hurting Resident 3 because he was tired of Resident 3 making noises in the middle of the night. The note indicated Resident 1 only agreed to hand over the knife when LVN 3 told him Resident 3 will be moved to a different room. A review of Resident 1's psychiatric note, dated 3/2/2023, indicated Resident 1 has a history of schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood) and anxiety (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). The note indicated Resident 1 was being evaluated for recent involvement in an altercation (threaten his roommate with a butter knife). The note indicated Upon further evaluation, patient present increased in agitation and observed Responding to Internal Stimuli (RTIS, a process that involves responding to one's own emotions and physical sensations). A review of Resident 1's SNF (Skilled Nursing Facility) Hospital Transfer Form, dated 3/2/2023, indicated Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) secondary to physical and verbal aggression toward others. A review of Resident 1's Physician orders, dated 3/2/2023, indicated to transfer Resident 1 to GACH 1 for psychiatric evaluation and management of self-endangerment and to others. A review of Resident 1's Progress Note, dated 3/3/2023, indicated Resident 1 came back from GACH 1. A review of Resident 3's Admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a serious mental disorder in which people interpret reality abnormally), chronic obstructive pulmonary disease (COPD, group of lung disease that block airflow and make it difficult to breathe), muscle weakness, lack of coordination, difficulty in walking and anxiety. A review of Resident 3's Minimum Data Set (MDS - a standardize assessment and screening tool), dated 1/31/2023, indicated Resident 3 has intact thought process. A review of Resident 3's Change in Condition (CIC / COC), dated 3/2/2023, indicated Resident 3 is alert, oriented and able to make needs known. The COC indicated that Resident 3 reported to the charge nurse my roommate (Resident 1) suddenly became aggressive to me. I'm just here in bed lying down. A review of Resident 3's Care Plan titled Resident had physical aggression from a roommate, dated 3/2/2023, indicated a goal that resident will feel safe with continuous stay in the facility. During an interview on 3/8/2023 at 1:20 pm, Resident 3 stated Resident 1, his previous roommate threw things at him including glass and pitchers, unprovoked which hit him in the hand and left him with a scratch. Resident 3 stated he informed a nurse for the second time about Resident 1's behavior after which he was moved and transferred to a different room. Resident 3 stated when he sees Resident 1 in the hallway, he (Resident 1) scares him. Resident 3 was not able to state the day the incident occurred. During an interview on 3/8/2023 at 3:56 pm, the DON stated and confirmed that they found Resident 1 to be keeping butter knives in his room on 3/2/2023 including a butte knife hidden in the frame of his bed. During an interview on 3/9/2023 at 3:57 pm, LVN 2 stated and confirmed she was the one who called the police on 3/2/2023 around 8:15 am regarding the altercation between Resident 1 and Resident 3. LVN 2 stated she observed Resident 3 with a small little abrasion on his hand, but we could not tell where it came from. LVN 2 stated and confirmed that after the incident between Resident 1 and Resident 3, the facility informed the kitchen staff to not put metal utensils on Resident 1's (meal tray). During an interview on 3/10/2023 at 2:59 pm, LVN 3 stated that on 3/2/2023 around 6 am in the morning, Resident 3 approached her and stated his roommate is trying to hurt him. LVN 3 stated she immediately went to Resident 3's room and found Resident 1 with a butter knife silverware on his left hand. LVN 3 asked Resident 1 to give her the knife and Resident 1 did. LVN 3 returned to the nursing station and assisted Resident 3 back to his room to get his belongings because he will be moved to another room. Upon return to the same room, LVN 3 stated he observed Resident 1 holding another knife. LVN 3 stated she told Resident 1 that if he does not give her the knife, she will call the police. Resident 1 handed LVN 3 the knife. Resident 3 was moved to another room. A review of the Progress Note, dated 2/2/2023, indicated Seen resident (Resident 1) fondling and touching his self in front of the public staff. A review of Resident 2's Admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy (a congenital disorder caused by abnormal brain development, often before birth, that causes problems with movement, posture, and balance.), autistic disorder (a developmental disability caused by differences in the brain manifested by problems with social communication and interaction, and restrictive or repetitive behaviors or interest), schizoaffective disorder, cognitive communication deficit (difficulty in thinking and use of language), restlessness and agitation. A review of Resident 2's History and Physical form, dated 2/3/2023, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2's Health Status Note by Registered Nurse Supervisor 1 (RN 1), dated 2/3/2023 indicated due to constant roaming, wandering aimlessly, hoarding, collecting whatever she can grab in her hand she collected it kept to herself, dietary staff informed on how to help her maintain her functional weight offering mostly her food in a cup easy for her to grab on because she is always busy with her hands. Provided a 1:1 sitter for the resident effective today for close watch observation. A review of the Behavior Note by RN 1, dated 2/7/2023, indicated Resident 2 wandered around in her room roaming aimlessly nonverbal communicates by facial and hand gestures, reported by staff that resident at times goes to closet hid herself as per her sitter 1:1 assigned . A review of Resident 2's MDS, dated [DATE], indicated Resident 2 has impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS also indicated Resident 2 needed supervision with bed mobility, limited assistance (resident highly involved in activity but staff provide guided maneuvering of limbs or other non-weight bearing assistance) with transfer, walking and eating and extensive assistance (resident involved in activity but staff provide weight-bearing support) in dressing, toilet use and personal hygiene. A review of Resident 2's Care Plan titled The resident is/has potential to be physically aggressive related to anger, depression (persistent feeling of sadness and loss of interest), history of harm to others, poor impulse control, dated 2/17/2023 indicated the facility provided a sitter 1:1 to closely monitor wandering behavior of resident to ensure safety. A written and signed statement by CNA 1, dated 3/7/2023, indicated Around 1:30 am I was walking around doing my rounds on my patients. I walked in (room deducted, Resident 2's room) to check on (name deducted, Resident 2's name), making sure she was still sleeping. I wasn't assigned to her, but since I was walking by, I decided to check on her. I witnessed (deducted Resident 1's name) on top of (deducted Resident 2's name) hampering her. I was standing there in shock, so I walked to (deducted LVN 1's name) the LVN and told him to come to (deducted Resident 2's room) immediately. We walked back in the room and (deducted LVN 1's name) told (deducted Resident 1's name) to get off her. (Deducted Resident 1's name) got up with her, male genitalia all out (exposed). (Deducted Resident 2's name) incontinence briefs and pants were at her ankles. (Deducted Resident 1's name) walked back to his room with his male genitalia all out still. (Deducted Resident 2's name) pulled back her incontinence briefs and pants. After I reported the situation, I went to answer my call lights that was on. Before the situation occurred, I was checking on (Deducted, Resident 2's name) every hour and she was sleeping. A review of Resident 1's Change in Condition (CIC, COC) Evaluation, dated 3/7/2023 at 6:48 am but signed on 3/8/2023 by LVN 1, indicated Resident 1's change in behavior of sexual assault towards peer. The COC indicated Patient was found lying on top of a female patient in her room. He was asked to get up and go back to his room form one of the charge nurses. As he was walking away, he was noticed to be fully clothed (pants on at waist and buttoned, shirt on, and jacket on. His genitals were out of his pants through his zipper. Recipient (Resident 2) was noted to be fully clothed (pants and incontinence briefs on, and shirt on. A record review of the Progress Note by Registered Nurse Supervisor (RN 1), dated 3/7/2023 at 1:28 pm, indicated that on 3/7/2023 at 11 am, three police officers visited Resident 1 but Resident 1 pretended to be asleep and did not respond to the officers' questions. The note indicated that on 3/7/2023 at 12:20 pm, two police officers handcuffed Resident 1. The note indicated He (Resident 1) went quietly with no words ambulated with his shoes on accosted by 2 police officers to transport him to (deducted hospital name, GACH 2) via police car. A review of Resident 2's Health Status Note by RN 1, dated 3/7/2023 at 2:24 pm, indicated that on there was a report of alleged incident on sexual assault regarding Resident 1 and Resident 2. RN 1 indicated that she was unable to illicit (get) information from Resident 2 due to Resident 2's medical history of autism (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), cerebral palsy, and developmental delay. RN 1 indicated in her note that on 3/7/2023 at 9:20 am, the Fire Department (FD) came surprisingly stating someone had call 911 on behalf of the resident. The note indicated the paramedics transported the resident (Resident 2) to General Acute Care Hospital 2 (GACH 2) for further evaluation 0n 3/7/2023. A review of Resident 2's Physician Order, dated 3/7/2023, indicated an order to transfer Resident 2 to GACH 2 for medical evaluation and management related to alleged sexual assault incident. A review of Resident 1's Progress Note by RN 1, dated 3/7/2023 at 6:27 pm, indicated Resident 1 returned from GACH 2 with 2 police officers and was led to the conference room to be interviewed by two detectives. The note indicated Resident 1 was provided a 1:1 sitter after return to the facility. A review of Resident 2's Health Status Note by RN 1, dated 3/7/2023 at 6:44 pm, indicated Resident 2 returned to the facility from GACH 2 on 3/7/2023 at 6 pm and was provided a 1 on 1 sitter. A review of Resident 1's Physician Orders, dated 3/7/2023, indicated an order to transfer Resident 1 to GACH 1 for psychiatric evaluation and management of self-endangerment and to others and alleged sexual assault. A review of Resident 1's Care Plan titled Resident had an attempted sexual aggression towards another resident, dated 3/7/2023, indicated goal of resident will have no episode of sexual aggression through next review date. A review of Resident 2's Care Plan titled Resident had an attempted sexual aggression from another resident, initiated on 3/7/2023, indicated a goal of resident will feel safe in her continued stay in the facility. Interventions included in the care plan are to check on resident whereabouts, frequent visual checks, providing a one-on-one sitter to resident, providing a safe and secure environment, psychiatry consultation and psychology consultation. A review of Resident 2's Care Plan titled Resident at risk for psychosocial well-being problem related to S/P (status post, after) incident with another resident, initiated on 3/7/2023, indicated a goal of resident will develop effective coping skills through review date. Interventions included in the care plan are to anticipate resident needs, frequent visual checks, one to one sitter as possible, provide resident activities and encourage resident to participate in daily activities. A review of the Change in Condition Evaluation on Resident 2, dated 3/8/2023, indicated Noted that the resident is grimacing and crying. She had her arm guarded and fist clenched around the abdomen area. When ambulating (walking), she is hunched over with the arms around the abdomen area. In addition, noted that the resident has not voided (pee) throughout the shift. MD (Medical Doctor) notified. The note indicated MD ordered to transfer Resident 2 to the hospital. A review of the Progress Notes, dated 3/8/2023 at 1:03 am, indicated Resident 1 was transferred to GACH 1 for psychiatric evaluation. A review of Resident 1's Emergency Note from GACH 1, dated 3/8/2023 at 4:19 am, indicated a history of present illness of Resident 1 was noted to be combative agitated aggressive both physically and verbally. Patient also was said to have inappropriately touched a resident or staff member. This patient was also noted to be unable to calm down with lashing out at individuals both staff and or family. During a phone interview on 3/8/2023 at 12:33 pm and physical interview on 3/8/2023 at 6:39 pm, Certified Nursing Assistant 1 stated Resident 2 was not her assigned resident, but when she checked on her on 3/7/2023 at 1:30 am, she found Resident 1 humping (It's an option for people who want to engage sexually without losing their virginity or face the possibility of pregnancy) on top of Resident 2. CNA 1 stated Resident 1's pants were below his butt area and Resident 2's diaper and pants were at her knees. CNA 1 stated that upon witnessing the incident, she immediately told LVN 1 and LVN 1 went to Resident 2's room. At this time, CNA 1 stated Resident 1 was still continuing to hump on Resident 2. LVN 1 tapped Resident 1's shoulder and told him to get up. Resident 1 pulled his private part out of Resident 2, got up with his private part still erected and walked out of Resident 2's room. CNA 1 stated that post incident on 3/7/2023 at 1:30 am, she observed Resident 2 had a change in behavior of not leaving her bed and not moving out of her bed. CNA 1 stated this is an unusual behavior for Resident 2 who is usually up and moving. On the same interview on 3/8/2023 at 12:33 pm, CNA 1 stated and confirmed Resident 2 did not have a sitter the night of the incident. CNA 1 stated there should have been five CNAs that night but only three worked. CNA 1 stated the facility is really short staffed. CNA 1 stated she does not know who Resident 2 was assigned CNA, but she was Resident 1's assigned CNA. CNA 1 stated the sexual abuse incident between Resident 1 and Resident 2 could have been prevented if Resident 2 had a sitter. CNA 1 stated Resident 2 needed a sitter. During an interview on 3/8/2023 at 1:31 pm, the DSD stated there have been complaints about Resident 1 ejaculating in front of residents and staff. The DSD stated Resident 2 is developmentally challenged and does not have the capacity to consent. The DSD also stated Resident 2 cannot speak. DSD stated the sexual abuse incident between Resident 1 and Resident 2 could have been prevented if the facility had more staff. The DSD stated the facility was short staffed during the night of the incident. The DSD stated there should have been five CNAs that night but only three worked. The DSD stated adequate staffing could have prevented the sexual abuse incident between Resident 1 and Resident 2 because with more staff, someone would have been available to be Resident 2's sitter. The DSD stated Resident 2 needed a sitter because she wanders in the facility. After the incident, the DSD stated when she asked Resident 2 if she was in pain, Resident 2 pointed to her lower abdomen area. During an interview on 3/8/2023 at 3:02 pm, RN 1 stated the alleged sexual abuse incident could have been prevented with more staffing in the facility. RN 1 stated Resident 2 has cerebral palsy and autism. RN 1 stated Resident 2 is non-verbal and is unable to make her own decisions while Resident 1 is alert and oriented and is able to make his decisions. During an interview on 3/8/2023 at 4:02 pm, the DON stated between 1:30 am (the time the incident allegedly happened) and 7 am (the time the DSD was made aware), there were no interventions done. The DON stated Resident 1 is alert, oriented and able to make needs known, while Resident 2 is like a three-year-old toddler . The DON stated Resident 2 is not able to give consent to sexual activity. The DON stated the incident could have been prevented if staff was watching Resident 2. The DON stated the incident could have been prevented by watching all patients and staff watching their own residents. During a phone interview on 3/9/2023 at 1:10 pm, LVN 1 stated on 3/7/2023 around 1 am, CNA 1 informed him that another resident was inside Resident 2's room. When he and CNA 1 went into the room, he found Resident 1 laying on top of Resident 2. LVN 1 stated he called Resident 1's name and Resident 1 got off Resident 2's bed. LVN 1 stated that after the incident, he closed Resident 2's room and went back to the nursing station. LVN 1 stated the incident between Resident 1 and Resident 2 was a sexual assault. During an interview on 3/9/2023 at 2:20 pm, the Administrator stated she was notified of the alleged sexual abuse on 3/7/2023 at 7:30 am by the DSD. The administrator stated and confirmed that on the night of the incident, there were only three CNAs when there should have been four CNAs. During an interview on 3/9/2023 at 3:57 pm, LVN 2 stated at 7:30 am on 3/7/2023, CNA 1 informed her that she found Resident 2 was involved with sexual behavior with Resident 1. LVN 2 stated she saw LVN 1 that morning leave facility, but he (LVN 1) did not mention anything about the incident. LVN 2 stated she informed RN 1 of the incident and RN 1 told her not to let anyone changed Resident 2. LVN 2 stated that for 40 minutes while waiting for a sitter to arrive, Resident 2 was assigned to a male sitter. LVN 2 stated she would also Put eyes on them, put on the sitter on the victim more so on the perpetrator. LVN 2 stated it is important to report immediately so we can make sure it doesn't happen to anybody else and get the resident out of the building and separated them. During a follow up interview on 3/9/2023 at 4:38 pm, the DON stated and confirmed all residents in the facility should have an assigned Certified Nursing Assistant. The DON stated it is important for residents to have an assigned CNA so they can receive care. The DON also stated it is important for all residents to have an assigned LVN, so they are supervised. During an interview with the DSD and concurrent record review of the CNA assignment for 3/6/2023 11 pm to 7 am shift on 3/10/2023 at 11:12 am, the DSD, who is also a Licensed Vocational Nurse, stated that from 3/6/2023 11 pm to 7 am, the nursing assignment indicated Resident 2 was assigned to a sitter but there was no sitter that arrived that night. The DSD stated LVN 1 should have assigned the CNA working in that area where Resident 2 was at. During an interview on 3/10/2023 at 2:59 pm, LVN 3 stated she observed Resident 1 had his pants open, with his private part out and masturbating in his room alone on 3/2/2023. During an interview on 3/10/2023 at 3:15 pm, LVN 3 stated and confirmed she was one of Resident 1's sitter on 3/8/2023, the day after the incident occurred. On 3/8/2023, the day after the incident occurred, Resident 1 was violent and aggressive. LVN 3 stated Resident 1 hit her on the right eye which resulted to some redness on 3/8/2023. During an interview on 3/10/2023 at 3:20 pm, LVN 3 stated that if she were the LVN who witnessed the alleged sexual abuse, she would have immediately separated both residents, call for help, and report the incident immediately to the authorities (police), DON, and supervisor. LVN 3 stated it is important to call the police because it (sexual abuse) is considered a crime. LVN 3 also stated that interventions she would have done a head-to-toe assessment and make sure there is a sitter to stay in the perpetrator's room and the victim's room to monitor them. A review of the facility's policy and procedures (P & P) titled Abuse - Reporting & Investigations, revised 3/2018, indicate the following: 1. To protect the health, safety, and welfare of facility residents by ensuring that all reports of resident abuse, mistreatment, neglect, exploitation or injuries of an unknown source and suspicion of crimes are promptly reported and thoroughly investigated. 2. The administrator or designated representative will provide for a safe environment for the resident as indicated by the situation. 3. If the suspected perpetrator is another resident, separate the residents so they do not interact with each other until circumstances of the reported incident can be clarified. 4. Upon receiving allegations of sexual abuse, the Administrator or designated representative will notify the Attending Physician to promptly examine the resident or obtain an order to transfer Resident to the acute hospital for exami [TRUNCATED]

Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement care plan interventions when necessary for one sampled resident (Resident 2). For Resident 2, who was assessed as requiring a mobility device (wheelchair) and requiring extensive assistance for transfer, the facility failed to implement care plan interventions while transporting Resident 2 in the wheelchair. This deficient practice resulted in Resident 2's left leg being caught beneath the wheelchair, as the therapist was pushing the wheelchair forward. Resident 2 had a fractured left leg and required surgery. Findings: On 5/24/18, at 8:45 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding resident safety. A review of the face sheet indicated Resident 2 was admitted to the facility, on 3/8/18 with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - assessment and care planning tool), dated 3/14/18 indicated Resident 2 required a mobility device (wheelchair) and required extensive assistance with two person assist for transfer (moving between bed and wheelchair). The history and physical examination [REDACTED]. A review of the care plan indicated Resident 2 had a problem with Alteration in Physical Functioning due to end stage [MEDICAL CONDITIONS], muscle weakness, difficulty in walking, required extensive assist with transfers, and totally dependent with ambulation. The care plan interventions indicated resident would be kept comfortable, activities of daily living (ADL) needs would be met daily for three months, assist with ADL's to the highest degree possible within physical and medical limitations, goal dated 6/9/18. The care plan interventions included to assist with transfers and mobility as needed, PT/OT care plan status. A review of the care plan indicated Resident 2 had loss of bone mass, potential for injury or fracture due to [DIAGNOSES REDACTED]. The care plan interventions included do not attempt to extend a stiff joint unless instructed by the therapist (rehab) or physician. A review of the care plan indicated Resident 2 was at risk for fracture related to [MEDICAL CONDITION], and the goal indicated resident would have minimized risk of signs and symptoms of complications of fracture related injury for 90 days, goal date of 6/9/18. The care plan interventions included to assist Resident 2 with ADLs and mobility as needed, immobilize fracture site during care / transfers, maintain body in good alignment and to monitor affected extremity / area for changes. The care plan did not indicate the specific fracture location. A review of the Clinical Notes, dated 5/2/18, indicated Resident 2 remained on skilled physical therapy (PT) and occupational therapy (OT) rehabilitation services five times per week, with good tolerance. The clinical note indicated Resident 2 received [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. A review of the Situation Background Assessment Request form (SBAR), dated 5/11/18, at 12:50 p.m., indicated Resident 2 had a change in condition, the physical therapist pushed Resident 2 up the ramp and stumped the resident's left foot causing the knee to hyperextend (flexion of a limb or part beyond the normal limit). The SBAR form indicated Resident 2 had pain rated 8 out of 10 (on a scale from 0 - 10, 10 being the worst pain), and pain medication was given. The SBAR form indicated Resident 2 stumped foot on ramp in care of physical therapy, resident noted with left foot discoloration and [MEDICAL CONDITION] to knee, continuing to monitor, physician aware. A review of the Clinical Notes, documented by Licensed Vocational Nurse 2 (LVN 2), dated 5/11/18, at 6:34 p.m., indicated Resident 2 complained of pain to left knee and foot, status [REDACTED]. A review of the Clinical Notes, dated 5/13/18, at 2:57 a.m., indicated Resident 2 had facial grimacing, when asked regarding pain resident stated, Yes, my left leg is hurting. The left leg was noted having [MEDICAL CONDITION], bruising and discoloration (over two days after the incident). A review of the Clinical Notes, dated 5/13/18 at 11 a.m., indicated monitoring for for left leg swelling, no adverse changes at this time, kept area elevated. There was no additional information documented regarding Resident 2's status [REDACTED]. A review of the Clinical Notes, dated 5/14/18, at 1:14 p.m., indicated there was no additional information documented regarding Resident 2's status [REDACTED]. According to the History of Present Illness form, documented by the GACH physician, dated 5/15/18, at 5:54 a.m., indicated Resident 2 presented to the GACH with pain in left leg that occurred last Friday, when he was transported in the wheelchair with physical therapy. The GACH form indicated Resident 2 stated the leg rest was unlocked and he was caught beneath the wheelchair as the therapist was pushing the wheelchair forward. The GACH form indicated Resident 2 was complaining of persistent pain in this extremity since last Friday. A review of the Inter-Facility Transfer Report GACH form indicated, on 5/15/18, Resident 2 had a left Tibial Open Reduction Internal Fixation (ORIF - a type of surgery used to stabilize and heal a broken bone, shin bone (tibia, the larger bone in your lower leg), or your fibula - more toward the outside of the leg.) According to Medscape.com, 11/30/17, the tibia is the only weightbearing bone, fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the membrane to the fibula, causes include direct forces such as those caused by falls and motor vehicle accidents and indirect or rotational forces. A review of GACH's discharge summary note, dated on 5/19/18, indicated Resident 2 had a left proximal (next to or nearest the point of attachment) third Tibia-Fibular fracture on 5/11/18, after leg was caught underneath a wheel chair. During an interview, on 5/24/18, at 9:34 a.m., Resident 2 stated, I was not good because my left leg got fractured. When questioned about the incident, Resident 2 explained that it was about two weeks ago, when the PT 1 (physical therapist) brought him back in the wheelchair to the room after a therapy session. Resident 2 stated the left foot dropped back and got caught underneath the wheelchair, because the foot rest was not locked in position. Resident 2 stated, I was sent to a General Acute Care Hospital (GACH) and had surgery on my left leg. During an observation, on 5/24/18, at 9:41a.m., Resident 2's left lower leg was seen wrapped with an ace bandage and an ankle-foot orthosis (AFO- a support intended to control the position and motion of the ankle). On 5/24/18, at 2:45 p.m., during an interview, the Director of Rehabilitation Service (DOR) stated when PT 1 pushed Resident 2 in the wheelchair up onto the ramp in the hallway, one foot stumped back. The Director of Rehabilitation Service stated according to her notes, the wheelchair used for Resident 2 did not have a foot rest. The DOR stated there should have been a foot rest on the wheelchair. During an interview with Licensed Vocational Nurse 2 (LVN 2), on 5/24/18, at 2:45 p.m., she stated Resident 2 was brought to the nurse's station in a wheelchair. LVN 2 stated she was told Resident 2 had an incident with PT 1. She stated she did the assessment and administered pain medication to the Resident 2. During an interview with the Maintenance Supervisor (MS), on 5/24/18, at 3:50 p.m., he stated he replaced a footrest for Resident 2's wheelchair after the incident because the screw to the footplate was broken. The MS stated, Most likely the incident happened when the footrest was not locked in properly and got moved to the side while it's loose. During an interview, on 5/24/18, at 4:40 p.m., the Director of Nursing (DON) stated PT 1 was not fully aware of Resident 2's safety. The facility suspended PT 1 because the incident happened on Friday, but not until next Monday, PT 1 came to the DON saying that Resident 2 might need an X-ray. A review of the facility's Wheelchair Safety Tips from, indicated procedures on assisting the client to transfer into the wheelchair included to make sure both of the brakes are on and the front casters are swiveled forwards, swing the footrests to the front and fold down the footplates. The safety tips also indicated to fold up both footplates and swing them to the sides and out of the way.

Based on interview and record review, the facility failed to ensure a resident who had a history of [REDACTED]. The facility also failed to provide other means of hydration when the nasogastric tube ((NGT) a tube inserted through the nose and into the stomach to feed and/or provide hydration) was changed awaiting X-ray confirmation of the NGT placement for one of one sampled residents (1). These deficient practices resulted in Resident 1's admission to a general acute care hospital (GACH) with a [DIAGNOSES REDACTED]. Findings: An unannounced complaint visit was concluded on February 3, 2014, regarding the allegation that Resident 1 was transferred to a GACH with a [DIAGNOSES REDACTED]. Resident 1's Admission Record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated January 28, 2013, indicated Resident 1's cognitive skills for daily decision-making were impaired. The resident required extensive assistance to totally dependent on staff with her activities of daily living, including fluids and nutrition. The resident had the following physician's orders [REDACTED]. 1. [MEDICATION NAME] (feeding formula) 1.5 at 60 cubic centimeters (cc) an hour for 18 hours by NGT (for nutrition). 2. Flush (administer water) NGT with 120 cc of water every six hours (for hydration). 3. Give nothing by mouth (NPO). A Care Plan with goal dated May 15, 2013, indicated Resident 1 was at risk for dehydration related to failure to thrive. The intervention included to monitor (to watch/check) the resident for signs and symptoms of such poor skin turgor, dry oral mucosa, sunken eyeballs, foul odor urine, thick consistency, decreasing output of urine, low blood pressure, faster than usual heart rate, sudden onset of confusion, and change in level of consciousness, and to notify the physician if necessary. The Clinical (nurses) Notes dated January 21, 2013, at 3:02 p.m., indicated Resident 1's NGT was changed and an x-ray was ordered to check the placement of the NGT in the resident's stomach. The Clinical Notes dated January 22, 2013, at 4:16 a.m., indicated the x-ray result was pending. At 1:38 p.m., the Clinical Notes indicated the X-ray result was obtained and the result indicated no pneumonia. The Clinical Notes dated January 22, 2013, at 3:33 p.m., (24 hours after the NGT was changed) indicated the X-ray result for NGT placement was confirmed in the right place, and the NGT feeding was started. There was no documented evidence that Resident 1 was monitored for signs and symptoms of dehydration. Also, there was no documentation that the resident's physician was notified that the resident was not receiving feeding formula while waiting for the NGT X-ray result for further instructions for alternative interventions. There was no documented evidence that Resident 1 received any fluids from January 21, 2013, at 3:03 p.m., to January 22, 2013, at 3:33 p.m., (24 hours) to prevent dehydration. The Clinical Notes dated February 5, 2013, at 1:50 p.m., indicated at 1 p.m., Resident 1's NGT was out and the afternoon medications were held. The note indicated the NGT was changed and a Kidney Ureter Bladder (KUB) x-ray was called to check the NGT placement. The Clinical Notes dated February 5, 2013, at 8:14 p.m., indicated at 6:02 p.m., the KUB results was received; the notes further indicated the NGT was in the proximal (next to) stomach. The x-ray reader (radiologist) was called to determine the exact location of the NGT and stated they were unable to determine the exact location of the NGT, and to advance the NGT. The documentation indicated the feeding was resumed. The resident went over 6 hours without any fluids on February 5, 2013, at 1:50 p.m. to 8:14 p.m. The Clinical Notes dated February 6, 2013, at 3:30 a.m., indicated Resident 1's blood pressure was 90/57 (normal systolic range 120 to 129 millimeter mercury (mmHg), diastolic normal range 80 to 84 mmHg), heart rate 121 per minute (normal range 60 to 80 per minute), and respiratory rate 36 to 39 per minute (normal range 16 to 20 per minute). The physician was notified and the resident was transferred to a GACH at 7:28 a.m. The History and Physical (H&P) obtained from the GACH dated February 6, 2013, indicated the resident was [MEDICAL CONDITION] (fast heart rate) and was dehydrated. The resident was given intravenous (administered into a vein) fluids and antibiotics for pneumonia. On April 8, 2013, at 11 a.m., during an interview and record review with the director of nurses (DON), she confirmed Resident 1 did not received any types of hydration while waiting for the NGT X-ray confirmation result. She was also unable to provide documentation that Resident 1 was monitored for signs and symptoms of dehydration. The DON stated the licensed nurses should have notified the physician that the resident was not receiving fluids/formula while waiting for NGT placement to be confirmed, and to get an order for [REDACTED]. According to the facility's policy and procedure titled "Tube Placement and Patency, Check, Dislodging/Pulling Out" if correct tube placement is not completely assured, do not administer feeding or medication. Do not attempt to reinsert the tube, and contact the physician for further instruction.