Every finding on record at Pacific Villa, Inc

Based on observation, interview and record review, the facility failed to observe infection control measures for 82 of 82 sampled residents. The facility failed to:1.Implement and document regular monitoring of water temperature for their water management plan ( a written safety plan that identifies, monitors, and controls water systems to prevent the growth of legionella bacteria[bacteria commonly found In water that can cause a severe type of pneumonia known as Legionnaires disease {[serious lung infection caused by legionella bacteria that grow in warm water}] ) designed to minimize growth and transmission of Legionella in the facility water systems.This failure had the potential of not detecting deviations in water temperature that can create conditions conducive to Legionella growth leading to an outbreak (occurs when two or more people get sick with Legionnaire's disease [serious lung infection caused by legionella bacteria that grow in warm water] from the same contaminated water source).2.Ensure dirty linens were placed in a plastic bag and plastic bags were closed securely before placing them in an open laundry bin intended for soiled linen outside the facility.This failure had the potential to cause cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) leading to spread of infection among the residents and staff. Findings:1.During an interview on 2/26/2026 at 11:28 a.m. with the Maintenance Supervisor (MS), the MS stated the facility checked the water temperature daily for Legionella in the resident's room, laundry and kitchen and documented in a log. MS stated the water temperature should be at 110 degrees Fahrenheit ( F- unit of measurement) to 115 degrees F. MS stated Assistant Maintenance had the binder for the water temperature log.During an interview on 2/26/2026 at 12:11 p.m. with the Assistant Maintence (AM), the AM stated he misplaced the binder for the water temperature and he did not have it. AM stated he took the temperature of the water in the morning but unable to remember where he placed the binder. AM stated he checked the temperature of the water in the laundry and kitchen. AM stated 72 F was the temperature that was safe for the residents to use and the facility prevents the growth of Legionella in the water by monitoring and documenting the temperatures of the water. AM unable to answer what temperatures of the water should he alert the Administrator (ADM) and Infection Preventionist Nurse (IPN).During a concurrent interview and record review on 2/26/2026 at 12:29 p.m. with the IPN, the facility's policy and procedure (P&P) titled, Legionella Surveillance, revised 2022 was reviewed. The P&P indicated Legionella grows best in water temperatures of 77 degrees F to 108 degrees F. IPN stated not monitoring and documenting the temperature of the water can put all residents at risk for legionnaires disease (serious lung infection caused by legionella bacteria) because the facility will not know if the water was contaminated with Legionella.During an interview on 2/26/2026 at 3:56 p.m. with the ADM, the ADM stated he oversees the Maintenance Department and was part of a team that reviews the policy for Water Management Plan. ADM stated the AM left the binder at home and temperatures were not being checked consistently. ADM stated not monitoring the water temperature can put the residents at risk for Legionella outbreak (occurs when two or more people get sick with Legionnaire's disease from the same contaminated water source).During a review of facility's P&P titled, Legionella Surveillance, revised 2022, the P&P indicated primary strategies for prevention and control of Legionella infection included temperature controls. The P&P indicated cold water shall be stored and distributed below 68 F, hot water should be stored above 140 F and circulated at a minimum return temperature of 124 F.During a review of facility's P&P titled, Water Management Program, revised 2022, the P&P indicated water temperature logs are used for risk assessment by the water management team to identify where legionella and other waterborne pathogens can grow and spread in the facility's water systems.2.During a concurrent observation and interview on 2/26/2026 at 8:15 a.m. with the Housekeeping Supervisor, observed an uncovered large blue bin for dirty linens were located outside the facility. HS stated the facility outsource laundry services for their dirty linens. Observed dirty linens not placed in a plastic bag and mixed with other plastic bags filled with dirty laundry. Observed open plastic bags filled with dirty linens in the uncovered large blue bin. HS stated all dirty linens were placed in a plastic bag and securely closed before putting them in the blue bin. HS stated certified nursing assistants (CNAs) sort the dirty laundry and should place them in a closed plastic bag to prevent spread of infection.During a concurrent observation and interview on 2/26/2026 at 9:34 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 brought the rolling hampers outside the facility and tied the plastic bags filled with dirty linens before placing them in the uncovered blue bin. CNA 1 stated he closed the plastic bag securely to ensure no dirty linens will fall out of the plastic bag causing cross contamination and spread of infection in the facility.During an interview on 2/26/2026 at 11:08 a.m. with the IPN, the IPN stated dirty linens should be placed in a bag and should be closed securely before placing them in the uncovered laundry bin outside facility to ensure prevention of cross contamination and spread of infection. IPN stated leaving the dirty linens not in the plastic bags or plastic bags not securely closed can attract insects or bugs and can cause spread of infection.During a review of facility's P&P titled, Handling Soiled Linen, undated, the P&P indicated The facility will handle, process and transport linen in a safe and sanitary manner to prevent spread of infection. The P&P indicated soiled linen should be placed in a linen bag or designated lined receptacle and the bag should be closed securely and placed in the soiled utility room.

Based on observation, interview, and record review, the facility failed to provide dental services in a timely manner for two of five sampled residents (Resident 32 and Resident 59). The facility failed to:1.Ensure appropriate follow up for Resident 59's denture needs.2.Provide a dental check up and evaluation for Resident 32, who was admitted with missing and broken teeth.These failures had the potential to result in discomfort and impaired chewing ability, which could lead to decreased appetite and weight loss for both Resident 32 and Resident 59. Findings:1.During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 69 with diagnoses including heart failure( chronic condition where the heart muscles becomes too weak or stiff to pump blood efficiently in our body), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and anxiety disorder(mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life).During a review of Resident 59's Care plan titled, Nutritional Status Risk for significant weight change due to behavior problem and mechanically altered diet related to pureed and mildly thick consistency (liquids thicker than water but easily pourable) initiated on 1/10/2026. The Care Plan interventions included monitoring tolerance to diet texture, consistency and notifying the physician if difficulties are noted.During a review of Resident 59's Minimum Data Set (MDS-a resident assessment tool) dated 1/17/2026, the MDS indicated Resident 59 had moderately impaired cognitive skills (a person is having trouble with thinking, memory, and learning). The MDS indicated Resident 59 required substantial/maximal assistance (helper does more than half the effort) with eating and oral hygiene.During a concurrent observation and interview with Resident 59 on 2/24/2026 at 10:02 a.m., observed Resident 59 had no lower teeth. Resident 59 stated he only had upper teeth and had been waiting for his lower denture for six months. Resident 59 stated he was on a pureed diet foods blended into a smooth, thick, pudding-like texture with no lumps, chunks, or seeds) because he was unable to chew regular texture foods (normal, everyday, solid foods that require standard chewing and swallowing) due to the absence of his lower teeth. Resident 59 stated he would like to occasionally eat a sandwich or have regular texture foods.During an interview on 2/25/2026 at 3:03 p.m., with the Social Worker (SW) , the SW stated that in December 2025 the dentist made an impression for Resident 59's lower denture, but she did not follow up on its status. The SW stated it was her responsibility to follow up and determine the cause of the delay. She stated without the lower denture, Resident 59 would be unable to eat well, which could lead to weight loss.2. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted on [DATE] to the facility with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder.During a review of Resident 32's Order Summary Report dated 1/8/2026, the Order Summary Report indicated an order of Dental Consult with treatment as needed and as indicated.During a review of Resident 32's Oral/Dental assessment dated [DATE], the Oral/Dental Assessment indicated Resident 32's had missing and unclean teeth.During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had intact cognition (thought process) and required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes the activity) with eating and oral hygiene.During a concurrent observation and interview on 2/24/2026 at 12:32 p.m. and subsequent interview on 2/25/2026 at 3:43 p.m. with Resident 32, Resident 32 was eating lunch in his room. Observed missing and broken teeth on his lower and upper mouth. Resident 32 stated sometimes his teeth hurt and unable to eat harder food like apple.During an interview with the SW on 2/25/2026 at 2:49 p.m., and again during a follow up interview on 2/27/2026 at 11:42 a.m., the SW stated newly admitted residents are typically seen by a dentist within a couple of weeks. The SW stated she must have missed arranging the dental appointment for Resident 32 due to her workload, which resulted in the resident not being seen in a timely manner. The SW stated that Resident 32 may experience discomfort while eating, which could prevent him from consuming solid or harder foods.During an interview on 2/27/2026 at 2:08 p.m. with the Director of Nursing (DON), the DON stated that Resident 32 and Resident 59 could develop toothaches and experience discomfort while eating, which may lead to weight loss.During a review of facility's policy and procedure(P&P) titled, Ancillary Services, undated, the P&P indicated The facility will assess, arrange, coordinate and monitor ancillary services like dental services based on the resident's needs, physician orders, and interdisciplinary care plan.During a review of facility's P&P titled, Dental Services, undated, the P&P indicated dental needs of each resident are identified through physical assessment and identified needs as specified in resident's plan of care. The P&P indicated the facility will assist the resident with making dental appointments and obtaining routine and emergency dental care.

Based on observation interview and record review the facility failed to ensure food items kept in the refrigerator and freezer were labeled and dated.These failures had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) for all residents residing in the facility.Findings:During a concurrent observation and interview on 2/24/2026 at 8:50 a.m. in the kitchen with the Assistant Dietary Manager (ADM), the walk on freezer was observed with a bag of frozen tamales, a bag of frozen carrots, frozen turkey, frozen chicken and a frozen roast beef were scattered throughout the walk-in freezer out of the boxes unlabeled and undated. The ADM stated the tamales, carrots, turkey, chicken and roast beef should be labeled and dated. During an interview on 2/27/2026 at 12:42 p.m. with the ADM, the ADM stated the food in the walk-in freezer should be inside the correct box with an open date. The ADM stated the food needed to be labeled and dated so the facility will know what the product is and if it's expired. The ADM stated if there was an old food product it is important to know the date it was opened so the residents would not get sick from Salmonella (a common bacteria that causes food poisoning) or Escherichia coli (E. coli- bacteria spread by eating undercooked ground beef, contaminated produce or unpasteurized dairy). The ADM stated labeling and dating the food helps to prevent residents from getting sick, especially residents that are in a high-risk environment for foodborne illneses. During an interview on 2/27/2026 at 12:55 p.m. with the Dietary Supervisor (DS) the DS stated when the kitchen received food products, the kitchen staff need to label the food product and write the date it was received. The DS stated the dietary staff needed to know how long the food has been in the freezer because expired food could cause food borne illness. During a review of the facility's policy and procedure (P&P), titled Food Receiving and Storage, undated, the P&P indicated All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 12) attempted a Gradual Dose Reduction ([GDR] an attempt to decrease or discontinue psychotropic [acting on the mind] medication three months after starting on the psychotropic medication) for Resident 12.This failure resulted in Resident 12 receiving Remeron (an antidepressant) 0.5 milligrams ([mg] unit of measurement) for depression and Risperdal (an antipsychotic medication used to treat schizophrenia) 0.5 mg for schizoaffective disorder without a documented gradual dose reduction. Findings:During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), major depressive disorder (serious mental health condition characterized by persistent sadness and loss of interest), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During an interview on 2/27/2026 at 1:25 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 12 had an order for Remeron 0.5 mg for depression and Risperdal 0.5 for schizoaffective disorder. RNS 1 stated there was no documentation that a GDR was done. RNS 1 stated the GDR is to ensure Resident 12 received the right amount of medication. RNS 1 stated that the GDR is important to monitor and decrease the dosage of the medication.During an interview on 2/27/2026 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the GDR is done to reduce the administration of unnecessary medications that have side effects like sleepiness which could have an effect on the residents' Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of the facility's Policy and procedure (P&P), titled Tapering Medications and Gradual Drug Dose Reduction, undated, the P&P indicated, Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Based on observation, interview and record review the facility failed to implement its abuse policy and procedure for one of 20 sampled residents (Resident 9). The facility failed to:1. Follow facility's policy and procedure (P&P) titled, Abuse, Neglect, and Injury Reporting Policy, undated, which indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations.This failure had the potential to result in undetected abuse and compromised resident safety, affecting Resident 9 and other residents in the facility.Findings:During a concurrent observation on 2/24/2026 at 10:14 a.m. with Resident 9, Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses included autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Change in Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 1/6/2026 timed at 12:02 p.m., the COC indicated Resident 9 was complaining of pain to right shoulder due to dislocation ( a joint injury where bones are forced out of their normal positions). The COC indicated Resident 9's physician ordered to transfer Resident 9 to GACH to manage the right shoulder dislocation.During a review of Resident 9's general acute care hospital (GACH) 1 Hospital Records titled, General History of Present Illness (HPI-detailed and chronological description of the development pf the patient's present illness) dated 1/6/2026 at 5:15 p.m., the HPI indicated Resident 9 came to the emergency room for right shoulder pain from Skilled Nursing Facility (SNF). The HPI indicated Resident 9 was assaulted in another GACH.During a review of Resident 9's GACH 1 Medical Records titled, X-ray of Right Shoulder, dated 1/6/2026 timed at 6:50 p.m., the x-ray of the right shoulder indicated there is no fracture (broken bone) or dislocation and mild soft tissue swelling (a slight temporary buildup of fluid in the tissue causing puffiness) was present.During a review of Resident 9's Care Plan titled, The Resident has Alteration in comfort related to Dislocation of Right Shoulder Joint, initiated on 1/14/2026 and revised on 1/15/2026, the Care Plan indicated to monitor pain every shift, administer pain medicine and Resident 9 will wear sling for his right shoulder as ordered.During a review of Resident 9's Rehabilitation Screening ( a quick initial checkup if a person needs specialized therapy to improve their daily functioning such as mobility) dated 1/15/2026, the Rehabilitation Screening indicated no Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) or Physical Therapy ( healthcare service that helps a resident move better and restores physical function after an injury, surgery or disease) was warranted. The Rehabilitation Screening indicated Resident 9 had a non-weight bearing ( no weight, contact or pressure is applied on the affected area) to right upper arm with soft sling.During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Radiology Report of right shoulder x-ray dated 2/23/2026, the right shoulder x-ray report indicated greater tuberosity (large lateral bony prominence on the upper arm bone ) minimally comminuted fracture (bone broken into 3 or 4 pieces) and acute appearing humeral head fracture (a new, sudden break in the long bone of the upper arm usually caused by a fall, accident or direct blows).During a review of Resident 9's COC Evaluation dated 2/23/2026, the COC indicated Resident 9 had a humeral fracture (broken bone in the upper arm, between the shoulder and elbow) and would be transferred to GACH 2 for orthopedic evaluation (a comprehensive assessment by a specialist to find the cause of pain or limited movement).During a review of Resident 9's Care Plan titled, The resident had a humeral head fracture, initiated 2/24/2026, the Care Plan interventions included orthopedic evaluation and administration of anti-inflammatory (medicine that decrease swelling and pain) pain medications.During an interview on 2/26/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 9 was transferred to a GACH on 1/6/2026 because Resident 9 was not compliant with the use of a sling. RNS 1 stated she became aware on 2/23/2026 that Resident 9 had sustained a humeral fracture. She stated she did not know how the fracture occurred, and the injury was not investigated to rule out abuse or neglect. RNS 1 stated Resident 9's right humerus fracture should have been investigated and reported to the California Department of Public Health immediately per facility's policy and procedure titled Abuse, Neglect, and Injury Reporting Policy.During an interview on 2/27/2026 at 1:08 p.m., RNS 1 stated Resident 9 was admitted to the facility on [DATE] for a right shoulder dislocation and was transferred to a GACH on 1/6/2026. RNS 1 stated the right shoulder X ray taken on 1/6/2026 showed no fracture or dislocation, with only mild tissue swelling noted. RNS 1 stated a subsequent X ray obtained on 2/23/2026 revealed a fracture of the right humerus, and she did not know how the resident developed the injury. RNS 1 stated the facility should have initiated an investigation on 2/23/2026 when the fracture was discovered, as the cause of the injury was unknown. She stated the facility sent Resident 9 to GACH on 2/23/2026 for evaluation, and the resident returned early in the morning of 2/24/2026. RNS 1 stated the facility needed to determine what occurred, how it occurred, and why the fracture developed, and that an investigation should have been started immediately to rule out abuse or neglect. RNS 1 stated she did not know why an investigation was not initiated. RNS 1 stated the fracture should have been reported to the California Department of Public Health (CDPH) immediately because it met the definition of an injury of unknown origin under the facility's policy and required investigation to determine whether abuse occurred. RNS 1 stated she did not know what happened between 1/6/2026 and 2/23/2026 that could have resulted in the fracture. RNS 1 stated she informed the Director of Nursing (DON) of the fracture on 2/23/2026 but did not discuss initiating an investigation or reporting the incident to CDPH. She stated the facility should have investigated the injury to ensure Resident 9's safety, protect other residents, and prevent potential abuse.During an interviews on 2/26/2026 at 4:26 p.m. and on 2/27/2026 at 1:08 p.m., with the DON and a record review of the facility's policy titled Abuse, Neglect, and Injury Reporting Policy (undated), the Director of Nursing (DON) stated Resident 9 was admitted to the facility on [DATE] with a dislocated right shoulder and was wearing a sling. The DON stated she did not know how Resident 9 developed a right humeral fracture on 2/23/2026. The DON stated she neither reported the incident to the California Department of Public Health (CDPH) nor initiated an investigation to rule out abuse. The DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her that the fracture was an injury of unknown origin. The DON stated she did not notify the Administrator when Resident 9 was found to have a right humeral fracture on 2/23/2026. She stated the Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral fracture on 2/23/2026. The DON stated the right humeral fracture should have been reported to CDPH immediately so that the incident could be investigated to rule out abuse or neglect.During a review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, undated, the P&P indicated to take appropriate actions when abuse, or neglect is suspected. The P&P indicated the facility will consider factors indicating possible abuse, neglect and exploitations of residents the following possible indicators such as physical injury of a resident from unknown source.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment.Cross reference F609 and F610

Based on observation, interviews, and record review, the facility failed to report an injury of unknown origin (the cause of injury was not observed by any person or could not be explained by the resident) to the California Department of Public Health (CDPH) for one of 20 sampled residents (Resident 9) when Resident 9 sustained a right humeral fracture (a break in the upper arm bone between the shoulder and elbow, typically associated with falls or direct impact) on 2/23/2026.This failure had the potential to delay an investigation to determine whether abuse or neglect contributed to Resident 9's injury.Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses included autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Change in Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 1/6/2026 timed at 12:02 p.m., the COC indicated Resident 9 was complaining of pain to right shoulder due to dislocation ( a joint injury where bones are forced out of their normal positions). The COC indicated Resident 9's physician ordered to transfer Resident 9 to GACH to manage the right shoulder dislocation.During a review of Resident 9's general acute care hospital (GACH) 1 Hospital Records titled, General History of Present Illness (HPI-detailed and chronological description of the development pf the patient's present illness) dated 1/6/2026 at 5:15 p.m., the HPI indicated Resident 9 came to the emergency room for right shoulder pain from Skilled Nursing Facility (SNF). The HPI indicated Resident 9 was assaulted in another GACH.During a review of Resident 9's GACH 1 Medical Records titled, X-ray of Right Shoulder, dated 1/6/2026 timed at 6:50 p.m., the x-ray of the right shoulder indicated there is no fracture (broken bone) or dislocation and mild soft tissue swelling (a slight temporary buildup of fluid in the tissue causing puffiness) was present.During a review of Resident 9's Care Plan titled, The Resident has Alteration in comfort related to Dislocation of Right Shoulder Joint, initiated on 1/14/2026 and revised on 1/15/2026, the Care Plan indicated to monitor pain every shift, administer pain medicine and Resident 9 will wear sling for his right shoulder as ordered.During a review of Resident 9's Rehabilitation Screening ( a quick initial checkup if a person needs specialized therapy to improve their daily functioning such as mobility) dated 1/15/2026, the Rehabilitation Screening indicated no Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) or Physical Therapy ( healthcare service that helps a resident move better and restores physical function after an injury, surgery or disease) was warranted. The Rehabilitation Screening indicated Resident 9 had a non-weight bearing ( no weight, contact or pressure is applied on the affected area) to right upper arm with soft sling.During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Radiology Report of right shoulder x-ray dated 2/23/2026, the right shoulder x-ray report indicated greater tuberosity (large lateral bony prominence on the upper arm bone ) minimally comminuted fracture (bone broken into 3 or 4 pieces) and acute appearing humeral head fracture (a new, sudden break in the long bone of the upper arm usually caused by a fall, accident or direct blows).During a review of Resident 9's COC Evaluation dated 2/23/2026, the COC indicated Resident 9 had a humeral fracture (broken bone in the upper arm, between the shoulder and elbow) and would be transferred to GACH 2 for orthopedic evaluation (a comprehensive assessment by a specialist to find the cause of pain or limited movement).During a review of Resident 9's Care Plan titled, The resident had a humeral head fracture, initiated 2/24/2026, the Care Plan interventions included orthopedic evaluation and administration of anti-inflammatory (medicine that decrease swelling and pain) pain medications.During an interview on 2/26/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 9 was transferred to a GACH on 1/6/2026 because Resident 9 was not compliant with the use of a sling. RNS 1 stated she became aware on 2/23/2026 that Resident 9 had sustained a humeral fracture. She stated she did not know how the fracture occurred, and the injury was not investigated to rule out abuse or neglect. RNS 1 stated Resident 9's right humerus fracture should have been investigated and reported to the California Department of Public Health immediately per facility's policy and procedure titled Abuse, Neglect, and Injury Reporting Policy.During an interview on 2/27/2026 at 1:08 p.m., RNS 1 stated Resident 9 was admitted to the facility on [DATE] for a right shoulder dislocation and was transferred to a GACH on 1/6/2026. RNS 1 stated the right shoulder X ray taken on 1/6/2026 showed no fracture or dislocation, with only mild tissue swelling noted. RNS 1 stated a subsequent X ray obtained on 2/23/2026 revealed a fracture of the right humerus, and she did not know how the resident developed the injury. RNS 1 stated the facility should have initiated an investigation on 2/23/2026 when the fracture was discovered, as the cause of the injury was unknown. She stated the facility sent Resident 9 to GACH on 2/23/2026 for evaluation, and the resident returned early in the morning of 2/24/2026. RNS 1 stated the facility needed to determine what occurred, how it occurred, and why the fracture developed, and that an investigation should have been started immediately to rule out abuse or neglect. RNS 1 stated she did not know why an investigation was not initiated. RNS 1 stated the fracture should have been reported to the California Department of Public Health (CDPH) immediately because it met the definition of an injury of unknown origin under the facility's policy and required investigation to determine whether abuse occurred. RNS 1 stated she did not know what happened between 1/6/2026 and 2/23/2026 that could have resulted in the fracture. RNS 1 stated she informed the Director of Nursing (DON) of the fracture on 2/23/2026 but did not discuss initiating an investigation or reporting the incident to CDPH. She stated the facility should have investigated the injury to ensure Resident 9's safety, protect other residents, and prevent potential abuse.During an interview on 2/27/2026 at 1:34 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 9 was screened for Joint Mobility on 1/15/2026 and no OT and PT were provided because of the sling on his right shoulder and Resident 9 required non- weight bearing on the right arm while moving. The DOR stated RNS 1 approached her to obtain recommendation for mobility (movement) regarding Resident 9's right shoulder dislocation on 2/23/2026. The DOR stated she consulted OT who recommended an orthopedic consultation (specialized appointment with a bone and joint physician to diagnose and treat issues with muscles, bones, joints and ligaments). The DOR stated the DON stated to obtain an x-ray of the right shoulder first before getting an orthopedic consultation for Resident 9.During an interview on 2/26/2026 at 4:26 p.m. and on 2/27/2026 at 1:08 p.m., with the DON and a record review of the facility's policy titled Abuse, Neglect, and Injury Reporting Policy (undated), the DON stated Resident 9 was admitted to the facility on [DATE] with a dislocated right shoulder and was wearing a sling. The DON stated she did not know how Resident 9 developed a right humeral fracture on 2/23/2026. The DON stated she neither reported the incident to the California Department of Public Health (CDPH) nor initiated an investigation to rule out abuse. The DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her that the fracture was an injury of unknown origin. The DON stated she did not notify the Administrator when Resident 9 was found to have a right humeral fracture on 2/23/2026. She stated the Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral fracture on 2/23/2026. The DON stated the right humeral fracture should have been reported to CDPH immediately so that an investigation could be initiated promptly to rule out abuse or neglect.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment. Cross reference F607 and F610

Based on observation, interview and record review, the facility failed to investigate an injury of unknown origin (cause of injury was not observed by any person or could not be explained by the resident) for one of 20 sample resident (Resident 9).The facility failed to:1. Investigate Resident 9's injury of unknown origin. Resident 9 was admitted to the facility on [DATE] with no documented fracture (broken bone) to the right shoulder, as confirmed by X ray (imaging that create images of structures inside the body) results dated 1/2/2026 and 1/6/2026. While under the facility's care, Resident 9 developed a humeral fracture (a break in the upper arm bone connecting the shoulder and elbow) on 2/23/2026.This failure had the potential to prevent the facility from determining whether Resident 9's injury resulted from abuse or neglect.Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9, observed Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses included autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Change in Condition (COC-a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 1/6/2026 timed at 12:02 p.m., the COC indicated Resident 9 was complaining of pain to right shoulder due to dislocation ( a joint injury where bones are forced out of their normal positions). The COC indicated Resident 9's physician ordered to transfer Resident 9 to GACH to manage the right shoulder dislocation.During a review of Resident 9's general acute care hospital (GACH) 1 Hospital Records titled, General History of Present Illness (HPI-detailed and chronological description of the development pf the patient's present illness) dated 1/6/2026 at 5:15 p.m., the HPI indicated Resident 9 came to the emergency room for right shoulder pain from Skilled Nursing Facility (SNF). The HPI indicated Resident 9 was assaulted in another GACH.During a review of Resident 9's GACH 1 Medical Records titled, X-ray of Right Shoulder, dated 1/6/2026 timed at 6:50 p.m., the x-ray of the right shoulder indicated there is no fracture (broken bone) or dislocation and mild soft tissue swelling (a slight temporary buildup of fluid in the tissue causing puffiness) was present.During a review of Resident 9's Care Plan titled, The Resident has Alteration in comfort related to Dislocation of Right Shoulder Joint, initiated on 1/14/2026 and revised on 1/15/2026, the Care Plan indicated to monitor pain every shift, administer pain medicine and Resident 9 will wear sling for his right shoulder as ordered.During a review of Resident 9's Rehabilitation Screening ( a quick initial checkup if a person needs specialized therapy to improve their daily functioning such as mobility) dated 1/15/2026, the Rehabilitation Screening indicated no Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) or Physical Therapy ( healthcare service that helps a resident move better and restores physical function after an injury, surgery or disease) was warranted. The Rehabilitation Screening indicated Resident 9 had a non-weight bearing ( no weight, contact or pressure is applied on the affected area) to right upper arm with soft sling.During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Radiology Report of right shoulder x-ray dated 2/23/2026, the right shoulder x-ray report indicated greater tuberosity (large lateral bony prominence on the upper arm bone ) minimally comminuted fracture (bone broken into 3 or 4 pieces) and acute appearing humeral head fracture (a new, sudden break in the long bone of the upper arm usually caused by a fall, accident or direct blows).During a review of Resident 9's COC Evaluation dated 2/23/2026, the COC indicated Resident 9 had a humeral fracture (broken bone in the upper arm, between the shoulder and elbow) and would be transferred to GACH 2 for orthopedic evaluation (a comprehensive assessment by a specialist to find the cause of pain or limited movement).During a review of Resident 9's Care Plan titled, The resident had a humeral head fracture, initiated 2/24/2026, the Care Plan interventions included orthopedic evaluation and administration of anti-inflammatory (medicine that decrease swelling and pain) pain medications.During an interview on 2/26/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 9 was transferred to a GACH on 1/6/2026 because Resident 9 was not compliant with the use of a sling. RNS 1 stated she became aware on 2/23/2026 that Resident 9 had sustained a humeral fracture. She stated she did not know how the fracture occurred, and the injury was not investigated to rule out abuse or neglect. RNS 1 stated Resident 9's right humerus fracture should have been investigated and reported to the California Department of Public Health immediately per facility's policy and procedure titled Abuse, Neglect, and Injury Reporting Policy.During an interview on 2/27/2026 at 1:08 p.m., RNS 1 stated Resident 9 was admitted to the facility on [DATE] for a right shoulder dislocation and was transferred to a GACH on 1/6/2026. RNS 1 stated the right shoulder X ray taken on 1/6/2026 showed no fracture or dislocation, with only mild tissue swelling noted. RNS 1 stated a subsequent X ray obtained on 2/23/2026 revealed a fracture of the right humerus, and she did not know how the resident developed the injury. RNS 1 stated the facility should have initiated an investigation on 2/23/2026 when the fracture was discovered, as the cause of the injury was unknown. She stated the facility sent Resident 9 to GACH on 2/23/2026 for evaluation, and the resident returned early in the morning of 2/24/2026. RNS 1 stated the facility needed to determine what occurred, how it occurred, and why the fracture developed, and that an investigation should have been started immediately to rule out abuse or neglect. RNS 1 stated she did not know why an investigation was not initiated. RNS 1 stated the fracture should have been reported to the California Department of Public Health (CDPH) immediately because it met the definition of an injury of unknown origin under the facility's policy and required investigation to determine whether abuse occurred. RNS 1 stated she did not know what happened between 1/6/2026 and 2/23/2026 that could have resulted in the fracture. RNS 1 stated she informed the Director of Nursing (DON) of the fracture on 2/23/2026 but did not discuss initiating an investigation or reporting the incident to CDPH. She stated the facility should have investigated the injury to ensure Resident 9's safety, protect other residents, and prevent potential abuse.During an interview on 2/27/2026 at 1:34 p.m. with the Director of Rehabilitation (DOR), the DOR stated Resident 9 was screened for Joint Mobility on 1/15/2026 and no OT and PT were provided because of the sling on his right shoulder and Resident 9 required non- weight bearing on the right arm while moving. The DOR stated RNS 1 approached her to obtain recommendation for mobility (movement) regarding Resident 9's right shoulder dislocation on 2/23/2026. The DOR stated she consulted OT who recommended an orthopedic consultation (specialized appointment with a bone and joint physician to diagnose and treat issues with muscles, bones, joints and ligaments). The DOR stated the DON stated to obtain an x-ray of the right shoulder first before getting an orthopedic consultation for Resident 9.During an interviews on 2/26/2026 at 4:26 p.m. and on 2/27/2026 at 1:08 p.m., with the DON and a record review of the facility's policy titled Abuse, Neglect, and Injury Reporting Policy (undated), the DON stated Resident 9 was admitted to the facility on [DATE] with a dislocated right shoulder and was wearing a sling. The DON stated she did not know how Resident 9 developed a right humeral fracture on 2/23/2026. The DON stated she neither reported the incident to the California Department of Public Health (CDPH) nor initiated an investigation to rule out abuse. The DON stated she had been sidetracked and that it was her mistake, explaining it did not occur to her that the fracture was an injury of unknown origin. The DON stated she did not notify the Administrator when Resident 9 was found to have a right humeral fracture on 2/23/2026. She stated the Administrator was aware of the prior shoulder dislocation but not of the newly identified humeral fracture on 2/23/2026. The DON stated failing to investigate could place Resident 9 at risk for fear, isolation, and unsafe conditions if abuse or neglect had occurred.During a review of facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, undated, the P&P indicated to take appropriate actions when abuse, or neglect is suspected. The P&P indicated the facility will consider factors indicating possible abuse, neglect and exploitations of residents the following possible indicators such as physical injury of a resident from unknown source.During a review of facility's P&P titled, Abuse, Neglect, and Injury Reporting Policy, undated, the P&P indicated injuries of unknown origin will be promptly evaluated and reported in accordance with federal and California regulations. The P&P indicated an injury of unknown origin is considered when the injury was not observed by staff, injury is inconsistent with the resident's clinical condition, or there is insufficient information to determine the cause after assessment.Cross reference F607 and F609

Based on observation, interview and record review the facility failed to ensure one of one sampled residents (Resident 78) was assisted with eating during meals.This failure had the potential to place Resident 78 at risk for weight loss. Findings:During an observation on 2/24/2026 at 12:24 p.m. in the dining room, Resident 78 was seated in wheelchair, rocking back and forth and holding spoon in his right hand for 10 minutes before spooning food into his mouth while staff being observed by facility staff.During an observation on 2/24/2026 at 12:48 p.m. in the dining room, Resident 78 was observed with 75% of his meal still on his plate and not eaten after 30 minutes without staff assistance.During an observation on 2/24/2026 at 12:54 p.m. in Resident 78's room, Certified Nursing Assistant (CNA) 4 was observed assisting Resident 78 with his meal after not being assisted in the dining room for 30 minutes.During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with diagnoses including lack of coordination, heart failure(heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (abnormal high levels of fats in the blood), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety (emotion characterized by feelings of tension, worried thoughts).During a review of Resident 78's History and Physical (H&P), dated 10/17/2025, the H&P indicated Resident 78 had the capacity to understand and make decisions.During a review of Resident 78's Minimum Data Set (MDS- a resident assessment tool) dated 1/22/2026, the MDS indicated Resident 78 was dependent (helper does all the effort) on nursing staff with showering. The MDS indicated Resident 78 needed setup or clean-up assistance with eating.During an interview on 2/24/26 at 1243 p.m. with Resident 78, Resident 78 was asked if he needed assistance with eating, and Resident 78 stated yes.During an interview on 2/25/2026 at 2:21 p.m. with CNA 4, CNA 4 stated Resident 78 takes more than a one hour to feed himself. CNA 4 stated when Resident 78 feeds himself, he takes a long time and his food gets cold. CNA 4 stated Resident 78 needs help with eating because he is unstable and rocks back and forth.During an interview on 2/25/2026 at 2:55 p.m. with CNA 5, CNA 5 stated Resident 78 eats slow and takes too long for him to finish the food due to the movement it takes resident takes an hour to eat. CNA 5 stated when she assists Resident 78 with eating, he finishes in less than hour. CNA 5 stated Resident 78 will benefit from help and assistance with eating.During an interview on 2/26/2026 at 10:40 a.m. with Registered Nursing Supervisor, (RNS) 1, RNS 1 stated Resident 78 could have a potential for weight loss with an inability to feed himself if not assessed properly.During an interview on 2/27/2026 at 2:41 p.m. with the Director of Nursing (DON), the DON stated a negative outcome for weight loss could result in actual mental health issues, muscle loss, and nutrient deficiencies, for Resident 78 due to his lack of coordination with feeding.During a review of the facility's policy and procedure (P&P), titled Activities of Daily Living (ADLs), undated, The P&P indicated The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to bathe, dress, and groom, transfer and ambulate, toilet, eat and use speech, language or other functional communication systems.

Based on observation, interview and record review the facility failed to provide one of 18 sample residents (Resident 63) with activities or regular room visits as part of an ongoing program to support the resident's chosen activities. This failure had the potential to negatively impact on Resident 63's sense of self-worth and psychosocial well being, including feelings of usefulness, social connection, and personal satisfaction.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, the MDS indicated Resident 63's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was moderately impaired. The MDS indicated Resident 63 required setup or clean up assistance (helper set up or clean up; resident completes activity) 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 an observation on 02/24/2026 at 11:11 a.m., Resident 63 was observed lying quietly in bed on his side.During a concurrent observation and interview on 02/25/2026 at 10:44 a.m. with Resident 63, Resident 63 was observed lying quietly in bed, staring at the walls of the room. Resident 63 stated, no one regularly brought him books, and it only happened occasionally during his stay. Resident 63 stated he does not like going out for activities due to personal reasons. He stated he preferred his television in his room to be working so he could watch programs. Resident 63 also stated that his wife had recently passed away, and he often feels bored.During a concurrent observation and interview on 02/25/2026 at 11:55 a.m. with the Activity Director (AD), the AD stated she was not aware that Resident 63's room television was not working. The AD stated the Resident 63 had not reported the issue, but acknowledged that it is the responsibility of all staff to observe and ensure that resident rooms are maintained in a homelike manner. The AD stated she does not provide in room activities herself and primarily conducts rounds. The AD stated she will in service staff to ensure resident needs were addressed before leaving their rooms and will increase the frequency of rounds to better identify and meet residents' in room needs.During a concurrent interview and record review on 02/26/2026 at 7:55 a.m. with the Activity Assistant (AA),the activity participation logs were reviewed, including room visit and independent activity codes. The activity participation logs indicated the in room activity option coded as V4 (movies/TV) was not offered to Resident 63 according to his preferences throughout the month of February 2026. The AA stated she thought Resident 63 did not like to watch television. The AA stated she could not recall the last time she checked whether Resident 63 wanted to watch television or movies. She stated she should be asking Resident 63 during each activity visit about his preferred activities and provide it to Resident 63 to help maintain a homelike environment for the resident.During an interview on 02/27/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated activities should be encouraged for all residents, and that if a resident refuses one activity, staff should offer an alternative aligned with the resident's preferences. The DON stated resident preferences should be obtained, and any refusals or actions taken should be documented.During a review of the facility's policy and procedures (P&P) titled, Activities, undated. The P&P indicated, Facility to provide an ongoing program of activities designed to meet the interest's choice and preference as well as to meet the interests of and support the physical, mental and psychological well-being of each resident, encouraging both independence and interaction in the community , as well as the physical, Mental and psychological well-being of each resident, encouraging both independence and interaction in the community. Activities will be designed with intent to promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence.

Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 48) was offered functional hearing aids available for use. This failure resulted in Resident 48 not being able to hear adequately and communicate appropriately for care, safety needs and basic services for hygiene.Findings:During a review of Resident 48's admission Record (Face Sheet- front page of the chart), the admission Record indicated Resident 48 was originally admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included hypertensive heart disease (heart damage leading to high blood pressure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), cataracts (a common age-related eye condition involving the clouding of the eye's normally clear lens) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 48's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 48 was self responsible. The H&P indicated Resident 48 had hearing loss and difficulty. The H&P indicated Resident 48 could read lips. The H&P indicated Resident 48 understands if you write the questions or statements then show it to him.During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 48 needed substantial to maximal assistance (helper does all the effort) with toileting, showering, dressing and taking off shoes. The MDS indicated Resident 48 needed partial to moderate assistance (helper does half the effort) with eating, oral hygiene, personal hygiene, transferring and walking.During a concurrent observation and interview on 2/24/2026 at 10:43 a.m., Resident 48 was observed hard of hearing. Resident 48 stated he had hearing aids but does not wear them because the hearing aids are too big.During an interview on 2/25/2026 at 11:04 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 48 is unable to hear. CNA 3 stated he types messages on his phone or gives Resident 48 paper to write down what he wants when he needs to communicate with Resident 48. CNA 3 stated Resident 48 does not have hearing aids and had not seen any hearing aids at Resident 48's bedside. CNA 3 stated he is not aware of anything being done to improve Resident 48's hearing.During an interview on 2/25/2026 at 11:47 a.m. with Restorative Nurse Aide (RNA) 1, RNA 1 stated Resident 48 is hard of hearing so you must speak loudly in his ear or pull your mask down so he can read your lips. RNA 1 stated Resident 48 can not understand or hear you when you are speaking with a mask on. RNA 1 stated Resident 48 would benefit from hearing aids.During a concurrent interview and record review on 2/25/2026 at 1:33 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 48's Care Plan, dated 12/19/2025 was reviewed, the Care Plan indicated Resident 48 required hearing aids to communicate. The Care Plan indicated to ensure availability and functioning of adaptive communication equipment. The Goal of the Care Plan indicated Resident 48 will be able to put on and work hearing aids. LVN 2 stated Resident 48 has difficulty hearing and has never seen Resident 48 with any hearing aids. LVN 2 stated Resident 48 would have a breakdown in communication and a problem hearing what is being said without his hearing aids.During an interview on 2/26/2026 at 11:27 a.m. with the Social Worker (SW), the SW stated her responsibility is to make sure residents have hearing aids. The SW stated Resident 48 has bilateral hearing aids that are kept in the medication cart. The SW stated the licensed staff are supposed to offer Resident 48 his hearing aids. The SW stated there is no system to check if Resident 48 is being offered his hearing aids. The SW stated Resident 48's hearing aids were not working and need to have the batteries replaced. The SW stated Resident 48 will not be able to communicate properly and would not be able to listen properly. The SW stated due to miscommunication Resident 48 may hear something different than what is said. During an interview on 2/27/2026 at 2:10 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 48's hearing aids are kept in medication cart. RNS 1 stated Resident 48 would not be able to understand the care rendered without his hearing aid.During an interview on 2/27/2026 at 2:39 p.m. with the Director of Nursing, the DON stated Resident 48 would not be able to communicate his needs with hearing aids that are not working.During a review of the facility's policy and procedure (P&P), titled Ancillary Services, undated, the P&P indicated the Purpose is to ensure residents receive ancillary services in a timely, coordinated, and safe manner to support their highest practicable, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to provide effective pain management for one of four sampled residents (Resident 9). The facility failed to:1. Ensure Resident 9 was provided with pain medicine based on his assessed pain level.This failure had the potential to result in Resident 9 having unrelieved pain or overmedication (receiving too much medication and taking excessively high doses). Findings:During an observation on 2/24/2026 at 10:14 a.m. with Resident 9, observed Resident 9's right arm was on a sling (a supportive device typically a strap or cloth used to immobilize, support, and protect an injured arm, shoulder or wrist).During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 9 diagnoses including autistic disorder ( a condition related to brain development ), unspecified dislocation of right shoulder joint ( ball-shaped top of the upper arm bone has popped out of its socket, causing severe pain, swelling, and inability to move), schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder (persistent, excessive fear or worry that interferes with life).During a review of Resident 9's Care Plan titled, Alteration in Comfort related to dislocation of right shoulder joint, initiated on 1/14/2026 and revised on 1/15/2026. The Care plan goals indicated Resident 9 will not have an interruption in normal activities due to pain. The Care plan interventions included to monitoring of pain every shift and administering Ibuprofen ( medicine used to reduce fever, pain, and inflammation) and monitoring for its side effects (unwanted or unexpected reactions to medicine or treatment).During a review of Resident 9's History and Physical (H&P) dated 1/16/2026, the H&P indicated Resident 9 had fluctuating capacity to understand and make decisions.During a review of Resident 9's Minimum Data Set (MDS- resident assessment tool) dated 1/25/2026, the MDS indicated Resident 9 had an intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 9 required supervision or touching assistance (helper provides verbal cues and contact guard assistance as the resident completes an activity) with transfer to and from a bed to chair, toilet transfer, oral hygiene, toileting hygiene and dressing.During a review of Resident 9's Medication Administration Report (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of January and February 2026, the MAR indicated an order of Ibuprofen 600 milligrams(mgs.-unit of measurement) dated 1/15/2026 to administer 1 tablet by mouth every 12 hours as needed for moderate pain ( pain rating using numerical rating of 1 to 10 that quantifies pain intensity from 0- no pain,1-3 mild pain, 4-6 moderate pain and 7 to 10 is severe pain). The MAR indicated Resident 9 received Ibuprofen 600 mgs. on the following days:On 2/2/2026 at 9:00 a.m. for a pain level of 2/10.On 2/5/2026 at 8:43 a.m. for a pain level of 9/10.On 1/25/2026 at 2:30 p.m. for a pain level of 2/10.On 1/27/2026 at 9:23 a.m. for a pain level of 2/10.During a concurrent interview and record review on 2/26/2026 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 9's MAR for February 2026 was reviewed. LVN 1 stated that Resident 9 would sometimes receive ibuprofen for mild discomfort. LVN 1 stated he should have notified the physician when Resident 9's pain level reached 9, because ibuprofen was ordered only for moderate pain levels of 5 to 7. LVN 1 stated he assessed Resident 9's pain level after giving the ibuprofen but did not document. LVN 1 stated he did not call Resident 9's physician regarding pain level of 9/10. LVN 1 stated that not providing pain medication appropriate for the assessed pain level could result in uncontrolled pain and ineffective pain management.During an interview on 2/26/2026 at 4:26 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse should have notified the physician when Resident 9's pain level was 9/10 because Ibuprofen would not be enough to relieve the pain. The DON stated Resident 9 can be at risk for unrelieved pain because the licensed nurse administered pain medicine not appropriate to the assessed pain level of the resident.During a review of facility's policy and procedure (P&P) titled, Pain Assessment and Management, undated, the P&P indicated the facility will identify pain in the resident and will develop interventions consistent with the resident's goals and needs.

Based on interview and record review, the facility failed to ensure staff competency in cardiopulmonary resuscitation (CPR- emergency lifesaving procedure that is performed when someone's stopped breathing or heartbeat has stopped) for one of three reviewed staff members (CNA 2). The facility failed to:1.Ensure CNA 2 demonstrates the knowledge and skills necessary to perform CPR by obtaining Basic Life Support (BLS-verifies training in essential, life-saving techniques for healthcare professionals and first responders focusing on CPR ) certification that includes an online training and in-person skills demonstrations.The failure to ensure CNA 2 completed the required hands on CPR skills competency had the potential to result in CNA 2 performing CPR ineffectively during life threatening emergencies (dangerous or serious that it could kill or pose a very high risk of death if not handled or treated immediately) in the facility.Findings:During a concurrent interview and record review on [DATE] at 10:13 a.m. with the Director of Staff Development (DSD), CNA 2's Basic Life Support (BLS (BLS- trains participants to promptly recognize several life-threatening emergencies, give high-quality CPR, deliver appropriate breaths and provide early use of an automated defibrillator [AED used to treat sudden cardiac arrest by delivering a controlled electrical shock to restore a normal heart rhythm]) certificate and the facility's policy titled Cardiopulmonary Resuscitation were reviewed. The DSD stated CNA 2 completed an online-only BLS course, and she acknowledged that she had accepted the certificate at that time. The DSD stated the facility's policy requires CPR training to include hands on competency for BLS, and because CNA 2 did not complete an in person skills demonstration, she would not be competent to perform CPR during an emergency.During an interview on [DATE] at 2:08 p.m., with the Director of Nursing (DON), the DON stated CNAs obtaining BLS certification through online only courses could negatively impact resident care, as staff would be unable to perform proper CPR safely or respond appropriately during emergencies.During a review of facility's policy and procedure (P&P) titled, CPR, undated, the P&P indicated Facility's staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. The P&P indicated CPR certification which includes an online knowledge component still requires in-person skills demonstrations to obtain certification.

Based on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) for one of five sampled residents (Resident 48) who was prescribed an antibiotic drug without meeting the McGeers Criteria (a set of clinical definitions used for surveillance to define the resident symptoms and other clinical criteria that are used to meet infection surveillance definitions).This failure had the potential to result in Resident 48 developing antibiotic resistance (when bacteria develop defenses against the antibiotics designed to kill them) from unnecessary or inappropriate antibiotic use. Findings:During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 48's diagnoses included hypertensive heart disease (heart damage leading to high blood pressure), osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), cataracts (a common age-related eye condition involving the clouding of the eye's normally clear lens) and schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 48's History and Physical (H&P) dated 6/18/2025, the H&P indicated Resident 48 was self responsible.During a review of Resident 48's Minimum Data Set (MDS-a resident assessment tool), dated 1/7/2026, the MDS indicated Resident 48 needed substantial to maximal assistance (helper does all the effort) with toileting, showering, and dressing. The MDS indicated Resident 48 needed partial to moderate assistance (helper does half the record) with eating, oral hygiene, personal hygiene, transferring and walking.During a concurrent interview and record review on 2/26/2026 at 1:05 p.m., with the Infection Preventionist Nurse (IPN), Resident 48's Order Summary, dated 1/10/2026, was reviewed. The Order Summary indicated Resident 48 had an order for metronidazole external cream (an antifungal antibiotic cream) to treat rosacea (a chronic long-term inflammatory skin) 0.75 percent ([%] unit of measurement) for 30 Days. The IPN stated today is the first-time she has heard about Resident 48's order for the antibiotic. The IPN stated the McGeer's criteria were not followed because it was not communicated that Resident 48 was on antibiotics. The IPN stated Resident 48 could develop a Multi Drug Resistant Organism (MDRO-bacteria or germs resistant to multiple types of antibiotics) if there is no monitoring if the antibiotic is effective.During an interview on 2/26/2026 at 3:29 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated on 10/31/2025 Resident 48 developed redness on the face and scalp. LVN 3 stated the doctor ordered the metronidazole external cream 0.75 %, on 12/12/2026, 1/10/26, and 2/13/2026. LVN 3 stated she did not notify the IPN Resident 48 was taking metronidazole cream, because she thought she only had to inform the IPN for antibiotics taken by mouth. LVN 3 stated Resident 48 was not monitored for effectiveness of metronidazole cream.During an interview on 2/27/2026 at 1:57 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated metronidazole cream is an anti-fungal medication and needed to be monitored for Resident 48 for side effects to see if the skin infection was getting better. RNS 1 stated all skin issues should be documented, to know the condition of the skin.During a review of the facility's policy and procedure (P&P), titled, Unnecessary Drugs-Without Adequate Indication for Use, undated, the P&P indicated, each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements dose, duration of use, indications for use, adequate monitoring, presence of adverse consequences which indicate the dose should be reduced or discontinued, any combination of the reasons stated above. The P&P indicated the use of any drug will be documented in the medical record to facilitate adequate care planning, including appropriate monitoring and resident centered care.

Based on observation, interview, and record review, the facility failed to ensure Activity Assistant accurately documented on Activity Attendance Record provided for one of five sampled residents (Residents 63) in 2/12/2026,2/13/2026,2/14/2026 and 2/2/24/2026.This deficient practice had the potential for confusion in the care and services provided to Resident 63 and placed the resident at risk of not receiving appropriate care due to inaccurate and incomplete medical information.Findings:During review of Resident 63's admission Records, the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses including anxiety (conditions that cause excessive and persistent feelings of fear or worry that can interfere with daily life), major depression ( mood disorder that causes a persistent feeling of sadness and loss of interest) and muscle weakness (loss of muscle strength).During a review of Resident 63's Minimum Data Set (MDS- resident assessment tool) dated 02/22/2026, the MDS indicated Resident 63's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was moderately impaired. The MDS indicated Resident 63 required setup or clean up assistance (helper set up or clean up; resident completes activity) 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 concurrent interview and record review on 02/26/2026 at 7:55 a.m. with the Activity Assistant (AA), Resident 63's Activity Attendance record was reviewed. The AA stated she did not know why the dates 2/12, 2/13, 2/14, and 02/24/2026 were not signed in the activity records. AA stated other activity staff sometimes assist with activities, and staff may have failed to sign the records. The AA stated she believed the activities were completed for Resident 63 on those dates. The AA stated if an activity was not recorded or documented, then it was considered not done. The AA stated failing to document accurately and timely prevent staff from knowing what activities were provided and when they were completed for Resident 63.During an interview on 02/27/2026 at 1:20 p.m. with the Director of Nursing (DON), the DON stated any activities completed for each resident must be documented to reflect that they were provided. The DON stated that all staff should know and understand the importance of documenting what was done, as documentation demonstrates the service was provided.During a review of the facility's policy and procedures (P&P) titled, Documentation, undated the P&P indicated Facility to maintain accurate, complete, and reliable documentation as part of the residents' medical records and designated service log. Staff are responsible for documenting service they personally provide in a clear, objective, and timely manner. The entry is completed and signed by the individual who provided the service.

Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program ( process for improving how antibiotics [medication used to treat infection] are prescribed and used by residents) was implemented for one of three residents (Resident 90). The facility failed to monitor antibiotic use and review the appropriateness of the prescribed antibiotic.This failure had the potential to put Resident 90 at risk for antibiotic resistance (ability of bacteria and other microorganisms to withstand the effects of antibiotics, rendering them ineffective) or inappropriate use of antibiotic.Findings:During a review of Resident 90's admission Record, the admission Record indicated Resident 90 was initially admitted to the facility on 1/13/2023 and was readmitted on [DATE]. The admission Record indicated Resident 90 diagnoses including urinary tract infection (UTI- an infection in the bladder/urinary tract), anxiety disorder(persistent, excessive fear or worry that interferes with life), diabetes mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior).During a review of Resident 9's General Acute Hospital (GACH) Record titled, Urinalysis ( laboratory test that analyzes a sample of urine to check for signs of health issue), dated 2/6/2026 at 6:30 a.m., the Urinalysis indicated presence of white blood count (WBC presence of white blood count in urine often signals infection) 25 to 50 A ( A- level of WBC in the urine and normal reference range is 0) in the urine.During a review of Resident 9's GACH Record titled, Urine Culture, dated 2/6/2026 timed at 11:10 a.m., the Urine Culture (laboratory test that is used to see if germs specifically bacteria or yeast grow from the sample of the urine) indicated normal genitourinary flora (laboratory found harmless bacteria that normally live in the skin or genital area) and presence of 25,000 colony forming units per milliliter( cfu/ ml- measurement of how many bacteria grew from the sample) in the urine sample.During a review of Resident 90's Physician Order dated 2/9/2026 timed at 2:21 p.m., the Physician Order indicated an order of Ciprofloxacin Hydrochloride (antibiotic used to treat serious bacterial infections like UTI) 500 milligrams (mgs. - unit of measurement) 1 tablet by mouth two times a day for UTI for 4 days.During a review of Resident 90's Minimum Data Set (MDS- a resident assessment tool) dated 2/16/2026, the MDS indicated Resident 90 had moderately impaired cognitive skills ( a person has trouble remembering, thinking, learning and making decisions). The MDS indicated Resident 90 required partial/moderate assistance with eating, oral hygiene, bathing and toilet transfer ( ability to get on and off a toilet or commode).During a concurrent interview and record review on 2/26/2026 at 9:57 a.m. with the Infection Preventionist Nurse (IPN), Resident 90's physician order for Ciprofloxacin dated 2/9/2026, Resident 90's urinalysis and urine culture obtained from GACH on 2/6/2026, were reviewed. The IPN stated she did not verify whether a urine culture had been obtained prior to initiating Ciprofloxacin for Resident 90. The IPN indicated that the urine culture from 2/6/2026 showed a bacterial count below the threshold required to start antibiotic therapy. She stated the culture also did not include sensitivity testing, which identifies which antibiotics would be effective for the specific bacteria. The IPN stated that, according to McGeer Criteria (standardized, evidence based definitions used in long term care facilities to determine true infections and ensure antibiotics are prescribed only when appropriate) a urine culture should show greater than 100,000 CFU/mL to indicate a urinary tract infection. The IPN acknowledged she should have confirmed whether a urine culture was obtained and clarified the order with the physician before starting the antibiotic. The IPN stated Ciprofloxacin was initiated in the facility for Resident 90, who received the full course of the medication. She stated it was her responsibility to track and monitor antibiotic use to ensure compliance with the Antibiotic Stewardship Program. The IPN stated that implementing the Antibiotic Stewardship Program was important to prevent the development of multidrug resistant organisms (MDRO- bacteria that have become resistant to multiple antibiotic making infections difficult to treat) in the facility.During an interview on 2/27/2026 at 2:08 p.m. with the Director of Nursing (DON), the DON stated Resident 90 will develop resistance to most antibiotic leading to MDRO if an antibiotic was administered without proper indication.During a review of facility's policy and procedure (P&P) titled, Antibiotic Stewardship Program, undated, the P&P indicated the program includes antibiotic use protocols and a system to monitor antibiotic use including laboratory testing will be used in accordance with current standards of practice. The P&P indicated antibiotic orders obtained upon admission, new admissions or readmission to the facility will be reviewed for appropriateness,

Based on interviews and record review, the facility failed to ensure that the attending physician was notified of a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death ) for one of three sampled residents (Resident 1), after Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This failure had the potential to delay or prevent medical and mental health evaluation, resulting in unaddressed psychosocial distress, continued fear, lack of appropriate interventions, and increased risk to resident safety and well-being.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities). During a review of Resident 1's History and Physical (H&P) dated 10/18/2025, the H&P indicated Resident 1 had the capacity to understand and make own decisions. During a review of Resident 1's Minimum Data Set ([MDS]resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with memory and thinking and dependent (helper does all of the effort, resident does none of the effort to complete the activity) for oral care, toileting hygiene, and shower/bathe self. During an interview on 12/16/2025 at 8:32 a.m. with Resident 1, Resident 1 stated that he could not recall the allegation of an unknown black male striking him in the stomach and was unable to provide additional details related to the reported incident. Resident 1 stated I feel safe while you were here, but I won't feel safe when you leave, because he believes nothing will be done to address his concerns when surveyor leave. During a concurrent interview and record review on 12/16/2025 at 10:10 a.m. with License Vocational Nurse (LVN) 1, Resident 1's Care Plan was reviewed, the Care Plan indicated that there was no documentation indicating Resident 1's care plan was reviewed or updated in response to the resident's reported allegation of unknown black male striking him in the stomach. LVN 1 stated that he was first made aware of the alleged allegation on 12/9/2025 at approximately 9:00 a.m. to 10:00 a.m. by the ombudsman (an official appointed to investigate individuals' complaints). LVN 1 stated that the ombudsman informed him that Resident 1 reported that an unknown black man struck him, in the stomach, and that the date of the alleged incident could not be verified. LVN 1 stated that if a resident reports being struck and expressing fear, it would be considered a change in condition including a psychosocial change. LVN 1 stated that when a resident experiences a change in condition, the primary physician should be notified, the notification should be documented, and the resident's care plan should be reviewed and updated to address the identified concern. LVN 1 stated that failure to notify the physician and update the care plan could result in the residents' needs not being addressed, including unresolved fear, psychosocial distress, and lack of appropriate medical or mental health interventions. LVN 1 stated that he did not notify Resident 1's physician or document the incident because he believed it was not required, explaining that the resident has a history of making similar statements or allegations and that he therefore did not feel documentation was necessary. During an interview on 12/16/2025 at 10:30 a.m. with Registered Nurse Supervisor (RNS), the RNS stated that she was first made aware of the alleged incident on 12/9/2024 at approximately 2:00 p.m. by the Social Service Director (SSD). The RNS stated that the SSD stated that Resident 1 had reported that a black man came into his room and hit him in the stomach. The RNS stated that a resident reporting being struck and expressing fear would be considered a change in condition, including a psychosocial change. The RNS stated that when a resident experiences a change in condition, residents' physician should be notified, the notification should be documented, and the resident's care plan should be reviewed and updated to reflect the identified needs. The RNS stated that failure to follow these procedures could result in the residents' needs not being appropriately addressed, including continued fear, unresolved psychosocial distress, delay in medical or mental health evaluations, and staff being unaware of interventions necessary to ensure the resident's safety and well-being. The RNS stated that it was her role and responsibility to ensure that staff review and update resident's care plans. During an interview on 12/16/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that her role and responsibilities includes oversight of nursing operations, including supervision of nursing staff, ensuring compliance with facility policies and procedures, and ensuring appropriate follow-up when residents experience a change in condition. The DON stated that if a resident reports being struck and expressing fear a change in condition would be considered, including a psychosocial change. The DON stated that when a resident has a change in condition, physician should be notified, the notification should be documented, and the resident's care plan should be reviewed and updated to reflect the identified needs. The DON acknowledged that the change in condition was not documented, Resident 1's physician was not notified, and the resident's care plan was not reviewed or updated as required. The DON stated that these actions should have occurred in accordance with the facility's policies and procedures. The DON stated that she believed this represented a system failure, rather an isolated individual failure, due to a breakdown in communication and follow-through among nursing staff. The DON stated that failure to document a change in condition, notify the physician, and update the care plan could result in delayed medical or mental health evaluation, unaddressed psychosocial distress, lack of appropriate interventions, and increased risk to resident safety and well-being. During a review of Resident 1's Psychological Consultation, dated December 2025, the Psychological Consultation, indicated that Resident 1 shared that he feels unsafe and persecuted by others based on race. Resident 1 shared that he believes that people of a darker skin color were conspiring against him to harm him. During a review of the facility's policy and procedure (P&P) tilted, Change in a Resident's Condition or Status, [undated], the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.).

Based on interviews and record review, the facility failed to ensure the comprehensive care plan (a personalized, written guide detailing a patient's health status, specific needs, goals, and the nursing actions [interventions]) was developed and implemented for one of three sampled residents (Resident 1) following a change in condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death), when Resident 1 reported being struck and expressed fear, indicating a psychosocial change ( shifts in a person's thoughts, feelings, behaviors, and relationships) in condition. This deficient practice had the potential to result in staff being unaware of the residents' psychosocial and safety needs leading to inconsistent care, lack of protective interventions, continued fear, unaddressed psychosocial distress, and increased risk to resident safety and well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in activities). During a review of Resident 1's History and Physical (H&P) dated 10/18/2025, the H&P indicated Resident 1 had the capacity to understand and make own decisions. During a review of Resident 1's Minimum Data Set ([MDS]resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had moderate cognitive impairment (problems with memory and thinking and dependent ( helper does all of the effort, resident does none of the effort to complete the activity) for oral care, toileting hygiene, and shower/bathe self. During an interview on 12/16/2025 at 8:32 a.m. with Resident 1, Resident 1 stated that he could not recall the allegation of an unknown black male striking him in the stomach and was unable to provide additional details related to the reported incident. Resident 1 stated I feel safe while you were here, but I won't feel safe when you leave, because he believes nothing will be done to address his concerns when surveyor leave. During a concurrent interview and record review on 12/16/2025 at 10:10 a.m. with License Vocational Nurse (LVN) 1, Resident 1's Care Plan was reviewed, the Care Plan indicated that there was no documentation indicating Resident 1's care plan was developed and implemented after Resident 1's reported allegation of an unknown black male striking him in the stomach. LVN 1 stated that he was first made aware of the alleged allegation on 12/9/2025 at approximately 9:00a.m. to 10:00 a.m. by the ombudsman (an official appointed to investigate individuals' complaints). LVN 1 stated that the ombudsman informed him that Resident 1 reported that an unknown black man struck him, in the stomach, and that the date of the alleged incident could not be verified. LVN 1 stated that if a resident reports being struck and expressing fear that it would be considered a change in condition including a psychosocial change. LVN 1 stated Resident 1's care plan should be reviewed and updated to address the identified concern. LVN 1 stated that failure update the care plan could result in the residents' needs not being addressed, including unresolved fear, psychosocial distress, and lack of appropriate medical or mental health interventions. During an interview on 12/16/2025 at 10:30 a.m. with Registered Nurse Supervisor (RNS), the RNS stated that she was first made aware of the alleged incident on 12/9/2024 at approximately 2:00 p.m. by the Social Service Director (SSD). The RNS stated that the SSD stated that Resident 1 had reported that a black man came into his room and hit him in the stomach. The RNS stated that a resident reporting being struck and expressing fear would be considered a change in condition, including a psychosocial change. The RNS stated that when a resident experiences a change in condition, resident's care plan should be reviewed and updated to reflect the identified needs. The RNS stated that failure to follow these procedures could result in the residents' needs not being appropriately addressed, including continued fear, unresolved psychosocial distress, delay in medical or mental health evaluations, and staff being unaware of interventions necessary to ensure the resident's safety and well-being. The RNS stated that it is her role and responsibility to ensure that staff review and update resident's care plans. During an interview on 12/16/2025 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that if a resident reports being struck and expressing fear a change in condition would be considered, including a psychosocial change. The DON stated that when a resident has a change in condition, resident's care plan should be reviewed and updated to reflect the identified needs. The DON acknowledged that the change in condition was not documented, and the residents' care plan was not reviewed or updated as required. The DON stated that failure to update the care plan could result in delayed medical or mental health evaluation, unaddressed psychosocial distress, lack of appropriate interventions, and increased risk to resident safety and well-being. During a review of Resident 1's Psychological Consultation, dated December 2025, the Psychological Consultation, indicated that Resident 1 shared that he feels unsafe and persecuted by others based on race. Resident 1 shared that he believes that people of a darker skin color were conspiring against him to harm him. During a review of the facility's policy and procedure (P&P) titled, Reviewing and Revising the Care Plan, [undated], the P&P indicated, The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was not subject to abuse when Resident 2, who has history of schizophrenia (a mental illness that is characterized by disturbances in thought), and sudden mood changes threw water on Resident 1. This deficient practice resulted in Resident 1 feeling like she was drowning when the water that Resident 2 threw on her, covered her face, went into her mouth and down her throat.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired, and Resident 2 required partial/moderate assistance (helper does less than half the effort) to complete her ADLs. During an interview on 10/21/2025 at 9:04 a.m., Resident 1 stated while she was receiving ADL care from CNA 1, Resident 2 came over and poured water on her face, and the water went down her throat. During the interview Resident 1 was observed crying and stated she felt like she was drowning when the water was going down her throat. Resident 1 stated Resident 2 did not like her voice and had told her in the past, to shut the f*ck up and facility staff were present in the room when this happened. During an interview on 10/21/2025 at 9:45 a.m., Resident 3 stated she saw Resident 2 pour water on Resident 1's face. Resident 3 stated it looked like attempted murder, and it was intentional, like Resident 2 was drowning someone who could not move. Resident 3 stated the facility should have called the police, but they did not. During an interview on 10/21/2025 at 9:56 a.m., and a subsequent interview at 12:24 p.m., CNA 1 stated while providing ADL care to Resident 1, she (CNA 1) left the room to follow up on Resident 1's treatment. CNA 1 stated when she returned to the room she heard Resident 1 screaming. CNA 1 stated Resident 1 informed her that Resident 2 threw water on her. CNA 1 stated Resident 1 was crying, and her upper body was soaking wet. CNA 1 stated there were times when Resident 1 feared Resident 2 because when Resident 1 watched her television, Resident 2 would get mad at Resident 1 for having the volume up. CNA 1 stated on the same day, before the incident with the water pitcher, she saw Resident 2 move Resident 1's bedside table to her (Resident 2) side of the room, which made Resident 1 upset and caused her to cry. CNA 1 stated she had to remind Resident 2 that it was not her bedside table. During an interview on 10/21/2025 at 11:43 a.m., the Director of Nursing (DON) stated she was not aware of any incident occurring between Resident 1 and Resident 2. The DON stated if Resident 2 poured water on Resident 1, that would be considered abuse and had the potential for Resident 1 to be harmed. During a review of the facility's undated Policy and Procedure (P/P) titled Abuse, Neglect and Exploitation the P/P indicated each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P/P indicated a resident must not be subject to abuse by anyone, including but not limited to other residents

Based on interview and record review, the facility failed to report an allegation of abuse for one of two sample residents (Resident 1), when Resident 1 told Certified Nursing Assistant (CNA) 1, that Resident 2 threw water on her (Resident 1). This deficit practice resulted in the inability of the California Department of Public Health (CDPH) to conduct a timely investigation and had the potential for information to be lost and/or forgotten. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of hypertensive heart disease (a condition where the heart has been damaged by years of high blood pressure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact and Resident 1 was dependent on facility staff to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was severely impaired, and Resident 2 required partial/moderate assistance (helper does less than half the effort) to complete her ADLs. During an interview on 10/21/2025 at 9:04 a.m., Resident 1 stated while she was receiving ADL care from CNA 1, Resident 2 came over and poured water on her face, and the water went down her throat. During the interview Resident 1 was observed crying and stated she felt like she was drowning when the water was going down her throat. Resident 1 stated Resident 2 did not like her voice and had told her in the past, to shut the f*ck up and facility staff were present in the room when this happened. During an interview on 10/21/2025 at 9:56 a.m., and a subsequent interview at 12:24 p.m., CNA 1 stated while providing ADL care to Resident 1, she (CNA 1) left the room to follow up on Resident 1's treatment. CNA 1 stated when she returned to the room she heard Resident 1 screaming. CNA 1 stated Resident 1 informed her that Resident 2 threw water on her. CNA 1 stated Resident 1 was crying, and her upper body was soaking wet. CNA 1 stated the Director of Nursing (DON) came to the room to find out why Resident 1 was screaming, that's when she (CNA 1) reported to the DON about the allegation made by Resident 1 against Resident 2. During an interview on 10/21/2025 at 11:43 a.m., the DON stated she was not aware of any incident occurring between Resident 1 and Resident 2. The DON stated she did not go to Resident 1's room and CNA 1 did not report Resident 1's allegation to her. The DON stated CNA 1 should have reported the allegation of abuse to the charge nurse, to her (DON) or the ADM, so they could investigate, report to CDPH, and the ombudsman. During a review of the facility's undated Policy and Procedure (P/P) titled Reporting Abuse to Facility Management the P/P indicated employees must immediately report any suspected abuse or incidents of abuse to the DON. The P/P indicated any individual observing resident abuse or suspecting resident abuse must immediately report such incident to the ADM or DON.

Based on observation, interview and record review, the facility failed to follow enhanced barrier precautions ([EBP] an infection control intervention designed to reduce transmission of multidrug- resistant organisms that employs targeted gown and gloves use during high contact resident care activities) for one sampled resident (Resident 4) when Treatment Nurse (TN) 1 did not wear a gown while providing care to Resident 4's wound. This deficient practice resulted in an increased risk for Resident 4's wound to become infected. Findings: During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis of chronic (constantly recurring) osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the right ankle and foot and peripheral vascular disease ([PVD] a slow progressive narrowing of the blood flow to the arms and legs. During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool) dated 8/14/2025, the MDS indicated Resident 4's cognition was moderately impaired, and Resident 4 was dependent on facility staff to complete his activities daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 4's Physician's Order dated 8/7/2025, the Physician's Order indicated to use enhanced barrier precautions related to Resident 4's PVD and an ulcer (a small open sore or wound generally found in the stomach or on the skin) to Resident 4's right heel. During a review of Resident 4's Treatment Administration Record (TAR), dated 10/2025, the TAR indicated to cleanse Resident 4's left plantar (sole of the foot) foot with normal saline (a saltwater solution), pat dry, paint with povidone iodine (a solution used to clean and disinfect the skin), and cover with a dry dressing every day. During an observation outside of Resident 4's room on 10/21/2025 at 8:40 a.m., an EBP sign was observed to the left of the doorway to Resident 4's room. During an observation and interview on 10/21/2025 at 8:40 a.m., and 8:55 a.m., TN 1 was observed providing care to Resident 4's left plantar foot wound, wearing gloves only, no gown. TN 1 stated she was not aware a gown was required when providing wound care for residents who were on EBP. During an interview on 10/21/2025 at 11:56 a.m., the Infection Control Nurse (IPN) stated residents who have wounds, who were on dialysis, and had indwelling medical devices were placed on EBP to protect them from infection. The IPN stated facility staff should wear gowns and gloves during high contact activities such as transferring residents and dressing changes. During an interview on 10/21/2025 at 1:38 p.m., the Director of Nursing (DON) stated the purpose of EBP is to prevent the spread of infection especially for those residents who have indwelling medical devices and open wounds. The DON stated if the resident had an open wound, facility staff should wear gloves and gowns when providing wound care. During a review of the facility's Policy and Procedure (P/P) titled Enhanced Barrier Precautions dated 2024, the P/P indicated personal protective equipment ([PPE] - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for enhanced barrier precautions is only necessary when performing high contact care activities and may not need to be donned prior to entering the resident's room. The P/P indicated high contact resident care activities include wound care: any skin opening requiring a dressing.

Based on observation, interview and record review the facility failed to ensure the resident was free from physical abuse and was not punched on the face multiple times by another resident for one of three sampled residents (Resident 1). The facility failed to: 1. Supervise Resident 1 and Resident 2 who were smoking on the patio and having an argument on 4/12/2025 at 3:45 a.m. as indicated in both residents' Smoking Assessment Form. 2. Assess and monitor Resident 2 when he was restless and had an escalating behavior manifested by yelling and demanding staff for a cigarette to smoke, pacing (to walk in one direction and then back again) back and forth at the facility's nursing station and hallways on 4/12/2025, from 12:00 a.m. to 3:30 a.m. 3. Ensure Certified Nursing Assistant (CNA) 1 knew the whereabouts of Resident 1 and Resident 2 while she was assigned to care for them on 4/12/2025. 4. Inform Resident 2's physician when Resident 2 was exhibiting behavior manifested by yelling, demanding staff to give him cigarettes, pacing in the hallways and verbalizing that a guy was giving him Methamphetamine (stimulant [substance that raises nervous activity in the body] that is highly addictive). . These failures resulted in Resident 1 and Resident 2 smoking unsupervised on 4/12/2025 at 3:35 a.m. leading to Resident 2 and Resident 1 having an argument resulted in Resident 2 punching Resident 1 multiple times on the mouth and face. Resident 1 sustained mid left corner of the lower lip a cut/tear on his mid left corner of the lower lip and swelling. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and chronic obstructive pulmonary disease(COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P the process of a healthcare provider obtaining a thorough medical history from a patient and performing a physical examination) dated 8/16/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 1 required set up or clean-up assistance (helper sets up or cleans up) with eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene. The MDS indicated Resident 1 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair. During a review of Resident 1's Smoking Assessment Form (a questionnaire used to understand a person's current smoking habits, their interest in quitting, their level of nicotine [an addictive chemical found in tobacco] dependence) dated 2/7/2025, the Smoking Assessment Form indicated Resident 1 utilizes tobacco, must be supervised at all times and had to wear a protective non-flammable apron ( designed to protect the user from ash or other cigarette debris that could be a danger to resident) when smoking. During a review of Resident 1's Body assessment dated [DATE], the Body Assessment indicated Resident 1 had a cut on the lower lip. During a review of Resident 1's Change in Condition (COC-a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) Evaluation dated 4/12/2025 at 4:21 a.m., the COC Evaluation indicated Resident 1 was hit in the face by Resident 2 and sustained a cut /tear at the mid left corner of the lower lip. The COC Evaluation indicated Resident 1 was in distress when he reentered the facility from the patio where he was smoking. The COC Evaluation indicated Resident 1 stated he was hit by Resident 2 on the mouth and face after an argument with Resident 2. The COC indicated Resident 1 sustained a cut to mid-bottom corner of his lip with a minimal bleeding. The COC indicated LVN 1 applied ice pack. During a review of Resident 1's Care Plan, titled Resident 1 has the potential for injury related to smoking, initiated on 4/28/2025, the Care Plan indicated the interventions included maintaining the resident within line of sight of personnel supervising smoking schedule, strict implementation of smoking schedule (start at 8 a.m. and ends at 7:30 p.m.) and maintain safety at all times. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnoses including bipolar disorder, major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest causing impairment in daily life) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS indicated Resident 2 was independent in walking, rolling left to right on the bed, and transferring to and from bed to a chair. During a review of Resident 2's Smoking Assessment Form dated 3/7/2025, the Smoking Assessment Form indicated Resident 2 utilizes tobacco, must be supervised at all times and had to wear a protective non-flammable apron when smoking. During a review of Resident 2's COC Evaluation dated 4/12/2025, timed at 4:19 a.m., the COC Evaluation indicated on 4/11/2025, at 11:00 p.m. Resident 2 asked the licensed nurse at the nursing station to smoke in the patio which was facing the facility's lobby. The COC Evaluation indicated Licensed Vocational Nurse (LVN 1) observed Resident 2 pacing the hallways and nursing station on 4/12/2025 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 3:30 a.m. The COC indicated at around 3:45 a.m. Resident 1 entered the facility from the patio and was distressed. The COC indicated Resident 1 stated that Resident 2 punched him in the face multiple times and Resident 1 sustained a cut with small amount blood on Resident 1's lip. During a review of Resident 2's Care Plan titled, Resident 2 has a behavior problem (fluctuations of emotions from pleasant to angry) related to diagnosis of bipolar disorder initiated on 4/8/2025.,the Care Plan indicated a goal for Resident 2 was to have fewer episodes of emotional fluctuations by review date on 7/8/2025. The Care Plan indicated the interventions included to assist the resident to develop appropriate methods of coping and interacting with others, monitoring behavior episodes of fluctuations of emotions from pleasant to angry every shift, considering time, location, time of the day, persons involved and situations. During a telephone interview on 4/28/2025, at 8:25 a.m. with Certified Nursing Assistant (CNA 1), CNA1 stated she was assigned to Resident 1 and Resident 2 on 4/12/2025 but did not know that they had a resident-to-resident altercation and did not remember that altercation happened that day of 4/12/2025. CNA 1 stated there were no smoking breaks for residents at night. CNA 1 stated the last daily smoking time for the residents was scheduled at 7:30 p.m. CNA 1 stated Resident 1 and Resident 2 were both ambulatory (able to walk and move around) and independent. During a telephone interview on 4/28/2025, at 9:07 a.m. with LVN 1, LVN 1 stated Resident 2 was getting aggressive at the start of the 11 p.m. to 7 a.m. shift on 4/11/2025, at around 11:00 p.m. LVN 1 stated Resident 2 kept coming to the nursing station and demanding a cigarette to smoke threatening to leave the facility if he did not get a cigarette to smoke. LVN 1 stated Resident 2 was having hallucination (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) when he stated there was a guy giving him methamphetamine. LVN 1 stated they were able to redirect his behavior several times during the night. LVN 1 stated Resident 2 was pacing in and out of the patio and around the facility, yelling and demanding to have a cigarette. LVN 1 stated she was in the nursing station and saw Resident 1 went out to the patio to smoke but did not see Resident 2 going out to the patio LVN 1 stated Resident 1 came inside from the patio and told her Resident 2 was trying to beat him up. LVN 1 stated Resident 1 had a cut on his lip with redness and slight swelling. During a telephone interview on 4/28/2025, at 9:30 a.m. and subsequent telephone interview, at 10:57 a.m. with LVN 2, LVN 2 stated the incident between Resident 1 and Resident 2 happened around 3:30 a.m. to 4:00 a.m. on 4/12/2025. LVN 2 stated Resident 1 had been going out to smoke on the patio at random times during the night and carried his own cigarettes. LVN 2 stated Resident 1 was not supervised when he goes out to smoke and smokes by himself because Resident 1 was independent and could pretty much do it on his own. LVN 2 stated on 4/12/2025 the patio was dim and the only light that could be seen was the light coming from the nursing station and the lobby. LVN 2 stated Resident 2 was agitated and had been yelling walking around the facility and asking random staff members for a cigarette during that night (4/12/2025). LVN 2 stated LVN 1 instructed him to go back to his room and gave Resident 2 a cigarette on 4/11/2025, at 11:30 p.m. LVN 2 stated on 4/12/2025 at around 3:30 a.m., she heard a sound coming from the patio door when Resident 1 walked in with blood on his mouth while Resident 2 followed him behind. LVN 2 stated Resident 2 was talking loudly and was agitated while Resident 1 was trying to explain what happened to LVN 1. During an interview on 4/28/2025, at 12:40 p.m. with the Director of Staff Development (DSD), the DSD stated she provided an in-services related to resident-to resident abuse that happened between Resident 1 and Resident 2 on 4/12/2025. The DSD stated if a resident was going to smoke outside on the patio from 3:00 a.m. to 4:00 a.m., the staff must be present to supervise and monitor the residents for safety. The DSD stated the CNAs should be making rounds every two hours to ensure the whereabouts of each resident. The DSD stated the CNAs should be aware where their assigned residents were to prevent falls, any change in condition, injury and/or elopement (the act of leaving the facility unsupervised and without prior authorization). The DSD stated residents unsupervised smoking could lead to injury and physical abuse. The DSD stated the residents (in general) were not allowed to have cigarettes in their possession because the residents could burn, hurt themselves, or hurt other residents. During an interview on 4/28/2025, at 1:10 p.m. with the Director of Nursing (DON), the DON stated residents do not smoke at night and if the residents carry a cigarette, the staff should confiscate their lighter and cigarette. The DON stated the licensed nurse should have assigned a CNA to monitor Resident 2's aggressive behavior and notify the physician to manage his behavior on 4/12/2025. The DON stated there should be staff supervising Resident 1 and Resident 2's while smoking to prevent the risk of injury. The DON stated this incident was avoidable and preventable if only the staff supervised Resident 1 when he went out to smoke in the patio, and the licensed nurse identified and managed Resident 2's aggressive behavior. During a review of facility's policy and procedure (P&P), titled Abuse, Neglect and Exploitation (undated), the P&P indicated Each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The P&P indicated the residents must not be subject to abuse by anyone in the facility and will make efforts to protect the residents. The facility will observe residents' behavior and their reaction to other residents, and train staff about appropriate interventions to deal with aggressive reactions by residents. The P&P indicated the facility will assess, monitor and develop appropriate plans of care with needs and behaviors which might lead to conflict or neglect like residents with history of aggressive behaviors to prevent abuse, neglect and exploitation of residents. During a review of facility's P&P titled, Resident Smoking, (undated), the P&P indicated Residents who smoke will be further assessed using Resident Safe Smoking Assessment to determine if the resident would need supervision or not or will be allowed to smoke in designated smoking areas, at designated times and in accordance with the resident's care plan. The P&P indicated smoking materials of residents requiring supervision will be maintained by nursing staff. Cross referenced F689

Based on interview and record review, the facility failed to ensure the residents who were smoking on the patio were supervised and monitored for two of three sampled residents (Resident 1 and Resident 2). The facility failed to: 1. Ensure Resident 1 and Resident 2, who were assessed as needed supervision at all times, were supervised while smoking on the patio on 4/12/2025, at around 3:45 a.m. in accordance with the facility's policy and procedure titled, Smoking Policy-Residents and Resident 1's and Resident 2's Smoking Assessment Forms. 2. Ensure Resident 2's aggressive behavior was monitored and addressed on 4/12/2025. Resident 2 had been manifesting aggressive behavior and asking staff for a cigarette all night before the incident happened on 4/12/2025 at 3:35 a.m. These failures resulted in Resident 1 and Resident 2 unsupervised smoking on 4/12/2025 at 3:35 a.m. leading to Resident 2 and Resident 1 having arguments resulted in Resident 2 punching Resident 1 multiple times on the mouth and face. Resident 1 sustained a cut / tear at the mid left corner of the bottom lip and swelling. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizophrenia(a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and chronic obstructive pulmonary disease(COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P- the process of a healthcare provider obtaining a thorough medical history from a patient and performing a physical examination) dated 8/16/2024, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/19/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills (ability to think, understand, learn, and remember). The MDS indicated Resident 1 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair. During a review of Resident 1's Smoking Assessment Form (a questionnaire used to understand a person's current smoking habits, their interest in quitting, their level of nicotine [an addictive chemical found in tobacco] dependence) dated 2/7/2025, the Smoking Assessment Form indicated Resident 1 utilized tobacco, must be supervised at all times and had to wear a protective non-flammable apron ( designed to protect the user from ash or other cigarette debris that could be a danger to resident) when smoking. During a review of Resident 1's Body assessment dated [DATE], the Body Assessment indicated Resident 1 had a cut on the lower lip. During a review of Resident 1's Change in Condition (COC-a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional condition) Evaluation dated 4/12/2025 at 4:21 a.m., the COC Evaluation indicated Resident 1 was hit in the face by Resident 2 and sustained a cut / tear at the mid left corner of the bottom lip. The COC Evaluation indicated Resident 1 was in distress when he reentered the facility from the patio, where he was smoking. The COC Evaluation indicated Resident 1 stated he was hit by Resident 2 on the mouth and face after an argument and Resident 1's mid left corner of his lip had minimal bleeding. During a review of the facility's Incident Report dated 4/12/2025 and timed at 3:45 a.m., the Incident Report indicated Resident 1 was smoking on the patio near the lobby at 3:45 a.m. The Incident Report indicated Resident 1 verbalized to Licensed Vocational Nurse (LVN 1) that Resident 2 hit him due to argument over a cigarette. The Incident Report indicated Resident 2 hit Resident 1 multiple times in the face and Resident 1 had lost his balance. During a review of Resident 1's Care Plan, titled Resident 1 has the potential for injury related to smoking, initiated on 4/28/2025, the Care Plan indicated the interventions included maintaining within line of sight of personnel supervising smoking schedule, strict implementation of smoking schedule and maintain safety at all times. During a review of Resident 2's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] to the facility with diagnosis that included bipolar disorder, major depressive disorder(mental health disorder characterized by persistently depressed mood or loss of interest causing impairment in daily life) and schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 2 was independent in walking, rolling left to right on the bed, and transferring to and from a bed to a chair. During a review of Resident 2's Smoking Assessment Form dated 3/7/2025, the Smoking Assessment Form indicated Resident 2 utilized tobacco, must be supervised at all times, and had to wear a protective non-flammable apron when smoking. During a review of Resident 2's COC Evaluation dated 4/12/2025, timed at 4:19 a.m., the COC Evaluation indicated on 4/11/2025, at 11:00 p.m. Resident 2 asked staff at the nursing station, which was facing the facility lobby, to smoke in the patio The COC Evaluation indicated the licensed nurse (unknown) observed Resident 2 pacing the hallways and nursing station on 4/12/2025 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 3:30 a.m. The COC indicated at around 3:45 a.m. Resident 1 entered the facility from the patio and was distressed. The COC indicated Resident 1 stated that Resident 2 punched him in the face multiple times and Resident 1 sustained a cut with a small amount of blood on Resident 1's lip. During a review of Resident 2's Care Plan titled, The Resident 2 has a behavior problem (fluctuations of emotions [changes in mood or feelings] from pleasant to angry) related to bipolar disorder, initiated on 4/8/2025, the Care Plan indicated a goal for Resident 2 was to have fewer episodes of fluctuations of emotions by review date on 7/8/2025. The Care Plan indicated the interventions included monitoring behavior episodes of fluctuations of emotions from pleasant to angry and attempting to determine underlying cause. During a telephone interview on 4/28/2025, at 8:25 a.m. with Certified Nursing Assistant (CNA 1), CNA1 stated she was assigned to Resident 1 and Resident 2 on 4/12/2025 but did not know that they had a resident-to-resident altercation and did not remember that it happened that day of 4/12/2025. CNA 1 stated there were no smoking breaks for residents at night, on 11 p.m. to 7 a.m. shift. CNA 1 stated the last smoking time for the residents was at 7:30 p.m. daily. CNA 1 stated Resident 1 and Resident 2 were both ambulatory (able to walk and move around) and independent. During an interview on 4/28/2025, at 11:00 a.m. with CNA 2, CNA 2 stated she was assigned as a Smoking Monitorer on 4/28/2025 and her responsibilities were to provide cigarettes, smoking aprons, lighting the cigarette and monitoring the residents while smoking for safety. CNA 2 stated the facility provides Resident 1 and Resident 2 cigarettes during regular smoking schedule. CNA 2 stated there were no smoking times at night from 11:00 p.m. to 7:00 a.m. shift. During an interview on 4/28/2025, at 11:39 a.m. with Activity Assistant (AA 1), AA 1 stated the Smoking Monitorer was in charge of passing out cigarettes, providing smoking aprons to residents, ensure residents do not have a lighter in their possession for safety. AA 1 stated the residents cannot smoke whenever they want, and facility staff should supervise residents while residents were smoking. During a telephone interview on 4/28/2025, at 9:07 a.m. with LVN 1, LVN 1 stated Resident 2 was getting aggressive at the start of 11 p.m. to 7 am. shift on 4/11/2025, around 11:00 p.m. LVN 1 stated Resident 2 kept coming to the nursing station and demanding to smoke, threatening to leave the facility if he did not get a cigarette to smoke. LVN 1 stated Resident 2 was having hallucination (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) when he stated there was a guy giving him Methamphetamine (stimulant [substance that raises nervous activity in the body] that is highly addictive). LVN 1 stated Resident 2 was pacing in and out the patio and around the facility, yelling and demanding to have a cigarette. LVN 1 stated she was at the nursing station on 4/12/2025 and saw Resident 1 going out to the patio to smoke but did not see Resident 2 going out to the patio. LVN 1 stated Resident 1 came inside from the patio and told LVN 1 that Resident 2 was trying to beat him up. LVN 1 stated Resident 1 had a cut on his lip with redness and slight swelling. LVN 1 stated it was all about Resident 2 getting cigarettes and throwing tantrums. LVN 1 stated she does not know where Resident 1 got his cigarette to smoke on 4/12/2025, at around 3:45 a.m. During a telephone interview on 4/28/2025, at 9:30 a.m. and subsequent telephone interview, at 10:57 a.m. with LVN 2, LVN 2 stated the incident happened between 3:30 a.m. and 4:00 a.m. on 4/12/2025. LVN 2 stated Resident 1 had been going out to smoke on the patio at random times during the night and carried his own cigarettes. LVN 2 stated Resident 1 was not supervised when he goes out to smoke and smokes by himself because Resident 1 was independent and could pretty much do it on his own. LVN 2 stated Resident 2 was agitated and had been yelling, walking around the facility and asking random staff members for a cigarette during that night (4/12/2025). LVN 2 stated LVN 1 instructed him to go back to his room and gave Resident 2 a cigarette on 4/11/2025, at 11:30 p.m. LVN 2 stated on 4/12/2025 at around 3:30 a.m., she heard a sound coming from the glass door, leading to the patio, when Resident 1 walked in with blood on his mouth while Resident 2 followed him behind. LVN 2 stated Resident 2 was talking loudly and was agitated while Resident 1 was trying to explain to staff what happened. During a concurrent interview and record review on 4/28/2025, at 12:40 p.m. with the Director of Staff Development (DSD), Resident 1's and Resident 2's Smoking Assessment Forms dated 3/7/2025, were reviewed. The DSD stated Resident 1 and 2 required supervision while smoking. The DSD stated Resident 1 should have staff supervision on 4/12/2025 at around 3:00 a.m. and 4:00 a.m. when Resident 1 went out to the patio to smoke for safety. The DSD stated the CNAs should be making rounds every two hours to ensure the whereabouts of each resident. DSD stated the CNAs should be aware where their residents were to prevent fall, any change in condition, injury and elopement (the act of leaving the facility unsupervised and without prior authorization). The DSD stated the residents (in general) were not allowed to have cigarettes in their possession because the residents could burn, hurt themselves or an altercation can occur between residents. During an interview on 4/28/2025, at 1:10 p.m. with the Director of Nursing (DON), the DON stated residents do not smoke at night and if the residents carry a cigarette, the staff should confiscate their lighter and cigarette. The DON stated the licensed nurse should have assigned a CNA to monitor Resident 2's aggressive behavior and notify the physician to manage his behavior. The DON stated there should have been a staff supervising Resident 1's while smoking to prevent the risk of injury. The DON stated this incident was avoidable and preventable if only staff supervised Resident 1 when he went out to smoke on the patio, and the licensed nurse identified and managed Resident 2's aggressive behavior. During a review of facility's policy and procedure (P&P) titled, Accidents and Supervision, undated, the P&P indicated the resident's environment should remain free of accident hazards and each resident receives adequate supervision to prevent accidents. During a review of facility's P&P titled, Smoking Policy- Residents, undated, the P &P indicated smoking articles for residents without independent smoking privileges may not have or keep any type of smoking articles, including cigarettes, tobacco except when they are under direct supervision. The P &P indicated any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member at all times while smoking. Cross referenced F600

A Citation [NAME] Aristoza CA 261 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Title 22: Quality of Care On 12/20/21, the Department received a complaint in regards to staff hitting Resident 1. On 12/21/2021, an unannounced onsite investigation was conducted at the facility.The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, for one of three sampled residents (Resident 1) by failing to intervene for over 22 hours after Resident 1 had a change of condition of throwing up black colored vomitus (matter that has been vomited). As a result, Resident 1 was admitted to Intensive Care Unit (department of a hospital in which patients who are dangerously ill are kept under constant observation [ICU]) on 12/19/2021 at 3:11 a.m. due to [CONDITION(S)] (low blood pressure) and Gastrointestinal (GI) bleed. Findings: During a review of the Resident's 1 Admission record (Face Sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/9/2021, the MDS indicated Resident 1 had severe impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 1 needs limited assistance with bed mobility, extensive assistance with transfer, dressing, bathing, toilet use, and personal hygiene. During a review of Resident 1 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/21/2021 at 3:36 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, Resident 1 vomited black colored vomitus with food particles on 12/18/2021 at 12:15 a.m. LVN 1 stated that it was endorsed to her that attending physician was paged but no return call. LVN 1 stated there was no vomiting on her 7-3 shift. LVN 1 stated, she did not call attending physician on her shift. LVN 1 stated Resident 1 vomited again on 12/18/2021 at 5:00 p.m. LVN 1 stated that she informed nursing supervisor of Resident 1's condition. LVN 1 stated that she did not call attending physician since she informed the nursing supervisor. During a review a Resident 1's Nurses Progress Notes dated 12/18/21. The nurse's notes indicated the following: At 12:15 a.m., Certified nursing assistant (CNA) reported to LVN that resident threw up. LVN assess resident and noted a dark vomitus with undigested food. Vital signs were taken, Temperature (Temp.) 96.9 degrees Fahrenheit (F), Pulse rate (PR) 86, Respiratory rate (RR) 20, Blood pressure (BP) 100/60. At 7:00 a.m., Endorsed to incoming nurse, notified 'physician' waiting for the reply. At 3:00 p.m., No vomiting the whole 7-3 shift. Vital signs were taken, BP 108/62, RR 17, PR 98, and Temp. 97.4. At 5:30 p.m., Resident 1 vomited twice. Resident 1 stated I feel a little weak, when asked by Registered Nurse Supervisor (RN Sup) how does he feels? Vital signs were taken, BP 101/60, PR 101, RR 17, and Temp 97.2. At 9:15 p.m., Resident with another episode of vomiting three times, small to moderate amount of black colored vomitus. Follow up message sent to attending physician. Vital signs BP 85/58, PR 103, RR 17, and Temp 97.0. At 11:00 p.m., Order received from physician's nurse practitioner, to transfer resident to acute hospital via paramedic. At 11:20 p.m., Estimated time of departure to transport resident to the GACH. During an interview on 12/21/2021 at 4:19 p.m. with Director of Nursing (DON), DON stated that any change of condition should be reported to attending physician. DON stated that if attending physician is not responding, licensed staff should have call medical director. DON acknowledged there was a delay of transferring the resident to higher level of care after a change in medical condition. DON stated it is important that the resident be sent to the hospital as soon as possible when there is a change of condition to be evaluated and get the care needed. During a telephone interview on 1/3/2022 at 10:19 a.m. with Registered Nurse Supervisor (RN Sup), RN Sup stated he received a report on 12/18/2021 from 7:00 a.m.-3:00 p.m. shift licensed staff that resident vomited on 12/18/2021, 11-7 shift. RN Sup. stated that Resident 1 vomited again twice on 12/18/2021 at 5:00 p.m. RN Sup. stated, he called attending physician on 12/18/2021 at 5:45 p.m. but did not received a return call. RN Sup. stated, Resident 1 vomited again at 9:15 p.m. RN Sup stated, a follow up message was sent to attending physician. RN Sup stated, he did not call medical director when attending physician was not calling back. RN Sup stated, Resident 1 could have had cardiogenic shock (inability of the heart to pump sufficient blood for the needs of the body) due to the delay of transfer to the acute care hospital. During a review of SBAR Communication Tool form dated 12/18/2021 at 12:30 a.m. indicated, Resident 1 threw up to black liquid with food particles. During a review of the facility's Emergency Department Encounter dated 12/19/2021 at 1:54 a.m. indicated patient here for hematemesis (vomiting of blood), the resident was supposedly on [MEDICATION(S)] (medication that thins the blood). Systolic blood pressure (pressure exerted when the heart beats) remains low in the 80's (improved from 60's). [CONDITION(S)] (low blood pressure) appears most likely related to dehydration (dangerous loss of body fluid) and gastrointestinal bleed (GI) bleeding from stomach and intestines). Resident 1 was admitted to Intensive Care Unit on 12/19/2021 at 3:11 a.m. due to [CONDITION(S)] and GI bleed. During a review of Resident 1's care plan titled Plan Potential for bleeding/bruise/skin tear due to anticoagulant (blood thinner) use undated, indicated interventions includes monitor for hematuria (bleeding in the urine), bleeding of gums, emesis (throwing up) , black tarry stools, gastrointestinal (GI) distress. During a review of Resident's care plan titled Potential risk for gastrointestinal (stomach and the intestines) discomfort, dated 9/28/202, indicated, Resident 1 potential risk for GI discomfort, interventions include report to medical doctor any changes in condition. A review of the facility's policy and procedure (P&P) titled, Notification of Changes (Revised 2021), the P&P indicated, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member when there is a change requiring such notification. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, this may include life threatening conditions, clinical complications.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure the necessary care and services were provided to prevent pressure ulcer development (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of three sampled resident (Resident 1). Resident 1, who was at high risk for development pressure ulcer. The facility failed to do the following: a. Turn Resident 1 every two hours as per policy. b. Ensure Resident 1 received adequate protein for wound prevention and healing. c. Use of special pressure relieving mattress as per the resident's care plan and facility's policy. d. Refer Resident 1 to the Registered Dietician for nutritional assessment as per the facility's policy. This deficient practice resulted in Resident 1 developing two unstageable pressure ulcers (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured (concealed), at risk for delay in wound healing, and put the resident at risk for further wound development and infection. Findings: A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was initially admitted to the facility on (MONTH) 1, (YEAR), and was last readmitted on (MONTH) 17, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 31, (YEAR), indicated a Brief Interview for Mental Status (BIMS) score of 5 (0-7 severe impairment), which indicated that Resident 1 had severe problems with memory and cognition (thought process). The MDS indicated Resident 1 required an extensive assistance from one staff for bed mobility, transferring, locomotion, personal hygiene, and toilet use. The MDS indicated Resident 1's range of motion (ROM) was impaired at bilateral (both) upper and lower extremities and the resident used a wheelchair for mobility. According to the MDS, Resident 1 had a feeding tube and received more than 50 percent of his calories through the feeding tube. The MDS also indicated Resident 1 was at risk to develop pressure ulcers, but did not have any unhealed pressure ulcers or any other skin problems at the time of assessment. A review of Resident 1's physician's orders [REDACTED]. A review of GACH 1's Nutritional Reassessment, dated (MONTH) 9, (YEAR), indicated Resident 1 weighed 55.1 kilograms ((kg) 121 pounds) and had a sacral pressure ulcer. The Nutritional Assessment indicated Resident 1 required an estimated 87-110 grams (g) of protein per day. A review of GACH 1's physician's orders [REDACTED]. A review of Resident 1's Admission Body Assessment, dated (MONTH) 17, (YEAR), indicated there was no documentation Resident 1 had any pressure ulcers upon admission. A review of Resident 1's Care Plan, dated (MONTH) 17, (YEAR), indicated the resident was at risk for skin breakdown related to a history of pressure ulcers and would have a minimized risk for skin breakdown in the next three months. The staff's interventions included repositioning the resident every two hours. A review of Resident 1's Care Plan, dated (MONTH) 17, (YEAR), indicated the resident required tube feedings due to a swallowing impairment. The staff's interventions included monitoring the resident's labs, nutritional assessments and follow-up from the Registered Dietician ((RD) food and nutrition expert) and elevating the resident's head of bed (HOB) 30-45 degrees while feeding infusion or administering medication. A review of Resident 1's Physician Orders, dated (MONTH) 17, (YEAR), indicated the resident was to receive a tube feeding for 20 hours or until the dose was completed. The order indicated Resident 1's HOB was to be elevated between 35 and 45 degrees during feeding times. A review of Resident 1's Nutritional Screening and Assessment, dated (MONTH) 21, (YEAR), indicated Resident 1 weighed 131 pounds (59.5 kg) and required an estimated 48-60 g of protein per day. A review of Resident 1's Braden Scale (an assessment tool used to assess risk for developing pressure ulcers) dated (MONTH) 17, (YEAR), indicated the resident had a score of 10 (0-12 high risk). A review of Resident 1's Care Plan, dated (MONTH) 1, (YEAR), indicated the resident had a deep tissue injury (DTI) to the sacral coccyx. The staff's interventions included providing the resident with a Low Air Loss Mattress ((LAL) a mattress that uses air to alternate pressure and prevent skin breakdown) and a turning and repositioning program. The care plan did not indicate a RD evaluation. A review of Resident 1's Skin Progress Report, indicated the following: 1. (MONTH) 1, (YEAR), Resident 1 had an unstageable deep tissue injury to the sacral coccyx that measured five (5) centimeters (cm) in length and 5 cm in width. The wound was described as intact with a purplish skin discoloration. 2. (MONTH) 2, (YEAR), Resident 1's unstageable wound to the sacral coccyx measured 4 cm in length and 4 cm in width and 0.2 cm in depth. The wound was described as an opened wound with 90 percent (%) slough (dead tissue separating from an ulcer) and 10% necrotic (dead tissue, usually brown or black in color) tissue. 3. (MONTH) 2, (YEAR), Resident 1, had a new wound, an unstageable wound to the left buttock that measured 1 cm in length and 1 cm in width and 0.1 cm in depth. The form did not indicate a description of the left wound buttock. A review of Resident 1's Nurse Progress Note, dated (MONTH) 5, (YEAR), and timed at 12 p.m., indicated the resident was repositioned to his back. A review of Resident 1's Minimum Data Set (MDS), a care screening and assessment tool, dated (MONTH) 5, (YEAR), indicated the resident had one unhealed Stage II pressure ulcer. A review of Resident 1's Discharge Body Assessment, dated (MONTH) 5, (YEAR), indicated the resident had an opened wound on the sacral coccyx and right buttock. A review of Resident 1's physician's orders [REDACTED]. a. (MONTH) 29, (YEAR), Resident 1 had a low pre [MEDICATION NAME] (a protein found in the blood indicative of diagnosing one's nutritional status) level of 9 (Normal Reference Range (NRR) 17-34). b. (MONTH) 5, (YEAR), Resident 1 had a low [MEDICATION NAME] level of 2.2 (NRR 3.5-5.7) and a low pre [MEDICATION NAME] level of 8 (NRR 17-34). A review of an online article titled, NPUAP Pressure Injury Stages, by The National Pressure Ulcer Advisory Panel - NPUAP, dated 8/28/12, indicated the importance of maintaining nutrition, especially protein levels in the prevention of pressure ulcers development. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/. A review of the facility's Skin Management In-Service, dated (MONTH) 17, (YEAR), indicated resident's at the facility would be turned every two hours and positioned on their back at 12 p.m., 6 p.m., and 12 a.m. On (MONTH) 1, (YEAR) at 9:50 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated residents with contractures, low protein [MEDICATION NAME] levels and who could not turn themselves were at high risk for developing pressure ulcers. LVN 1 stated residents with previously healed pressure ulcer sites would be provided with an alternating pressure point mattress ((APP) an air mattress that is placed on top of a regular bed mattress and used to prevent skin breakdown) to prevent the previously healed pressure ulcers from reopening. LVN 1 was unable to locate a care plan, documentation in the resident's medical record or an order for [REDACTED]. On (MONTH) 3, (YEAR) at 12:49 p.m., during an interview, the Registered Dietician (RD) stated Resident 1 was receiving less than the desirable amount of protein needed for wound healing. The RD stated Resident 1 was receiving 76 g of protein and should have been receiving 86 g of protein. The RD stated without an adequate amount of protein, wounds would take longer to heal. The RD stated resident's with new pressure ulcers would be reassessed for increased nutritional needs as soon the as nursing staff notified the RD of the new pressure ulcers. The RD was unable to locate a nutritional reassessment for Resident 1 after the resident developed pressure ulcers. On (MONTH) 3, (YEAR) at 2:11 p.m., during an interview, LVN 2 stated residents on tube feeding were at high risk for pressure ulcers on the sacral coccyx and buttocks due to the pressure of being in a seated position for long periods of time. LVN 2 stated a wedge pillow could help prevent sacral coccyx and buttock pressure ulcers for those residents. LVN 2 stated Resident 1 was placed in a seated position, during tube feeding, for 20 hours per day. LVN 2 was unable to locate a wedge pillow physician's orders [REDACTED]. On (MONTH) 3, (YEAR) at 2:50 p.m., during a concurrent interview and record review, LVN 3 stated Resident 1 had a pressure ulcer on the sacral coccyx and buttocks. LVN 3 stated to prevent the resident's pressure ulcers from worsening, Resident 1 should have been turned every two hours and not be positioned on his back. LVN 3 stated on (MONTH) 5, (YEAR) at 12 p.m., he documented and repositioned Resident 1 to his back, but stated Resident 1 should not have been positioned on his back. A review of facility's undated policy and procedure titled, Prevention of Pressure Ulcers, indicated the facility would use a special mattress containing air, foam, gel or water and to consider offloading (process in which pressure was reduced) pressure hourly for residents with tube feeding. A review of facility's undated policy and procedure titled, Support Surface Guidelines, indicated turning every two hours was inadequate for residents with a pressure ulcer. The policy indicated the date and time the specialty bed was placed would be documented in the resident's medical record. A review of facility's undated policy and procedure, titled Nutritional Assessment, indicated the RD would estimate the resident's calorie, protein and fluid needs and assess whether the intake was nutritionally adequate.

Based on interview and record review, the facility staff failed to provide the necessary care and services to develop a comprehensive plan to identify and ensure a resident was free from illicit (illegal) drug use for one of three sampled residents (Resident 1). Resident 1, a dependent non-ambulatory resident, had two incidents of requiring emergency transfer to the hospital after exhibiting an altered mental status with respiratory problems (difficulty in breathing) and having a positive drug screening test for illicit drugs in her system on 9/4/17 and 10/29/17 These failures resulted in Resident 1 being transferred to the general acute care hospital (GACH) twice, once into intensive care unit (ICU), after being found with an altered level of consciousness ((AL[NAME]) not as awake, alert, or able to understand or react normally) and in [MEDICAL CONDITION]. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident [DIAGNOSES REDACTED]. A review of Resident 1's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 10/4/17, indicated Resident 1 had memory problems, impaired decision-making, but was able to make needs known and understand others. According to the MDS, the resident was assessed as being dependent with bed mobility, transferring, locomotion on and off the unit, requiring assistance with eating and personal hygiene. A review of the paramedics report, dated 9/4/17, indicated Resident 1 was transferred to the GACH after being found with an altered level of consciousness (AL[NAME]) and low oxygen saturation at 90 percent (%) (the amount of oxygen in the blood (normal reference range (NRR) 95-to 100%)) in the facility. Resident 1's urine toxicology test taken from the GACH indicated it was positive for [MEDICATION NAME] (highly addictive stimulant that affects the central nervous system) drug use. A review of Resident 1's urine drug screen results, dated 9/4/17 and timed at 2:05 p.m., indicated a positive screening for [MEDICATION NAME] and cannabinoids (marijuana). A review of another paramedic's report, dated 10/29/17, indicated Resident 1 was transferred to the GACH after being found with AL[NAME] in the facility and in [MEDICAL CONDITION] (inadequate oxygen exchange by the lungs) due to [MEDICATION NAME] use for a second time. Resident 1's urine toxicology test taken at the GACH indicated a positive screen for [MEDICATION NAME] drug use a second time. A review of the emergency department (ED) provider notes, dated 10/29/17 and timed at 7:34 p.m., indicated Resident 1 was admitted for acute hypoxic hypercapnic [MEDICAL CONDITION] (inadequate gas exchange by the lungs in which, oxygen and carbon [MEDICATION NAME] cannot be kept at normal levels by the respiratory system). The ED note indicated Resident 1 tested positive for [MEDICATION NAME], and has extensive medical history such as hypertension (high blood pressure), diabetes (a condition that affects the way the body processes blood sugar), and [MEDICAL CONDITION] disorder (a sudden attack of involuntary convulsions). Resident 1 was placed on a Bi-level Positive Airway Pressure (([MEDICAL CONDITION]) non-invasive ventilation use of airway support administered through a high-pressure facemask) machine. According to the ED note, Resident 1's medical condition placed her at an increased risk of decompensation (the failure of an organ) and death. Care was performed in order to manage the high probability of life-threatening deterioration to the respiratory function involving the [MEDICAL CONDITION]. Resident 1 was admitted to the intensive care unit (ICU). A review of Resident 1's urine drug screen results, dated 10/29/17 and timed at 8:34 p.m., indicated a positive screening for [MEDICATION NAME]. A review of the GACH's Social Worker note, dated 10/30/17 and timed at 2:15 p.m., indicated Resident 1 admitted to smoking cigarettes and using illicit drugs. A review of Resident 1's care plans indicated there was no documented plan of care for supervision of drug use after readmission to the facility on [DATE]. On 11/2/17 at 10:26 a.m., during an interview, Resident 1 stated, I have a problem; I do not want to say who gave me the drugs. On 11/2/17 at 10:55 a.m., during an interview the GACH physician stated, I am intrigued as to how this patient is getting the drugs; she cannot walk or even bathe herself. On 11/3/17 at 9:19 a.m., during an interview, the facility's social services director (SSD) stated, The resident (Resident 1) has not gone out on pass and she does not have any visitors. The family came to see her a few weeks ago. At 9:24 a.m., on 11/3/17, during an interview, Certified Nursing Assistant 1 (CNA 1) stated, On 10/29/17, the resident sounded like she had a cold, but was not responding to her name, she would wake up and then go back to sleep. It was hard to wake her up. During an interview on 11/3/17 at 10:14 a.m., Resident 1's family member (FM 1) stated, The Director of the facility told me the urine drug test was a false positive the first time back in September, now it happened again. How can this happen if she has special needs from a stroke and cannot walk? During an interview on 11/03/17 at 4:09 p.m., Licensed Vocational Nurse 1 (LVN 1) stated, One of the CNAs told me she (Resident 1) was falling asleep, I went to the dining area and transferred the resident back to her room. The oxygen saturation was 86% (NRR 95-100%), we then placed a non-rebreather mask (a device used to assist in the delivery of oxygen therapy) on her (Resident 1). The paramedics were called and I stayed with the resident until they arrived. I initiate the care plans for residents after readmission from the hospital. The DON (Director of nursing) told me that the resident had drugs in her system before readmission, and that it was a false alarm, I did not look for her to continue to use the drugs. I was not told to monitor the resident for drug use, so we didn't. On 11/3/17 at 4:36 p.m., during an interview, the Director of Nursing (DON) stated, I met with the family member and told her the drug test was presumptive, but during the interdisciplinary meeting we talked about the use of [MEDICATION NAME]. According to the americanaddictioncenters.org website, urine drug tests can usually detect meth for up to 72 hours after the last dose. However, in heavy, chronic users, the drug can be detected in urine for up to one week after last use. A review of the facility's policy titled, Care Plans Comprehensive, dated (MONTH) 2010, indicated an individualized comprehensive care plan would be developed for each resident and it would include measurable objectives and timetables to meet the residents' medical, nursing, mental and physiological needs. The policy indicated the interdisciplinary team was responsible for the review and updating of the care plans when the resident had been readmitted to the facility from a hospital stay.

Based on interview and record review, the facility failed to provide the necessary care and services and follow-up on a physician's recommendation for one of 18 sampled residents (Resident 16). A [MEDICATION NAME] ((GI) a physician who specializes in gastrointestinal tract problems which includes the esophagus (tube that carries food, liquids and saliva from your mouth to the stomach), stomach, small and large intestine (colon), and biliary system (liver, pancreas, gallbladder, and bile ducts)), recommended 8 months prior (2/2015) for Resident 16 to have an esophagogastroduodenoscopy ((EGD) a test to examine the lining of the esophagus, stomach, and first part of the small intestine) and a colonoscopy (an exam that views the inside of the colon (large intestine) and rectum, using a tool called a colonoscope) after the resident had an abnormal computed tomography ((CT) an imaging method that uses x-rays to create cross-sectional pictures) of the abdomen. The results showed thickening of the [DIAGNOSES REDACTED] gastric antrum (stomach). According to the National Institute of Health, an article titled, Gastric/[DIAGNOSES REDACTED] wall thickening, positive results of gastric thickening could be indicative [MEDICAL CONDITION]. The article concluded a gastric or [DIAGNOSES REDACTED] wall thickening was a significant finding and should be followed-up (http://www.ncbi.nlm.nih.gov/pubmed/ 11). This failure of not following-up on the GI physician's recommendation resulted in Resident 16 continuing to have severe abdominal pain requiring narcotic pain medication ([MEDICATION NAME] 5/325 milligram, an opiod/[MEDICATION NAME] of 5 mg of [MEDICATION NAME] (opioid synthesized from [MEDICATION NAME]) with 325 mg of [MEDICATION NAME] used for moderate to sever pain ) of 130 tablets over an 8 month period without a definitive [DIAGNOSES REDACTED]. Findings: A review of Resident 16's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. remove waste and help balance fluids and electrolytes in your body), unspecified dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior), gastroesphageal reflux disease ((GERD)a condition when the content of the stomach regurgitates (backs up or refluxes) into the esophagus, which can cause esophagitis(inflammation of the esophagus), difficult and painful swallowing, heartburn, mouth sores and feeling of something stuck in the throat, and nausea and vomiting), and chronic pancreatitis (inflammation of the pancreas causing swelling of the pancreas which causes abdominal tenderness and pain). A review of an annual Minimum Data Set (MDS), a resident assessment and care screening tool, dated 4/13/15, indicated Resident 16 was able to make needs known and understand others. According to the MDS, the resident was assessed as requiring limited assistance with bed mobility, transferring, locomotion on and off the unit, and eating. A review of Resident 16's care plan initiated on 12/8/14, and recently updated on 10/12/15, titled, Alteration in comfort/ signs and symptoms of [MEDICAL CONDITION] ulcer disease (PUD), a condition where open sores develop on the inside lining of the esophagus, stomach and the upper portion of the small intestine. The staff's interventions included to monitor for patterns of discomfort and/or gastric distress and precipitating factors, assess the type, intensity, and quality of pain, administer pain medication per the physician's orders [REDACTED]. A review of a nurse practitioner's (NP) note, dated 1/13/15, indicated the resident's assessment included chronic pancreatitis, chronic liver [MEDICAL CONDITIONS], and [MEDICATION NAME] (inflammation of the gallbladder, which if left untreated, can lead to serious, sometimes life-threatening complications, such as a gallbladder rupture). The NP's note indicated a cholecystectomy (removal of the gallbladder) was attempted on Resident 16, but was aborted due to excessive bleeding. The NP's note indicated the plan included to monitor changes in the resident's right upper quadrant pain, anorexia (an eating disorder), nausea and vomiting, fever, or jaundice (a condition in which a person's skin and the whites of the eyes are discolored yellow due to an increased level of bile pigments in the blood resulting from a liver disease), and a GI consult as planned. A review of a GI physician's progress note, dated 2/20/15, and timed at 3:37 p.m., indicated Resident 16 had a history of [REDACTED]. The GI physician's note indicated he wanted the resident to have further studies done due to the resident's abnormal CT scan of the abdomen and he recommended for an EGD and colonoscopy procedures to be done. A review of Resident 16's primary physician's progress notes, dated 2/9/15, 3/4/15, and 4/4/15, indicated the resident had protein malnutrition, history of [MEDICAL CONDITION], and status [REDACTED]. A review of a nurse's note, dated 2/20/15, and timed at 5:55 p.m., indicated a licensed vocational nurse (LVN 7) called the GI physician to get an appointment for resident's colonoscopy, but was told that the GI physician would call back in a week to give the date for the colonoscopy. A review of the Resident 16's Interdisciplinary Annual Care Conference, dated 4/13/15, indicated the resident's plan of care, medications, diagnoses, diet, and activity preference were discussed. There was no documented evidence the GI physician's recommendation (2/20/15) for Resident 16 to have an EGD and colonoscopy, due the resident's abnormal CT scan with abdominal pain, was followed-up and the procedures had been done. On 10/30/15, at 1:55 p.m., during an interview, the social worker (SW) stated that all physicians' recommendations are followed-up by the licensed nurses. The SW also stated that once a physician's orders [REDACTED]. On 10/30/15, at 2:10 p.m., during an interview, a licensed vocational nurse (LVN 1), stated it was the responsibility of the nurses to review the physician's progress notes and if a physician made a recommendation, the LVN would follow-up to obtain and carry out the physician's recommendations. LVN 1 reviewed Resident 16's clinical record and stated that a call was made by LVN 7 regarding the physician's GI procedure recommendation on 2/20/15, but there was no further documented evidence to indicate that the facility's staff followed-up on the GI physician's recommendations. A review of a physician's orders [REDACTED]. On 10/30/15, at 4:50 p.m., during an interview, LVN 11 stated Resident 16 complained almost everyday of general body pain in the month of October 2015. A review of Resident 16's Pain Assessment Flow Sheet, for the month of October 2015, indicated from 10/1-10/29/15, the resident complained of pain at 8/10 (0 being no pain and 10 being the worse pain) for 26 times, requiring a narcotic pain medication, [MEDICATION NAME] 5/325 mg. The prior months, 9/2015, from 9/1-9/30/15, Resident 16 complained of pain 28 times on a pain scale of 8/10. For the month of 8/2015 (from 8/1-8/31/15) indicated the resident complained of pain 25 times on a pain scale of 8/10. For the month of 7/2015 (7/1/15-7/31/15) the resident had 19 episodes of pain 8/10 requiring a narcotic pain medication. For the month of 6/2015 (6/1-6/30/15), Resident 16 had 11 episodes of pain 8/10 requiring a narcotic pain medication ([MEDICATION NAME]). On 10/30/15, at 5:05 p.m., during an interview, Resident 16 stated he had stomach pains everyday of at least 7/10 on a pain scale. The resident stated he received medication for the stomach pain, but stated it did not always help. A review of Resident 16's controlled drug record (Individual patient narcotic record) and the Medication Administration Record [REDACTED]. A monthly recap of the [MEDICATION NAME] 5/325 mg doses received, indicated Resident 16 received the following: March 2015 - 3 tablets April 2015 - 0 May 2015 - 3 tablets June 2015 - 22 tablets July 2015 - 23 tablets August 2015 - 23 tablets September 2015 - 28 tablets October 2015 - 28 tablets On 10/30/15 at 6:10 p.m., during a concurrent interview and record review, LVN 7 stated that he called the GI physician on 2/20/15, to follow-up on the physician's recommendation for an EGD and colonoscopy. LVN 7 reviewed his written note, dated 2/20/15, and timed at 5:55 p.m., which indicated he spoke to the GI physician and was told by the GI physician he would call back the following week for a date for the colonoscopy procedure for Resident 16. LVN 7 stated he endorsed the above information to the night shift licensed nurse regarding the GI physician would be calling back in a week, but it was not reflected on LVN 7's note. There was no further documentation to indicate it was followed up. On 10/30/15, at 6:18 p.m., during an interview, LVN 7 stated he had called the GI physician earlier that day, before 5 p.m., to follow-up on the recommendation for Resident 16's EGD and colonoscopy. LVN 7 stated he left a message at the physician's office and was waiting for a return call. According to the facility's undated policy titled, Lab and Diagnostic Test Results - Clinical Protocol, the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The policy stipulated the staff would process and arrange for the tests and procedures.

Based on observation, interview, and record review, the facility failed to: (a) Provide adequate supervision to prevent avoidable falls with injury for one of 18 sampled residents (Resident 1). Resident 1, had a history of [REDACTED]. Resident 1's proposed plan of cares were not implemented, reevaluated, and/or analyzed according to the resident ' s needs to prevent repeated falls and injuries as stipulated in the facility's policy and procedures. These deficient practices resulted in Resident 1's incidents of unsupervised avoidable falls on 12/18/14, 1/1/15, 6/30/15, and 8/5/15, over a period of eight months. Cross reference to F279 and F329. On 6/30/15 at 8:05 a.m., twenty-five minutes before the facility's scheduled smoke break, Resident 1 was wheeled outside on the facility's patio, was given a lit cigarette and was left unsupervised while smoking. Resident 1 fell during a seizure activity and sustained blunt head trauma with a three centimeter (cm) right frontal hematoma (bleeding into the tissue) with abrasions (open scratched skin). According to the facility's nursing progress notes, the facility called 911 (emergency services) and the resident was transferred by paramedics to a general acute care hospital (GACH) emergency room . The resident was hospitalized for [REDACTED]. (b) Provide residents' environment that was free of accident hazards due to: 1. Bed cranks were protruding outward in two observed residents' rooms and in one of 18 sampled resident's rooms (Resident 3). These deficient practices, of having bed cranks presented a hazard and had the potential of causing injuries to residents, staff and visitors. Findings: a. A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/8/15, indicated Resident 1 was able to understand others and make her needs known with moderate cognitive (ability to think and reason) impairment. According to the MDS, Resident 1 required extensive assistance (resident involved in activity with one staff providing support) with bed mobility, transferring, walking, hygiene and dressing. Resident 1 was occasionally continent (ability to control) of bowel and bladder, but was not on bowel program. A review of a Fall Risk Assessment, indicated Resident 1 was identified at a high risk for falls. According to the assessment, a total score of 10 or above represents high risk for fall. On 1/22/15, the resident's score was fourteen on 2/9/15, 5/8/15, and 6/30/15. A review of a Resident Smoking Assessment, dated 1/22/15, 2/9/15 and 5/8/15, indicated Resident 1 required extensive assistance by the staff when smoking due to intermittent confusion, assistance with holding the cigarette, history of seizures, and had a balance problem. On 10/27/15 at 6:10 p.m., during a telephone interview, a registered nurse (RN 2) stated the facility's policy indicated smoking begins at 8:30 a.m. However, on 6/30/15 around 8 a.m., Resident 1 insisted on going to the patio before the scheduled smoke break. RN 2 stated, It was not smoking time yet, but it is the resident's choice to smoke and we cannot stop her. During a change of shift report a staff reported to me that the resident was having a seizure. When RN 2 was asked who was supervising the resident smoking in the patio. RN 2 stated, I do not remember who was monitoring the residents out in the patio. On 10/28/15 at 8 a.m., Resident 1 was observed by the surveyors unsupervised attempting to change her own diaper. Resident 1 was standing directly above a puddle of urine on the floor on the side of the bed, hunched over (due to a spine deformity) with body tremors and unsteady. Upon knocking, and asking permission to enter the room, the surveyors saw the resident's call light behind the head board of the bed, out of the resident's reach. On 10/28/15 at 2:53 p.m., in an interview, a certified nursing assistant (CNA 6), stated, Resident 1 is spoiled, when she wants things done, she will do it. She likes to do things on her own. When CNA 6 was asked about the residents smoking schedule, CNA 6 stated, She does not want you to mess with her smoke breaks and she usually goes out to smoke before the scheduled smoke break in the morning and the facility's staff allows her. In an interview on 10/28/15 at 4:20 p.m., Resident 1 was asked about the fall incident on 6/30/15, and stated, I was out smoking with a friend and I fell , I was taken to the hospital by the ambulance. When asked if she was told that she could not smoke before the facility's scheduled smoke break time at 8:30 a.m., Resident 1 stated, I usually smoke alone early in the morning. They use to tell me I cannot smoke before 8:30 a.m., but that was a long time ago. Now, the staff give me a cigarette, light it for me, and sometimes there is somebody there to supervise me, sometimes nobody. A review of the paramedic's emergency medical report, dated 6/30/15, indicated Resident 1 had a fall with a seizure. The report indicated the resident fell out of the chair sustaining blunt head trauma, with a hematoma to the head. The resident's blood pressure was recorded at 165/87 (normal reference 120/80), heart rate at 104 (normal reference range is 60-100 beats per minute (bpm)), and a respiratory rate at 19 (normal reference range 12-20 per minute). The resident's blood glucose level was checked at 122 (normal reference range 70-100 milligram per deciliter (mg/dl)). According to the paramedic's report, an intravenous ((IV) into the vein) line was placed and morphine sulfate was given (the amount not indicated) to Resident 1 for pain. According to the facility's investigation report, dated 6/30/15, Resident 1 had the following falls; 1. On 12/18/14 at 2:40 p.m., Resident 1 had an unwitnessed fall while trying to put on her diaper and lost her balance. The resident was found by the facility's housekeeper on the floor at the edge of doorway in her room with her pants at her knees. 2. On 1/1/15 at 3:50 p.m., Resident 1 had an unwitnessed fall and was found sitting on the floor in her room by a CNA, after losing her balance while attempting to self-transfer to the wheelchair. On 1/26/15, after Resident 1's second fall, the resident's primary physician ordered a neuro consult, due to the resident's bilateral lower extremity weakness that was completed on 2/10/15. 3. On 6/30/15 at 8:09 a.m., after being wheeled to the facility's patio by the activity director (AD) to smoke, Resident 1's was left unsupervised after being given a lit cigarette. The resident had a seizure and fell to the concrete ground. Another resident alerted the facility's staff. A facility's investigation report, dated 6/30/15, indicated Resident 1's fall incident was witnessed by another (unnamed) resident, who informed the facility's staff Resident 1 might have had a seizure prior to the fall. As a result of the fall, Resident 1 sustained a blunt head trauma with a hematoma and abrasion measuring three cm to the right frontal area, resulting in 911 being called and requiring hospitalization . A review of the Resident 1's October 2015 Medication Administration Record (MAR), indicated on 6/30/15, timed at 1 a.m., and again at 7 a.m., prior to Resident 1's fall, the resident received Norco 5/325 (potent narcotic pain medication) milligrams (mg) tablet for complaint of back pain. The resident received Norco twice within the seven hour period prior to falling and having a seizure. According to the Davis Drug Guide, a book used to define medications, indications for clinical use, and safe practices, Norco is 5 milligrams of Hydrocodone (codeine derivative) and 325 milligrams of acetaminophen (Tylenol), Norco can result in lightheadedness, drowsiness and dizziness. 4. On 8/5/15, Resident 1 had an unwitnessed fall and was found by a licensed vocational nurse (LVN 4) on the floor in her room after losing her balance, attempting to transfer unsupervised to a wheelchair. The resident required neurological monitoring (to assess mental status and weakness and injuries) for 72-hours. A right hip x-ray was done to rule-out broken hipbones, as ordered by the physician. On 10/29/15 at 1:55 p.m., during an interview, the activities director (AD) stated on 6/30/15 at 8 a.m., Resident 1, and other residents who were smokers were given lit cigarettes. The AD stated she was aware Resident 1 required supervision when smoking, but she left Resident 1 and the other residents, who were smoking unsupervised. The AD stated she went to assist other residents in the dining room to bring them to the patio. According to the AD, there was no specific direct care staff assigned to supervise the residents on 6/30/15 at 8 a.m., before the facility's scheduled smoke break at 8:30 a.m. A review of Resident 1's plan of care to prevent fall and injury were as follows: 1. A plan of care titled, Supervision with smoking dated 1/22/15, and updated on 5/8/15, indicated Resident 1 required supervision while smoking. The staff intervention included, allowing the resident to smoke according to the facility's policy with precautions for the safety of the resident and others. There was no documented staff intervention to address how Resident 1, who was non-compliant with the Smoking Policy, would be monitored and supervised during Resident 1's unscheduled smoking breaks to ensure the resident and other residents and staff would be safe. 2. A plan of care titled, Seizure Disorder, dated 1/23/15, and revised on 5/8/15, indicated Resident 1 had a high risk for trauma and injuries due to the seizure disorder. The staff's intervention included to maintain 'vigilant' supervision at all possible times, monitor for seizure activity every shift, and obtain labs as ordered. According to the resident's last anti-seizure medication (Valporic Acid) laboratory level, dated 5/26/15, the level was low at 16.0 (normal reference range is 50-100 µg/mL). 3. A review of another care plan initiated on 1/22/15, and revised on 5/8/15, and titled, Needs assistance with activities of daily living (ADL) related to Resident 1 requiring extensive assist with bed mobility, transferring, toilet use, and personal hygiene. The staff's interventions indicated to monitor the resident for tremors and an unsteady gait, assess the resident's functional status, and assist as needed and have the call light within reach. However, during an observation on 10/28/15 at 8 a.m., Resident 1 was observed with tremors to her bilateral upper and lower extremities while attempting to change her diaper without the staff's assistance. There was no documented evidence in Resident 1's plan of care to suggest that the resident's non-compliance with not calling for assistance with ADLs and doing things her own way was addressed to ensure that adequate supervision was provided to the resident to prevent accidents and falls with injury. 4. A review of a care plan initiated on 1/22/15, and revised on 5/8/15, indicated Resident 1 was at risk for falls due to osteoporosis, generalized weakness, poor safety awareness, and a history of falls. The staff's interventions included to place the resident in front of the nurse's station or recreational areas, where staff was present for visual checks. However, Resident 1's room was observed located away from the nursing station and where the resident could not be visualized easily. On 10/30/15 at 9:07 a.m., during an interview, the director of nursing (DON) was unable to provide further evidence of effective safety measure to ensure Resident 1 was supervised to prevent repeated episodes of fall. The DON stated, Resident 1 required supervision when she goes out to smoke. She's very independent and often tries to do things on her own. When asked why the resident who was non-compliant with the smoking policy and calling for assistance with care, did not have a plan of care to address how the resident could be best supervised and assisted, the DON answered, That should have been addressed. The DON was asked who supervised the residents who smoke before the smoke break, the DON stated, There is no specific staff assigned to supervise the residents before the scheduled smoke break, it is not put on the assignment sheet. However, if the activity staff or a CNA is available, or have a lighter assignment, he or she they can supervise the residents. The DON was asked if he had a record to indicate who was assigned to supervise the residents on 6/30/15 at 8 a.m., he stated, I do not have a document. A review of the facility's undated, policy and procedure titled, Safety and Supervision indicated, the interdisciplinary team ((IDT), a team of various facility staff collaborating on the resident's plan of care) shall analyze assessments, observations to identify any specific accident hazards or risk for the resident. The policy also stipulated the care team shall target interventions to reduce the potential for accidents. However, there was no documented evidence in Resident 1's record that the IDT collaborated to address the residents care needs to prevent repeated falls with injury. According to another facility's policy and procedure, dated 12/2009, titled, Care Plans Comprehensive, the comprehensive care plans are based on thorough assessment of the resident and are revised as the resident's condition change. The facility's policy and procedures were not implemented for Resident 1. b. On 10/28/15 at 12:30 p.m., in the presence of the facility's maintenance supervisor and the regional maintenance supervisor, while in Room 27, one of the three beds in the room was observed to have hand crank handles that were positioned protruding into the walkway in front of the bed, presenting a trip hazard. The maintenance supervisors stated that it was not appropriate for the hand crank handles to protrude into the walkway. They both stated the hand crank handle protruding presented a trip hazard to residents and staff. c. On 10/29/15, at 10 a.m., during a concurrent observation and interview, two bed handle cranks were observed protruding out from Resident 24's bed, not tucked in to prevent hazards for the resident's roommate, other residents and staff. A licensed vocational nurse (LVN 4) observed and confirmed the two bed cranks were protruding out presenting a hazard for staff and residents, especially Resident 24's roommate, Resident 3, who was mobile and observed up out of bed sitting in a wheelchair. A review of Resident 24's Admission Face Sheet indicated the resident was diagnosed with [REDACTED]. A review of a quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/13/15, indicated Resident 24 was non-ambulatory and required total assistance from staff for all care. A review of Resident 24's care plan titled, Impaired Activities of Daily Living (ADL)/ Physical Functioning, included a staff's approaches to maintain a safe and hazard free environment. d. A review of the Admission Face Sheet for Resident 3, the roommate to Resident 24, indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident 3 required extensive assistance from staff with transition and walking, but used a walker and wheelchair. A review of Resident 3's care plan titled, Impaired Activities of Daily Living (ADL)/ Physical Functioning, included a goal that the resident would not have fall incidents and the staff's an interventions included to maintain a safe and hazard free environment. A review of Resident 3's care plan titled, High Risk for Falls, included a goal that Resident 3 would not have fall incidents. The staff's plan of approach included to implement fall precautions, to provide a safe environment free of any clutters, and to keep floors non-slippery. A review of the facility's policy undated and titled, Bed Safety, indicated the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety and to try to prevent deaths/ injuries from the beds and related equipment.

Based on observation, interview, and record review, the facility failed to provide assistance in walking in accordance with the comprehensive assessment for 2 of 17 sampled residents (5, 11). Resident 5 had dementia (loss of brain function that occurs with certain diseases and affects memory, thinking, language, judgment, and behavior) and was assessed as requiring extensive assistance (resident involved in the activity, staff provide weight-bearing support (staff member supports some of the weight of the resident or performs part of the activity for the resident)) in walking, not having a steady balance during walking and turning around and facing the opposite direction while walking, and only able to stabilize himself with staff assistance. The resident walked by himself (or with no staff beside him) in the hallway without staff intervening. This deficient practice resulted in a fall with injuries, that included laceration on the forehead and a nasal (nose) non-displaced fracture (the bone is broken but still remains in place). Resident 11 had dementia and was assessed as requiring extensive assistance in walking and locomotion, not having a steady balance during walking and turning around and facing the opposite direction while walking, and only able to stabilize with staff assistance. The resident walked by herself (or with no staff beside her) in the hallway without staff intervening. This deficient practice had the potential to result in fall with injuries. Findings: 1. A review of Resident 5's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].), and paranoid schizophrenia (a mental disorder which may result in some combination of hallucinations, delusions, and disorganized thinking and behavior). A review of the Nursing Admission Record, dated 5/6/14, at 6:30 p.m., indicated Resident 5 was noted with unsteady gait upon assessment and he was referred to physical therapy (PT) and occupational therapy (OT) for evaluation and treatment. A review of the Fall Risk Evaluation, dated 5/6/14, indicated the resident was assessed as having a total fall risk score of 21 (a total score of 10 or above represents high risk for falls). A review of Resident 5's care plan titled "Needs Assistance with ADLs (activities of daily living)" dated 5/6/14, indicated goals which included the resident will not have fall incidents. The care plan did not indicate what level of assistance he needed (e.g. supervision, limited, extensive, or total assistance) and for which particular ADL (e.g. transfer ambulation, etc.). The approach plan included to assist as needed. A review of another plan of care, dated 5/6/14, indicated Resident 5 declined with functional mobility related to weakness. One of the interventions was to assist with ADLs. A review of the plan of care, dated 5/7/14, indicated Resident 5 was at high risk to experience complications related to the use of psychotropic medication (medications affecting mental activity, behavior, or perception, as a mood-altering drug), such as Ativan (an anti-anxiety medication) PRN (as needed). One of the approaches was to observe the resident's gait for steadiness and ability to position and turn. A review of the Interdisciplinary Care Review and Conference, dated May 9, 2014, indicated Resident 5 was receiving PT services for difficulty walking and lack of coordination and OT services for muscle weakness. Resident was identified as a fall risk due to his poor safety awareness and his need for cuing and re-direction due to confusion, disorientation, and short and long term memory problem related to dementia. The resident was assessed as needing extensive assistance with one person assist with ambulation and locomotion (act or power of moving from place to place). A physical therapist performed the Tinetti Performance Oriented Mobility Assessment (a task-oriented test that measures an older adult's gait and balance abilities, which included turning 360 degrees) on 5/12/14, and the results indicated Resident 5 was a high risk for falls by having a total score (balance and gait) of 12 (a score of less than 19 represents high risk). A review of the admission assessment MDS (Minimum Data Set, a resident assessment and care screening tool), dated 5/10/14, and the 14-day assessment MDS dated [DATE] indicated the following: a. Resident 5 was able to make his needs known and able to understand others. b. Resident 5 was moderately impaired in cognitive skills. c. Resident 5 was assessed as requiring extensive assistance with one person assist while walking in the resident's room (how resident walks between locations in his room) and walking in the corridor (how resident walks in corridor on unit), and during locomotion on unit (how resident moves between location in his room and adjacent corridor) and locomotion off unit (how the resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities or treatment). If the facility has only one floor, how the resident moves to and from distance areas on the floor). d. Resident 5's balance during walking and turning around and facing the opposite direction while walking was not steady and he was only able to stabilize with staff assistance. According to the nursing notes dated 5/18/14 (a Sunday) at 10 a.m., Registered Nurse (RN 1) documented that a certified nursing assistant (CNA) reported that the resident fell on the floor in front of Room 25. RN 1 found the resident lying with his face down. First aid treatment and cold compress were applied to the bleeding forehead of the resident. When asked what his name was, Resident 5 stated his name. When asked if he had pain, the resident stated right at his forehead. RN 1 documented that per the licensed nurse, they were doing their job functions when they saw Resident 5 turn around and lose his balance. The resident fell and hit his head on the railings of the hallway. A review of the nursing progress notes, dated 5/18/14 at 10:28 a.m., indicated the physician ordered Resident 5 to be sent to an urgent care facility for evaluation and treatment. At 11 a.m., the resident was picked up by an ambulance for transportation. At 2 p.m., the resident was readmitted to the facility. The nursing progress notes indicated on 5/19/14 at 10 a.m., the licensed nurse called the urgent care to inquire if an x-ray of the nose was done and the staff in the urgent care stated Resident 5 did not have an x-ray and he was just evaluated for his laceration and monitored for any changes in his mental status. At 10:30 a.m., the licensed nurse called the physician because the patient complained of nasal (nose) deviation (abnormal shift) and an x-ray was ordered. At 10 p.m., the licensed nurse called the physician in regard to the x-ray result and the physician ordered an ENT (ear, nose, throat specialist) consult for evaluation of the resident's non-displaced nasal fracture. A review of the radiology (x-ray) result of the nose indicated Resident 5 had a non-displaced fracture mid nasal bones and there was soft tissue swelling. On 7/19/14 at 9:30 a.m., during an interview, the Rehab Director/Physical Therapist (PT) stated an extensive assistance meant the staff had to actually touch the resident to provide support during the activity. During the course of the interview, Resident 5's physical therapy initial assessment dated [DATE], was reviewed with the Rehab Director. The Rehab Director stated the resident was a high risk for falls and his safety was moderately impaired, which meant his balance was off, his muscles were weak, and he was at risk for falls. The Rehab Director stated the resident should not walk by himself without staff assistance beside him. On 7/20/14 at 10:25 a.m., during an interview, Resident 5 stated he remembered falling on the floor but he did not remember why he was walking and where he was going before the fall. The resident stated he was walking by himself on the day of the fall and he was passing by staff at the hallway. At 10:30 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated he had seen Resident 5 walking in the hallway by himself, without staff assistance or beside the resident prior to the day of the resident's fall. CNA 1 stated after the resident fell , the resident used the wheelchair. At 11 a.m., LVN 3 stated that before the fall incident, Resident 5 liked to walk around and he was compliant and could be re-directed. LVN 3 was asked to explain what an extensive assistance in walking mean. LVN 3 answered extensive assistance meant the resident needed two to three person assist. At 11:30 a.m., during an interview, the MDS Coordinator stated extensive assistance in walking meant the staff had to touch and help the resident physically when the resident was walking. At 2:55 p.m., during an interview, CNA 2 stated that on the day Resident 5 fell , she saw the resident walking in the middle of the hallway by himself, no staff member was beside him, and his walk was steady. CNA 2 stated when the resident turned around, he became unsteady with his feet and he fell down. CNA 2 demonstrated the resident's act of turning by crossing her (CNA 2) feet. CNA 2 stated the resident sometimes refused care but he listened and could be re-directed. At 3:05 p.m., during an interview, Registered Nurse (RN) 1 stated he was in the nursing station and he went to see the resident in the North Station hallway after a CNA informed him that the resident fell . RN 1 stated the resident was facing down on the floor and he helped LVN 4 and 2 CNAs, who were already at the resident's side, in turning the resident to a supine (lying face up) position. RN 1 stated there was blood on the resident's forehead so he got gauze and placed pressure on the site. On 7/22/14 at 10:25 a.m., during an interview, CNA 2 stated LVN 4 was passing medications nearby but LVN 4 was behind the medication cart and would not be able to catch the resident from falling because the medication cart was blocking her (LVN 4). 2. A review of Resident 11's clinical record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (a progressive brain disease that slowly destroys memory and thinking skills). The resident was currently receiving physical therapy services at the facility. A review of the Fall Risk Evaluation dated 6/18/14 indicated the resident was a high risk for falls by having a total score of 13 (total score of 10 or above represents high risk). According to the admission assessment MDS, dated [DATE], Resident 11 was able to make her needs known, was able to understand others sometimes, she was moderately impaired in cognitive skills, and she needed extensive assistance with one person physical assist when walking in the room and corridor, and during locomotion on and off unit. On 7/21/14 at 10:45 a.m., during an observation, Resident 11 was walking by herself in the hallway as she was going towards the direction of the activity room at the end of the hallway. Resident 11 walked passed LVN 2 and two (2) staff members. The LVN 2 and the two staff members were busy with their tasks and did not go beside Resident 11 to provide extensive assistance or weight bearing support while she was walking in accordance with the comprehensive assessment. At 10:50 a.m., during an observation, Resident 11 was walking by herself at the opposite end of the same hallway. At 1:40 p.m., during an interview, CNA 4 stated she was assigned to Resident 11 and she had seen the resident walk by herself. CNA 4 stated she would redirect the resident whenever she saw her walking by herself so that the resident would not be alone. When asked what it meant when a resident needed extensive assistance in walking with one person assist, CNA 4 stated the resident needed help in walking and the staff should hold the hand of the resident while the resident was walking. Cross refer to F279 and F520