Every finding on record at Pioneer House

Based on observation, interview, and record review, the facility failed to implement ordered measures to promote wound healing for one of four sampled residents (Resident 1), when staff did not ensure that low air loss (LAL) mattress (a specialized medical-grade support surface used to prevent and treat bedsores [pressure ulcers] by combining continuous airflow with pressure relief) air pump for Resident 1 was working or connected to the power outlet. This failure increased the potential for slower healing or worsening pressure ulcer in Resident 1.Findings: During a review of Resident 1's admission Record (AR), dated 6/3/26 (print date), the AR indicated, Resident 1 was admitted to the facility in March of 2026 with diagnoses which included a need for assistance with personal care, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 1's Care Plan Report (CPR), dated 6/3/26 (print date), the CPR indicated, [Resident 1] is at risk for worsening skin breakdown/pressure injuries.Utilize pressure-relieving mattress and other pressure redistribution devices as ordered. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for June of 2026, the MAR indicated that the following order was carried out daily on every shift, including the morning shift of 6/3/26, Low air loss mattress. Monitor for functioning and correct setting. During a review of Resident 1's wound progress note (WPN), dated 6/3/26, the WPN indicated, [Resident 1] has MASD [moisture associated skin damage caused from prolonged exposure to moisture] to coccyx [tailbone], progressed as stage 3 pressure ulcer [Stage 3 PU, Full-thickness loss of skin. Dead and black tissue may be visible] and identified as such on 06/03/26 per [wound physician]. During an observation on 6/3/26 at 10:45 a.m. in Resident 1's room, the room was observed without a roommate, and Resident 1 was sleeping in her bed with the LAL mattress air pump at the feet of the bed. The air pump was observed not working, and its power cord was observed unplugged under the bed. During a hallway observation commencing on 6/3/26 at 10:59 a.m. multiple staff room checks or entries were observed for Resident 1's room, including the following events:- On 6/3/26 at 11:55 a.m. a Certified Nursing Assistant (CNA 1) delivered a lunch food tray to Resident 1.- On 6/3/26 at 12:01 p.m. CNA 2 and Licensed Nurse (LN 1) entered Resident 1's room to check on the resident.- On 6/3/26 at 12:07 p.m. LN 1 entered Resident 1's room and attempted to talk to the resident.- On 6/3/26 at 12:24 p.m. CNA 2 came to Resident 1's room and took the food tray out of the room.- On 6/3/26 at 12:40 p.m. CNA 2 came to Resident 1's room and brought sheets for the second (empty) bed in the room and made the bed. During a concurrent observation and interview on 6/3/26 at 1:09 p.m. with LN 1 in Resident 1's room, the LAL air pump was observed unplugged from the power outlet. LN 1 confirmed the observation and re-plugged the pump, and the light indicator on the pump came on, and the pump started making humming noises. During a concurrent observation and interview on 6/3/26 at 1:20 p.m. with LN 2, LN 2 was observed exiting Resident 1's room. LN 2 stated that Resident 1's LAL mattress air pump was not working correctly because the mattress wasn't firm enough, and the pump will likely need a replacement. LN 2 stated that she expected the LAL mattress air pump to be plugged in and working at all times. LN 2 further stated that on 5/21/26, Resident 1 developed MASD on the coccyx, which worsened over time and during examination today was determined to be a Stage 3 pressure ulcer. During an interview on 6/3/26 at 2:21 p.m. with the Director of Nursing (DON), the DON confirmed that she expected the LAL mattress pump to be plugged in and working when ordered and staff to be checking on its function every shift or when they attend to the resident. The DON confirmed that if the LAL mattress air pump was not on, it could increase the risk of skin breakdown for the resident. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, the P&P indicated, .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents.

Based on interview and record review, the facility failed to implement measures to prevent an avoidable elopement for one of three sampled residents (Resident 1), when staff was unaware Resident 1 had left the facility unsupervised. This failure had the potential to negatively affect Resident 1's health and safety and could result to harm and injury. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). A review of Resident 1's Wandering Risk Assessment, dated [DATE], indicated Resident was high risk for elopement. A review of Resident 1's physician orders and notice of admission form, both dated [DATE], indicated Resident 1 did not have the capacity to understand choices and make decisions. A review of Resident 1's Care Plan Report (CPR), initiated [DATE], indicated Resident 1 was non-compliant to facility's wander management system (WMS - a system to monitor wandering residents), and there were no nursing interventions on how staff were to monitor for safety and to decrease risk for elopement. The CPR indicated Resident 1 was a fall risk, and there was no schizoaffective disorder focus on how Resident 1's behaviors would be monitored. A review of Resident 1's progress notes, dated [DATE], indicated Resident 1 refused use of WMS, and staff documented as patient is on High Elopement risk.is currently restlessness and agitated. The staff did not document best practice monitored interventions on how Resident 1 would be kept safe from elopement. A review of Resident 1's progress note, dated [DATE] at 7:35 p.m., Licensed Nurse 1 (LN 1) documented Resident 1 was not found in the facility. There was no documentation LN 1 announced Code Pink to alert staff of Resident 1's elopement. A review of Resident 1's progress note, dated [DATE] at 10:05 p.m., LN 1 documented notified the Director of Nursing (DON) that Resident 1 had left the facility. The timeframe for administration notification was greater than two hours. A review of Resident 1's progress note, dated [DATE] at 3:17 a.m., indicated the DON faxed notification to police department that Resident 1 had eloped from facility. The timeframe for police notification was greater than 30 minutes. During an interview on [DATE] at 11 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the main entrance doors automatically locked at 5 p.m., the residents outside smoking, without a staff chaperone, would need to ring the doorbell which would notify staff for re-entrance. During a telephone interview on [DATE] at 12:25 p.m., with LN 1, LN 1 stated when she realized Resident 1 was missing from facility, she did not announce Code Pink. During a telephone interview, on [DATE] at 1 p.m., with CNA 2, CNA 2 stated, I can't tell when they [residents] leave the floor, if I'm busy on the other end of the hallway. [Resident 1] does not wear a [WMS], nothing. CNA 2 stated he did not hear Code Pink announced overhead. During an interview and record review, on [DATE] at 1:15 p.m. with the DON, the DON confirmed Resident 1 did not have capacity to make decisions, had high risk for elopement, that the care plan focus' did not address Resident 1's diagnosis for mental illness, and there were no interventions of how staff would monitor Resident 1's safety when no [WMS] was worn. The DON stated her expectations were for staff to follow the elopement policy, and to notify me so I can follow appropriate actions. The DON stated these procedures were important for patient safety, especially if they don't have capacity. During an interview, on [DATE] at 3:30 p.m., with the Administrator (ADM), the ADM stated his expectations were for staff to communicate everything as soon as they know, staff should let management know if a resident needs a [WMS]. The ADM stated this was important for the well-being and safety of the resident. During a review of the facility's procedure titled, Elopement In-Service, undated, the procedure indicated, Elopement places residents at high risk for injury or harm and requires immediate action .Emergency Procedures: Missing Resident . Immediate Actions .Announce Code Pink .Notify Administration .If resident is not located after 30 minutes .notify police. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, revised 3/2019, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm.If identified as at risk for wandering, elopement,.the resident's care plan will include strategies and interventions to maintain the resident's safety.If a resident is missing, initiate the elopement/missing resident emergency procedure.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one of 3 Residents (Resident 1) when Resident 1 who was homeless was discharged without proper arrangements for home health nursing services to manage multiple burn wounds, food, or transportation to follow up medical appointments. A review of the admission record indicated the facility admitted Resident 1 in the fall of 2025 with multiple diagnoses which included aftercare for multiple burn wounds that had been surgically grafted (a procedure where healthy skin is taken from one part of the body and transplanted to cover another area where skin is damaged). Resident 1's medical history indicated Resident 1 had third degree burns over 20-29% of her body surface area, muscle wasting and atrophy, gait and mobility disorders, and a carrier of Methicillin Resistant Staph Aureus (MRSA- a type of bacteria that becomes resistant to common antibiotics).A review of a document titled Order Summary Report dated 12/8/2025 , with the current physician's orders indicated Tx: (Treatment) generalized burn wound to lower bac (sic) cleanse with NS (Normal Saline), pat dry, apply mupirocin cream 2% (medicated ointment) and cover with dry dressing QD (daily) and PRN (as needed) for dislodgement until resolved, and, Tx: healed burn wounds apply Eucerin lotion (lotion used to moisten the skin) and leave open to air BID (two times per day).During an interview on 12/9/2025 at 9:15 a.m., the Case Manager/ Social Worker (CM/SW) stated her responsibility in the process of resident discharge is to ensure a safe discharge to home or another suitable place. The CM/SW stated she had not made an attempt to reach out to homeless shelters or home health agencies to provide follow up care for Resident 1's planned discharge. Further discussion as to why Resident 1 was being discharged , the CM/SW stated Resident 1 went in and out of the facility too often and stated It is Medi-Cal fraud for her to stay in the facility. The CM/SW acknowledged Resident 1 followed the facility policies for leaving the property to smoke and returned as expected. CM/SW stated she had not advised Resident 1 of the right to appeal the discharge.During an interview on 12/9/2025 at 9:55 a.m., with Resident 1 in Resident 1's room in the presence of the Ombudsman and CM/SW, Resident 1 stated she was homeless due to a fire when she was burned, which destroyed her home. Resident 1stated she was advised by the CM/SW on 12/8/2025 at approximately 3:30 p.m., that she would be discharged the next day (12/9/2025). Resident 1 stated when she questioned why she was being discharged she was told by the CM/SW You are committing Medi-Cal fraud by staying here. Resident 1 further stated she could not care for herself as she had burns on her back, legs and arms as well as open blisters on both upper legs that needed medicated ointment applied that she is not able to apply herself. Resident 1 stated she did not have a relationship with family who could help care for or house her. Resident 1 stated she had not received written discharge instructions or information for follow- up care. Resident 1 confirmed only receiving the verbal instructions from the CM/SW that she would be discharged on 12/9/2025 and that she could leave whenever she could get a ride. During an interview on 12/9/2025 at 10:24 a.m., with the Director of Nursing (DON) in the presence of the CM/SW, DON stated she believed Resident 1's discharge was safe and appropriate. DON stated Resident 1 was being discharged because She comes and goes too often from the facility. DON stated Resident 1 followed the facility policy and had physician's order to leave the facility for no specified amount of time or frequency. DON stated, Resident 1 signed in the book (used to track leaves of absence) what time she went out and when she returned. DON indicated she was not aware if discharge planning had been completed for Resident 1. During an interview on 12/9/2025 at 11:15 a.m., with the Administrator (ADM), DON and CM/SW, the ADM stated on 12/8/2025 in the morning he had driven to a motel in Sacramento and had spoken to the front desk clerk who indicated the motel would have a room available for Resident 1. ADM stated he did not make a reservation to hold a room for Resident 1, nor did he have any idea how Resident 1 would obtain food or care for herself since home health nor any other organization had been contacted to provide food or nursing to care for Resident 1's burn wounds. Further discussion with ADM, he stated he intended to pay for a three night stay at the motel then had no plan nor idea as to where Resident 1 would go for shelter or burn care when those three days were over. The ADM stated he did not document the information in a discharge plan or medical record and did not discuss the plan with Resident 1. During an interview on 12/9/2025 at approximately 11:30 a.m., with the Wound Nurse (WN) in the presence of the ADM and CM/SW, the WN stated Resident 1 had two open wounds on her right upper leg and three open wounds on her left upper leg. WN stated she had not measured the open wounds but felt Resident 1 was capable of caring for the open wounds on both legs. WN further described the wounds on both upper legs as blisters that had opened on the graft sites. WN stated she had not done any education or training for Resident 1 to care for her wounds and stated that Resident 1 would not be able to care for the wounds on her back.In a concurrent interview and record review of a document titled, Name of Facility, SNF Progress Notes New, on 12/9/2025 at 12:30 p.m. with the CM/ SW, the document dated 11/21/2025, indicated Resident [1] is homeless. D/C [Discharge] help with placement at a lower level of care. Facility will assist with establishing a PCP [Primary Care Physician] for post discharge. Rehab team will conduct a caregiver training session with whomever will be providing care to the resident upon discharge. The CM/SW stated the above were goals identified upon admission and stated the goals had not been met or reviewed at time of discharge on [DATE].A review of Resident 1's clinical record document titled, Notice Of Proposed Transfer/Discharge, dated 12/8/2025 at 3:28 p.m., revealed Resident 1 was to be discharged on 12/9/2025. The document indicated Resident 1 would be discharged to other with the description, Resident plans to [discharge] to motel for a few days and then move to her sister or family members house . The document further revealed a transfer/discharge reason as, Resident met her goals here and plans to [discharge] to community.A review of a document titled Communication Form, dated 12/8/2025, and identified by DON as the physician's orders for Resident 1's discharge included, Res [Resident 1] to d/k w/ (discharge) current meds and belongings. The DON stated, the order indicated, Resident 1 was to discharge with current medications and belongings. Review of a policy titled Discharge Plan and Summary with no initial date or signatures revised March 2025, indicated, When a discharge is anticipated, a discharge summary is created, and the discharge plan is finalized to assist the resident with plans for care after discharge, and, By the time a resident leaves the facility, the discharge summary is furnished to the provider who is assuming responsibility for care of the resident after discharge. The medical record contains a copy of the discharge summary. Every resident has an individualized discharge plan, which begins at admission and is part of the comprehensive care plan. The discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and the representative to develop interventions to meet the residents discharge goals and needs that must be addressed before the resident the resident can be safely discharged . Discharge planning identifies the discharge destination, and ensures that it meets the resident's health and safety needs, as well as preferences. A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality for three of 13 sampled residents (Resident 20, Resident 36 and Resident 2) when:Resident 20's medical record was not updated with the correct diagnosis;Resident 20's physician's order to wear a cervical collar was not followed;Resident 36's physician's order for weight monitoring was not followed; andResident 2's physician's order for daily weights was not followed.These failures resulted in an inaccurate medical record for Resident 20, Resident 36 and Resident 2 and had the potential for injury to Resident 20's neck. Findings: 1.Resident 20 was admitted to the facility in Fall of 2025 with diagnoses which included injury of the spinal cord in the neck area, fracture of the neck and lower back spine. A review of the Resident 20 Physician's Progress note (PN) dated 10/30/25 indicated, Late Entry: Psych Evaluation.medical history of significant.anxiety, depression, schizophrenia (a serious mental health condition that affects how people think, feel and behave).Patient was started on [Brand Name] (Olanzapine, a medication used to treat schizophrenia).during last visit. A review of Resident 20's Medication Administration Records (MAR, used to document medications taken by each individual) indicated, OLANZapine Oral Tablet 5 MG [a Milligram, unit of measurement] (Olanzapine) Give 1 tablet by mouth at bedtime for schizophrenia m/b auditory hallucinations -Start Date- 10/23/2025 2000. A review of Resident 20's Electronic Medical Records (EMR, an electronic record of health-related information on an individual) on 12/03/25 at 10:23 a.m., indicated no schizophrenia diagnosis in the medical diagnosis section. A review of Resident 20's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 10/27/25, indicated Resident 20 had no diagnosis of schizophrenia. During an interview on 12/3/25 at 9:47 a.m., Resident 20 confirmed that he was aware of receiving Olanzapine. Resident 20 further stated that the medication was prescribed to help manage the voices he heard. Resident 20 also mentioned that he had previously been on this medication. During a concurrent interview and record review with License Nurse 3 (LN 3) on 12/3/25 at 10:13 a.m., LN 3 confirmed that Resident 20 had a physician's order for Olanzapine 5 mg at bedtime, prescribed for schizophrenia and hallucinations and confirmed that there was no documented diagnosis of schizophrenia in the resident's medical record, nor was the diagnosis reflected in the resident's MDS. LN 3 further emphasized the importance of maintaining accurate medical records and stated that all pertinent information should be documented in the resident's EMR. During a concurrent interview and record review with MDS coordinator, the MDS Coordinator stated that a resident's MDS should be routinely updated to accurately include current medical diagnoses. The MDS Coordinator further stated, We should have updated the patient's MDS and medical diagnosis information in our system. The MDS Coordinator confirmed that Resident 20 did not have a documented diagnosis of schizophrenia in either the MDS or the medical diagnosis section. During an interview with the Director of Nursing (DON) on 12/4/25 at 8:11 a.m., the DON emphasized the importance of documenting medical diagnoses in the resident's MDS. The DON also confirmed that Resident 20's MDS and medical records were missing a diagnosis of schizophrenia and stated that the MDS should have been updated accordingly. The DON further stated that maintaining complete and accurate documentation was a requirement and expectation under CMS guidelines. 2. Resident 20 was admitted to the facility in Fall of 2025 with diagnoses which included injury of the spinal cord in the neck area, fracture of the neck and lower back spine. A review of Resident 20's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 10/27/25, indicated Resident 20 had an active diagnosis of Fractures and Other Multiple Trauma. A review of Resident 20's Order Summary Report (ORS) indicated, c-collar [cervical collar, instrument used to support the neck and spine and limit head movement after an injury] to be worn at all times d/t [due to] spinal injury, dated 10/17/25. A review of Resident 20's MDS, dated [DATE], indicated Resident 20 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating Resident 20 was cognitively intact. During a concurrent observation and interview on 12/3/25 at 9:47 a.m., Resident 20 was observed lying in bed without the prescribed cervical collar in place. When asked, Resident 20 stated, It was removed last night by a staff member, but they never came back to put it back on today. My doctor told me to wear it all the time. Resident 20 further stated that a nurse had visited him earlier that day but did not reapply the cervical collar. The cervical collar was observed resting on the left bedside table. Resident 20 later confirmed that the collar belonged to him. During a concurrent interview and record review with License Nurse 3 (LN 3) on 12/3/25 at 10:13 a.m., LN 3 confirmed that she did not offer the cervical collar to Resident #20. LN 3 stated that Resident 20 was required to always wear the cervical collar and stated that failure to do so could negatively impact the resident's healing process. LN 3 further explained that if Resident 20 was found without the cervical collar, staff should offer it to him and to encourage its use. During a concurrent observation and interview with the Director of Nursing (DON) in Resident 20's room on December 4, 2025, at 10:07 a.m., the DON confirmed that the physician's order for Resident 20 to wear a cervical collar was current and that the resident should be wearing it at all times. The DON confirmed that Resident 20 was observed in bed without the cervical collar in place and emphasized that physician orders were important and must be followed by staff. 3. Resident 36 was admitted to the facility in Summer of 2025 with diagnoses which included digestive system (includes the anus, appendix, esophagus, gallbladder, large intestine, liver, pancreas, rectum, small intestine, and stomach) surgery and malnutrition from inadequate protein and calorie intake. A review of Resident 36's Medication Review Report (MRR) indicated, Resident does have the capacity to understand choices and make medical decisions. A review of Resident 36's Care Plan Conference (CPC) date 11/14/25 indicated, Patient has PEG tube [percutaneous endoscopic gastrostomy, is a small tube that goes through the skin and muscle into the stomach] in situ [in place]. A review of Resident 36's MRR indicated, admission weight. May weigh resident weekly or monthly as indicated. With order date of 5/4/25. A review of Resident 36's MRR indicated, NPO [nothing by mouth] diet NPO texture, NPO consistency, with order date of 5/4/25. A review of Resident 36's Care Plan (CP) indicated, [Resident's name] is at risk for altered nutritional status.Weigh on admission, monthly and as indicated., initiated on 5/4/25. The CP also indicated, Wt [weight] loss: [Resident's name] has weight loss.Resident will not have acute complications related to weight loss, Initiated on 7/4/25. A review of Resident 36's Weights and Vitals (WV) records on 12/3/25 indicated that the last documented weight was 105.4 lbs. (pounds, unit of weight measurements) on 7/9/25. No weight entries were recorded for the months of August, September, October, November, or December. During an interview on 12/3/25 at 12:49 p.m., Resident 36 reported that she was currently receiving tube feeding. She also stated that she did not recall the last time staff offered to obtain her weight and stated, They use a machine to lift me up so they can take my weight. Resident 36 indicated an interest in knowing her present weight. During a concurrent interview and record review with Licensed Nurse 3 (LN 3) on 12/3/25 at 1:23 p.m., LN 3 stated that Restorative Nursing Assistants (RNA) were primarily responsible for obtaining residents' weights, which were typically ordered weekly. She further stated that it was important to document residents' weights to monitor changes and support physician decisions, especially for residents with CHF (congestive heart failure). LN 3 confirmed that Resident 36's last recorded weight was on 7/9/25. During an interview with the Director of Nursing (DON) on 12/4/25 at 8:11a.m., the DON stated that weights should be obtained weekly or as ordered. She further stated that if a resident refused, staff were expected to document the refusal and report it to the dietitian or physician. The DON also stated that missing weight data could impact the accuracy of diagnoses and treatment decisions. The DON also confirmed that Resident 36's weight documents were missing for the months of August, September, October, November, and December. A review of the facility's policy and procedures (P&P) titled, PHYSICIANS ORDERS, indicated, It is the policy of this facility to ensure that:.treatments are administered according to standards of clinical practice upon the written order of a person duly licensed and authorized to prescribe. The Licensed Nurse or Therapist will note Physician's Orders upon receipt of orders and carry orders out in a timely manner. 4. Resident 2 was admitted to the facility late 2024 with diagnosis which included a condition where the kidneys were unable to filter waste and extra fluid from the body. Resident 2 received dialysis (process that removes waste and excess fluid from the body) twice a week. During a review of Resident 2's Order Recap Report [ORR], the ORR indicated an order was placed on 10/21/25 for weights to be taken daily. During a review of Resident 2's electronic health record (EHR), effective date ranges from 1/1/25-12/31/25, the EHR indicated the last weight was entered on 10/31/25. During a concurrent interview and record review on 12/3/25 at 11:32 a.m. with the DON and Nurse Consultant (NC) of Resident 2's EHR, the DON and NC confirmed Resident 2 had an order for daily weights which were not entered daily. The NC stated staff should be following the physician orders. The DON stated residents on dialysis should have an accurate weight in the EHR. During a review of the facility's policy and procedure (P&P) titled, Physicians Orders, undated, the P&P indicated, .Medications and treatments are administered according to standards of clinical practice. During a review of the facility's P&P titled, DIALYSIS SERVICES, undated, the P&P indicated, It is the policy of this facility to provide adequate and appropriate care to dialysis clients in coordination with the dialysis center, under the management and direction of the resident's attending physician.

Based on observation, interview, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL, basic self-care tasks) to maintain personal hygiene for two of 13 sampled residents (Resident 33 and Resident 23) when nail care was not performed.These failures increased the risk of infection and had the potential to diminish the residents' sense of dignity. 1.Resident 33 was admitted to the facility mid-2023 with diagnosis which included stroke with loss of movement to one side of the body, and high blood sugar. During a review of Resident 33's Minimum Data Set (MDS, federally mandated resident assessment tool) dated 9/29/25, the MDS indicated resident 33 could not perform personal hygiene (wash/dry face and hands) without full assistance from a staff member. During an observation and interview on 12/1/25 at 9:28 a.m. with Resident 33 in her room, Resident 33's right hand fingernails were long with thick dried dark matter underneath each nail, there was dried dark matter around the cuticles. Resident 33 stated it would be nice if her nails were clean. During a concurrent observation and interview on 12/1/25 at 9:35 a.m. of Resident 33's fingernails with Licensed Nurse (LN 1), LN 1 confirmed Resident 33's nails were not clean. LN 1 stated she would expect nails to be cleaned and trimmed, because it was important for the residents to look clean, and for hygienic and infection control reasons. During an interview on 12/3/25 at 10:21 a.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP was shown a picture of Resident 33's nails. The DSD/IP stated staff were supposed to clean all resident's hands before meals, she stated it was important to keep nails clean, and she would expect staff to clean and trim the nails of all residents every Sunday. During a review of Resident 33's Care Plan Report [CP], initiated 10/4/23 and 10/10/23, the CP's indicated, .Keep fingernails short .Monitor/document residents abilities for ADLs and assist as needed . During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living [ADL], Supporting, dated 3/18, the P&P indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including appropriate support and assistance with: hygiene. During a review of the facility's P&P titled, Fingernails/Toenails, Care of, dated 2/18, the P&P indicated, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 2. Resident 23 was admitted to the facility in May of 2025 with diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following non-traumatic intracerebral hemorrhage (bleeding in the brain) affecting left dominant side. A review of Resident 23's Care Plan (CP), revised on 11/3/25, indicated, Mr. [Resident 23] Is at risk for altered ADL's [activities of daily living].Provide assistance with ADLs as indicated. During an observation on 12/2/25 at 11:19 a.m., Resident 23's fingernails on his left hand were untrimmed and contained a dark brown substance underneath. During an observation on 12/3/25 at 10:39 a.m., Resident 23's fingernails still had not been trimmed and cleaned by staff. During a concurrent observation and interview on 12/4/25 at 7:48 a.m. with Licensed Nurse 2 (LN 2), LN 2 confirmed that nail care had not been provided and stated that staff were expected to perform nail care on Sundays.

Based on observation, interview, and record review, the facility failed to ensure that one of 13 sampled residents (Resident 4) were offered sufficient fluid intake to maintain proper hydration.This failure placed Resident 4 at risk for dehydration.Findings:Resident 4 was admitted to the facility in September of 2025 with diagnoses that included multiple sclerosis (a nervous system disease that affects the brain and spinal cord). A review of Resident 4's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 11/5/25, indicated Resident 4 required set-up assistance to drink fluids. A review of Resident 4's Care Plan (CP), revised 11/13/25, indicated, Ms. [Resident 4] is at risk for fluid volume deficit (Dehydration) R/T [related to] impaired mobility.offer fluids as tolerated or as indicated by diet order.A review of Resident 4's fluid intake sheet indicated Resident 4 had 240 milliliters (ml, 240ml of fluid is equal to one cup) on 12/3/25 and 240ml on 12/1/25.During a concurrent observation and interview on 12/1/25 at 1 p.m., Resident 4 was observed lying in bed with no water available within reach. Resident 4 stated she was thirsty and wanted water. During a concurrent observation and interview on 12/2/25 at 8:43 a.m., with Certified Nursing Assistant 3 (CNA 3), Resident 4's bedside table was not within her reach and did not have any water or fluid available for her to drink. Resident 4 indicated that she was thirsty and nodded yes when asked if she wanted water. CNA 3 confirmed that Resident 4 did not have water within reach despite Resident 4 being thirsty. During an observation on 12/2/25 at 3:30 p.m., Resident 4's water cup was placed on her nightstand, which was not reachable by Resident 4. Resident 4 nodded yes when asked if she was thirsty. During an observation on 12/3/25 at 10:34 a.m., Resident 4 did not have water available, and her bedside table was not within reach. During an interview on 12/3/25 at 3:27 p.m. with the Director of Nursing (DON), the DON indicated she expected facility staff to offer water to residents for hydration and comfort. During a review of the facility Policy and Procedure (P&P) titled, Hydration - Clinical Protocol, revised 11/10, the P&P indicated, The staff will provide supportive measures such as providing fluids and adjusting environmental temperature.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 49 when expired medications were available for residents use and medications were not stored properly.These failures had the potential for residents to receive ineffective medications and placed residents at risk for cross contamination. Findings: During a concurrent observation and interview on 12/2/25 at 10:33 a.m. of the medication cart with Licensed Nurse (LN 2), a nasal spray and eye drops stored next to oral medications were observed. LN 2 confirmed the findings and stated the nasal sprays and eye drops should not be mixed with oral medications. Also, a clear plastic bag labeled only with a resident's first name contained an oral inhaler and a nasal spray was observed. LN 2 confirmed the findings and stated the inhaler, and nasal spray should not be stored together due to cross contamination.During a concurrent observation and interview on 12/2/25 at 11:30 a.m. of the medication supply closet with LN 2 multiple vitamins and anti-diarrhea medications were found expired. LN 2 confirmed the findings and stated the medications needed to be discarded so residents would not receive expired medications.During an interview on 12/3/25 at 3:33 p.m. with the Director of Nursing (DON), the DON was shown pictures of expired medications and items stored together in the medication cart. The DON confirmed the findings and stated the different medications should not be stored together and expired medications should have been discarded because of the potential for cross contamination and infection.During a review of the facility policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/23, the P&P indicated, Medication Storage: if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding retuning or destroying these items.Medications are stored in an orderly manner in cabinets, drawers.Medications for external use.are clearly marked as such, and are stored separately from other medications.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and stored in a safe and sanitary manner for a census of 48 residents who received food prepared from the kitchen, when:1. Trash can by the hand washing station was found without plastic liner with used gloves, paper towels and coffee creamer cups;2. Food debris was found on several kitchen utensils inside the plastic tray, while the bottom of the tray designated for storing clean kitchen utensils contained visible dirt and food debris;3. Several plastic water pitchers and metal pans were found stacked wet and stored at the clean and ready-to-use storage areas;4. Water collected in the plastic pan under refrigerator one's evaporator located on the top of the metal shelf used to store resident foods;5. Liquid was observed leaking from the bowl onto the base and surrounding countertop during food processor operations. Staff used a wiping cloth taken from another countertop to clean the liquid from the bowl, base, drive shaft, and counter. The same cloth was reused to wipe these areas on two separate occasions,6. Water was observed leaking from the hot water faucet at the coffee station onto the bottom of the metal shelf, where clean resident coffee urns were stored. A mixture of clear and brown liquid was observed on the shelf surface beneath the urns; And7. Sanitized dishes were placed near the handwashing station and directly beneath the soap dispenser. A white foamy substance was observed on the tray holding the sanitized coffee cups.These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.Findings:1. During the initial kitchen tour and a concurrent observation and interview with Dietary Aide 2 (DA 2) on 12/1/24 at 8:35 a.m., a trash can located under the handwashing sink was found without a plastic liner and contained several used gloves, paper towels, and several coffee creamer cups. DA 2 confirmed the findings and stated, Normally, they should put a garbage bag inside and it should not have any trash in it, adding that the liner should have been replaced after the previous shift disposed of trash.During an interview with the Dietary Consultant (DC) on 12/3/25 at 2:50 p.m., the DC stated that trash cans and bins should not be overflowing and must be kept clean. The DC emphasized that plastic liners should be replaced each time trash was removed, and no trash should be disposed of in bins without liners. The DC further stated that failing to follow these practices may lead to cross-contamination and attract pests in the kitchen.A review of the facility document titled Job Description, dated 2023, the document indicated, Position: Dietary Aide. Cleaning as assigned. Keep work area clean,A review of the facility policy and procedures (P&P), titled Sanitation, dated 2023, indicated, The kitchen staff is responsible for all the cleaning.2. During a concurrent observation and interview with DA 2 on 12/1/25 at 8:45 a.m., food debris were found on several clean kitchen utensils inside a plastic tray. The bottom of the tray used for storing clean utensils contained visible dirt and food residue. DA 2 confirmed the findings and stated that resident food should not be prepared using those utensils.During an interview with the DC on 12/3/25 at 2:50 p.m., During an interview with the DC on 12/3/25 at 2:50 p.m., the DC stated that kitchenware and utensils must be free of food debris and residue. The DC also emphasized that kitchenware and utensils should appear visibly clean before being stored. The DC further explained that storing unclean items may lead to food safety concerns and cross-contaminationA review of the facility P&P titled, Dishwashing, dated 20123 (SIC), the P&P indicated, Gross food particles shall be removed by carefully scraping and pre-rinsing in running water.A review of the facility P&P titled, Sanitation, dated 2023, the P&P indicated, All utensil, counters, shelves, and equipment shall be kept clean maintained in good repair.3. During the initial kitchen tour and a concurrent interview with the DC on 12/1/25 at 9:12 a.m., several plastic pitchers and metal pans were observed stacked while still wet on the clean dish rack. The DC confirmed the findings and stated that these items should be completely dry before being stored. The DC further stated that using unsanitized or dirty dishes during food preparation could lead to foodborne illness and presents a food safety concern. A review of the facility P&P titled, Dishwashing, dated 20123 (SIC), the P&P indicated, Dishes are to be racked loosely without overlapping. Dishes are to be air dried in racks before stacking and storing.4. During a concurrent observation of the resident food refrigerator (refrigerator 1) and an interview with the Dietary Manager (DM) on 12/1/25 at 9:29 a.m., a plastic pan more than halfway filled with water leaking from the bottom of the evaporator was found placed on top of the metal shelf used to store resident food. The DM confirmed the findings and stated that the evaporator had been broken for some time but could not recall when the problem beganDuring a concurrent observation and interview with the Maintenance Supervisor (MS) on 12/1/25 at 9:44 a.m., inside Refrigerator 1, the MS stated it was the first time he became aware of the evaporator leaking and denied prior knowledge of the issue. The department made multiple attempts to obtain maintenance logs for the refrigerators and freezers from the MS but did not receive any documentation.During an interview with the DC on 12/3/25 at 2:50 p.m., the DC confirmed that the evaporator inside Refrigerator 1 was leaking and stated that the collected water should be discarded immediately. The DC further stated that the issue should have been reported and repaired promptly because the standing water may pose sanitation concerns and could affect the refrigerator's internal temperature, potentially compromising food safety.A review of the facility P&P titled, Sanitation, dated 2023, the P&P indicated, All equipment shall be maintained as necessary and kept in working order. The Maintenance Department will assist. as necessary in maintaining equipment.A review of the facility P&P titled, Maintenance Service, dated 12/2009 indicated, The maintenance director is responsible for maintaining the following records/reports. Maintenance Schedules.5. During the initial kitchen tour observation on 12/1/25 at 10:30 a.m., the cook was operating the food processor to puree resident food when liquid was observed leaking from the bottom of the processor bowl onto the base and countertop. The cook used a wiping cloth taken from a different countertop to clean the bowl, base, and counter, then placed the used cloth near the food processor. Without removing gloves or washing hands, the cook continued to puree food. When the liquid leaked again during operation, the cook reused the same cloth to wipe the bowl, base, drive shaft, and countertop, and again resumed food preparation without handwashing or changing gloves.During a concurrent observation and interview with the DC on 12/2/25 at 11:12 a.m., the DC confirmed the observation and stated that leaking liquid could pose a risk of food contamination. The DC stated that kitchen staff must wash their hands and change gloves each time they touch anything other than food during preparation and stated, they need to follow the facility protocol [hand washing].A review of the facility P&P titled, Sanitation, dated 2023, the P&P indicated, The FNS Director is responsible for instructing employees in the fundamental of sanitation in food service. All equipment shall be maintained as necessary and kept in working order. equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. All Food and Nutrition Services staff shall know the proper hand washing technique. Note that hands must be thoroughly washed and clean.6. During a concurrent observation and interview with DA 2 on 12/2/25 at 11:01 a.m., water was observed leaking from the hot water faucet at the coffee station onto the bottom of the metal shelf where clean resident coffee urns were stored. A mixture of clear and brown liquid was present on the shelf surface beneath the urns. DA 2 confirmed the findings and stated, It has been leaking for 3 months now. [Maintenance Supervisor's name] put up a little spout to make sure dripping water goes into the bucket, but they should have fixed that properly.During an interview with the DC on 12/3/25 at 2:50 p.m., the DC confirmed the observation and stated that broken kitchen equipment poses food safety risks and may interfere with accurate food production processesA review of the facility P&P titled, Sanitation, dated 2023, the P&P indicated, All equipment shall be maintained as necessary and kept in working order. All utensils, counters, equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas.7. During a concurrent observation and interview with DA 2 on 12/1/24 at 8:35 a.m., sanitized plastic coffee cups were found placed on a tray directly beneath the soap dispenser near the handwashing station. A white foamy substance was observed on the tray holding the cups. DA 2 confirmed the findings and stated that the cups were clean but should not have been stored in that location.During a concurrent observation and interview with the Nurse Consultant (NC) on 12/2/25 at 9:38 a.m., multiple sanitized dishes were observed lined up on a dishwasher tray placed on the countertop near the handwashing station. DA 1 was then observed washing hands at the station and water splashes were seen reaching the sanitized dishes nearby. NC confirmed the findings and stated that the clean dishes were placed too close to the handwashing area.During an interview with the DC on 12/3/25 at 2:50 p.m., the DC confirmed that sanitized dishes should not be placed near the handwashing area due to the risk of cross-contamination. The DC explained that when staff wash their hands, splashes may contaminate nearby clean dishes. A review of the facility P&P titled, Sanitation, dated 2023, the P&P indicated, All utensils, counters, equipment shall be kept clean.

Based on observations, interviews, and record review, the facility failed to follow proper infection control practices for two of 13 sampled residents (Resident 19 and Resident 23) when:1. Resident 23's tube feeding syringe (a large syringe used to administer nutrition through a tube placed in the stomach) was not labeled with a date, and2. Staff did not put on a gown while providing care to Resident 19 and Resident 23 who were on Enhanced Barrier Precautions (EBP, precautions taken to prevent the spread of disease and require the use of a gown and gloves).These failures had the potential to increase the spread of infection. Findings:1. Resident 23 was admitted to the facility in May of 2025 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following non-traumatic intracerebral hemorrhage (bleeding in the brain) affecting left dominant side and dysphagia (trouble swallowing). During a concurrent observation and interview on 12/2/25 at 1:06 p.m. with Licensed Nurse 2 (LN 2), LN 2 was administering a tube feeding bolus (tube feeding given using a syringe instead of a pump; it is considered open-system) to Resident 23 with an unlabeled syringe. LN 2 confirmed that the syringe was unlabeled and indicated that tube feeding syringes should be labeled with a date. During an interview on 12/3/25 at 11:20 a.m. with the infection preventionist (IP), the IP indicated that tube feeding syringes should be labeled with a date to prevent staff from using it beyond 24 hours, as doing so could increase the risk of infection.During a review of the facility policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, revised 11/18, the P&P indicated, Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufacturer. 2. Resident 19 was admitted to the facility in November of 2025 with diagnoses that included pneumonia (an infection that affects one or both lungs and it causes the air sacs of the lungs to fill up with fluid or pus).A review of Resident 19's Care Plan (CP), revised on 10/2/25, indicated, Monitor adherence to EBP guidelines especially gown and gloves during high contact activities.During a concurrent observation and interview on 12/2/25 at 8:37 a.m., with CNA 5, CNA 5 was replacing Resident 19's soiled dressing used to cover his tracheostomy (an opening through the neck into the windpipe) scar. CNA 5 was not wearing a gown during the dressing change. CNA 5 verbally confirmed he was not wearing a gown and indicated staff should wear a gown if they provided direct care to Resident 19.A review of Resident 23's CP, revised on 11/3/25, indicated, Monitor adherence to EBP guidelines especially gown and gloves during high contact activities.During a concurrent observation and interview on 12/2/25 at 1:06 p.m. with LN 2, LN 2 did not wear a gown while administering a tube feeding bolus (tube feeding given using a syringe instead of a pump) to Resident 23. LN 2 confirmed that administering a tube feeding bolus to Resident 19 requires wearing a gown and acknowledged that she should have worn one prior to providing care.During an interview on 12/3/25 at 3:27 p.m. with the Director of Nursing (DON), the DON indicated she expected facility staff to follow the EBP guidelines when performing direct care for residents on EBP. The DON also indicated EBP were used to help prevent the transmission of disease-causing organisms. During a review of the facility P&P titled, Enhanced Barrier Precautions, revised 12/24, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs).Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).wound care (any skin opening requiring a dressing).

Based on observation, interviews, and record review, the facility failed to implement an effective pest control program to prevent cockroach infestation in the kitchen, dining hall, and surrounding areas when multiple cockroaches were observed in these locations.This failure posed a potential health risk to the 49 residents due to exposure to pests. Findings:During an interview with Resident 62 on 12/1/25 at 12:19 p.m., Resident 62 indicated that she woke up one night to find a cockroach on her body and after turning on the lights, she observed a large cockroach on the bathroom wall stating, We turned on the lights, and it was a big cockroach!During an interview with Resident 28 on 12/1/25 at 12:23 p.m., Resident 28 stated that she observed cockroaches crawling on the walls in the dining hall.During an interview with the Dietary Aide (DA 2) in the Kitchen on 12/1/25 at 2:35 p.m., DA 2 stated that the facility underwent a major pest control spray last month and that pest control services had been since visiting weekly to perform additional spraying in the kitchen. DA 2 further stated that cockroaches were entering the kitchen via the meal carts used to transport trays to and from resident rooms. DA 2 stated, They came upstairs and got in here [kitchen] via the carts. The facility's kitchen was located on the first floor of the building while the residents' living area was on the sixth floor with a residential apartment positioned between these levels.A concurrent observation and interview was conducted on 12/1/25 at 3:27 p.m., with the Nurse Consultant (NS) in the kitchen. The NS confirmed the presence of cockroaches under the sink behind the exposed pipes. The NS stated, We have been spraying them, but because there's assisted living upstairs, we don't know what's going on up there. It's a shared building. During an observation of the countertop and cabinets inside the dining hall on 12/2/25 at 3:25 p.m., a cockroach was seen crawling along the counter wall. The cockroach then scurried into an opening located between the countertop and the counter wall.During a concurrent observation and interview with Licensed Nurse 3 (LN 3) on 12/3/25 at 10:03 a.m., a cockroach was observed emerging from behind the medication cart and crawled on the wall near the entrance to the residents' dining area. Both the Department and LN 3 witnessed the presence of the cockroach during the observation.A review of facility documents from [Pest Control Vendor Name] indicated that pest control services were provided to the facility on the following dates: October 30, 2025, November 13, 2025, and November 20, 2025. The document also indicated, Target Issues: Cockroaches.A review of facility document from (agency name) titled, Official Inspection Report OIR dated 12/2/25, the OIR indicated, .13 live adult German cockroaches found between cabinet edge and countertop in the 6th floor dining room kitchenette. Fecal focal points found on sides of cabinet and inside the cabinet. Insulation around water pipes under dishwasher contributing to cockroach harborage. During an interview with Dietary Consultant (DC) on 12/3/25 at 3:51 p.m., the DC stated that cockroaches should not be present in the facility's kitchen, as they pose a risk of contaminating resident food and may lead to foodborne illness. The DC further stated, They [the facility] cannot have it [cockroaches] here in the facility.A review of the facility's Policy and Procedure (P&P) titled, Pest Control dated 5/2008 indicated, Our facility shall maintain an effective pest control program. to ensure that the building is kept free of insects and rodents. During a review of the facility's P&P titled, Homelike Environment, Revised 2/21, the P&P indicated, The Facility staff and management provides, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics may include:. Clean and sanitary environment.

Based on interview and record review, the facility failed to ensure accurate reconciliation of controlled medications for two of 13 sampled residents (Resident 56 and Resident 57) when random controlled medication audits did not reconcile.These failures resulted in the facility not having an accurate accountability of controlled substances and increased the potential for diversion. The controlled medication record for two random residents (Resident 56 and Resident 57) who received as needed controlled medications were requested for review during the survey.During a review of Resident 57's Medication Administration Record (MAR) dated 11/1-12/31/25, Resident 57 had orders for Hydromorphone (opioid analgesic) 4 mg to be given every two hours as needed for pain.During a review of Resident 57's CONTROLLED DRUG RECORD [CDR], [a form that keeps count of the number of narcotics dispensed to a resident], entries dated from 11/30/25-12/2/25, the CDR indicated one tablet of Hydromorphone 4 mg was removed from the medication card (pre-packaged medications dispensed from a pharmacy) on 11/30/25 at 11 p.m. This medication was not documented as given on the MAR.During a review of Resident 57's MAR dated 12/1/25, the MAR indicated Resident 57 had received Hydromorphone 4mg at 12:33 a.m., this medication was not documented as given in the CDR.During a review of Resident 56's MAR dated 11/1/25-11/30/25, Resident 56 had orders for Oxycodone (opioid analgesic) 5 mg to be given every 6 hours as needed for pain.During a review of Resident 56's CDR, the CDR indicated one tablet of Oxycodone 5 mg was removed from the medication card on 11/29/25 at 3:27 p.m. This medication was not documented as given on the MAR.During a review of Resident 56's MAR dated 11/25/25, the MAR indicated Resident 56 had received Oxycodone 5 mg at 3:42 a.m., this medication was not documented as given in the CDR.During a concurrent interview and record review on 12/2/25 at 2:20 p.m. with the Director of Nursing (DON) of Resident 56 and Resident 57 CDR and MAR, the DON confirmed the missing documentation on the CDR and MAR. The DON stated she would expect the CDR to be signed, It should be an accurate record.During a review of the facility's policy and procedure (P&P) titled, Controlled Substances, dated 4/07, the P&P indicated, The facility shall comply with all laws and regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule ll and other controlled substances.

Based on observation, interview, and record review, the facility failed to provide appropriate supervision when they did not ensure one of three sampled residents (Resident 1) was wearing a wandering device (a wearable device, commonly referred to as a wander guard, with sensors that trigger alarms, used to prevent residents at risk of wandering from leaving a safe area unsupervised) according to Resident 1's physician orders (PO) and care plan (CP).This failure resulted in Resident 1 walking out of the facility unsupervised and without the facility's knowledge, which exposed the resident to cold temperatures, nightfall, and traffic, which could have resulted in serious injury, medical complications, and/or death. Findings:Resident 1 was admitted to the facility in September 2025 with multiple medical diagnoses which included dementia (a progressive state of decline in mental abilities), a history of falling, and a spinal fracture. Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 4 out of 15 which indicated Resident 1's cognitive function was severely impaired.During an interview on 11/24/25 at 11:30 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 was a known wanderer who frequently walked up and down the hallways, exhibited exit-seeking behavior, and often needed re-direction. During an interview on 11/24/25 at 11:46 a.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 was confused and would frequently wander down the hallways and into other residents' rooms, requiring re-direction. LN 1 further stated Resident 1 was supposed to wear a wandering device on his left ankle; the wandering device would activate an alarm when Resident 1 neared the exit to signal staff. During an observation on 11/24/25 at 12:27 p.m. near the elevators, Resident 1 and their Responsible Party (RP) walked into the facility through the elevators. An alarm sounded upon the elevator doors opening.During an interview on 11/24/25 at 12:30 p.m. with RP, RP stated the facility notified him on 11/15/25 that Resident 1 had gone missing from the facility and they didn't know how he got out. RP stated the facility was aware Resident 1 had a history of wandering and elopement. RP further stated Resident 1 was very confused and like a little kid. RP, who stated he regularly visited Resident 1 twice weekly, had no recollection of Resident 1 wearing a wandering device prior to his elopement on 11/15/25.During a review of Resident 1's Wandering Risk Assessment (WRA), dated 9/29/25, the WRA indicated, Score of 3 or more = High risk for elopement .[Resident 1] Score: 8 .Has the resident [Resident 1] wandered before? Yes .Does the wandering place the resident [Resident 1] at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes.During a review of Resident 1's CP, dated 10/1/25, indicated, [Resident 1] is an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended, [Resident 1] wanders aimlessly at a risk for elopement assessment done with the score 8.0.Monitor [Resident 1] whereabouts.During a review of Resident 1's CP, dated 10/8/25, indicated, [Resident 1] have wander guard on left ankle r/t (related to) high risk of elopement and wandering .Ensure the [wander guard] device is functioning properly and securely attached to [Resident 1].During a review of Resident 1's PO, dated 10/8/25, indicated, Make sure Pt [Resident 1] have wander guard on left ankle # 9000-0138J exp 05/15/2026 every shift.During a review of Resident 1's Interdisciplinary Team (IDT) note, dated 11/17/25, the IDT indicated, ELOPEMENT November 15, 2025, at 5:45 PM .the resident [Resident 1] was missing .the PD (Police Department) .reported that the resident [Resident 1] had been located at . 7:00 PM .At 8:35 PM, the resident [Resident 1] was returned to the facility by law enforcement .[wander guard] was missing.During an interview on 11/24/25 at 1:22 p.m. with LN 2, LN 2 stated Resident 1 was a known wanderer and would attempt to walk out of the facility through the elevators. LN 2 further stated Resident 1 had an order to wear a wandering device and nurses were supposed to check off in the electronic Medication Administration Record (MAR) that Resident 1 wore it each shift.During a review of Resident 1's MAR, dated November 2025, the MAR indicated, Make sure Pt [Resident 1] have wander guard on left ankle .every shift .start date 10/08/2025. The MAR further indicated, n/N [no], on the following dates and shifts: 11/13/25 evening shift, 11/13/25 night shift, 11/14/25 day shift, 11/14/25 evening shift, 11/14/25 night shift, and 11/15/25 day shift. During a concurrent interview and record review on 11/24/25 at 2:22 p.m. with Director of Nursing (DON), Resident 1's MAR for November 2025 was reviewed. DON verified there was no documentation indicating Resident 1 was wearing a wandering device from 11/13/25 evening shift through the time of elopement on 11/15/25 and there should have been. DON acknowledged Resident 1 had PO, initiated on 10/8/25, to wear a wandering device, which should have been followed. DON stated it was the expectation for nurses to indicate yes or no in the MAR that Resident 1 was wearing his wandering device. If a resident was found without a wandering device on, it was expected for nurses to replace the wandering device immediately. DON stated without wearing a wandering device, the risk was that a resident might elope. DON verified nursing staff had marked n which indicated Resident 1 was not wearing his wandering device for six shifts prior to elopement. DON stated Resident 1 eloped from the facility on 11/15/25. Police found Resident 1 walking around outside, more than two miles from the facility. DON stated she observed Resident 1 was not wearing a wandering device when he returned to the facility. During a review of the facility's policy and procedure titled, Wandering and Elopements, dated March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering .if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated March 2022, A comprehensive, person-centered care plan .is developed and implemented.During a review of Weather Underground titled, [City of facility location], CA Weather History, retrieved on 12/3/25 from https://www.wunderground.com/history/daily/us/ca/[City of facility location/KSAC/date/2025-11-15, on 11/15/25 at 6:53 p.m., during the time Resident 1 left the facility unsupervised, the temperature was 59 degrees Fahrenheit with a wind speed of 12 mph (miles per hour). During a review of Almanac titled, Sunrise and Sunset for [City of facility location], CA, retrieved on 12/3/25 from https://www.almanac.com/astronomy/sun-rise-and-set/CA/[City of facility location]/2025-11-15, on 11/15/25 the sunset was at 4:52 p.m.

Based on observation, interview and record review, the facility failed to protect the rights to be free from physical abuse for two of four sampled residents (Resident 2 and Resident 3), when: 1. Resident 1 entered Resident 2's room, touched Resident 2's belongings, ate his food, and swung her arms at Resident 2 when Resident 2 tried to intervene; and2. Resident 1 approached Resident 3 in the dining room and hit her on the back. These failures resulted in Resident 2 and Resident 3 sustaining pain and injury from physical contact and voicing their safety concerns.Findings:1. During a review of Resident 1's admission Record (AR), dated 9/5/25, the AR indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia with behavioral disturbance (a condition where cognitive decline is accompanied by significant behavioral changes). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/14/25, the MDS indicated Resident 1 had severe impaired cognition. During a review of Resident 1's care plan (CP), initiated on 8/25/25, the CP indicated, [Resident 1] has a change in condition: pt [patient] hit another resident.Resident's change in condition will improve or resolve by next review. During a review of Resident 1's CP, initiated on 6/9/25, the CP indicated, [Resident 1] at risk for altered nutritional status r/t [related to]: dementia, wanders around facility & snacks often. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for August of 20025, the MAR indicated, Monitor patient Q shift [every shift] for wandering.Start date 06/09/2025. During a review of Resident 1's Nursing Progress Notes (NPN), dated 8/29/25 at 7:30 p.m the NPN indicated, [At] 1930 [Resident 2] called staff that this [Resident 1] was touching all of his belongings and this res tried to scratch him, and [Resident 2] tried stopping this [Resident 1] and came outside the room and asked for staff help. Per [Resident 1] I don't know, no, I don't remember. Staff immediately redirected the [Resident 1]. Upon assessment [Resident 1] alert and verbally responsive to care. During a review of Resident 2's AR, dated 9/5/25, the AR indicated Resident 2 was admitted to the facility in mid-2025 with diagnoses which included depression and chronic pain. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition. During a review of Resident 2's NPN, dated 8/29/25 at 7:30 p.m., the NPN indicated, [At] 1930 [Resident 2] called this writer that someone [Resident 1] is in his rm [room] touching all his belongings and eating his chips and that [Resident 1] tried to scratch him when he was trying to let her stop what [Resident 1's] been doing. This writer went to the room and saw [Resident 1] picking up the chips on the floor and eating it.skin check was done on [Resident 2], slight redness noted on [Resident 2's] right neck. [Resident 2] asked for a PRN [as needed pain medication]. During a concurrent observation and interview on 9/5/25 at 9:40 a.m. in Resident 2's room, Resident was alert and verbally responsive, and stated that about five days ago, as he entered his room, he saw his grocery bags open and Resident 1 eating his [Resident 2's] chips. Resident 2 stated that he asked Resident 1 to get out of his room, but Resident 1 approached him and started swinging her arms at him. Resident 2 further stated that Resident 1 moved her arms erratically and hit him on his face and neck, and it was burning afterwards, but he backed out of the room and called for help. Resident 2 further stated that he felt that he was abused, and he was scared whenever Resident 1 was around. Resident 2 stated that he had to refrain from activities more and stay in his room to ensure his safety and the security of his belongings. During a phone interview on 9/5/25 at 11:06 a.m. with Licensed Nurse 1 (LN 1), LN 1 indicated that on 8/29/25 he was in a different room providing care to another resident as Resident 2 called for help, and stated Resident 1 was in his room. LN1 stated that when he came to Resident 2's room, he saw Resident 1 inside the room eating chips. LN 1 further stated that Resident 2 was stating that Resident 1 tried scratching him. LN 1 stated that when he assessed Resident 2, he saw redness on his neck. LN 1 confirmed that Resident 1 had instances of aggression and was known to wander around. During an interview on 9/5/25 at 1:59 p.m. with the Director of Nursing (DON), the DON confirmed that Resident 1 was known to be moving around and entering different residents' rooms, and she had prior incidents of aggressive behavior. The DON confirmed that Resident 1 entered Resident 2's room on 8/29/25, and Resident 2 was found with redness to the neck after the incident. The DON further stated that she expected residents to be free from physical and verbal abuse. 2. During a review of Resident 3's AR, dated 9/5/25, the AR indicated Resident 3 was admitted to the facility in the middle of 2024 with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and depression. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had a moderate cognitive impairment. During a review of Resident 1's NPN, dated 9/4/25 at 14:20, the NPN indicated, Staff notified that [Resident 1] slapped back of the other res head [Resident 3] . During a review of Resident 3's NPN, dated 9/4/25, the NPN indicated, [At] 1420 Staff notified that other res [Resident 1] was touching res bag, activity director tried redirecting [Resident 1], when res [Resident 3] tried stopping res [Resident 1] to stop touching her belongings, [Resident 1] slightly slapped back of [Resident 3's] head, other staff immediately came to redirect [Resident 1].[Resident 3] c/o [complained of] pain to back of head, administer PRN [as needed] pain med. During an interview on 9/5/25 at 10:35 a.m. with the Activities Director (AD), the AD stated that yesterday, around 2:30 p.m. in the dining room, Resident 3 was sitting on a wheelchair as Resident 1 came behind her and slapped her on the back of her head. The AD further confirmed that Resident 1 had prior incidents of aggression and slapping and was under special monitoring. During a concurrent observation and interview on 9/5/25 at 10:51 a.m. with Resident 3 in the dining room on her wheelchair. Resident 3 was able to communicate using words and short phrases, and with the help of hand gestures. Resident 3 indicated that yesterday she was hit on the back by another resident, and she was still hurting, and her hand was also hurting. Resident 3 stated that she did not feel safe and wanted to go home. During a review of Resident 4's AR, dated 9/5/25, the AR indicated Resident 4 was admitted to the facility in the late 2024 with diagnoses which included paraplegia (loss of movement in the legs), and end stage renal disease (ESRD - irreversible kidney failure). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognitive abilities. During an interview on 9/5/25 at 10:20 a.m. in Resident 4's room, Resident 4 stated that yesterday he saw in the dining room how Resident 3 was sitting in the wheelchair and Resident 1 walked up to her and started touching her bags, and when Resident 3 told her to stop, Resident 1 slapped Resident 3 on the back with a loud, audible slap. Resident 4 further stated that Resident 1 often wandered around unsupervised, entering other residents' rooms, and that he [Resident 4] often had to stay in his room's entrance monitoring to make sure that Resident 1 did not enter. Resident 4 further stated that the facility did not provide enough staff to sufficiently supervise Resident 1. During an interview on 9/5/25 at 11:18 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 indicated Resident 1 was known to have wandered and had aggressive behavior, and she was on special monitoring by staff, but she was not monitored at all times. CNA 1 further stated she had to get Resident 1 out of other residents' rooms on a daily basis. During an interview on 9/5/25 at 11:56 a.m. with LN 3, LN 3 confirmed that Resident 1 was known to wander around and had instances of aggression towards other residents. LN 3 stated that direct care staff were busy providing care to other residents, and the facility did not provide sufficient staff to monitor Resident 1 at all times. During an interview on 9/5/25 at 1:59 p.m. with the Director of Nursing (DON), DON confirmed that Resident 1 was known to be moving around and entering different residents' rooms, and she had prior incidents of aggressive behavior. The DON confirmed that Resident 1 was seen physically touching Resident 3 in the dining room yesterday. The DON further stated that she expected residents to be free from physical and verbal abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:. b. other residents.

Based on observations, interviews and record reviews the facility failed to ensure one out of two sampled residents, Resident 1, was provided a therapeutic diet as ordered by the physician. This failure had the potential for Resident 1 to experience malnutrition and weight loss. Findings: A review of Resident 1's Admission Record indicate Resident 1 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a broad term for any brain disease that alters brain function or structure) and dysphagia (difficulty swallowing). A review of Resident 1's Order Summary Report (OSR, physician orders) indicated an order for a regular diet, soft and bite sized texture (foods that are soft, and chopped into bite-sized pieces) with a start date of 2/7/25. During a concurrent observation and interview on 2/18/25 at 12:05 p.m. in Resident 1's room, with Certified Nurse Assistant (CNA) 1, Resident 1's lunch and lunch tray card were observed. Resident 1's tray card indicated mince moist (foods that are soft, moist and minced to size) as the diet. Resident 1's meal included a green food item that was pureed (a food item that is smooth and free of lumps, holds their shape, without being too firm or sticky and will not weep). Resident 1 stated, I don't know what this green stuff is, I'm supposed to be getting a different diet, not this pureed stuff. CNA 1 confirmed Resident 1's lunch included an unidentified pureed food item and a lunch tray card that indicated Resident 1 should be receiving foods with a mince moist texture. CNA 1 confirmed Resident 1's lunch tray card and pureed food item on the lunch tray was incorrect. During a concurrent observation, interview and record review on 2/18/25 at 12:54 p.m. with Licensed Nurse (LN) 1, Resident 1's tray card, meal served and OSR were reviewed. LN 1 confirmed Resident 1's diet order was incorrect and did not match the lunch tray card or the food item that was served. During a concurrent observation, interview and record review on 2/18/25 at 2:02 p.m. with [NAME] (CK) 1, Resident 1's tray card, meal served and OSR were reviewed. CK 1 confirmed Resident 1's diet order did not match the lunch tray card or the food item that was served. CK 1 stated, Those diets [the mince moist and soft, bite sized] are two different orders. During a concurrent observation, interview and record review on 2/18/25 at 2:32 p.m. with the Director of Nursing (DON), Resident 1's tray card, meal served and OSR were reviewed. The DON confirmed Resident 1's diet order did not match the tray card or the food that was provided during lunch. The DON acknowledged they should have provided the correct diet that was indicated on the physician's order. A review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised October 2017, indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes .Diet order should match the terminology used by the food and nutrition services department.

Based on interview and record review, the facility failed to provide a safe discharge for one of three sampled residents (Resident 1), when Resident 1 was discharged to a room and board facility (a home that offers housing accommodations, may offer meals, but does not provide personal care services) and did not have care needed for activities of daily living (ADL). This failure resulted in Resident 1 living in an unsafe environment that could not meet Resident 1's needs which prompted a transfer to the hospital. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility in September 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death), right leg above the knee amputation, bipolar disorder (mental health condition causing extreme mood swings that include emotional highs and lows) and chronic obstructive pulmonary disease (lung disease that blocks air flow and makes it difficult to breathe). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool). Cognitive Patterns, dated 12/18/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's MDS, Functional Abilities, dated 12/18/24, indicated Resident 1 used a wheelchair, required substantial assistance for toileting, showering, dressing, bed mobility, and transfers. Resident 1's MDS, Bladder and Bowel, dated 12/18/24, indicated Resident 1 was always incontinent of bladder and bowel. A review of Resident 1's MDS, Functional Abilities-Discharge, dated 1/7/25, indicated Resident 1 required substantial assistance for toileting, showering, dressing, bed mobility, and transfers. A review of Resident 1's MDS, Bladder and Bowel, dated 1/7/25, indicated Resident 1 was always incontinent of bladder and bowel. A review of Resident 1's PT [Physical Therapy] Discharge Summary, dated 10/7/24, indicated Resident 1 was minimum assist for bed mobility and moderate assist for transfers. A review of Resident 1's OT [Occupational Therapy] Discharge Summary, dated 10/10/24, indicated Resident was minimum assist for lower body dressing and moderate assist for toileting. A review of Resident 1's Order Summary Report indicated order dated 1/7/25, Resident may discharge with current medications and belongings when ready. A review of Resident 1's Progress Note, dated 1/7/24, indicated .Resident is set to discharge today 01/07/25, with all proper orders in place. This writer met with resident to ensure she is prepared to be discharged and answer any questions if any .Resident will discharge to [name] Room & Board .Resident declined all HH [Home Health] Services . During an interview on 1/24/25 at 1:40 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was discharged to room and board on 1/7/25 with Resident 1's consent. The DON stated the Social Service Director (SSD) handled the discharge. During an interview on 1/24/25 at 1:48 p.m. with the SSD, the SSD stated Resident 1 decided to move to a room and board. The SSD stated the manager from a room and board came to talk to the resident on 1/6/25 and Resident 1 went to the room and board on 1/7/25. The SSD stated Resident 1 was able to transfer to wheelchair with help using a transfer pole. The SSD stated she was not present in the room when the room and board manager came to interview Resident 1 and was not aware what Resident 1 told the room and board manager about ability to care for himself or what assistance was needed. The SSD stated Resident 1's insurance and healthcare provider was arranging for In Home Supportive Services (IHSS- program that provides in home assistance to eligible aged, blind, or disabled individuals). The SSD acknowledged she did not document her conversation on 1/6/25 with the room and board manager. During a telephone interview on 1/24/25 at 2:41 p.m. with the Room and Board Representative (RBR), the RBR stated he met with Resident 1 on 1/6/25 who indicated he could stand and mobilize with the wheelchair. The RBR stated he relied on Resident1's assessment of his abilities. The RBR stated that Resident 1 reported he had applied for IHSS. The RBR stated he relied on Resident 1's reporting that IHSS had been applied for and was going to provide care. The RBR stated he believed that IHSS was in place based on what Resident 1 told him. The RBR stated he expected IHSS to be in place when Resident 1 arrived, but no IHSS caregiver came to see him. The RBR stated that in a room and board the resident needs to be very independent. The RBR stated, In my opinion, [Resident 1] needs help. The RBR stated Resident 1 was managing on day 1 and day 2, not doing well on the 3rd day, then on the 4th day, Resident 1 was not able to care for self and went to the hospital. During an interview on 1/24/25 at 2:53 p.m. with the SSD, the SSD stated she was aware that IHSS was not in place when Resident 1 was discharged to the room and board. The SSD stated she was not present during Resident 1's discussion with the RBR on 1/6/25 but relied on a conversation with the RBR on 1/6/25 that Resident 1 had the assistance needed. The SSD stated Resident 1 indicated the RBR could provide the help he needed. The SSD stated she did not confirm IHSS was in place. During an interview on 1/24/25 at 3:09 p.m. with Licensed Nurse (LN) 1, LN stated Resident 1 was able to transfer self with much assistance. LN 1 stated if discharged to room and board, and no one to help, he should have stayed in the facility. During an interview on 1/24/25 at 3:18 p.m. with LN 2, LN 2 stated Resident 1 was dependent for transfers, for changing briefs due to incontinence, and needed help with ADLs. During a concurrent interview and record review on 1/24/25 at 3:33 p.m. with the DON, the DON acknowledged that Resident 1's MDS on 1/7/25 indicated Resident 1 needed substantial assistance for transfers and ADL care. The DON acknowledged that the SSD did not document on 1/6/25 any discussion with the RBR regarding Resident 1's functional ability and the room and board's ability to provide care. The DON acknowledged that IHSS was not confirmed prior to Resident 1's discharge on 1/7/25. The DON stated, IHSS should have been confirmed prior to discharge. Review of the facility's Policy and Procedure (P&P) titled Transfer or Discharge, Preparing a Resident for, revised 12/16, indicated .Residents will be prepared in advance for discharge .A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and /or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility . Review of the facility's P&P titled Discharging the Resident, revised 12/16, indicated .The resident should be consulted about the discharge .If the resident is being discharged home, ensure that resident and /or responsible party receive teaching and discharge instructions .

Based on interview and record review, the facility failed to make sure that an inventory of personal belongings sheet was completed, and a copy was given upon admission to one of three sampled residents (Resident 1.) This failure had the potential for the resident ' s personal belongings being lost or stolen. Findings: During a review or Resident 1 ' s Admission Record (AR), the AR indicated, Resident 1 was admitted in late 2024 with diagnoses which included anxiety. During a review of Resident 1 ' s Inventory of Personal Effects (IPE - inventory sheet), dated 12/2/24, the IPE did not have the Resident 1 ' s signature on the ' Certification of Receipt ' portion of the document. During a review of Resident 1 ' s closed record, there was no documented evidence that Resident 1 signed the inventory sheet and was given a copy upon admission on the nurse ' s notes or admission record. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool) Section C, dated 12/5/24, the MDS indicated, Resident 1 was cognitively intact. During a telephone interview on 12/26/24 at 11:00 a.m.with Resident 1, Resident 1 stated that an inventory of his belongings was not done upon his admission, and he was not given a copy of the inventory sheet during his admission. During an interview on 12/26/24 at 12:26 p.m.with Director of Nursing (DON), DON stated that during admission an inventory sheet for resident ' s belongings should be done and either the resident or responsible party for the resident would sign it and a copy would be given to them. During an interview on 12/26/24 at 2:45 p.m.with Director of Nursing (DON), DON stated that the facility cannot provide a documentation that Resident 1 was given a copy of the inventory sheet upon admission. The DON indicated there wasno documentation on the chart or in the notes. During a review of the facility ' s policy and procedure (P&P) titled, Admitting the Resident: Role of the Nursing Assistant, dated September 2013, the P&P indicated, When all personal items have been inventoried and recorded on the Inventory of Personal Effects Record, sign your name and title and instruct the family member that witnessed the inventory to also sign the form .provide the resident and/or family member with a copy of the completed and signed inventory record.

Based on interview and record review, the facility failed to protect two sampled residents (Resident 3 and Resident 2) from abuse, when, Resident 3 was verbally threatened and punched by Resident 1 in the face and neck and Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1, who had a known history of verbal aggression and sexual inappropriateness. These failures resulted in Resident 3's physical injury and emotional distress and feeling dirty for Resident 2. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Program, revised 4/2021, indicated, Residents have the right to be free from abuse .This includes . freedom from . verbal, mental, sexual or physical abuse. According to the admission record, the facility admitted Resident 1 in the fall of 2024 with diagnoses which included multiple fractures of left leg. A review of Resident 1's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 10/3/24 indicated the resident scored 15 out of 15 on the assessment and was cognitively intact. A review of Resident 1's Order Summary Report' contained two physician's orders dated 9/27/24 and 11/12/24 for psychiatric evaluation. A review of Resident 1's care plan dated 10/31/24 and revised 12/11/24 indicated, The resident is/has potential to be sexually inappropriate to staff .to other residents r/t [related to poor impulse control .The resident will verbalize .need to control behavior. The interventions included, monitoring behaviors, documenting observed behaviors and attempted interventions, monitoring resident's whereabouts every 30 minutes, and arrange for psychiatrist consult. A review of Resident 1's care plan dated 11/15/24 indicated, The resident is reported to be verbally aggressive and threatened peer .The resident will not harm self or others. The interventions directed staff to monitor for irritability . monitor/document any s/sx [signs and symptoms] of resident posing dangers to others . intervene before agitation escalates . A review of the nursing progress notes (NPN) indicated Resident 1 had been having history of multiple episodes of verbal and physical aggression and sexually inappropriate behaviors. There was no documented evidence that the resident had been referred or had been evaluated by a psychiatrist as was ordered by the resident's physician on 9/27/24 and 11/12/24 and as indicated in Resident 1's care plan. A review of the NPN dated 10/31/24, at 11:15 a.m., indicated Resident 1 made inappropriate sexual comments toward a female staff. A review of the NPN dated 11/8/24, at 3:42 p.m., indicated that Resident 1 was noted with increased behaviors . continues to make false, accusatory, and paranoid/delusional statements . The NPN indicated the physician was notified and the psychiatric consult was requested. A review of the social services note dated 11/15/24, at 11:56 a.m., indicated that Resident 1 has had verbal altercation with another resident from across his room and continued to go back to his room and is threatening the other resident, all verbal only. A review of the NPN dated 12/9/24, at 7:22 p.m., indicated that Resident 1 was witnessed by staff entering Resident 3's room. Per NPN, Resident 1 started yelling at Resident 3, and then was noted . charging toward [Resident 3], hitting him [Resident 3] in the head. A review of Resident 1's 'Change in Condition Evaluation' dated 12/10/24 at 3:29 p.m., indicated, Resident [1] made unwanted sexual advances multiple times towards another resident. A review of the admission record indicated the facility admitted Resident 3 earlier this year with multiple diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk of the left side of the body). A review of Resident 3's quarterly BIMS assessment dated [DATE] indicated that Resident 3 scored 15 out of 15 and was cognitively intact. A review of the NPN note dated 12/9/24, at 7:09 p.m., indicated Resident 3 was verbally threatened and then was hit in the head by Resident 1. The nurse documented that Resident 3 was assessed after the incident and complained of severe headache. Per NPN, Resident 3 rated the pain as an 8 on a scale from 1 to 10, where 8 indicated a severe pain. A review of Resident 3's care plan dated 12/9/24 indicated, Peer to Peer - Resident received episode of physical aggression by another resident. A review of the admission record indicated the facility admitted Resident 2 earlier this year with multiple diagnoses which included left-sided hemiplegia and above the knee amputation (AKA- surgical removal of the portion of right leg above the knee). A review of Resident 2's BIMS dated 9/22/24 indicated that Resident 2 scored 13 out of 15 and was cognitively intact (had sufficient judgement). A review of Resident 2's care plan dated 10/6/24 indicated the resident used anti-anxiety medication related to anxiety disorder. One of the interventions directed staff to monitor the resident for safety. A review of Resident 2's 'Change in Condition' document dated 12/10/24, at 4:04 p.m., indicated, Resident verbalized to charge nurse .about 6-8 days ago [Resident 1] came to me again and made sexual advances towards me. He said, 'I want you to come lay in my bed so I can .you and you can suck my .Lately nothing has happened but 3-4 more advances .I didn't want to do it .I didn't tell anyone because I was uncomfortable. A review of Resident 2's 'PSYCHO-SOCIAL/WELL BEING' care plan dated 12/10/24 indicated, [Resident 2] recently experienced unwanted sexual advances. At risk for altered wellbeing [and] reduced sense of well-being . The interventions included, Daily psychosocial visit from Social Services for next 3 days & [and] as needed . Determine if mood endangers the resident and intervene if necessary .Identify relationships that the resident could draw on. The care plan did not contain any interventions to show how the facility will ensure Resident 2's safety. During an interview on 12/19/24, at 1:20 p.m., Restorative Nursing Assistant (RNA 1) stated she and another staff assisted Resident 3's roommate with care when they overheard Resident 1 in the hall screaming and yelling loudly calling Resident 3's name. RNA 1 stated both staff attempted to unsuccessfully calm down Resident 1 before he quickly barged into room and hit Resident 3 in the head. RNA 1 stated Resident 3 did not argue or talk back during all this time and it all happened so fast, the staff was not able to stop Resident 1 from hitting Resident 3. During a continued interview with RNA 1 on 12/19/24, at 1:20 p.m., RNA 1 stated that she was aware of Resident 1's inappropriate sexual advances towards Resident 2. RNA 1 described Resident 2 as alert and oriented. RNA 1 stated that a few days after Resident 2 reported the alleged incident, the resident approached RNA 1 and talked about the incident with Resident 1. RNA 1 stated that Resident 2 verbalized to her that she was weary of [Resident 1's] behaviors. During an observation and interview on 12/19/24, at 1:35 p.m., Resident 3 was observed lying in his bed. Resident 3 stated he was eating dinner when he heard Resident 1 yelling loudly. Resident 3 continued, I don't remember what he was saying, it was very quick. He came here and hit me in the face and my neck with his fist . It hurt bad. Resident 3 demonstrated the area on his face and neck where he was hit and continued, That guy is always mean and angry. We were in the same room before, across the hall and he always yelled at me. He even threatened to kill me, said he is going to smash my head with a fan. Resident 3 added that he complained about Resident 1 and the facility moved him to a different room. Resident 3 stated, Every time I hear his voice I cringe because I'm still scared of him. I cannot walk and cannot defend myself. I am safe when he's not around. During an interview with CNA 1 on 12/19/24, at 1:50 p.m., CNA 1 stated Resident 1 had lots of behaviors and described him as very short tempered and irritable. CNA 1 stated Resident 1 had frequent arguments with Resident 3 in the past when they were roommates. CNA 1 stated that Resident 1 had history of saying sexual things and making sexual advances towards female staff and the staff was aware of it. During a concurrent interview and record review on 12/19/24, at 2:10 p.m., the Assistant of Director of Nursing (ADON) validated that on 12/9/24 Resident 1 yelled at Resident 3 and then physically assaulted him in the face. The ADON stated she was aware that Resident 1 and Resident 3 were not getting along when they were roommates. The ADON stated was not aware of Resident 1's threats to Resident 3 and not aware if they had physical altercations prior. The ADON stated she was not sure what happened .and what triggered to move [Resident 3] to a different room. During a continued interview on 12/19/24, at 2:10 p.m., the ADON stated she was present when Resident 2 reported the sexual allegation incident with Resident 1 on 12/10/24. The ADON stated that Resident 2 did not report alleged encounter with Resident 1 right away and reported the incident 6 - 8 days after the incident happened. The ADON stated that Resident 2 reported that Resident 1 made 3 or 4 more advances after the first incident and put his arm around Resident 1 and that she [Resident 2] was uncomfortable with that. The ADON added, I asked . if she was scary of him and if she felt safe. She said she was okay. During an interview on 12/19/24, at 2:20 p.m., Resident 2 stated that Resident 1 had been having inappropriate conversations and sexual suggestions on many occasions when they were in the hall, dining room or outside. Resident 2 stated, [Resident 1] would put his arm around me and even tried to put his hand into my pants . I've told him to stop, but he did not listen .I did not like what he was doing . I didn't want to talk to anyone about it because it was so gross, and I felt dirty. Resident 2 stated she decided to report Resident 1 when the incidents became more frequent. Resident 2 continued, They moved him away from me, but he continues talking to me and even yelled at me when I was outside . I'm okay if other people around but not comfortable to be alone with him. Resident 2 stated she did not report to anyone that Resident 1 continues talking to her inappropriately when they are outside after she reported it first on 12/10/24. A joint interview with Resident 2, Social Services Director (SSD), and Administrator (ADM), was conducted on 12/19/24, at 2:40 p.m. SSD stated that Resident 1 was moved to a different hall and had been on frequent monitoring every 30 minutes since the incident was reported. The SSD and ADM assured that the staff did not observe any further incidents of Resident 1 being inappropriate. During the interview, Resident 2 explained that Resident 1 continues talking inappropriately when they are outside and when there are no other residents around and added that she did not talk to anyone about this. During an interview on 12/19/24, at 2:55 p.m., Resident 1 was asked about the incident of physical aggression toward Resident 3. Resident 1 stated, We were not getting along when we were living in the same room; he always called me words and racial slurs . That day I was in the hall talking on the phone . He overheard me and started calling me . word again .I lost it . went to his room and slapped him. During a continued interview on 12/19/24, at 2:55 p.m., Resident 1 was asked regarding alleged incident with Resident 2. The resident denied the allegations and stated, it's false, it's all lie. I have never said or done anything like that. During a joint interview with Director of Nursing (DON) and ADM on 12/19/24, at 3:25 p.m., the DON validated that Resident 1 had history of verbal altercations with another resident prior to the incident with Resident 3. The DON acknowledged that Resident 1 had a known episodes of sexually inappropriate behaviors toward the staff, but no incidents towards the residents prior to Resident 2's report. The ADM stated the facility will implement additional steps to ensure Resident 2's safety and the ADM added, It is our goal for everyone to feel safe here. We are responsible for protecting our residents. A review of the facility's policy titled, Safety and Supervision of Residents, with the revision date of 7/2017, indicated, Resident safety and supervision . are facility-wide priorities . Resident supervision is a core component of the systems approach to safety.

Based on interviews and record reviews the facility failed follow physician orders for one resident out of five sampled residents (Resident 1) when Resident 1 ' s weight was not measured at admission. This failure had the potential for facility to be unable to recognize if Resident 1 experienced unexpected weight loss. Findings: A review of Resident 1 ' s admission records indicate Resident 1 was admitted to the facility in October 2024 with diagnoses including dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (critical deficiency in protein and calories in the diet). During a review of Resident 1 ' s Order Summary Report (OSR, physician orders), dated 10/31/24, an order for admission weight was noted. During a concurrent interview and record review on 11/26/24 at 4:03 p.m., with the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Nurse Consultant (NC), the following documents were reviewed: 1. Resident 1 ' s OSR, 2. Progress Notes, dated 10/31/24 - 11/17/24 and, 3. Weights and Vitals Summary, dated 10/31/24 - 11/13/24. The ADON, DON and NC confirmed there was no admission weight for Resident 1 per the OSR and no way to track weight loss. A request for the facility ' s policy and procedure (P&P) for their Admission Assessment, which included documentation of a resident ' s admission weight was requested on 11/26/24 and 11/27/24. The facility did not provide the requested P&P.

Based on interviews and record reviews the facility failed to ensure one resident out of five sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene, when Resident 1 did not receive showers as scheduled. This failure had the potential for Resident 1 to experience a decrease in hygiene and psychosocial wellbeing. Findings: A review of Resident 1 ' s admission records indicate Resident 1 was admitted to the facility in October 2024 with diagnoses including cerebral infarction (blood flow to the brain is blocked, causing brain cells to die) and muscle weakness. A review of Resident 1 ' s Order Summary Report (OSR, physician orders), dated 10/31/24, indicated Resident 1 had the capacity to understand and make his own health care decisions. During a review of Resident 1 ' s 48 Hour Baseline Care Plan, (a document that provides person centered instructions for a resident's care), dated 10/31/24, indicated Resident 1 was dependent on staff for grooming and hygiene care, needed the assistance of one to two staff members for bathing and had a preference for showers. A review of Resident 1 ' s Care Plan (a plan that outlines the type of care a resident needs and the steps nurses will take to meet them), dated 10/31/24, indicated Resident 1 was at risk for altered ADLs related to the cerebral infarction, with an intervention that included providing a shower or bathing at least two times a week. During a review of Resident 1 ' s Task: Bathing Performed, dated 10/31/24 to 11/16/24, indicated Resident 1 ' s bathing task was completed on 11/5/24 and 11/7/24. There were no bathing tasks completed from 11/8/24 to 11/16/24. During a concurrent interview and record review on 11/26/24 at 4:03 p.m., Resident 1 ' s 48 Hour Baseline Care Plan, Care Plan, and Bathing Tasks were reviewed with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Nurse Consultant (NC). The ADON, DON and NC confirmed Resident 1 was dependent on staff for grooming and hygiene needs and he did not receive showers as indicated. The CN stated, The CNA (Certified Nursing Assistant) should have told the nurse why that specific task wasn ' t done. A review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview and record review the facility failed to ensure medications were stored in their original containers and in a safe manner for 16 sampled residents. This failure had the potential for medications to be incorrectly identified and misused. Findings: During a concurrent observation and interview on 11/14/24 at 9:01 a.m. with Licensed Nurse (LN) 3, at Medication Cart 1 (Med Cart 1). LN 3 opened the top drawer to Med Cart 1 where there were three 30 mL (milliliters, a unit of measurement) plastic cups observed, stacked on top of one another, in the top drawer. Each plastic cup had two or more items in it, unlabeled and unidentified. LN 3 confirmed the plastic cups were not labeled and included the following: 1. One plastic cup had one pink pill and one red liquid-gel pill, 2. One plastic cup had two orange-colored pills, 3. One plastic cup had seven red and white liquid-gel pills. LN 3 acknowledged the medications should not be removed from their original packaging; this is a safety concern. During an interview on 11/15/24 at 10:42 a.m. with the Director of Nursing (DON), the DON confirmed medications are not to be removed from their original packaging. The DON stated, The next nurse who takes over the medication cart won't know what these pills are .this is a safety hazard. A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised February 2023, indicated, Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Medications may not be transferred between containers.